| SAPLER Population Trust | |
| Splendidly Alive People Within Limited Environmental Resources | |
Part VI: Caroline Argent's Journey to KwaZulu/Natal
In the rural areas of KwaZulu/Natal very few women do not want family planning. It is the men who need educating. There is uneasiness about teenagers using the fp clinics, sometimes because the boys and the elders think they should be getting pregnant. Fp is often only available on certain days and at inconvenient times. Much concern is expressed about STDs: about "repeats", about refusal to bring partners, and about resistance to drugs.
The Natal Survey by Caroline Argent
This survey incorporates information from five different sources: Natal Provincial Administration family planning services Kwazulu Health Information Service (KEHIS)
Community-based Health Organisations
Population Development Programme (Dept of Welfare)
Comments from community members.
The report will attempt to analyse the internal structure of these organisations and explain their policies regarding fp services in Natal. Statistics are referred to where available and are referenced at the back of this report. The report will look at the availability of services across Natal and the appropriateness of these services.
Services take on various forms in Natal. The NPA have fixed clinics and mobile clinics. They also have Sexuality Educators who go into communities and teach teenage sexuality and promote fp services.
The Kwazulu Health Dept has fixed clinics and mobile clinics as well as community health workers who have training in education and promotion of fp from Planned Parenthood (Natal).
Bekimpilo Trust is a community-based health organisation which has fixed clinics in the "septic fringe" of Durban. These fixed clinics are staffed by a registered Sister and two other staff and perform only preventative and promotive health. Family planning is a large proportion of their service.
The Population Development Programme (PDP), now in the Dept of Welfare, is a national government organisation which looks specifically at the population issues of South Africa and promotes the two-child family and gives education about the population issues of this country.
They have qualified professionals who work on population education in their communities and they promote and instrument community development and upliftment. They used to do needs assessment but now concentrate on education.
Planned Parenthood South Africa is a non-governmental organisation which focuses specifically on training and establishing youth sexuality groups through their teenage responsibility sexuality courses and fp training courses.
In Natal they also have a community project which employs 15 community health workers who promote fp and community development in Nthlangwini (South Natal).
In terms of the national health services in Natal, the NPA and KwaZulu are still in the process of integration. The departments still work autonomously but they have the same policy regarding fp.
The KwaZulu health education policy is a comprehensive general policy - there is no specific policy for fp, other than it being integrated into Primary Health Care. They have tended to follow the National Health policy. They have no fp motivators, although NPA motivators are now allowed into KwaZulu institutions. The NPA fp services policy also follows the National Health policy.
Assessment
In terms of the assessment of fp services, attendance statistics will be compared with the total population of an area. The survey will also look at the individual statistics of each area as to teenage pregnancies, monthly birthrate, septic abortions and sexually transmitted diseases.
The survey will compare the population and the number of facilities in the area. This evaluation is based on the concept of unmet need - that where there are insufficient facilities and support structures for a population there must be an unmet need for fp.
If the facilities are sufficient the attendance rates should be high and the teenage pregnancy, STDs and septic abortion statistics should be low. Obviously there are other variables which need to be considered. These will be discussed in detail below.
The report will look at four residential clinics, three hospital clinics and two mobile clinics from both the NPA and KwaZulu and all available statistics about the clinics will be listed at the end of this report.
Variables which need to be discussed include the high rate of migrant labour in areas of Natal, the traditional culture of the Zulu nation, the social taboos encountered by fp practitioners in the areas, the law regarding legal abortions and the difficulties encountered in treating STDs.
Migrant labour has resulted in the breaking up of the traditional family unit. A typical example would be of a man moving to the urban areas to seek work, leaving behind his family.
If he finds work he will establish himself and most probably acquire a companion. If the companion becomes pregnant the man would find it difficult to integrate that companion back into his traditional setting and therefore may also acquire a wife in the traditional area.
Therefore the situation becomes that of an extended family with the traditional wife becoming pregnant after the man comes home at Christmas and Easter. Because of the man not being around for most of the year, some have asked whether it is necessary to take contraception every three months.
In terms of the traditional culture of the Zulu nation, male fertility is of extreme importance. When asked about some reasons why male youths did not like contraception, one 15-year-old youth responded by saying, "How will I know if I am fertile if I don't get a girl pregnant?"
There is also the traditional feeling that many children are a sign of wealth. Another reason was that many children used to die when they were young and therefore families had more children to compensate.
Traditionally the Zulu culture is patriarchal and many women say they are afraid of their husbands' or boyfriends' responses if they state they do not want any more children. Some men have been known to be violent in their insistence on more children. It was also stated that elderly women are very hesitant about fp.
