More than 800 women across the globe die each day from complications related to pregnancy. Some of them bleed to death. Some of them develop infections or severe life-long medical conditions because they are delivering their babies in unsafe environments.
Many of these deaths could be prevented if more young people had access to birth control and other reproductive health care. Pathfinder International is a nonprofit working with communities in 20 countries to make this a reality.
On the latest episode of The Dose, Pathfinder CEO Lois Quam, a member of the Commonwealth Fund’s board, recounts some of the stories she’s heard from young people around the world. Quam tells host Shanoor Seervai about the challenges they face in deciding whether and when to have children — and how their lives change when they are able to make this choice.
Guest: Lois Quam
Illustration by Rose Wong.
LOIS QUAM: There was one really interesting nurse who said, “You know, this woman came to me, this young woman who wasn’t married came to me and asked for family planning. And I said no, because I didn’t think she should be needing it. And the next time I saw her, she was heavily pregnant, and she died as a result of that pregnancy.” And this nurse said, “You know, it was my decision that led to that.”
SHANOOR SEERVAI: Hi everyone. Welcome to The Dose. You just heard from Lois Quam, who heads Pathfinder International, an organization committed to expanding access to reproductive health care across the globe. Today Lois is going to talk about what happens when young people don’t have access to birth control, what it means for their health and their lives, and how Pathfinder is working with local communities to change that.
Lois, welcome to the show.
LOIS QUAM: Well, thank you so much. I’m delighted to be with you today.
SHANOOR SEERVAI: Let’s get started by really digging into what the problem is. What happens when young people don’t have access to reproductive health care and birth control?
LOIS QUAM: Well, let me give you two statistics to start out. There are 1.8 billion young people in the world today. This is a huge number of young people, the most at any time in the history of the world, of course. And, of course, they bring so much talent and creativity to help us solve all the challenges we have in front of us. The second statistic I’d give you, which points at part of the challenge is: Today, across the world, 45 percent of all pregnancies are unintended.
SHANOOR SEERVAI: That’s almost half.
LOIS QUAM: Yeah. Yeah. And women who have said that they’d like to use contraception but don’t have access to it account for over 80 percent of those pregnancies. And by some estimates, if every woman and every girl who wanted to have contraception was able to have contraception at that time, that number would go from 45 percent to well under 10 percent in terms of unintended pregnancy.
And so let’s think about what that means in the life of one girl in this 1.8 billion people, she’s young, smart, energetic. She is 12, 13 years old. She is going to school, she’s learning, she’s getting ideas about her future. Maybe she will be a doctor, maybe she’ll do something else. And she goes through puberty, kind of understands what that means. Has challenges getting menstrual supplies but keeps going to school. Very motivated. And then she, she meets a young boy that she likes quite a bit and they’re about 15 years old now and, you know, they start seeing each other and she’s pregnant and she has to set aside all those dreams. She has challenges. The family’s not too happy about it. She and the young man get married, they don’t really have the resources to set up a household very effectively.
She drops out of school. She has a very tough time giving birth because she, you know, just isn’t fully developed as a woman. So she has a very tough time delivering the child and has some lifelong injuries that result from that. And there she is. There she is, you know, somebody that we need to come up with the creative solutions to the world’s challenges, you know, is now struggling at home with one child, some lifelong disability and, you know, just trying to put food on the table. And that happens every day over and over and over again. And it doesn’t need to.
SHANOOR SEERVAI: I mean there’s so much in the scenario you just described. Let’s start with this idea of a woman, women, young girls entering puberty, but not really knowing that much about what’s going on. I imagine that in many of the parts of the world where you work, young people don’t really have access to sex education the way that young people in the U.S. may have.
LOIS QUAM: Well, you know, this is a global problem. It is a problem in the U.S. as well. At Pathfinder we focus globally. So that’s where all focus. But yeah, it’s a challenge. It’s a challenge in a lot of places. Young people don’t get good education about how to avoid pregnancy. Even at times, how you become pregnant. I had a young woman say to me, you know, I really didn’t realize that this was a result of having sex and she said after I had two kids, nine months apart I did, but one of the babies died and, you know, it was just a huge, huge thing. So, you know, none of this needs to happen because we know how to provide this education and there are lots of different kinds of contraception and so the opportunity for a young person to have this understanding, to be able to decide that they want to use contraception and then pick a form of contraception that works well for them, that exists.
SHANOOR SEERVAI: Right. Now, obviously, a baby dying is a terrible health consequence. It’s terrible for the mother to have to experience something like this, the emotional trauma. But what are some of the other life-threatening medical conditions that women can face if they’re having unplanned pregnancies at a young age? You know, a 15-to-16-year-old girl has gone through puberty, but her body certainly isn’t fully developed.
LOIS QUAM: Yeah, yeah. Well, you know, about a thousand women die every day as a result of their pregnancy. They die in labor and delivery principally and most of the women who die, you know, they bleed to death and those deaths are very preventable, and younger women are at a greater risk. Women who have children close together are at greater risk. Women who have poor nutrition, so they’re iron deficient or have other risks are more at risk. Women who have other conditions like malaria or who are HIV-positive are more at risk. The other thing, I was in Ethiopia recently and we’ve worked in Ethiopia for over 50 years. We set up the first family planning clinic in Ethiopia. I’ve seen the picture; it’s a little house on a dirt plain. And my colleague, our country director, Dr. Mengistu Asnake, and I visited the very famous Fistula Hospital in Ethiopia.
