International
N’DAKRO, Cote d’Ivoire — After Kouame Koffi’s daughter Grace was born in 2008, he swore he would not have any more children. Koffi’s wife, Odette, had given birth twice before, in their one-room home in N’Dakro, a remote village about three hours outside of Abidjan, the economic capital of Cote d’Ivoire. Those two babies were stillborn, and while Grace was born healthy, Odette started hemorrhaging and would have died if there hadn’t been a man with a truck delivering bread to the village. He drove Odette to the hospital in Bonikro, about four miles away, and she survived.
During her first pregnancies, Odette consulted the village’s midwives and planned to have her babies at home, as most women here do. When her second child died before he even took a breath, Odette decided that for her next pregnancy she would go to the doctor for prenatal checkups and give birth at the hospital. But she needed Koffi’s permission to do so.
“Men are in charge. They are the ones who have the money. They are the ones who decide whether or not the woman should go to the hospital,” Koffi explained. However, he says he “did not know about the good in hospitals.”
Men in the village often believe that birth-control pills and injectable contraceptives will make their wives ill or sterile or encourage them to cheat. They also don’t understand or know about the need for prenatal care and don’t want to spend the money for their wives to go to clinics when they believe traditional medicine works just as well.
Now, as part of a government and United Nations Population Fund (UNFPA)-sponsored “school for husbands” in N’Dakro, Koffi uses the story of his wife’s near death to teach other men in his village about the importance of prenatal care and encourages them to give their wives money so that the women can give birth at the hospital instead of at home in the village.
Cote d’Ivoire has one of the highest rates of maternal and neonatal mortality in the world. Every day, 16 women die in childbirth and almost 40 out of 1,000 children are stillborn. Cote d’Ivoire ranks 138th out of 148 countries on the Gender Inequality Index, which measures women’s reproductive health, empowerment and economic activity.
“Men play a key role in bringing about gender equality since, in most societies, men exercise preponderant power in nearly every sphere of life, ranging from personal decisions regarding the size of families to the policy and program decisions taken at all levels of government,” said Babatunde Osotimehin, executive director of UNFPA. In order to create lasting, positive change, it isn’t sufficient to educate women about reproductive and maternal health and gender equality; men have to be educated as well.
In 2012, the government of Cote d'Ivoire, along with UNFPA, launched a program to educate husbands about women’s health. There are now 27 schools for husbands in the country, with a plan to open an additional 25 this year. District health directors selected the villages based on lack of access to medical facilities, the rate of maternal mortality and teenage pregnancy and other criteria. UNFPA representatives, along with district leaders, then went to the villages to meet with the chiefs to discuss the idea of forming the schools, and community leaders were put in charge of identifying 8 to 10 “model husbands” who would lead the initiative, teaching other men in the village about maternal health, contraceptives and other issues.
While there are no leaders in the schools for husbands—even village chiefs who participate have no more say than anyone else—each school has a coach to help facilitate meetings and a supervisor and a nurse or midwife designated by the district.
Hadiza Ba, National Program Officer of Behavior Change Communication / Community Mobilization at UNFPA, says the schools have for the most part been left to operate autonomously and men are not paid to participate, although UNFPA and the government will assist villages that have taken initiative.
N’Dakro’s school for husbands was launched in August 2013. The 10 model husbands hold meetings every other Monday morning in a hut made from branches and wooden planks, with black plastic draped over the roof. During these meetings, they decide on an issue that needs to be addressed and then go out in pairs to speak with the other men in their village.
These 10 men were selected based on their character and leadership abilities and because they recognized the need for health services for their wives and children. When the school was founded, they went through a three-day training on reproductive and maternal health, gender equality, female genital mutilation and other issues that adversely affect women and girls.
Even though these model husbands were chosen in part because they were more progressive than other men in the village, they still did not immediately accept everything they were told during the training.
“They had a vague idea that things should be different,” says Mathies Yao, the schools for husbands coordinator in Toumodi, the closest town to N’Dakro, “but it’s hard because we’re reversing their culture. To say to a man you have to help your wife with household activities, you can’t beat your wife — it was hard for some of the men to understand. At the beginning they were very skeptical; they thought it was a violation of their rights.”