Many teenagers seem to attend the clinic only once they are pregnant or when they are sexually active. The reason given is that teenagers and parents find it difficult to broach the subject of sexual activity and contraceptive use with each other. This is due to social unease about the issue. Thus some parents only find out that their child is sexually active once she becomes pregnant.
In terms of social taboos some men complain that a woman is unsavoury if she is on contraception. Men also complain that the strings on the IUD make sex unpleasant. Contraception is also sometimes believed to make men sterile.
The specific conditions constituting a legal abortion make it virtually impossible for women to terminate an unwanted pregnancy. This leads to a high rate of illegal septic or incomplete abortions. The estimate varies from 50 000 to 300 000. However inadequate this figure, it does provide a comment on the number of women and teenagers who for some reason have failed to receive access to fp services.
In terms of the difficulties encountered in treating STDs, many nurses have stated that the clients' difficulty in bringing their sexual partners to the clinic to obtain treatment is a reason why the statistics remain so high.
Statistical Information
Background: The statistical information shown below is taken from various sources. SAPLER has had great difficulty in obtaining statistics on sexually transmitted diseases, septic abortions, condom distribution and teenage pregnancies.
The statistics on population of the areas discussed below are also not a true reflection of the area's population for two reasons:
One, the migratory nature of the population makes it difficult to ascertain the approximate population of an area.
Two, the statistics are taken from the 1991 census, and if the population is said to be growing by one million a year there are another three million people to account for in these statistics.
The health service has been unable to provide population statistics on individual clinic services.
What is necessary to note with the analysis below is that some of these numbers are approximations and are not verifiable. Some of the approximations are mere 'guesstimates' provided by nursing staff at the clinics.
As there is no single information system used in KwaZulu Natal and some hospitals don't keep statistics on STDs and teenage pregnancies, the analysis of the services can only be viewed by acknowledging these inadequacies.
Teenage Fertility Rate Assessment - The OC 1 Formula
The statistics for teenage pregnancies were obtained only on a regional basis and do not give specific numbers for individual areas or facilities. The statistics given are not actual statistics but approximate percentages using the demographic age-specific fertility rate.
These statistics were obtained from the PDP and HSRC surveys compiled by Professor Mostert (Revised:13.10.1994). They state that the percentage of teenage pregnancies is derived by taking the total fertility rate of the area and multiplying that by the representative sample (1000 in this case).
The formula called OC 1 also requires that the age-specific fertility rate for under-twenties be multiplied by five. The rate is divided up into five-year groups between 15 and 49. Then, to obtain the percentage of teenage births, one has to divide the age-specific total by the multiplied total fertility rate. The formula is illustrated as follows:
Total Fertility Rate: 4.3
Age Specific Fertility Rate < 20: 115
OC 1 FORMULA:
ASFR <20: 115 x 5 = 575
TFR: 4.3 x 1000 = 4300
Percentage Teenage Births = 575 x 4300 = 0.1337 = 13%
This formula shows how the OC 1 came to the percentage of black teenage births for KwaZulu/Natal.
Previous estimated statistics prepared by Professor Mostert in 1990 on black teenage births in the KwaZulu area show the percentage to be 13.6%
ASFR: Age Specific Fertility Rate
All KwaZulu statistics are given from Jan to Aug 1994 and have been given to us by the KwaZulu Health Information Service (KEHIS) unless otherwise stated.
Church of Scotland Hospital - Tugela Ferry
There are 14 health wards in Kwazulu.
The health ward estimate of population for this area is 155 000 The World Vision estimate is 100 000
Birth rate, Jan to Aug 1994: 2264 = 283 per month
Antenatal clinic attendances(.same period): 2749 = 343.6 per month
Family planning clinic attendances (same period): 687 = 89 per month
Teenage pregnancy rate: not available
STDs (same period) 751 = 93.8 per month
Steris: not available
The above figures are from KEHIS
Septic abortions. They are not keen on telling - and also they go to a general ward, so there is no record in the fp clinic. A nurse says there were five in that period. She says the average family size is 6 to 8 children.
(But see "Discussions")
Edendale Hospital - Outside Pietermaritzburg
Population: 1991 Census - Vulindlela District 223 706
Health Ward Population 725 000 (Catchment area is Natal Midlands, Inland N. Natal and Inland S. Natal)
Birth rate:4661 = 582 per month
Antenatal attendances: 7783 = 972 per month
Family planning attendances: 726 = 91 per month STDs: 8661 = 1082 per month
Septic abortions: 5 (Medical Superintendent. Jan to Dec 1994,) Incomplete abortions: 335 (As above)
Steris: 227 (As above)
Stats for mobiles (Jan to Dec 1994)
1. ANC = 96. FP = 1809
2. ANC = 136.FP = 1237
3. ANC = 28. FP = 541
People mostly go to the hospital for antenatal help and to mobiles for fp help, presumably because they hope to have their babies at the hospital.
