Joyce was 16-years old and the only girl at her school to have completed primary education when she became pregnant and contracted HIV. “A man offered me money to have sex. I did not know what contraception was,” she recalls. Food and income often became unexpectedly scarce in her hometown, which lies near the intermittent warzone area that marks the border between South Sudan, and its parent country and long-time opponent, the Republic of Sudan. Pregnancy carries enormous stigma for unmarried girls in South Sudan. Joyce remembers her sense of guilt and fear. “My parents allowed me to study instead of marriage, so I was even more frightened to tell them.”
She took one of the few options open to pregnant adolescents in South Sudan, where abortion is illegal and modern contraceptive methods are almost unheard of. Joyce sought the help of an itinerant traditional healer, who attempted to induce an abortion and left her bleeding heavily, alone and afraid for her life. Now a serious young woman of 22, she reflects on how lucky she was to survive. “When my parents found out they took me to a hospital.
They finished the abortion because I was bleeding a lot.” After nearly two months of recovery, she was released. Determined to avoid another abortion, she now visits a family planning charity in the nearby town of Malakal for contraception. With access to contraception and an understanding of how to use it, Joyce’s story had a happier ending than those of most South Sudanese women. Despite the huge risks associated with unprotected sex in South Sudan, including an HIV epidemic and one of the highest maternal mortality ratios in the world, the rate of contraceptive prevalence amongst women of childbearing age remains at just 1.7%.
A 15-year-old schoolgirl in South Sudan has a higher chance of dying in childbirth than of finishing school, and those who survive can expect to face danger again, as each woman bears an average of six children in her lifetime. Family planning is not a well-understood concept throughout much of the country, and misunderstanding surrounds both the term itself and most contraceptive methods. “When you ask people what family planning is they say making sure children go to school, making sure the compound is clean,” remarks Dan Williamson, country director for Marie Stopes in South Sudan. “Those who do understand it a bit more sometimes think it’s sterilisation, and many associate it with prostitution.”
Healthcare is rudimentary in South Sudan, with a lack of basic medical supplies dating back to the 1990s. Medical facilities not in use by either the government or the SPLA rebel group became inoperable, taking a heavy toll on the training of nurses and other medical professionals.
“As you get into the field, many nurses and midwives don’t understand what contraception is, let alone the methodology of its use.” Williamson adds. The government of the newly independent nation is working on a draft plan to begin establishing both the awareness and the structures required to spread family planning. But the country’s war-ravaged infrastructure has made the collection of reliable data an almost impossible task. The country’s politicians, currently preoccupied with maintaining an increasingly fragile peace, have little concrete information to guide their reproductive health policies. Current proposals take their cue from the government’s 2008 action plan, which focused on integrating contraceptives into the healthcare system and improving facilities.
Unaddressed in all this is a significant cultural obstacle to contraceptive use in South Sudan, with deeper roots than the common misconceptions. In areas where women enjoy a basic understanding of contraception, the attitudes of their male partners can often prevent access.
In a town not far from South Sudan’s capital city, Juba, 17-year old Jane describes her search, for contraception that her husband would not discover, after a painful miscarriage two years ago. “He would not use a condom. To him, it is not natural.” Jane visited a clinic run by local health care workers to ask for a contraceptive injection. “They had lots of condoms that no one was using. They told me, you need the permission of your father or husband.
” The male-dominated nature of South Sudanese culture can make it almost impossible for women to access contraception alone, whilst their partners and families remain wary.
It is a problem that disproportionately affects the young. Girls are widely expected to marry upon reaching puberty, meaning that adolescents face cultural pressure to have intercourse without protection, and to experience regular pregnancies.
The tradition is driven, like so much in South Sudan, by the civil war’s legacy of poverty and violence. Marriage offers protection from sexual assault and a source of income for the bride and her parents. Of the more than 20% of women aged 15-19 in South Sudan who experience pregnancy, most are married.
“It’s difficult for women who want to use contraception, because there is a lot of resistance from partners,” remarks Nhial Wiyat, head of the Reproductive Health Programme run by the American Refugee Committee (ARC) in South Sudan.
“They think the condom is not good for them, or that if their wife or lover suggests it maybe she thinks he has HIV, or is sleeping with other men. There is huge demand for hidden methods, like implants or injections.”
The spread of family planning in South Sudan poses a monumental challenge, requiring the government to extend its work beyond a drive for general contraceptive awareness through healthcare facilities. In the long-term, this will require the return of reliable infrastructure and an end to the cycle of poverty and violence that drives girls and their families to seek protection and income in return for sex, both within marriage and outside it.
For now, male engagement must be made more of a priority. “Women on the whole absolutely want family planning when they hear about it,” says Wiyat. “But until men understand it and accept its implementation, both married and unmarried women will struggle to access contraception.”
The Juba Post.