At the end of the training, Yao showed a picture of his family to the class and explained that he and his wife had used contraceptives in order to space out the births of their three children, who were born three years apart.
“Initially, I did not want my wife to take birth-control pills, even though they told us that it would help the wife to rest and recover before having another child,” Koffi said. “But when I saw Yao’s wife and she was beautiful and healthy, I was convinced!”
One of the main issues regarding women’s health in N’Dakro is the use of contraceptives. Many men in the village struggle to provide for all their children. The families in N’Dakro farm cocoa and coffee. In a good year, the men said, they earn as much as $2,100; in a bad year, it’s about $840. They estimate that between school fees, uniforms and medical treatment, it can cost as much as $200 per year to take care of each child.
The chief of N’Dakro, Julien N’Goran, was 29 when he married his first wife, who was 15, in 1991, and 35 when he married his second wife, who was 13. He has 10 children — four with his first wife, six with his second.
“We did not know about contraceptives, and the children came one after another,” said N’Goran. “In the beginning, it was fine, but now it’s getting tough.”
N’Goran learned the importance of contraceptive use from the model husbands and now gives his second wife about $2 every three months so she can go to the clinic to get injectable contraceptives. (He and his first wife are now divorced.)
He also has mandated that women in the village go to the hospital to have their babies.
“Before the school for husbands, women were having their children at home and dying in childbirth,” said N’Goran. “After, I told the women of the village not to have their babies at home, and I told the traditional midwives — my mother was one — not to do that anymore.”
Though the nearest hospital, in Bonikro, is only four miles away, it takes two or three hours to get there on motorcycle because the roads are bad. While some women have made that journey while in labor, on the back of a motorcycle, the model husbands decided it would be better to find a way for women to stay in Bonikro when they’re close to their due dates, so that they can be sure to get to hospital in time.
Similarly, in the village of Oussou, there is no easy way to get to the hospital. So the local model husbands gathered a list of the phone numbers of people with cars, whom they called when a woman went into labor. The model husbands each pitched in to pay the drivers, and other villagers contributed as well. The men then saved money so that they were recently able to buy a used car, which they use as an ambulance.
Twenty-two of Cote d’Ivoire’s schools for husbands are in the Toumodi district, and Dr. Bernard Konan, departmental health director of Toumodi, says there has been a decrease in the number of maternal deaths since the schools were introduced. In 2012, 11 women died in childbirth, in 2013, there were 8, and there have only been 2 deaths in 2014. More women are also using contraceptives: “Generally, woman are having seven to eight children,” said Konan. “In the first four sites [of the schools for husbands] we went from zero cases of family planning to 69, in two years.”
Teenage pregnancy is also an issue: “In the village of Akakro a few years ago, 15 out of 20 students at school were pregnant,” said Konan. “With the initiative of the school for husbands, where there is now education of schoolchildren and community-based distribution of condoms, last year there were only two or three cases of pregnancy.”
“Both the use of family-planning services and of prenatal consultations have increased dramatically where a school for husbands is located,” said UNFPA’s Osotimehin. “It is a good example of how sexual and reproductive health are linked to women’s rights and critical to saving lives."
In N’Dakro, Kouame Kouassi Benoit has six children, five of them girls. His plan was to have three sons, and he planned on having more children. His wife Delphine, on the other hand, wanted to take birth-control pills so that she could have a break between pregnancies, but her husband believed they would make her sick.
“I asked many times. He said no,” said Delphine. “He is head of the family, so once he decides, that’s it.”
The problem, Delphine explained, is when two or three children become sick at the same time, typically with malaria, and they have to find the money to take them to the hospital. But managing six children is always hard: “They always do what you tell them not to do, and then you have to yell at them!” she said. Benoit did not help with any of the cooking, cleaning or household chores, and Delphine had to carry heavy loads when they walked the two and half miles to the fields to farm, sometimes with a baby strapped to her back.
Emmanuel Mian, one of the model husbands, went to Benoit’s home several times to discuss the advantages of using contraceptives.
“The first time, I didn’t believe what he was saying,” Benoit said, “but as he kept coming back, I eventually thought about it and agreed to let her take the pills.”
He also has been helping Delphine with the household duties, carrying the food when they go to the fields instead of letting her to carry the load alone. “The idea is to be a better husband. Now I help my wife, and she is happier,” he said.
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