Most of the women were in line to get an Implant inserted. When I asked why they had chosen an implant as their FP method they mentioned that they wanted a long term method. An IUD was not considered because they believed that the IUDs would travel through your body.

We then walked over to where doctors were performing tubal ligations. They had performed three female sterilizations so far and two more women were waiting for the procedure. One of the women waiting was crying. We were told that the woman who was crying had come in with her 3 week old baby and her husband, who announced that unless she got a tubal ligation she could not return home and left. The woman just cried and said that she wanted to get an IUD and not sterilized because she was scared of the tubal ligation procedure. When the counselors went to her they learned that she was holding her 11^th child and that she was only in her mid-thirties, making her a poor candidate for an IUD. Since she had tried the implant before and did not like it they recommended that she go through with the sterilization.

Since her concerns with sterilization were based on fear, I suggested that they have a woman who had just been sterilized that morning share her experience. It was when she spoke to her that we learned the real reason for why she did not want to be sterilized. It was not that she feared the procedure, but rather that her husband had a second wife. She explained that if she got sterilized, she would not be able to have any more of his children, which would put the younger wife at an advantage and with higher status. We were all speechless and out of counseling talking points to address her concern.  And yet, in an area where 23% of married women have a husband that has at least one other wife, hers was a very real concern. If her status in her home and community center around the number of children she has, then it’s clear how an operation that made her unable to have any more children would be devastating. And yet this woman had no real choice. And worst we had no options to offer. She could either get sterilized and stop being a “valued” woman or not have the procedure and be homeless and away from her children. In the end the medical staff convinced her into getting the sterilization out of concern for her health. But I couldn’t help but feel like she had been coerced by her husband and community and failed by us.

It is my hope that by the time that her baby girl is in need of FP services the social norms in this community will have changed to the point that she never has to face a similar choice in her future. Because it is clearly more than just about making FP services available, women need to be empowered.

The Western Region of Kenya has one of the highest fertility rates (TFR=5.6) in the country and over 27% of sexually active women there have an unmet need for contraceptives. The Packard Foundation is currently funding a project in this region that is being led by the African Population and Health Research Center, in collaboration with the Division of Reproductive Health, Ministry of Public Health. The other major partners funded under this grant are Family Health Options Kenya, Marie Stopes Kenya (which organized the mobile clinic I visited), and the Great Lakes University of Kisumu.

The long term goals of the project are to reduce unwanted and mistimed pregnancies, unsafe abortion, maternal morbidity and mortality, and the fertility rate, as well as to improve the general health status of the target communities by encouraging uptake of long term contraceptive methods, influencing men’s attitudes towards family planning, and influencing desired family size and fertility intentions among women and men.

Mother, the film, breaks a 40-year taboo by bringing to light an issue that silently fuels our most pressing environmental, humanitarian and social crises – population growth. In 2011 the world population reached 7 billion, a startling seven-fold increase since the first billion occurred 200 years ago.

Population was once at the top of the international agenda, dominating the first Earth Day and the subject of best-selling books like “The Population Bomb”. Since the 1960s the world population has nearly doubled, adding more than 3 billion people.  At the same time, talking about population has become politically incorrect because of the sensitivity of the issues surrounding the topic–religion, economics, family planning and gender inequality. Yet it is an issue we cannot afford to ignore.

Today, nearly 1 billion people still suffer from chronic hunger even though the Green Revolution that has fed billions will soon come to an end due to the diminishing availability of its main ingredients–oil and water.  Compounded with our ravenous appetite for natural resources, population growth is putting an unprecedented burden on the life system we all depend on, as we refuse to face the fact that more people equals more problems.

The film illustrates both the over-consumption and the inequity side of the population issue by following Beth, a mother and a child-rights activist as she comes to discover, along with the audience, the thorny complexities of the population issue.  Beth – who comes from a large American family of 12 and has adopted an African-born daughter–travels to Ethiopia where she meets Zinet, the oldest daughter of a desperately poor family of 12.  Zinet has found the courage to break free from thousand-year-old-cultural barriers, and their encounter will change Beth forever.