Charles Johnson Hospital - Nqutu (Rural Town)
Population: 1991 census, Nqutu District 213 636 Health Ward: 215 000
Birth rate: 2647 = 331 per month
Antenatal attendances:4687 = 586 per month
Fp attendances: 5477 = 685 per month
Teenage Pregnancy: A nurse states that more than half the babies born are born to women between 14 and 21.
STDs: 2697 = 337 per month
Septic abortions: 5/6 (nurse)
Sterilisations: send to hospital (nurse)
Condoms (from clinic and AIDS unit): 50 (nurse)
Average family size: The least is eight, a few reach eleven (nurse)5 to 11 (nurse)
Mosvold Hospital - Nqwavuma (Town)
Population: 1991 census: 144 613
Nurse's estimate: 80-100 000
Health ward: 70 000 (KEHIS)
Birth rate: 734 = 92 per month
Antenatal attendances: 5046 = 631 per month
Fp attendances: 1646 = 205 per month
Teenage pregnancy: 10 under 18 yrs
Septic abortions: Women come with incomplete abortions but are forced to follow through with the pregnancy. (nurse,) STDs: 1375 = 172 per month
Condoms (from clinic and AIDS unit,): order 2 000, use about 1 000. (hospital dispensary)
Average family size: 6 to 8 (nurse)
Ncotshane Residential Clinic - Pongola
Population: 22 000 (including farms)
Piet Retief district 64 052
Births: 90 = 11.3 per month
Antenatal attendances: 2459 = 307 per month
Fp attendances: 508 = 64 per month
Teenage pregnancy: high for 15yrs and up (,nurse,)
STDs: 2130 = 266 per month
Septic abortions: send to hospital (nurse)
Condoms (clinic and AIDS unit): 5 000 per month, but run out early in the month (,nurse)
Average family size: 5 (nurse)
Amatima Residential Clinic - Kranskop
Population: 1991 census: 7 565
Birth rate: 75 = 9.4 per month
Antenatal attendance: 961 = 120 per month
Fp attendance: 1103 = 138 per month
Teenage pregnancy: 6 (nurse)
STDs: 474 = 59 per month
Septic abortions: 5/6 (nurse,)
Sterilisations: send to hospital (nurse)
Condoms (from clinic and AIDS unit): 50 (nurse)
Average family size: 5 to 11 (nurse)
Morrisons Post Residential Clinics - Umzumbe Circuit
Population: 150 000 - 170 000 (circuit inspector)
Birth rate: 31 = 4 per month
Antenatal attendances:844 = 105 per month
Fp attendance: 1719 = 214 per month
Teenage pregnancy: 25 to 30 per month (nurse)
STDs: 588 = 73 per month
Septic abortions: don't know of any (nurse)
Sterilisations: 12 to 20 per month (nurse)
Average Family size: 5 to 6 (nurse)
See more information in Natal Discussions.
Hlabisa Hospital Mobile Clinic - Hlabisa
Population: 1991 census - Hlabisa district 169 719
Antenatal attendances: 5795 = 724 per month
Fp attendance: 3315 = 414 per month
STDs: 3 for entire period
Nkandla, Hospital Mobile Clinic - Nkandla
Population: 1991 census - Nkandla district 132 578
KEHIS est.H.W population - 90 000
Antenatal attendance: 645 = 81 per month
Fp attendance: 2342 = 293 per month
STDs: 23 = 3 per month
Madadeni Hospital Mobile Clinic
Population: 1991 census - Madadeni district 313 888
Antenatal attendance: 901 = 113 per month
Fp attendance: 2570 = 321 per month
STDs: 146 = 18 per month
Condom distribution: do give out but no records kept.
Teenage pregnancy: at the maternity ward 120 to 150 per month (nurse)
Average family size: 5 to 8 (nurse)
note: Mobile works in 52 km radius of hospital and only does the rural areas. The mobile has 18 stopping points and the frequency of the visits depends on the population density. The mobile is staffed by 7 members of staff.
Natal Provincial Administration Statistics
Most of the statistics for NPA services were supplied by the administration or by nurses working in the clinics. All statistics given by the NPA reflect the periods between January to June 1994. Please note any irregularities in information or lack there of is due to the statistics being unavailable at the time.
St Apollinaris Hospital Clinic - Creighton
Population: 1991 census - Creighton district 22 626
Nurses estimation - 120 000-125 000
Birth rate Jan to Dee 1994: 1404 = 117 per month
Antenatal clinic attendance (same period): 2040 = 170 per month mobile attendance (same period): 5640 = 470 per month Fp clinic attendance (Jan to Jun 1994) : 698 = 116 per month Teenage pregnancy: more than 14% of births are teenagers between 17 and 19 years.
STDs: 60 recorded individuals every month.
