Reproductive Health and the Women of Lesotho: The Challenges

ABSTRACT


INTRODUCTION
Reproductive health refers to complete physical, mental and social well-being in all matters relating to the reproductive system, its functions and processes (DFID, 2004). This includes the ability to have satisfying and safe sexual relationships, access to safe and effective contraception, the ability to conceive and carry a pregnancy to term, and access to appropriate healthcare services to prevent and treat reproductive disorders and diseases. Reproductive health also encompasses the right to make informed decisions about one's own reproductive life, free from discrimination, coercion, and violence. It is a fundamental human right and essential to overall health and well-being (Gable, 2010). Lesotho faces numerous challenges when it comes to female reproductive health. The country has one of the highest maternal mortality rates in the world, with an estimated 618 deaths per 100,000 live births (Unicef, 2017). In addition, teenage pregnancy is a major concern, with over 22% of girls aged 15-19 having already given birth or being pregnant (Lesotho Multiple Indicator Cluster Survey, 2018). One of the contributing factors to these issues is the lack of access to reproductive health services and education, particularly in rural areas. Cultural and societal barriers also prevent women from seeking and receiving the care they need. Poverty and gender inequality are major factors that exacerbate these problems, making it difficult for women to access the necessary resources and support to maintain their reproductive health (UNFPA, 2022). More effort must be made to address these challenges through various initiatives, including increasing access to family planning services and education, improving maternal health services, and advocating for women's rights and empowerment.

Theoretical Framework
The theory relevant to frame study on reproductive health communication is framing, therefore the framing theory informs this study. The theory of framing was established by Gregory Bateson in 1972, writes Arowolo (2017). Framing refers to how the media can attract and influence how people make choices on certain issues because of how the media presents/frames the issues. Frames are abstractions that work to organize or structure message meaning (Arowolo, 2017). Considering the levels of the inadequacy of sharing and exchanges of reproductive health communication in Lesotho, framing theory is ideal for stakeholders to effectively reach out to vulnerable communities.

LITERATURE REVIEW
Several organizations have worked on educating women in Lesotho about reproductive health. Here are some examples:

Lesotho Planned Parenthood Association (LPPA)
LPPA is a non-governmental organization that provides reproductive health education and services, including family planning, HIV/AIDS testing and counseling, and maternal health services (LPPA, 2015).

UNFPA Lesotho
The United Nations Population Fund has been working with the Lesotho government and other partners to improve access to reproductive health services and education, particularly in rural areas (UNFPA, 2022). Marie Stopes Lesotho: This organization provides a range of reproductive health services, including family planning, maternal health care, and HIV/AIDS testing and counselling (Marie Stopes International, 2018). World Vision Lesotho: This organization has been working to improve maternal and child health in Lesotho, including providing education on reproductive health and family planning (World Vision, nd).

Women's Health Foundation Lesotho
This organization focuses on promoting women's health and empowerment in Lesotho, including providing reproductive health education and services. There are several challenges with women's reproductive health in Lesotho, including: Limited Access to Reproductive Health Services Many women in Lesotho, particularly those living in rural areas, do not have access to adequate reproductive health services, including family planning, antenatal care, and skilled delivery care. In addition to the inadequate health provision facilities is lack of preparedness, ill treatment by nurse-midwives, staff and supply shortages at health centres, and a generally negative perception of health service provision in the country by those seeking services by the health service providers (Unicef, 2017).

High Rates of Maternal Mortality
Lesotho has one of the highest rates of maternal mortality in the world, with an estimated 618 deaths per 100,000 live births (Unicef, 2017). This is partly due to the lack of access to skilled delivery care and emergency obstetric care.

Teenage Pregnancy
Teenage pregnancy is a significant issue in Lesotho, with over 22% of girls aged 15-19 having already given birth or being pregnant. This can lead to a range of health and social problems for both the mother and child (Molupe, 2020).

