“The visitor has great big eyes…”

Last week when talking with a member of Pathfinder’s Board of Directors, he cited the organization’s reliance on nationals, rather than expatriates, as one of its unique strengths. A Ghanaian and former Pathfinder Country Representative himself, he cited a Ghanaian proverb to illuminate his point: “The visitor may have great big eyes; he sees but does not comprehend. The visitor has great big ears; he hears but does not understand.” This proverb immediately resonated with me as a visitor to Ghana, but its true meaning and its relevance to Pathfinder’s work became evident throughout my week in the North.

My two Pathfinder colleagues, Moses who is the RH Program Manager for all the PI Ghana activities and John who is the Project Coordinator of the Comprehensive Abortion Care (CAC) Project, are both nurses, MPH degree holders, and former professors at a nursing college in the Upper East Region. They were raised, educated and began their professional life in the North of Ghana. Their vast knowledge and obvious passion for improving the health of women in the three Northern regions is invaluable in implementing Pathfinder’s work. Moreover, their cultural awareness and ability to fully connect with the nurse/midwives carrying out the work is undeniably the strongest aspect of Pathfinder’s CAC programming.

The last facility that we visited in the Upper West was plagued by many of the same challenges as the other facilities: staffing shortages, lack of proper equipment and materials, low knowledge of infection prevention, and poor recordkeeping. But, unlike the other facilities, the nurse/midwives we encountered at our last stop were clearly reluctant to accept the introduction of CAC at their facility. After a full day of tirelessly completing the facility assessment, Moses, John and I sat down with the midwives of the maternity ward to further discuss the project and get our last few questions answered. Although we sensed it earlier, they finally said it: “I won’t participate because of religious reasons.” Although it was actually a surprise to me that we only encountered this kind of reluctance toward the end of our week, I nonetheless had no idea what to say to the midwives expressing their concern. The facts and figures related to women’s health and the issues surrounding abortion are so vastly different in Ghana than in the United States, that any response I could give would surely be off the mark. Moses, without skipping a beat, began to further explain the CAC project, emphasizing that it is a comprehensive program aimed at saving women’s lives by working to prevent unintended pregnancies through family planning provisions, training midwives to provide treatment for the complications from unsafe abortion, and most of all providing a place where women and even girls can come to receive counseling when faced with an unintended pregnancy. Moses went on to say that the project is not intended to encourage elective abortions, and explained the provisions under Ghana Health Services that require facilities to provide comprehensive abortion care in an effort to decrease maternal mortality. John supported the nurses in saying, “We are all religious people.” He made it clear to them that their concerns were respected, but that judgments should not be made without fully understanding the work. Moreover, John emphasized that “everyone can do their part” to save a life; sometimes this takes shape through medical procedures, but most times it takes shape through informed and non-judgmental counseling of women who have nowhere else to turn for help. I could see the midwives beginning to see the larger context of the program and getting beyond their initial preconceived notions of what we were there to do. Since the program relies almost entirely on the full participation of the midwives, it was necessary to gauge the feelings of each midwife in the hospital. A meeting was set for the next morning.

It was amazing for me to see that every midwife, most of whom had the day off, showed up to discuss the program. Moses and John again went through each and every part of the program, emphasizing the important goals we hoped to achieve and the reasoning behind each of the five components of CAC. The midwives were concerned about the legality of abortion and many, in fact, were not aware of the law legalizing elective abortions performed by trained personnel at registered health facilities. They described the evident need in the community and the women they had seen coming to the hospital with complications of unsafe abortion. Now they rely on the doctor to treat these cases, often times leaving the woman to wait a long time to receive services. Led by Moses and John’s intuition, the conversation began to shift to a discussion of the materials and refurbishments that the facility needed to house the CAC program. The midwives, individually and as a group, better understood the program, their role, and the potential impact on their community.

I believe that this conversation could never have taken place with non-Ghanaian staff leading Pathfinder’s effort. The level of cultural understanding needed to navigate such a sensitive topic could not be matched by an expatriate, and without such an understanding the project would have been plagued with problems and confusion throughout. Pathfinder’s reliance on nationals is unique. Many US-based organizations support US citizens to facilitate their work abroad, but I am truly grateful that I’ve had the experience to work for an organization that values and supports local professionals to carry out its work. I have seen that this organizational choice allows greater access to the community and ultimately a deeper impact through its programs.