Grounded in the theories of social scientist Riane Eisler, the film strives not to blame but to educate, to highlight a different path for humanity.  Overpopulation is merely a symptom of an even larger problem – a “domination system” that for most of human history has glorified the domination of man over nature, man over child and man over woman. To break this pattern, the film demonstrates that we must change our conquering mindset into a nurturing one. And the first step is to raise the status of women worldwide.

“Mother: Caring for 7 Billion” features world-renown experts and scientists  including biologist Paul Ehrlich, author of “The Population Bomb;” economist Mathis Wackernagel, the creator of the ground-breaking Footprint Network; Malcolm Potts, a pioneer in human reproductive health; and Riane Eisler, whose book “The Chalice and the Blade” has been published in 23 countries.

Emily with Girl Child Education program manager, Khadija, and head mentor, Habiba.

It’s 3 o’clock in the afternoon. School has been out for nearly an hour. Fifteen giggling teenage girls huddle outside a mud-brick structure near the center of the village. “Malama, malama (teacher, teacher),” several of the girls cry out. Malama puts a finger to her lips to silence the girls. We are speaking with the Sarki – the village head – who greeted my colleague and I when we entered the village several minutes earlier. “This program is important. Look at the girls’ excitement,” Malama translates the Sarki’s words. “He says we must go now, the girls need their time in that room.”

“That room” is home to a weekly, two-hour Safe Space Youth Club, an initiative of the Packard-funded Girl Child Education program in Northern Nigeria, implemented by Ahmadu-Bello University and UC Berkeley’s Bixby Center. Every week during the school year, the clubs meet in nine rural villages outside the northern city of Zaria. The clubs supplement formal education with lessons on literacy, numeracy, life-skills and health. But perhaps most importantly, the clubs offer a safe place for girls to share, teach, laugh and learn.

Since its inception in 2008, more than 600 girls ranging from 12 to 17 years of age have completed the year-long program that encourages girls to make the “jump” from primary to secondary school. As girls finish primary school around age 12, many drop out to work and soon after marry. Staying in school, even just one year longer, has tremendous benefits for a young girl, her family, her future family and her community. Research suggests that by staying in school longer, girls delay their age of marriage, which in turn delays their age of first childbirth and leads to women with fewer children over their life-course – ultimately reducing the risk of maternal morbidity and mortality.

As of 2012, 90% of girls who completed the year-long Safe Space Youth Club program went on to graduate from secondary school. This is remarkable compared to survey data from Zaria indicating that less than 7% of girls in the region attend secondary school (DHS Nigeria, 2008).

As a Bixby fellow this past summer (2013), my job was to help develop community-based research and evaluation of the program. Under the guidance of Principal Investigator Dr. Daniel Perlman and the Bixby team, my colleague, Kyle Engelman, and I worked with a team of ethnographers collecting qualitative data and helped with the design of an evaluation measuring the program’s impact. Preliminary findings from ethnographic field notes and interviews indicate that some girls in the program are using negotiation skills to stay in school, even after marriage. Community members are reporting increased acceptance of girls continuing on to secondary school, most notably among fathers and husbands. There is reporting of girls as more “responsible” and “hard-working” at home since their enrollment in the program. Some girls are even negotiating with their fathers and uncles to have a say on whom they marry.

In addition to such indicators of self-esteem and agency, qualitative research suggests an increase in reproductive and preventative health knowledge. As one participant reported, “As a girl and future mother, the program has improved (my) knowledge on a lot of things such as the oral rehydration solution, the knowledge of detecting danger signs during pregnancy and how to advise women with danger signs to get medical attention in the hospital.”

The Safe Space Youth Clubs are proof that when a dedicated Malama (teacher), a supportive Sarki (village head) and 15 twinkling-eyed girls come together – life transforming relationships and skills may grow. As I had the opportunity to witness with my own eyes, there is no doubt something special taking place in “that room.”

We were assisted by the field team of our local NGO partners, led by a nurse named Filomena. Filomena is a devout Christian and has been working as a family planning nurse for decades.  She sees access to family planning as an issue of public health and human rights, and she’s been a proud supporter of expanding access to these services in her country. On one of our fist outings with Filomena, we attended a women’s meeting at a local church. The church group had asked Filomena to give a talk about the benefits of modern family planning and Aidan and I jumped at the chance to see her in action.