Cultural and Societal Barriers
Cultural and societal barriers prevent women from seeking and receiving reproductive health services and education, particularly around issues such as family planning and sexuality (Shale, 2015).

Poverty and Gender Inequality
Poverty and gender inequality are major factors that exacerbate reproductive health challenges in Lesotho (Gender andDevelopment Policy 2018-2030). Women living in poverty are less likely to have access to reproductive health services and education and may face additional challenges related to gender-based violence and discrimination (Shale, 2015). Addressing these challenges requires a multifaceted approach that includes improving access to reproductive health services and education, addressing cultural and societal barriers, and addressing poverty and gender inequality. Many countries in Africa have experienced challenges related to women's reproductive health in the past. Here are some examples of countries that have faced these challenges and some of the strategies that have been used to address them:

Ethiopia
Ethiopia has significantly improved maternal and reproductive health outcomes over the past two decades. Some of the strategies that have been used include increasing access to family planning services, improving the quality of maternal and child health services, and training more health workers (DeMaria, Smith, Berhame, 2022, andAkwara, Worknesh, Oljiru, Mengesha, Asnake, Sisay, Demerwe, Plesons, Shirka, Hadush &Chandra-Mouli, 2022).

Ghana
Ghana has implemented several initiatives to improve reproductive health outcomes, including increasing access to family planning services and improving the quality of maternal and child health services (Hesse & Samba, 2006). Additionally, community-based approaches have been used to increase awareness and education around reproductive health issues (Adongo, Tapsoba, Phillips, Tabong, Stone, Kuffour, Esantsi & Akweongo, 2013).

Kenya
Kenya has implemented various policies and programs to improve reproductive health outcomes, including increasing access to family planning services and providing comprehensive sexuality education in schools (TNS, 2016). Additionally, the government has worked to improve the quality of maternal and child health services and to reduce maternal mortality rates (Ministry of Health, 2022).

Rwanda
Rwanda has significantly improved reproductive health outcomes over the past two decades. Strategies used include increasing access to family planning services, improving the quality of maternal and child health services, and increasing the number of skilled health workers (Abbott, Rwirahinga, Mugisha, Mutesi, Tuyishime & Vuningoma, 2014).

Uganda
Uganda has implemented a range of initiatives to improve reproductive health outcomes, including increasing access to family planning services and improving the quality of maternal and child health services (Tazinya, Hajjar, & Yaya, 2022). Additionally, community-based approaches have been used to increase awareness and education around reproductive health issues (Sarkar, Chandra-Mouli, Jain, Behera, Mishra & Mehra, 2015). These are just a few examples of countries that have faced reproductive health challenges in the past and some of the strategies that have been used to address them. While each country faces unique challenges, there are many common approaches that can be used to improve reproductive health outcomes, including increasing access to services, improving the quality of care, and addressing cultural and societal barriers. Lesotho can learn from the success stories of other African countries in addressing reproductive health challenges by examining the approaches and strategies used, and identifying those most applicable to the country's specific context.

Statement of Problem
Free education or discussion of sexual matters is taboo in Lesotho, as is the case with most African societies. Parents rarely open to discuss serious issues of reproductive health matters with their own children. In school, it is also a matter that is not prioritized in curriculum. This therefore young people to discover reproductive health business on their own or with the assistance of their equally limited peers on the subject matter. This leaves the young people even more vulnerable because for rural communities, professional guidance and education by health delivery specialists is scant. Therefore, there is need for health communicators to reach out to all members of Lesotho society to educate them broadly on reproductive health.

METHODOLOGY
The study interviewed young and old women from the cross section of Lesotho society. The interviewees were randomly selected, a method usually chosen by researchers to generalize about the larger population (Horton, 2022). The aim of random sampling is straightforward; that is, to aid the researchers in avoiding the unconscious bias that could manifest itself in the data they collect. With this study, we did not aim to collect specialist knowledge but to qualitatively glean information from women disadvantaged by reproductive health services in Lesotho. Women's reallife experiences were what the study sought to establish in order to come up with information on how best to solve the reproductive health challenges in the country. The simple random sampling technique was employed to give individuals an equal opportunity to participate in the study without giving special attention to special groups (Noor, Tajik & Golzar, 2022).

