Meeting with Maasai traditional birth attendants. Photo: Bernard Paul Muyanda. ACORD
Pastoralist women in many parts of Africa, including Northeast Africa and Nigeria, face many cultural practices which increase their vulnerability to HIV. At the current International AIDS Conference in Durban, despite it taking place on the same continent, there are no sessions or abstracts listed in relation to pastoralists at all. I would love to be there to raise awareness of pastoralist women’s rights myself, but with no funds available to travel, register or stay there, I am glad to be able to write about some of the issues they face here.
In Tanzania, the Maasai, Sonjo, Hadzabe and Mang’ati people number about 170,000, 51% of whom are female, living across 14,000 km. Whilst seeking to preserve their culture despite modern world pressures, they still embrace a system that denies most women and girls basic human rights. Lack of inheritance rights leave widows and their children very vulnerable when a man dies. In addition, pastoralist women lack access to political power or representation and frequently have development policies imposed upon them.
Tanzania has a 4.7% adult HIV prevalence rate, with 60% of the 1.3 million adults being women. Traditional practices which can increase HIV transmission include polygamy; female genital mutilation with un-sterile instruments; home-based childbirth with traditional birth attendants (TBAs) who are unskilled in modern sterile practices; early and forced marriages by older men where a young girl has no chance to say no to unprotected sex. Traditionally, girls do not attend school because they marry soon after their 12th birthday, despite primary education in Tanzania being compulsory and both primary and secondary education being free.
These cultural practices, gender inequalities and inadequate knowledge for most women – and men - about sexual and reproductive health (SRH) issues and HIV transmission limit their decision-making abilities regarding when to have sex, whether or not to use a condom or other contraceptive methods, whether or not to get pregnant, and whether or not to get tested for HIV or other STIs.
Deprived of rights to access basic needs such as healthcare, or a balanced diet, women are also particularly vulnerable to domestic violence, as their fragile socio-economic systems worsen. Furthermore, men and women face different challenges in living with HIV and AIDS, in access to health and support services, and with regard to stigma attached to the epidemic. Women have much less time and much less opportunity than men to access services.
Whilst laws do exist to prevent violation of women’s and children’s rights, their enforcement especially in Ngorongoro District is problematic. For example, whilst female genital mutilation and early FGM and ECM are illegal, pastoral communities still practise them in ceremonies involving long periods of preparations, huge numbers of girls, and traditional leaders and local community members. So HIV transmission through these routes continues.
To be effective, HIV and SRH services have to be accessible for all. Although public health facilities are free, such services are often underutilized and not available in all facilities. Other factors also affect SRH services, including demographic, economic, social and cultural dynamics, power relations and gender inequity, discrimination, sexual and domestic violence among others. For example, most public SRH programmes have focused uniquely on maternal and child health, but have left out other important populations including men, adolescents, and women who are not pregnant or mothers. These services have also focused more on the health facility level and have largely ignored other critical socio-cultural and economic barriers to accessing SRH information and services, such as women’s ability to buy condoms or negotiate their use.
Health providers, particularly those providing SRH and HIV services, have not been trained to interact with the community groups in a way that takes into account the traditional cultural taboos facing women and adolescent girls, people with disabilities and women heads of households - or the newer taboos of stigma and discrimination facing people living with HIV. Thus the education they provide is not tailored to meet their needs, realities and concerns.
For example, although the government of Tanzania is encouraging all women to have their babies at health facilities, in Ngorongoro almost 60% of births still occur at home with support from traditional birth attendants owing to long distances and other cultural, reasons and much work is needed to strengthen their skills and knowledge about how to protect everyone from HIV, while assisting women in home delivery. For instance, some birth attendants who are in high demand may have been diagnosed with HIV themselves, but are still having to conduct home deliveries without access to appropriate protective skills or equipment.
Meanwhile, most women, adolescent girls and young mothers have insufficient information on peri-natal transmission of HIV and safe motherhood. Only 38% of women with HIV who are on anti-retroviral treatment (ART) reported that their clinic discussed family planning with them. Available contraceptive prevalence data indicated a rate far below the national average. Women usually seek contraceptive advice from their husbands - who often know nothing and instead may mislead and prohibit its use. There is thus a great need to empower women to make informed choices about their SRH, giving them more autonomy and greater confidence to engage with structures and institutions that are critical to ensuring equitable access to services.
Much has been done to prevent and respond to SGBV issues within the district through key duty bearers, including police, judiciary, frontline health workers, police, members of human rights organizations, religious leaders, traditional leaders, media representatives, women councilors and local leaders. They have jointly developed a working group, work plan and terms of reference for their network. Yet much is still needed, to involve male community leaders to gain trust and motivate community members, including men who are the key perpetrators, strengthening the capacity of the SGBV district network members and increasing community awareness.
Reducing vulnerability to SGBV and HIV and mitigating their effect raises many challenges that require linkages with interventions on gender and livelihoods, while promoting integration of SRH services and HIV, to ensure universality of information and services.
This requires investment in the socio-economic development of women, men, children, household and communities at large. Decisions to invest in them should thus be taken by policy makers who are responsible for socio-economic development and not only by those responsible for health. The mainstreaming of SRH and HIV into development programming, centered specifically on the nomadic lifestyle and culture of these pastoralist communities, is critical in enhancing their access to human rights.
Due to stigma attached to adolescent sexuality, there have also been pockets of opposition to youth access to SRH information and services, for fear of promoting promiscuity. Yet I believe young people are the potential agents of change; they need better information for their SRH, and skills to embrace their own local culture and to change what hurts them (domestic violence, FGM, early and forced marriages). Much has been done which is stimulating great debate about cultural practices among youth groups. There is great need for supporting and engaging the young generation as agents for change, in particular by supporting school-based and out-of-school programmes on SRH, human rights, SGBV and HIV/AIDS.
In addressing cultural and gender barriers to accessing to SRH, it is of paramount importance to support training programmes such as Stepping Stones which uses a holistic rights-based approach. The training will work specifically with traditional structures and traditional leaders (both male and female), as well as with service providers. These include birth attendants, ngarimuratanyi who practise female genital mutilation, women and male elders, community volunteers, as well as health workers, youth workers and teachers, and ‘SGBV value chain actors’. This process will enable us to identify. Once sensitive social and cultural practices are identified, we can then develop a dialogue for action on which practices should be modified or changed in order to reduce vulnerability to HIV and other SRH issues; on how to change attitudes towards women’s rights; and ultimately on how to tackle the cultural barriers to accessing better tailored HIV services.
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