Filomena began her presentation in a way that seemed truly unique to me: she put the focus squarely on the group’s religious beliefs, emphasizing that there was no contradiction between those beliefs and modern family planning. She mentioned that, as wives, mothers, and members of their church, the women in the audience had an obligation to care for their families and look after one another, a task that could become impossible if they were faced with an unintended pregnancy.

After introducing family planning in this way, Filomena proceeded to give an informative and amusing presentation on modern family planning methods, even offering tips and stories from her own life. She handled potentially uncomfortable moments with humor and warmth, often playing up graphic or funny details to put the crowd at ease. It was obvious that Filomena was a pro – she knew her material inside and out, and she was great at encouraging questions and responding to them thoughtfully and honestly. When misconceptions arose – for example, when one woman expressed concern that the contraceptive implant was actually a “chip” designed to record her sexual activity for the government – Filomena managed to correct them firmly but respectfully.

Filomena’s performance seemed especially impressive to me when she told me that she had very little formal training in family planning, and none in health education. She simply thought of herself as someone who cared deeply about giving women the right to control whether and when they got pregnant. When the Angolan government started its official family program in the 1980s, she signed on enthusiastically, earning a basic level of training that allowed her to provide counseling and services related to family planning.  Although she’d initially hoped to gain more specialized training, Angola’s decades-long civil war and the lack of health and education infrastructure made it impossible to advance her knowledge formally. Her detailed, up-to-date understanding of family planning methods and her phenomenal skills as a public speaker were learned on the job, first as a government worker and then as an NGO employee, encouraging women one by one to use family planning to take control of their bodies and their lives.

Seeing Filomena’s presentation reminded me of how important community-based action is to the work that we do, especially in settings like Angola, where opportunities for women to interact with highly skilled health providers tend to be few and far between. Filomena’s ability to connect with her audience comes in large part from the fact that she’s a member of the communities in which she works. As a Christian, Angolan woman who has used modern family planning, Filomena is able to build relationships with these communities based on characteristics like their shared faith and to use those relationships as a way to connect women to the family planning services they need. Supporting these types of community-based efforts will be a crucial step for us as we work to expand access to these critical health services.

Beyond 7 billion: Bending the population curve

LA Times, 12/2/2012

Kenneth R. Weiss, Staff Writer

http://www.latimes.com/news/opinion/commentary/la-oe-population-package-20121202,0,1448743.story

Hunger. Environmental degradation. Political instability. These were among the consequences of rapid global population growth documented in a five-part series in The Times in July. Now, the opinion section of the L.A. Times has invited leading scholars to consider what, if anything, people and governments can do to address the issue. In the brief essays that follow, Malcolm Potts from UC Berkeley sets up the situation we are facing, and population experts from around the globe explain some of the approaches they’ve seen work — and the reasons others have not.

photo credit: Hewlett Foundation

M. M. Campbell, N. Prata, M. Potts

Although fertility decline often correlates with improvements in socioeconomic conditions, many demographers have found flaws in demographic transition theories that depend on changes in distal factors such as increased wealth or education. Human beings worldwide engage in sexual intercourse much more frequently than is needed to conceive the number of children they want, and for women who do not have access to the information and means they need to separate sex from childbearing, the default position is a large family. In many societies, male patriarchal drives to control female reproduction give rise to unnecessary medical rules constraining family planning (including safe abortion) or justifying child marriage. Widespread misinformation about contraception makes women afraid to adopt modern family planning. The barriers to family planning can be so deeply infused that for many women the idea of managing their fertility is not considered an option. Conversely, there is evidence that once family planning is introduced into a society, then it is normal consumer behaviour for individuals to welcome a new technology they had not wanted until it became realistically available. We contend that in societies free from child marriage, wherever women have access to a range of contraceptive methods, along with correct information and backed up by safe abortion, family size will always fall. Education and wealth can make the adoption of family planning easier, but they are not prerequisites for fertility decline. By contrast, access to family planning itself can accelerate economic development and the spread of education.

Read the full article here.

“It is a difficult task, but it is urgent. I am optimistic because we are here together. And I am optimistic because hundreds of millions of women desperately want to make a better life for themselves and their children. If we listen to them, I know we will succeed.”