And the young women there, you know, have severely disabling lifelong conditions because they weren’t able to deliver their babies without pushing so long that sometimes the baby, the babies died inside them. Sometimes they push so long that it just injured them in really serious ways. And of course, younger women are so much more at risk for that because their bodies just aren’t ready to deliver the baby even though they have a pregnancy. And many, many women deliver around the world still only with someone at their side whose experience is having a baby themselves. They have no training. So if something happens where it’s a challenge, it’s a big challenge fast. And you know, if women are able to decide that they want to use contraception and then make a choice with the method of family planning they want, these things can be prevented.
SHANOOR SEERVAI: Right. There’s no need for women to go through this terrible experience. It should be a joyful experience giving birth to a child.
LOIS QUAM: Yeah. Yeah. You know, what should be the happiest day in a woman’s life is actually the most dangerous day in her life: the day she gives birth.
SHANOOR SEERVAI: So we sort of have a sense of what the problem is and the magnitude. Some of the things you’ve said: a thousand women dying every day giving birth is just is just shocking. But as we start to think about what some of the solutions are, how the communities you work with are trying to innovate out of these problems, I wonder if you have any examples of people you’ve met who are doing this sort of work?
LOIS QUAM: So in Niger I went to a city called Zinder, which is just north of the border with Nigeria. And then we drove outside Zinder to some rural villages and we drove over a kind of sand road to get there. And in one of the villages I met a couple as that were a part of a group of young married couples who have met with Pathfinder peer educators who come from that village. And one couple was named Adama and Mamadou. And Mamadou shared with us that his parents had sent him to be married when he was a really a child — he was 15 — to another child: Adama was also 15. And he said his parents could no longer support him, provide him with food and lodging. And in their society, if someone’s married, then they’re no longer required to support the child.
So this couple was married very young, and they had their first child about nine months later. They’re a bright, sparkling energetic couple, Adama and Mamadou. And yet hadn’t had any of the training or education or knowledge that would help them, you know, make a decision whether they wanted to have a child immediately upon their marriage. And when I was with them, Adama was holding this beautiful baby, and the light that shown in both of their eyes as they shared that based on this work that my Pathfinder colleagues in Niger are doing, that they now knew that they could decide when they wanted to welcome their second child because they knew a lot of people who had welcomed their second child in the year, 10 months, 11 months, 12 months after the birth of the first child.
And you know, to be a 16-year-old with two small children is pretty difficult. So the sort of sparkle in their eye when they said that they could decide when to welcome their second child and that they also had received some training to understand what the impact of pregnancy is and the advantages of spacing a pregnancy a couple years apart. So that a woman has a chance to really recover from the first pregnancy. And part of what I liked about that was Mamadou explained that to me. Adama’s husband explained that to me. But I think that, you know, the kind of cool thing was we asked them, “What was the biggest thing you learned, getting to be part of this program?” And Mamadou said, “Well, we learned how to have difficult conversations about important things.” That was kind of thrilling to me because, you know, that’s what it’s about is, you know, how to have a conversation about when do you want to welcome your second child? And to have in that to be able to talk about the challenges of taking care of the baby and the challenges of pregnancy on a woman. And so it was really exciting and they’ve really stayed with me as I do my day-to-day work here at Pathfinder.
SHANOOR SEERVAI: I love that, the idea of learning to have difficult conversations, because that’s so much a part of married life, but also every aspect of a person’s life. And if you can bring that reflection and that capacity to this huge decision about when to have children, when to welcome your second child into the world, you can bring that capacity to other facets of your life.
LOIS QUAM: Yeah, absolutely. Because then they talked and, and I met with, I had a later meeting that same day that Mamadou was a part of with young husbands. And they talked about their understanding now of what their wives face in their life. You know, that a pregnancy, especially in a very young woman, is often pretty hard, and labor and delivery around giving birth to a child when you’re 15 or 16, it can often be very difficult. And that particularly in a setting where the supply of food isn’t great day to day and the ability to have a balanced, nutritious diet isn’t great. And this is an area that is really on the forefront. It’s in the Sahale. It is on the forefront of the changing weather patterns that directly affect food that women can, you know, can really suffer anemia, shortage of iron, or other kinds of deficiencies.
And for a husband to be able to understand that and then to say, “You know, I now know I need to help her more so that she can get some extra rest.” Because oftentimes in this kind of setting, women can be the last to eat, a mother can be the last to eat or her husband will eat first. Her children will eat first, the elders will eat first. And so, but for the husbands to say, “Wow, I didn’t really appreciate this. This wasn’t anything that my father shared with me or anything.” But you know, the kind of compassion that they had for their wives and the care that they had for their wives. And you know, these are really bright, capable people and like all of us, when that kind of capability is married with knowledge, it can really lead to some very different outcomes.