Findings Respondent 1
Reproductive Health is a right to access health services, other social services, and personal safety in our communities, particularly for young people. In marriages, especially women who are chasing their careers, are the ones who have a say on when to have children. Outside marriages they don't have say because the child was not planned. Men determines on the number of children to have with their wives. In rural areas it is not easy to be pregnant because hospital services are far away from home. In rural areas, they give birth on their way to the hospital due to lack of transportation. Also, they receive poor services in Government hospitals, they tend to attend patients when they want to. In the rural areas they get information from clinics and hospitals for those who are pregnant when they go for check ups. In urban areas there are small tents from different NGOs that give out pamphlets regarding such matters. Teenagers from disadvantaged homes tend to drop out of school due to lack of funds. Others do not receive much attention from their parents or guardians therefore they look for attention elsewhere. In most cases teenagers do not have enough information regarding safe sex because parents do not step in to educate their children about such matters. Therefore, they are not safe because they are not well informed about matters of safe sex and how they can approach them. Abortion is not legalized therefore they go to places that are not safe for such procedure. Young women tend to fall pregnant in the age between 18 to 24. The consequences are that they become single parents at a very young age. Also, it affects their studies since some of them drop out of school to parent their children.

Respondent 2
Reproductive health is a condition of male and female reproductive system made of organs during life stages. In Lesotho, it is not just reproductive health, it is sexual reproductive health and rights and there is a progress in delivering its services though there are still gaps to be addressed. Back then, Lesotho women had no say in matters of having children in marriages because they knew that being married, it was necessary to have children and expand the family or keep and carry the family name forward. However, they knew having children outside marriages was a disgrace to them and their families. Nowadays, women have a say in matters of having children because they do family planning and use contraceptives to prevent themselves from unwanted pregnancies. In marriages, mostly, the husband and the in-laws are the ones who determine on the number of children a couple should have, but it is different in today's time because most couples live on their own and decide on the number of children and when to have them. It is both safe and unsafe to be pregnant in Lesotho. It's safe because it is no longer like before when pregnant women would be assisted by other women who had no professional experience in delivering a baby, however, young people still face challenges in accessing sexual reproductive health services, there is limited access to maternal care and low proportions of skilled health workers during delivery. Pregnant women give birth prematurely because they go under a lot stress, lack of support and face physical and emotional abuse from their partners. Other women especially teenagers do unsafe abortions which endangers their lives and there is a lack of maternal care in Lesotho. We get information from different organizations such as UNICEF, Ministry of Social Development, World Vision, LPPA, new start, health centers and on the internet. Teenage girls lack knowledge and information about sexual and reproductive health and rights, there is an inadequate access to health services to young people, poverty, there is sexual violence, lack of education or school drop-out and early child marriages or family social pressure to marry. Young girls are not safe against unwanted sex because it leads to unplanned pregnancies, early child or forced marriages, HIV or Sexually Transmitted Infections. As for unwanted pregnancies, young girls and women are in danger because they are either stuck with pregnancy as abortion is not legalized in Lesotho or they undergo unsafe abortion which puts their lives at risk. Normally, women have children starting from their teen age, which is from 15 years. Young girls and boys watch J. Innov. Res. 1(2) 1-6, 2023 a lot of Television, watch pornography on the internet which exposes them to nudity, and they tend to copy. This leads to unwanted pregnancies, unsafe abortions, children abandoned, depression, suicide and early marriages.