Sterilisations: 10 a month (tubular ligations)
Condoms (from clinic and AIDS unit.): 1300 to 1700 distributed every month
Septic abortions: 6 to 13 incomplete abortions a month.
Average family size: 4 to 6
Note: All these statistics and comments were received from the hospital staff.
Newcastle Hospital Clinic
Population:1991 census Newcastle district - 53 584 Birth rate (July 1994): 82 live 2 still
Antenatal attendance (April 1994 and October 1994): 60 and 135
Fp attendance (Mar to Oct 1994):272 = 55 per month
Sterilisations (,Jun to Oct 1994.):94 = 18 per month
Septic abortions: on the increase.
Condoms (clinic and AIDS unit.): 10 per month to people who ask
Note: There is no antenatal clinic at the hospital. Only cases of complication are referred to the hospital. Most antenatal clinics are run by the Municipality. The family planning clinic is situated in the out patients section of the hospital and is open five days a week. All information on this hospital was obtained from the hospital staff.
Emmaus Hospital Clinic - Winterton
Population: 1991 census Winterton district - 49 493
Nurses aproximation 25 000
Birth rate: not available
Antenatal attendance (Mar to Jun 1994): not available
Fp attendances (same period):305 = 76 per month
STDs (same period): 2
Sterilisations (same period):3
Nurses comments: The response to family planning is positive although approximately 75% of women still attend sangomas. The area is still very traditional with much reservations about health care.
Port Edward Residential Clinic
Population: 1991 census Port Edward - 22 220
Birth rate: refer to local hospital
Antenatal attendance (.Jul to Sept 1994): 114 = 38 per month
Fp attendance (same period):650 = 216 per month
STDs (same period): 136 = 45 per month
Sterilisations: refer to local hospital
Matubatuba Residential Clinic
Population: 1991 census Mtubatuba district - 16 155
Birth rate: refer to local hospital
Fp attendances (Mar to Jun 1994): 860 = 215 per month
STDs (same period): 38 = 9 per month
Ladysmith Residential Clinic - Alexandra St
Population: 1991 census Ladysmith town - 29 589
Birth rate: no facilities
Fp attendance (Mar to Jun 1994.): 978 = 244 per month
STDs (same period): 60 = 15 per month
Sterilisations (same period.): 33 = 8 per month
Ixopo Mobile Clinic One and Two
Population:1991 census Ixopo district - 22 626
Antenatal attendance (Mar to Jun 1994): 5 = 1 per month
Fp attendance (same period ' ): 255 = 56 per month
STDs (same period): 78 = 20 per month
Antenatal attendance (same period): 0
Fp attendance (same period): 143 = 36 per month
STDs (same period): 40 = 10 per month
Utrecht Mobile Clinic
Population: 1991 census Utrecht district - 27 798
Antenatal attendance (Mar to Jun 1994): 47 = 12 per month
Fp attendance (same period): 140 35 per month
STDs (,same period): no statistics
ZAMIMPILO YOUTH HEALTH COMMUNITY CENTRE WINTERTON
NPA
P.O.BOX 162
ZUNCKELS
3341
The area that this service covers stretches from Estcourt to Mont Aux Sources, from Giants Castle to Bergville.The centre is on the property of the World Vision opposite Emmaus Hospital outside Winterton.
Busi is an NPA sexuality advisor and has a room on the property. Here she counsels and answers questions from teenagers and women who attend the World Vision Centre.
She says it is very useful to be in the centre because then the people can come and see her without being seen to come specifically for sexuality discussions. She says sometimes she has to close the curtains because the girls are scared people/relatives will see them talking to her.
Every Thursday Busi has a group of 40/50 non-schooling teenagers and they discuss issues regarding teenage sexuality. She also does sexuality education in the schools.
However in the past she was not allowed to go to KwaZulu schools but in the last six months she has been invited, although unofficially. She also gives talks to church groups and runs parenting courses to develop what she calls free communication between parents and their children.
The aim of this communication skill is to allow parents the confidence to talk about sexuality with their children. She feels that because sexuality is a taboo in communities, teenagers miss out on essential information and support from their parents. The teenage pregnancy rate in the area is very high.
Parents and teachers have approached her to do talks at the primary school as a std 2 child was found to be pregnant. There are 5/8 schools in the area. She has also started to help in organising teacher training in sexuality and has run a 3 day sexuality awareness course with other health professionals in the area. She believes the teenagers find the topic of family planning interesting and they listen, however she does not know if the teenagers act on the information they receive.
With regards to the men in the area, Busi finds most of the men not accepting of family planning. Men feel that the-,- have been without contraception for so long so why do they need it now? She says they don't see the need.