These were the words that Melinda Gates used to introduce the London Summit on Family Planning on July 11, 2012. It was an explicit and successful attempt to put family planning back on the international agenda.  The overall goal is to make family planning accessible to 120 million women with unmet need by 2020.

The driving force in the UK parliament was Andrew Mitchell, the minister for overseas development. He suggested the Summit meeting to Melinda Gates. The UK prime minister, David Cameron, gave a stunning speech and received a standing ovation for what was probably the first speech made about family planning by any Western leader.  The UK government pledged to put in £1 billion over the next 8 years.  Australia and Germany also pledged to double their investment in family planning. It has taken 20 years to get family planning and population back on the international agenda.

The London Summit was well covered by the European press but little or no direct mention in the US. However, the Los Angeles Times ran five days of excellent articles on Population. The Lancet came out yesterday with an issue on Family Planning. Martha Campbell and I had been invited by Bert Peterson to the planning meeting on this issue last year at UNC – and we did some of the ghost writing of two of the papers and statements. Bert went out of his way to say the whole idea of a special issue had started when he attended the Bixby Forum in 2009.

So in some real way – although impossible to measure accurately – I think the Bixby Center and Venture Strategies played a genuine role in getting the Summit moving, through consistent interest and commitment to getting family planning back on the international agenda for 20 years, particularly when almost everyone else was silent on the topic. Certainly over 20 years, we have been some of the very few people keeping the focus on voluntary family planning and population and – along with Melinda Gates – we found the London Summit an exciting meeting.

At the end of the meeting Melinda also said “What we are doing is an enormous undertaking . . . it is a difficult task but it is absolutely urgent.” But the real work of turning the Summit budget commitments into reality starts now. At the Bixby Center, we do have an opportunity to contribute to making this meeting a genuine turning point in the international arena.

More information on the Summit can be found here. 

And midway through my summer internship with the Bixby Center in Ethiopia, I was a bit discouraged. My fellow intern Kristina and I were spending three months in Tigray, a region in Northern Ethiopia, to support the same program of community-based distribution of the injectable contraceptive DMPA that Karen wrote about last month. Our tasks were to collect GPS points for the houses of the project’s community-based reproductive health agents (CBRHAs), refresh CBRHAs on the data collection protocols, and assess whether they had any needs that the program wasn’t meeting. We had postponed our work due to scheduling conflicts with local partners; we were falling behind.

After a week of waiting, we were able to hold an educational meeting with the CBRHAs in one of the project areas. The meetings were well attended and were useful for the participants, a heartening success.

Another treat came that afternoon, when we attended a traditional Ethiopian coffee ceremony at the house of a public health nurse who was involved with the project. The coffee ceremony is a true feast for the senses: the wafting smoke from roasting coffee beans, the dull thud of the mortar and pestle as the beans are ground, then the taste of the strong black coffee, the smell of tree-bark incense, and the crunch of popcorn and sweetness of orange slices that are served with the drink.

During the coffee ceremony we looked through our colleague’s old photographs, black and white images of people with big Afros and somber eyes. She told us that she had been a commander in the Tigrayan People’s Liberation Front, when the region was fighting against the Derg – the communist regime that ruled over Ethiopia in the 1970s and 80s. Her troops were stationed in a nearby desert. Water was so scarce that one of her responsibilities as a commander was to regulate when her troops could sip from their flasks, and when they had to wait, thirsty.

Kristina and I were floored, while our Ethiopian colleagues simply listened calmly. As the coffee ceremony continued, we heard many more stories about the sacrifices this nurse and her colleagues had made during the years of fighting. Her stories put all the challenges we had been experiencing into sharp perspective. The colleagues we were sitting with had all found the strength and the spirit to fight for a worthy cause in circumstances far more extreme than our current situation.

Once we were more attuned to this recent history of resistance, we began seeing it everywhere. One of the project villages is called Guroro, which means “Throat”, because of the many who were hanged there during the years of fighting. Now the village wears that past like a mantle, or perhaps a defiant warning to any who would try to threaten it. At one of our meetings, a CBRHA said she tells women that if they have concerns about using contraception, they should draw upon their strength as fighters and do what is best for their families. And – my favorite – one of the project villages is called Ayin Birkaken, which means “Never Give Up”.