Respondent 3
Reproductive health in Lesotho simply means that both genders having healthy reproductive system and being able to provide the family with children or rather increase the bloodline of the family, and its a taboo for a new family to be unable to reproduce even though we have other means to increase the lineage like adoption or going to In Vitro Fertilisation. In rural areas I believe they hold the norms and culture of Basotho dearly, hence having children may depend on family say the family wants three children, the son will obey the elders and give his parents 3 grandchildren, so in rural areas women do not really express their feelings, their opinions are not considered, so they are very limited in decision making. In urban areas women are more expressive and vocal, they express themselves openly and stand by what they believe, so having children is solely their decisions with their spouse. Having children outside marriage is a sin and big embarrassment to the family's reputation, they say Lesotho is a Christian country that alone says that you have to behave in a certain way and carry yourself in a certain way as a woman, so having a child outside marriage is still a bit of a taboo and I also think it depends on geography. Back in the days it was the mother-in-law or the family or the head of the house that determines that, but now with high inflation and high cost of living it is men who take that decision because I believe they look at their financial strength. The limited resources we encounter at the public hospitals, low economy, high unemployment rate, these are the factors that I believe pregnant women face everyday, because pregnant women have a big appetite if you are not employed where will you get money to buy things you want? If you cannot afford to have a medical aid for a private hospital it means you are at risk as a woman, ironically it is not safe on certain extent to give birth in Lesotho and safe and the same time, so it is a probability of 1:1/ 1:2. Having a doctor online ready for you, or it could be giving birth in safe and clean environment, having the right medications and treatment after birth and being wrongfully diagnosed. Information on safe sex and safe pregnancy we get from NGOs that deal with health issues and targeting women's health, NGOs like SHE HIVE, PEPFAR and DREAMS are the ones that assist in giving us timely information about reproductive health and always ready to inform us about new products, other disease outbreak to be aware of. As for safe delivery I have not heard clear information about it from the professional person, only social media where people post about their experiences during delivery, Facebook always delivers when it comes to that, new moms post a lot about their journey. Teenagers are influenced by Western movies, social media and peer pressure and poor education about reproductive health. In Lesotho your mother can never ever sit with you down and educate you on what will happen when you do certain things, they won't be straight with you, all they do is make irritated stories which do not explain reproductive health in detail so it's a taboo again for parents to talk to children about reproductive health; so they take whatever they watch on TV, what their friends tell them and believe to be true, which lead them to fall pregnant at a young age. I remember telling my mother the first time I experienced menstruation, all she was " take care of yourself " nothing more nothing less, and I didn't ask questions of what she meant, it's only now that we slowly talk about reproductive health related matters, and she is being straightforward now. So, I wish parents could attend seminars where they could be trained on how to approach their child, calmly talk to them, and take them through all the stages of reproductive health without filtering. Young people are not safe because men are afraid to seek professional help, and girls and women sometimes do not want to hurt the ego of their spouses hence they sometimes allow them to do what they want which leads to unwanted pregnancy and opt to having illegal unsafe abortions. I think most women in Lesotho fall pregnant between the ages of 23 to maybe 35, because most of them get married at that time, they are more responsible and get the idea of having a child and can work and support the family. the consequences are slightly good when you are married because you can get all the help you need. It is bad when one has a child before marriage, you lose all your support and friends as they now concentrate on other things, and the depression of seeing your agemates progress in life makes it worse.