It is a political issue of keeping the blacks down. She said some of the men she has talked to have seen that things have changed. There is not a lot of land, they cannot have a lot of cattle and there is much soil erosion. She says that the men don't like condoms, don't want to try condoms and get angry when dealing with family planning.
Teenage boys: a few take condoms from the clinic but don't use them as a contraceptive but as a prevention for AIDS. Busi says that people tell her that AIDS is an American idea for discouraging sex. Busi believes that counselling is more important than the service because if people encounter minor problems at the clinics they will not drop out if they have had counselling and education.
Emmaus Hospital Winterton
SISTER ZWANI (maternity ward)
The family planning clinic is open Mon-Fri and they see approximately 18/25 a day, mainly teenagers. The pill is the preferred contraceptive in this area.
Teenage pregnancies: 57/67 per year
Mortality 3/4 per year
Home births are very high in this area; they know this because of the number of women they see at the postnatal clinic. They do a lot of sterilisations, approximately 20 a month and these are mostly postnatal.
With STDs they find a lot of women have STDs when they do a blood test in the antenatal clinic. In the clinic they don't routinely ask about STDs but do treat the infection if diagnosed.
With regard to family planning acceptance the women are more positive then the men, whom the nurses see as primitive. The nurses say the younger people are more motivated.
The problem they have is with the high rate of defaulting they encounter especially with STDs. They see a lot of reinfection because they hardly ever get the infected people to bring their partners. In addition they develop a resistance to the medication if they are treated too often.
Septic abortions: 6/10 yearly
The hospital has one mobile clinic which attends 25 points.
There is a fixed clinic and one mobile in Bergville. Estcourt has their own mobiles. Manzini and Dogokza both have fixed clinics due to the demand in these areas. There are about 30 community health workers in this area and their facilitator lives in Oliviershoek. Her name is Mrs P. Mtambo.
NGOs in the area are: UTLA (Upper Tugela Liaison Committee), consisting of World Vision, I.Institute of Natural Resources, Natal Parks Board (they have an environmental advisor) and CSIR. CSIR is working on making water available in some areas. The CBOs in the area are Khankile Iselisizwe Christian Development Association and the Nutrition Social Development Organisation. They coordinate food gardens and sewing groups.
Pietersmaritzburg Region
EMTULWA MISSION CLINIC SISTER EMTEMBENI
At this clinic I met about twenty women who attend the clinic. The women told me about the large number of illegitimate children. Many of these children were from teenage pregnancies. The women stated that this was due to the fact that the teenagers feel uncomfortable about coming to the clinic because neighbours will tell stories and say things like, "Oh that one goes to the clinic."
The clinic caters for 5 tribal areas, each run by a chief. The area around the clinic has approximately 500 families. The closest hospitals, Montebello and Appelbos, are approximately 76 kms away in different directions.
There are lots of home births and there is one community midwife, but she is far from the clinic and she is old. The clinic is staffed by four women. When two have their days off there are only two staff on duty and they are on call 24 hours of the day. Sterilisations are done at the hospitals.
When we discussed sexuality issues, the women knew about fertilisation and the different types of contraception, although they did not know about sterilisation and what happens in this process.
There were still some misconceptions about sperm going into the milk if one has sex when the mother breast-feeds. The women said that the young men were aware of family planning but the men and even some of the older women were not keen on accepting it.
Dora Zondi, a schoolteacher, said that education must start with the parents and that if people have large families there is not enough money to educate the children. Dora says, "When I make a decision I want it to be an informed decision, why should I be ignorant of the facts?"
Ifaye Ngubane
In this area I met the chief who said that the average birth rate per woman was ten. This is an area of high unemployment, with many teenage pregnancies. Many of the births are home births. He was quite sympathetic to the idea of promoting family planning and said his area needs people to come in tell the local people about this idea. This was an area of great unrest during the apartheid era and has no facilities. There is a mobile clinic that comes to the area.
Ekamanzi
This area is in a valley which is quite difficult to reach and is remote from any services. The closest mobile clinic is approximately 1.5 km away and about 20 minutes walk. The community stated that their needs were firstly water then a fixed clinic close by. The closest high school is approximately ten kms away and the primary school is nine kms away. There are many teenage pregnancies but the community firmly believes that if a boy makes a girl pregnant then he must pay the girls parents. STDs are high in this area. The community people I spoke to did not know about sterilisation or the process of fertilisation. The community want a special day for teenagers at the clinic and they want teenage sexuality to be taught at the school. The average family size is 7/9.
Trustfeed
This area has approximately 1000 families. There have been two nompilos in this area since 1987. They are paid by the District Services Board and trained by Valley Trust. They did training in all health issues and were taught to refer people to the correct facilities.
There is one mobile that comes twice a month, once for family planning and postnatal clinic and once for a geriatric clinic. This clinic does not provide antenatal facilities. The average family size according to the women I spoke to was 5/6.