When we work with young couples who are 15, 16, the people working with them are young couples who are like 20, 21, who have been identified as leaders, who’ve been trained in these areas. So that they’re working with people who identify with them. They’re a little bit older, a little bit wiser, you know, they’ve had more training, more life experience. They can understand each other. So that’s the model. Very community-based.
SHANOOR SEERVAI: Right. You’re hearing from people who are essentially your peers, slightly older, not from somebody who’s a significantly different age group from a different country, have a different culture.
LOIS QUAM: Right, right. You know, at Pathfinder we’re very community-focused. Our colleagues who work in Zender or Niamey or any place else in the world understand the local culture. They understand the history, they understand the language because it’s their culture. It’s their history, it’s their language.
SHANOOR SEERVAI: Being able to decide when to have children. Being able to have access to birth control also has huge benefits when it comes to economy’s innovation. Obviously for an individual woman and individual couple, having that agency over their lives, being able to work towards their dreams, is incredible. But countries and the globe has something to benefit from that as well.
LOIS QUAM: Well, you know, absolutely. We’ve got a lot of challenges in the world. Some of them are age-old challenges and some of them are really kind of new. You know, the way the weather’s changing is really very striking. And the talent and energy amongst young people globally and the kind of untapped potential of women everywhere is really vital to our coming up with the kind of innovation, the kind of creativity that we need to solve some of these challenges, to make some of the changes that are required for us all. And for women to be able to have that kind of voice, be able to have to participate in decision-making, be able to come up with new ideas. You know, women need support and access to family planning services. There’s just no question about that.
I guess the other thing I would say, what we’ve seen in many places where we work, is that if it is conveyed to women that they’re important because they’ve had an opportunity to be educated, they have had the kind of conversations that really do offer them the opportunity to birth control. And in that context make it powerfully clear that they have a lot of value to their family, their community, beyond their fertility. Women then step up and are much more likely to give voice and to have the skills to make their point heard, or to present kind of something new or novel that they’re doing, to others.
SHANOOR SEERVAI: I wonder how you are navigating some of the culturally complex situations that Pathfinder must find itself in. How you balance the tension between bringing these ideas about innovation, empowerment for women with cultures that are, you know, at different points along the spectrum of accepting these ideas.
LOIS QUAM: We’re really delighted we have a very strong program in Pakistan. Our leader there, Dr. Tabinda Sarosh, leads a team of colleagues in Pakistan, and one of the areas that we’re working on there is to work with health care providers to help them think about the way they approach their work. Because one challenge that can occur is that a health care provider, let’s say a nurse in Pakistan or frankly anywhere else, but we’re doing this, it was key to our work in Pakistan. When a young person comes in and says they’d like contraception, if that young person is not married and you know, they can come, they can show up with a lot of bias, a nurse can say, well, you shouldn’t be needing this. I don’t want to give this to you because I don’t think you should be needing this. And if I’m giving to you, I’m supporting you.
Or a young woman who’s married can show up and they could say, you shouldn’t be needing this because you need to demonstrate to your husband and his family that you can have a child. And if you don’t do that, you’re not going to be in a good position. Your husband could leave you. So I’m looking out for your best interest. So I’m not gonna. Or an older woman who’s had a many children and doesn’t feel very well and doesn’t want to have another child may come in and she may say, I just don’t think it’s right to for you to limit the number of children you have. So we work, it’s really interesting, we work with those medical providers, including nurses, to help them empathize with the women who are coming in to see them and help them, you know, put themselves in their shoes more, help them see the world from another’s eyes and help them really talk about the challenges that the women who are coming to them to them face.
And what you see, and we also try to understand kind of where that nurse or other medical provider is coming from. Sometimes it’s what her, his, or her own experience has been in their lives. Sometimes it’s a particular point of view, religious or philosophical. Sometimes they’re super rushed and they’re completely worn out and they don’t have time, and they’re feeling unnerved by their work.
And you know, there was one really interesting nurse who said, “This woman came to me, this young woman who wasn’t married came to me and asked for family planning. And I said no, because I didn’t think she should be needing it. And the next time I saw her, she was heavily pregnant, and she died as a result of that pregnancy.” And this nurse said, “You know, that was kind of my decision that led to that.” And so I think what I love about this work, again, is it’s very community-focused. It isn’t coming in and saying to the nurse, “Hey, you know, you’re wrong. You’re wrong, wrong, wrong.” It’s understanding that nurse and it’s helping that nurse understand others, and through that leading to greater openness, greater respect for the concerns that women are bringing in, and real change. So that’s kind of painstaking community-based work and that’s what we do in Pakistan and at Pathfinder.
SHANOOR SEERVAI: Well, this is a sobering story to end on but it’s also important to know that there is hope. I just want to thank you for sharing your work and also the stories of these incredibly inspiring young people that you and Pathfinder work with.
LOIS QUAM: Well, thank you. It’s been a delight. There is so much hope. All these young women and men I think have within them the ideas and the energy to help move the world forward for all of us. So let’s give them the tools they need so they can do that.
Editor’s note: Lois Quam is a member of the board of directors of the Commonwealth Fund.