‘We go to where
The story of outreach in Tanzania
Tanzania is a country with a young and rapidly growing population. Over a quarter of the country’s 45 million people are women of reproductive age, and many of them would like to be planning their families.
They want to choose whether or when to have children, or control and space the size of their existing family – but lots of things stand in their way.
As a result the country’s fertility rate remains high with an average of 5.4 children born to each woman. The maternal mortality rate also far exceeds that of developed countries, with around 410 deaths per 100,000 live births.
Most Tanzanians live in rural areas, and for many the daily average wage is around $1.25 or less. Contraception is often unavailable - a scarce luxury that cannot be obtained or afforded. For others it’s simply not something they trust or even know about. This is where our outreach work comes in.
Outreach is one of Marie Stopes International’s most powerful and effective ways of reaching people in need of contraception. Not all women can reach our clinics, so we must meet them where they are. We take services to some of the most remote and under-served communities in the world, bringing choice to people who cannot come to us.
We know first-hand the tremendous positive effect outreach is having on the everyday lives of Tanzanians, and the country as a whole. But what actually happens on an outreach trip, and who are the women behind the statistics?
Here is the story of outreach in Tanzania.
There are many women who want to delay, space, or limit their pregnancies - and choose whether and when they have children - but lack the means to do so.
There are lots of reasons for this: the cost of contraception, the cost of transportation, geographic distance, lack of information, and misinformation about contraception, and the stigmas about women who use contraception. These all result in a woman’s unmet need.
In Tanzania the people the team meet who are most in need are young, poor women living in remote areas. They face many obstacles to accessing contraception.
What are the obstacles?
Marie Stopes Tanzania already operates 11 clinics throughout the country’s urban and peri-urban areas, serving a range of clients on middle to low incomes. However many rural women in Tanzania aren't able to make it to these clinics.
The majority of the Tanzanian population live in remote areas or under-served urban slums. Here clinics and hospitals are scarce, too expensive to reach, or often without skilled staff and equipment. At these state-run facilities some contraception like condoms and pills might be available but stocks frequently run out. Longer acting methods like IUDs may be unaffordable or rarely offered because staff aren't trained to fit them.
Like many developing countries where the demand for health services is incredibly high, the Government of Tanzania has to contend with many financial and logistical challenges. In this short clip, you'll see how client Mwema depends on reliable supplies, and what Marie Stopes Tanzania is doing to prevent stocks running low.
Practical issues such as stock outs are compounded by cultural ones. Sex education is often not given in schools or within the family, so knowledge about sexual health and contraception is lacking. Religious and cultural tradition can restrict women’s freedom when it comes to their sexual health. Social stigma, myths and misconceptions deter people from even asking about information and services – particularly young girls.
These barriers are dangerous for women’s health and can lead to high rates of unintended pregnancy, STDs, maternal complications, and in the worst cases unsafe abortion and death. This can be devastating for women, men, families and communities.
So what do you do when people can’t come to you? Just like Shida, a nurse from our Kahama outreach team says: you go to them.
Globally Marie Stopes International operates over 500 outreach teams, delivering contraception and other reproductive health services to more than 30,700 sites in 28 countries. We’ve been in Tanzania for over 25 years, and it is home to one of our most successful outreach programs.
The Kahama team featured in the video above reach people in a range of ways – travelling long distances cross-country and offering them free services. The minimum that they need from an outreach location is a room with light, running water, and enough space to section off waiting areas and private counselling rooms.
Outreach by 4x4
Like the majority of our outreach teams, the Kahama team uses 4x4 vehicles. This small team usually comprising one physician, two nurses, a driver and a government nurse, will drive to different public health facilities.
They go to public facilities as these already have status in the community, but often lack the trained providers, equipment or stock to provide a full range of services. Additionally, these facilities are permanent places that women can return to for any necessary follow-up care. On other trips, if public facilities are unavailable, the team may set up in a large inflatable outreach tent instead.
Like all of our outreach teams, the Kahama team make the most of their small number of staff by sharing tasks. Dr. Peter will support on counselling and infection prevention, as well as acting as the clinical lead. Zakayo, the driver, will help soothe clients with ‘Vocal Local’ - a pain relief technique - and take on administrative tasks.