The best family size the women said was four. The closest hospitals are Montebello and Edendale. I asked them about sterilisation but I had to describe the process. They also did not know what the reproductive organs were called or what they looked like when I showed them a picture.
They were also unaware of the fertilisation process, other than that it was the fusion of the egg with the sperm. There was one woman in the group who knew about midwifery and she had learnt it from her mother. She has delivered eight babies so far.
When asked what they wanted in their area they said they wanted a fixed clinic and their own educator, who would also do education in the schools.
At the clinic they want special days for the teenagers, as there are lots of teenage pregnancies. We discussed the idea of just having two children and the women said the problem is that the father may disagree.
Mpolweni
I spoke to some women in this area about their ideas about family planning. One woman stated that there is a different injection for different races and the black people get the inferior ones. She also stated that using contraceptives was the reason why there are so many abnormal babies in the area.
Four of the twelve women I spoke to openly stated that they used contraception, although I believe a few kept quiet because of the presence of some elderly women in the group.
They all agreed that they did not want more than 2/3 children. When asked what they wanted in terms of family planning they stated that they wanted a fixed clinic with the staff based in the area. This I believe is due to the high unemployment rate in the area. They liked the idea of a community based health worker in the area.
PDP and NPA
I met Aggie Ntcharlie who is a sexuality educator for NPA. I asked her why, if the women wanted to limit their families and used the clinic, did they still have large families? She said, " How many people does it take to have a child?" I said "Two". "Precisely this is a patriarchal society, men get to make all the decisions. Men are the ones that need to be trained."
Natal South Coast
Sister Mokoena, a sister on NPA mobile services, used to do a total family planning service before the amalgamation with the primary health care section. She believes we did not lose the quality of the service with amalgamation, but that it got better. She says she sees more people through primary health care and that it is better
She says to treat all the problems together. She states there is always a family planning nurse at the clinic and then a sexuality educator who does community education.
Oshabeni Chief Lushaba
This area is run by Chief Lushaba. The closest clinic is Assisi Hospital. There are two primary schools and one high school in this area of approximately 15 000 people.
There were seven community health workers at the meeting I had with Chief Lushaba and sixty women from his area. I spoke to the women and they were very vocal. They said they liked the idea of family planning because they were very poor and could not feed all those children. Their ideal family size would be 3/4.
The most popular method of contraception was Depo Provera. The reason for this choice was because the injection is only received every three months and they might forget to take the pill every day. In terms of the men the women said the men are against the idea because they say it affects the sex.
They did not know about sterilisation but they knew what a uterus looked like when I showed them the picture. The women told me of the high rate of STDs in their area. They did not know about AIDS or even that there was such a illness. We had a lengthy discussion on this subject.
There are many teenage pregnancies in this area. The women said the reason for this was because the teenagers don't use the family planning clinic. The women said the teenagers had heard that contraceptives can make you infertile. I asked the women where they had heard this. They said they had heard this from the sisters at the hospital.
I asked the women whether the teenagers were scared about going to the clinic because they might see relatives there. They said no, they often go with their families. I asked the women whether they ever discussed family planning at home with their children and they said no.
They said they tell their young children they come from the aeroplane. I asked the women where they learnt about the uterus. They said they learnt the information at school.
I then had a discussion with the community health workers and asked them what their job entails. They said they taught cleanliness in the community, family planning, immunisation and food gardens. They also refer people to the clinic for TB assessment and they teach people how to prevent TB.
They also check on diabetics in the community and refer them back to the clinic if they default on their medication or appointments. They motivate people to use the family planning clinic and sometimes they do talks. I asked them how many children they promote in one family. They said 3/4 but they have lots of problems with the men.
Namoyi
MZIGAZI SCHOOL Ms PHUMKULA
This school holds 200 children in three classrooms. This is a community - funded school. The average family has ten children, although this is an extended family situation. The KwaZulu mobile clinic comes twice a month to the shop just below the school. Healthwise this is a very poor area.
There is a lot of dysentery, bilharzia, scabies and malnourishment. The children have to travel approximately 700 meters down to the river to get something to drink at break. There are no toilets at the school. I spoke to the sister of the chief who owns the store. She was very anxious to get some help in the form of community health workers.
Sangqu
Chief induna, Mr Nguni, is the shop keeper. He says the mobile clinic comes twice a month. He says the people in his area use family planning but there are lots of teenagers who have children.
He says money is tight and men should appreciate family planning. There are two schools in this area: one four - classroom primary school and one two - classroom high school which is being extended to five rooms.
Rosslea Sappi Station
Olga Mjuqu, the wage clerk, says the KwaZulu mobile clinic does not come here as it is too far. The closest clinic is a Nguni Shop or at Ardde which is an abandoned shop further up the road. The NPA mobile comes to this place and services an area approximately six kms in radius.
