O

UAGADOUGOU, Burkina Faso It was after dark when awoman and her husband arrived. They crossed the dirt road and entered the cement buildingin a western neighborhood ofthis sprawling West African capital.

He had a demand: Remove the metal rodsyouve put in my wifes arm.Hed heard rumors that the strange technological device was going to give her cancer, and itneeded to go.

The nurse on duty at the health clinic, Bernadette Nassa, was insistent. She explained that the tiny rods were there for a reason: They provided the womansbody with a hormone to keep her from having children. She needed to give her body rest before becoming pregnant again.Eventually, the husband relented.

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But, Nassa said, theres not always ahappyending. Shes seen womenwhose husbands insist on a divorce if their wife usescontraception.

Such encountersunderscore the difficultyof providingcontraceptive services and womenshealth care inOuagadougou and in other developing countries where reproductivehealth education is limited and husbands make many decisions for their wives.

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But since May, the clinic hashad a new partner: Pathfinder International, a nonprofit geared towardincreasing global access to reproductive health services. And soon many more clinics could receive their help. Pathfinder last month received a $10 million grant from theBill and Melinda Gates Foundation, based in part on the work theyve done in Burkina Faso, to study how tohelp women get access to contraception.

For instance,Nassas clinic is one of 84 in Burkina Faso that have received the tools to insert an intrauterine device, or IUD, from Pathfinder, according toDr. Bruno Ki, the organizations technical director in the country. Before that, theclinic didnt even have the basic specula and tongs used in gynecological exams. Since May, Nassaestimates, theclinic has performed 30 or 40 IUD insertions a month, and the devices remaineffective for up to 12 years.

Each morning, a hundred women crowd into Nassas small waiting room and spill out into the courtyard; she and her staff, just under a dozen, cant take care of all of them. Her cement clinic only has four rooms for patients, so one doubles as a birthing suite and a family planning consultation room.

Demand for the clinics services has soared since the government started subsidizing health care for new mothers and young children in April. Now, health care is free for womenfor six weeks after they give birth.

That makes for a crucial juncture for Nassa to intervene. Back-to-back births carry higher risks for both mother and baby, and non-hormonal methods of contraception, including IUDs, are safe to use while the woman is still breastfeeding.

If she comes in with her child, we can use that opportunity to chat with her about contraceptive methods before she gets pregnant again, Nassa said through a translator. She tells the women about all kinds of contraceptive methods, including IUDs.

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Pathfinder is also funding improvements at other health clinics around the city. It is building a cement incinerator for medical waste at a health clinic in Bangpoor, a poor neighborhood by the railroad tracks to Abidjan, where the current incinerator was nothing more than a brick fire pit in which a stack of papers smoldered next to a jumble of aluminum and a can of insecticide that had not yet exploded.

Meanwhile, the organization is working at a national level to change the countrys laws on abortion.

Abortion law is very restrictive in Burkina Faso, Ki said. In 2012, we [had] more than 105,000 unsafe abortions in Burkina Faso.

Currently, abortions are only legal if ordered by a judge, and only in four cases: rape, incest, if the mothers health is at risk, or if there is a high probability the child will be born with an incurable congenital disorder.

As a result, many women try to induce an abortion, with horrifying results. Ki has heard stories about women who stuck bleach pills into their vagina or drank soup laced with ground glass.

If the new statute is adopted, women would be able to receive an abortion if their mental health or social well-being is at risk. The legislature was supposed to vote on the changes in October, but never did, Ki said, and hes not sure when they will pick it up in the future.

If those at Pathfinder want their work to have a lasting impact, they know that it will have to involve changing the attitudes of husbands and mothers-in-law, who often exercise a lot of control over a womans choices.

A few years ago, Pathfinder completed a project where it educated mothers-in-law about the importance of contraception, convincing them to accompany their daughters-in-law to the health clinic. Ki said the project was successful: Pathfinder worked with local nongovernmental organizations to talk with hundreds of mothers-in-law, some of whom later accompanied their daughters-in-law to receive contraception.

And Nassa acknowledged that one of the reasons so many husbands abhor contraception is that their ideas are based on rumors; they rarely learn how implants, IUDs, or injections actually work.

And that can lead to confrontations like the one Nassa experienced with the angry husband last month.

Here in Africa, especially in Burkina Faso, a woman cannot take a decision by herself, she said through a translator. It is the men that decide.

Kate Sheridan contributed reporting.

Ike Swetlitz can be reached at ike.swetlitz@statnews.com Follow Ike on Twitter @ikeswetlitz

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In West Africa, clinics confront suspicion, and husbands, one IUD at a time - STAT

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