Outreach teams are equipped to travel long distances across difficult terrain, and they plan their routes to try and ensure the shortest distance between different sites. Sometimes this involves setting up camp and staying overnight, which also helps them build trust and relationships with the surrounding community.
The team is typically out in the field for over 20 days a month, returning to their home base only to do documentation, re-stock supplies, and rest.
Marie Stopes Tanzania started doing outreach by Bajaji – a type of auto-rickshaw - in 2010. They had noticed there was a core of low income women living in urban areas that they weren’t reaching. Only a limited number of people in surrounding areas could get to the static clinics, and rural 4x4 outreach wasn’t suited to the urban areas these women were living in.
A Marie Stopes Bajaji
Auto-rickshaws are three-wheeled vehicles that look like a cross between a car and motorcycle, they’re small and so ideal for navigating busy neighbourhoods and dense traffic in urban and peri-urban areas.
‘Bajaj nurses’, midwives, or paramedics drive them between different public health facilities and youth centres pre-selected by the local government. They also go door to door, bringing long-acting reversible contraception, short term contraception, and other reproductive health services directly to people’s homes.
This is an important difference: lack of time to visit clinics, concerns about discretion and, in some contexts, cultural norms requiring women to be accompanied when traveling outside of the home, are all things that hold women back from seeking family planning services.
If they can receive treatment and counselling in the privacy of their home, then this immediately removes these hurdles.
This is something no parent should have to say, and yet it’s all too often the reality for the women our outreach teams meet – some of the poorest in the world.
Elizabeth lives with her husband and four children in a small rural village just outside of Kahama in the Mwanza district of Tanzania. Even in this tiny roadside village, with just a few houses scattered between the road and surrounding fields, there are many, many children. The residents have limited access to quality medical care and contraception, and midwives or trained birth attendants are rare.
Elizabeth and her husband are both farmers; they survive on very little money. They struggle to provide for themselves and the children they already have, so having another mouth to feed would be disastrous for them.
Also Elizabeth’s health suffers whenever she falls pregnant. With each pregnancy, her husband worries about what will happen to her.
What choice is available to Elizabeth and the many women like her?
The scale of the need in Tanzania
Unfortunately, the numbers speak for themselves…
• 7900 women die every year in pregnancy and childbirth.
• Maternal mortality rate averages 410 deaths per 100,000 live births.
• 25% of women of reproductive age have an unmet need for family planning.
• Total fertility rate averages 5.4 children born to each woman.
Contraceptive prevalence rate is the percentage of women, or women’s sexual partners, who are using contraception.The Government of Tanzania aims to more than double this rate, taking it from 27% in 2010 to 60% by the end of 2015.
Marie Stopes Tanzania is working closely with them to help achieve this goal, and they're seeing enormous change. However, much of their outreach work would not be possible without generous support from donors and partners of the international community.
It is vital that investment in reproductive health is prioritised on the world stage. Elizabeth managed to receive the help she needed, but there are many more women like her in Tanzania and beyond, that our teams are still yet to reach.
When Elizabeth met the Kahama outreach team she chose a method of contraception that best suited her needs, and can now avoid further unwanted pregnancies. But what steps will she have taken to get this treatment? And how might she have been feeling when meeting the team?
Putting people at ease
There are inherent challenges to spending so much time on the road and moving from place to place. How do you build a sense of trust with the community?
Preparations for an outreach visit go far beyond simply loading up the vehicle. The Kahama outreach team carefully plans locations weeks in advance, and builds strong relationships with community leaders, such as village chiefs or religious leaders, in order to be welcomed by the residents.
These people are well respected in the community and they use their position to raise awareness and acceptance of contraception, translate into the local language if needed, and promote our visits in the days leading up to them. In the case of religious leaders they also help show people that family planning can be compatible with their beliefs. They are key to helping the outreach team foster trust with people who are unfamiliar with them.
All our outreach teams are trained in a pain reducing technique called Vocal Local - and you can see the team using this technique with Elizabeth during her tubal ligation. During her procedure the Kahama team reduces her anxiety and pain by talking to her, comforting her and asking questions to distract her. Elizabeth had Vocal Local alongside a local anaesthetic, but for other procedures it can be used on its own as a highly effective method of pain relief.