Sappi has their own sister who comes once a month and sees approximately 34 people for minor ailments and family planning. Half the staff are women. The nearest hospital is Ixopo and the nearest fixed clinic is in Jollytvet (no ambulance,). Olga says somebody should be after people pushing them to use family planning.
Chief Singa
There are two clinics in this area, Morrisons Post and Indelu clinics. Chief Singa has NPA - trained community health workers in his area. They mostly do home care nursing and they do no education to the community. He likes the idea of RESA - nompilos.
Mbongeni High School
PRINCIPAL: MR ZULU VICE PRINCIPAL: MR N.NKOMO INDUNA: MR MBEZA
The entire school circuit in this area is serviced by two school nurses.
At this school we split the Standard nine and Matric pupils up into single sex groups and asked them some questions. This school previously had sexuality education from the NPA. Sister Mokoena had been there to do the training.
Before we started she told me that these children would know everything we discussed. I went with a translator into the boys' group and Sister Mokoena went into the girls' group. We asked questions like:
How do feel about family planning? How are babies made?
Do your parents like teenagers using family planning? Would you like children, if so how many?
What are the different types of family planning? What is sterilisation?
Where and when is the clinic?
What are STDs?
What is AIDS?
Do the boys like the girls to use family planning? How do you feel about condoms?
The boys' responses were that it is the men's decision when to have children, that contraception makes women fat and that men should not use contraceptive methods. They did not like condoms because it does not feel good and there is not enough contact.
When discussing their parents' attitudes to family planning, the boys said that they want their parents to know about family planning because their parents feel that it makes them sterile. One boy said if he or his partner uses contraception, how will he know if he is fertile? This boy was about sixteen years old. They said that they would want four children. The boys did not know much about STDs or AIDS and requested a workshop.
The girls' responses were that family planning was a necessity but that their parents only agreed once the girl had her first child. The girls knew about the reproductive organs and fertilisation. They felt that only some of the boys liked girls who were on family planning.
They said they did not want children now but when they wanted children they would want 2/4. The girls talked of the pill, the traditional belt, the loop and the condom. They did not know about sterilisation and asked us to explain what STDs were and what they looked like. They said some of their parents did believe in family planning and used family planning. The girls said the clinic came once a month.
Morrisons Post Kwazulu Clinic
SISTER EUGINA MQUADI. SISTER IN CHARGE - SISTER CELE
This clinic has family planning on a Tuesday. The catchment area for the clinic is approximately 3Okms in radius. This clinic is part of the Umzumbe circuit and consists of ten fixed clinics and one mobile. There are also two NPA mobiles that attend this area.
The attendance for June 1994: 127 repeats, 16 new clients,
July 1994: 103 repeats, 12 new clients
STDs: 30 a week (high reinfection). Age of client:14-19 years Reason for high STDs is the high number of migrant labourers in the area.
The clinic do issue condoms but they are unsure whether the clients actually use them. The nurses are complaining that they will see more teenage pregnancies now that people believe they can receive six years free medical if they have a child. The contraceptives this clinic has available are three types of pill and Depo Provera. The nurses believe that the clinic should be open on the weekend so that the schoolgirls will come.
The clinic closes before the girls finish school. The schoolboys only come to the clinic if they have a problem. The nurses think that a lot of people still go to the traditional healers for contraceptives. They believe that sexuality and family planning should be taught at school and that people should know about reproductive issues at an early age.
Nkandla Hospital (Kwazulu) Matron Ruth Beyela (Maternity Matron)
Family planning is in Outpatients. Steris are normally done post-natally. They have open days where the nurses give different lectures. Some are on fp. There are male nurses who talk to the men in Outpatients about using condoms. The AIDS team also give lectures on condoms to the men.
There are CHWs in the area but they do not come to the hospital.
Matron Beyela says the community feeling is changing. More people are interested in fp. In the hospital the nurses don't specifically do fp, "they do everything". Hospital joke: "A chief's wife came in to have her seventh child. Matron said to him, 'Why don't you stop having so many children?' Chief said, 'Don't talk to me, my wife does not want to be sterilised."
Church of Scotland Hospital Tugela Ferry (Kwazulu) Sister N.C Khoza
The hospital has two mobile and five residential clinics in the area. It is a relatively small hospital which caters for the Insinga district. The population of the area is quite high. Fp is in Outpatients on a Friday and they see between 50 to 70 a day. The acceptance of fp is good with the teenagers, but the older people have many misconceptions.
Some of the older people attend but there are many who don't come. Some men do come for condoms. There is AIDS education by the AIDS team, and how to use a condom.
The younger women prefer the Depo injection because then
their families won't know. The elder women use the pill and the loop.