Respondent 4
From my perspective, society understands that we need to bear children since God gave us the opportunity. With couples, if the marriage is boring, and the intimacy does not happen frequently, women end up having relationships outside family and make kids. Women determine when to make kids because they use contraception without the knowledge of the husband. I can say that 70% of women in Lesotho give birth at home because other women believe in home delivery, which puts lives at risk, and we can lose both the mother and the baby. Others do not attend the clinic for regular check up and take medication in time, to have a healthy-looking baby. Carrying heavy weights for long distances, in Lesotho, especially in remote areas is a hazard for pregnant women. For example, for them to get water, they must travel long distances even for delivery they have to travel to a nearby health facility or delivery on the way, and that can make the child contract different diseases. We access reproductive health information from YouTube, google and other online platforms. Children are not taught reproductive health at school or at home the importance of using contraceptives. Children are indulging in sex at an early age because of the influence of high use of alcohol and drugs. Random pornographic material appearing on their phones does not show the use of condoms, so they assume that is the right way to have sex.
I can say 40% of teens are sexually active because they get involved while under the influence of alcohol, and 80% of pregnancies are unwanted because it is all about irresponsibility since condoms are all over and the clinic contraceptives are free. Girls aged between 16-18 fall pregnant due to lack of knowledge especially in remote areas. They end up dropping out school. Some parents are not supportive enough, or they leave children behind with the grand mothers who are too old to keep up with teenage energy. At the same time, most kids have no parents and therefore live alone with their relatives due to HIV/AIDS.

RESULT AND DISCUSSIONS
There are several solutions that can be implemented to address the reproductive health challenges of women in Lesotho, including:

Improving Access to Reproductive Health Services
This can be done by increasing the number of health facilities that provide reproductive health services, particularly in rural districts. Additionally, outreach programmes and mobile clinics can be used to reach women who are unable to access health services due to geographical or other barriers.

Promoting Family Planning
Increasing access to family planning services can help women and couples plan and space their pregnancies, which can reduce the risk of maternal and child mortality and improve overall health outcomes.

Providing Education on Reproductive Health
Education on reproductive health and sexuality can help to break down cultural and societal barriers that prevent women from seeking and receiving reproductive health services. This education should be targeted at both women and men.

Addressing Poverty and Gender Inequality
Poverty and gender inequality are major factors that exacerbate reproductive health challenges in Lesotho. Addressing these issues requires a comprehensive approach that includes improving access to education and economic opportunities for women, as well as addressing genderbased violence and discrimination.

Empowering Women
Empowering women to make their own decisions about their reproductive health is essential. This can be achieved through education, community mobilization, and policy reform that ensures that women's rights are protected.

Strengthening Health Systems
Improving the quality and availability of health services, as well as the training of healthcare providers, can help to improve maternal and child health outcomes. Addressing the reproductive health challenges of women in Lesotho requires a comprehensive and collaborative effort from government, civil society, and international organizations. By working together to implement these solutions, we can improve the health and well-being of women and girls in Lesotho.

The Importance of Political Commitment
Many of the successful interventions in other African countries were driven by strong political commitment and leadership. Lesotho can learn from this and work to ensure that reproductive health remains a priority on the government's agenda.

The Value of Community Engagement
Community engagement is often critical to the success of reproductive health interventions. Lesotho can learn from successful community-based approaches in other African countries, such as training community health workers and mobilizing communities to increase awareness and service demand.

The Need for Comprehensive Approaches
Many successful interventions in other African countries were comprehensive in nature, addressing multiple aspects of reproductive health simultaneously. Lesotho can learn from this and work to develop and implement comprehensive approaches that address not only access to services, but also issues related to education, poverty, and gender inequality.

The Importance of Partnerships
Many successful interventions in other African countries were the result of strong partnerships between government, civil society organizations, and international organizations. Lesotho can learn from this and work to strengthen partnerships and collaboration to ensure that efforts to improve reproductive health outcomes are coordinated and effective.

The Value of Innovation
Many successful interventions in other African countries were innovative in nature, utilizing new technologies and approaches to reach underserved populations. Lesotho can learn from these examples and work to identify and adopt innovative approaches that are tailored to the country's specific context and needs. By examining and learning from successful interventions in other African countries, Lesotho can develop and implement effective strategies to address the reproductive health challenges facing women in the country.

CONCLUSION
Reproductive health in Lesotho is not provided at the levels that can benefit the nation as a whole because of shortage of manpower to reach all corners of the country. Parents are not free to talk sexual matters with their children. Lesotho has a lot to learn from other African countries who are successfully providing reproductive health to their citizens. Lesotho should therefore use those success stories