I could end by saying that Kristina and I learned to “never give up” in global health work, and we redoubled our efforts as interns for the rest of the summer. While that’s true, it’s not the whole picture. The stories renewed my passion for global health work, in spite of the challenges. But even more, they gave me a new level of respect and admiration for the strength of my colleagues who live the reality of these challenges in ways that I can only begin to imagine. Poor roads might make it annoying for me to get to sites for monitoring and evaluation, but they also mean that women in that region may be less likely to travel to a health clinic for health care. Bureaucratic inefficiencies put us a few days behind schedule, but they can make it hard for people working in the public sector to retain their optimism and their passion. I may be outraged by the high mortality rates in developing countries, but they mean that the loved ones of our colleagues in these countries are more likely to die early. Our colleague’s experience as a resistance fighter is an extreme example of a broad phenomenon – the courage and the ability to rise up to the challenges that exist. I have an incredible respect for these colleagues. I simply bear witness to their strength.

I thank the Bixby center for providing me with this opportunity to contribute to a project I believe in, and to learn so much from the people involved. And I thank our colleagues for the coffee, the photographs and the stories.

Read the full article here.

Published by the Population Press, September 25, 2012.  The Population Press is a publication of Blue Planet United, a non-profit organization dedicated to education and grassroots action on issues of environment, population, and sustainability. http://populationpress.org

At the beginning of November, just as everyone in the US was starting to prepare for Thanksgiving, I returned to Ethiopia for a fourth time as part of our project to increase rural access to injectable contraceptives. While I made it back to California in time to celebrate the holiday with friends and family, the visit to our project made me even more mindful of all the opportunities and gifts for which I am thankful.

The journey to Ethiopia is never simple. And after three flights, I arrived in Axum, a small town in the Tigray region. There is a great deal of historical significance associated with Axum, including UNESCO World Heritage Site, but my colleagues and I were there to conduct a training of 100+ Community Based Reproductive Health Agents (CBRHAs), as part of our project to scale up community based distribution (CBD) of the injectable contraceptive depot medroxyprogesterone acetate (Depo Provera) in Tigray, Ethiopia. The goal of the training was to teach CBRHAs how to provide Depo Provera in their villages, where women often face challenges in receiving family planning services at health facilities, due to distance to facility, stock-outs and often privacy issues. By training CBRHAs to provide Depo Provera, we hope to reduce some of the barriers that women face and increase their access to Depo Provera, which is the modern method of choice among rural women in Ethiopia. In a previous pilot study, we had demonstrated that CBRHAs were safe, effective and acceptable distributors of Depo Provera. The focus now was to go beyond the pilot study and scale up the successful findings. We had already trained 137 CBRHAs in three districts. Those CBRHAs had gone on to provide 2540 injections of Depo Provera in their communities, a vast majority to women who were new to family planning or Depo Provera.

This was our second training since the project commenced a year prior and we were excited and nervous as we made final preparations. As with prior trainings, until the morning of the first day, it is impossible to know how many CBRHAs will in fact arrive for the training. Since they are widely-dispersed, often without formal means of communication, we are left wondering if our invitation to join the training was delivered. As always, I was amazed as they arrived, many from villages that required a full day of travel. In the end, we had 101 CBRHAs complete the 4 day training. There were several highlights to the training. We introduced more role play activities and the participants were so excited to demonstrate their skills with recruiting clients and provide family planning counseling that we actually had to interrupt their role play to move on to the next activity. We also invited high performers from the first training to share their experiences and give advice to the new trainees. As they shared their experiences with the participants, they also spoke about how the project positively impacted them and their community. During one of the afternoon breaks, the CBRHAs broke out into song and dance – an impromptu refresher. The energy of the groups was contagious and I couldn’t help but join the dancing and singing. I am sure I looked ridiculous, but at that moment, my smile and laughter were unstoppable.

As the CBRHAs left the training, beginning their journey back to their respective villages, carrying new blue bags with a supply of Depo Provera, I thought about how even though the training was a success, the work was far from done. In fact, we will train an additional 700 CBRHAs in the next two years. As I sat around the table with my family and friends at Thanksgiving, I also reflected on our work in Ethiopia. We are providing an important and necessary service to the women of Tigray, yet on Thanksgiving, I only thought about dancing in the circle with training participants and realized that they are also giving me a very important gift.