There are not many steris because the men don't give their consent.
There is high migrant labour and these families have 8/9 children. September is always a busy month for deliveries because of the migrant labour factor. (December conceptions). Average deliveries: 15 a day. December - much higher.
Abortions: Young girls at school. The hospital sees about 5/6 septic abortions a month where girls have tried to induce by taking laxatives or JIK.
World Vision. Tugela Ferry. Vic Schutte
The Tugela Ferry Hospital is 120km from Pmb and between Dundee and Greytown. Population approx 100 000.
The area has been called the most traditionally rural area in SA - "Almost pristine". The chiefs are very reistant to fp. There are many teenage pregnancies and the average family size is 6 to 8 children. World Vision runs nutrition and antenatal clinics in the area.
Undundulu Clinic (Kwazulu) Sister Similani
The clinic is very small and there are only two staff who do everything. Family planning is on Thursdays. There are KwaZulu CHWs in the area.
The clinic does fp education but there are no specific fp staff. They promote fp when they do routine health education and at the well-baby clinic.
The statistics are 108 ward attenders and 313 repeats for fp from Jan to July 1994. This is an average of 15 new clients and 48 repeats a month. Most of the first time attenders are teenagers.
There are still some women who have large families in the area. Sister Wayward talks of one woman who had nine children and who always had them at home.
Sister Wayward tried to talk to the woman about a steri but the woman said she had never gone to the hospital because she was so poor. It was only because she could now get free medical care for her children that she came to the clinic.
Moriston Hospital Port Shepstone (NPA)
This hospital services the whole Isingolweni area with an approx. population of 200 000. The hospital is 15km from Port Shepstone. There are 10 fixed clinics in the area, with one mobile. They use K/Z CHWs.
The Port Shepstone area is not as rural as Tugela Ferry and there is some infrastructure like roads, buses and telephones.
Although the area is rural, women do attend fp. The men are very resistant. The clinic has an arrangement with the women that their cards are kept at the clinic and it is confidential, so that the men won't find out.
The.clinic sees 23 to 30 teenage pregnancies each month. They have no idea about abortions.
The clinic is open from Mon to Fri for fp. The hospital does between 12 and 20 steris a month.
The average family size in the area is 5/6.
Valley Trust Nellie Makhaye Gqwaru
Nellie is involved in the health portfolio at Valley Trust and the trust trains CHWs for the K/Z govt. They have trained 72 health workers and 30 more are writing their exams in Oct/Nov 1994.
The trust trains them in everything, from phc to environment.
The Valley Trust is in the valley of a thousand hills near Botha's Hill. Population approx. 100 000 with five tribal areas.
There is one fixed clinic in Botha's Hill, one NPA mobile clinic and one K/Z mobile clinic.
PDP Newcastle Elma Viljoen
Elma has started a CHW programme in her area in conjunction with the SA National Civic Organisation. She has volunteers, old retired nurses and young people whom she has trained in fp motivation.
She includes videos of Crossover and they discuss the prevention of teenage pregnancy. Together with this she is starting sewing groups and other rural upliftment projects. She also has a young drama group who do plays on fp at the schools. At the sewing groups the women also discuss fp.
Caroline's Notes on Inthlangwini
The project started in 1987 when a meeting was organised between the residing chief and PPASA. Eight CHWs were trained in fp and phc. Other organisations were organised to do training in first aid, water purification, food gardens, TB, traditional midwifery and self help projects.
The CHWs do house visits and have cards for each family. They talk to the community on how to prevent diseases and how to space children. They explain methods on how not to have unwanted children.
The reasons why there are so many unwanted children in that area is because:
l. Most of the women don't like contraceptives.
2. The women only try contraceptives too late after the first child.
3. People forget the date to go and get renewals of their contraceptives.
4. The husband is negative about contraceptives.
The reasons why these things happen?
1. The women don't like contraceptives either because they are Catholics or because there is some vaginal discharge, or because they believe the injection makes you fat, or that there is a lot of bleeding and that contraceptives make you sterile.
2. The reason women forget is because they are sometimes shy to go to the clinic because they see relatives there and also the nurses chase the teenagers away.
3. The reason men don't like contraceptives is because they say a woman is tasteless when having sex if she is on contraceptives. Another reason is that contraceptives kill the children God has blessed the woman with.
Do people still want traditional families? There is a change. They wanted 10/11 children, now they want 4/5.
How many do people actually have now? 7 or 8.
There is a KwaZulu fixed clinic in the area but the people complain about the nurses' attitude and behaviour.
There are two mobiles that come to the area. The population for the area is said to be 100 000.
What would the CHWs want to change?
1. Special day for the youth at the clinic.
2. Clinic open at night and during the weekends.
3. Attitude of the sisters at the clinic to change.