Once they’ve completed their initial visit, teams like Kahama will continue to build on their relationships by returning to communities frequently – aiming to go back for follow-up visits every one to six months. The time left in between depends on factors such as demand and whether routes are accessible during rainy seasons, but the team always ensures clients have follow-up care arranged for things like contraception removal. The level of compassionate and high-quality care that the team demonstrates is what keeps communities welcoming them back, time and again.
The right medium for the right message
Sometimes, doing is better than telling.
The Kahama team aim to make a lasting impression on the women and men who come to their education sessions. They want to put people at ease, make them laugh, help them absorb information in memorable ways – all while mindful of their audiences and what approaches will suit them best.
They may choose to deliver these messages in a variety of ways, such as plays and skits, group discussions, and radio and SMS broadcasts. Often they’ll use anatomical models, or pull different types of contraception from their trusty blue Choice Kits and demonstrate how to use them.
Choice Kits contain real examples of different short and long acting contraception. People visiting education sessions can see what the different types of contraception look like, touch them and hold them, all while learning exactly what they do.
Myths and misconceptions about contraception are commonplace in Tanzania, with many believing it to be bad for your health, or something which leads to infertility and sexual promiscuity. The team may not change such opinions through one session alone, but by returning multiple times with lively and engaging sessions they can raise awareness and bust these myths.
Changing the life of one woman like Elizabeth has a positive ripple effect on the lives of her family and community. When we do this for thousands of women the cumulative impact can be staggering.
Types of contraception our clients chose
When women like Elizabeth are empowered to take control of their bodies, it has an immediate positive impact on her health, work and family life. But what happens when thousands of women have access to the tools to plan their families?
Marie Stopes Tanzania is achieving some phenomenal things through outreach. Between 2011 and 2014, with the help of investment from USAID and the Department for International Development (DfID), they scaled up their mobile outreach programme. More than half of the women they reached were not previously using contraception in the three months prior to visiting an outreach site.
The impact of this scale up alone helped:
• 600,000 clients to receive voluntary family planning services;
• 159,000 clients to take up voluntary counselling and testing, particularly important for those living with conditions such as HIV;
• avert an estimated 920,000 unintended pregnancies and 2,300 maternal deaths;
• over 400 government health staff to receive family planning training, including in long-acting reversible contraceptive methods;
• reduce reliance on short-term methods of contraception, with only 2% of clients opting to use condoms and 24% switching from a short-term to a more effective long-acting reversible method.
The overall outcome of this was that in 2014 over a quarter of Tanzanian clients received their method of contraception from Marie Stopes Tanzania. Also, between 2012 and 2014, Marie Stopes Tanzania increased the country's contraceptive prevalence rate by almost 2%.
The chart to the left shows the types of contraception our clients chose between 2011 and 2014. It’s encouraging because it shows that Marie Stopes Tanzania is filling the gap in demand for long acting contraception, and therefore widening choice for Tanzanian women.
We think long acting contraception carries many benefits for women who wish to delay having children until they’re ready, spend more time with their existing children, or just avoid having to travel frequently to reach health services. They have lower failure rates and are more reliable at preventing unwanted pregnancies, and the complications that sometimes arise from them.
The journey continues...
Outreach is having a phenomenal impact on Tanzania and other countries around the world, but it’s expensive and needs support from the international community.
At Marie Stopes International we’re looking into new and sustainable ways of getting women the contraception they want and need. Whether that’s using transport that’s cheaper to run, investigating new contraceptive products that will increase choice, or harnessing digital technology that makes it easier for women to access our services.
And as for the team in Kahama? Like all our other outreach teams across the globe, they’ll continue their journeys down those bumpy dirt roads and through lush green fields. They’ll continue meeting women like Elizabeth, helping them to plan their lives with dignity and respect.
Marie Stopes International would like to thank Marie Stopes Tanzania, the Kahama outreach team, and Elizabeth for helping us tell this story. Our special thanks also go to The William and Flora Hewlett Foundation for their funding of this story-telling project – helping us to share real stories of the people we work with in Tanzania and Cambodia.