Yesterday I ate my last Kenyan fish fry with ugali and sukuma wiki, which nearly left me crying over my plate. I am already telling myself I’ll come back and bring my husband and hopefully family so that they can also appreciate this beautiful place. I am so grateful for the opportunity to work and live here for a bit, and I have such deep respect for colleagues that continue to advocate for a world where no woman or girl ever dies from unsafe abortion- a world where women can decide if and when to have children, and access the resources needed to raise them in a healthy and supportive environment. We can’t know whether this might be a reality in our lifetime, but the deep transformations of the community members, providers, and decision-makers that the Ipas Africa Alliance works with fills me with optimism.
Last week I had the chance to present to Ipas staff on some of the work I’ve been privileged to do while here. Though I primarily sought to collect and organize feedback from community health volunteers, providers, youth champions and leaders of community-based organizations on how Ipas can improve its’ work to refer young women for contraception, I quickly realized the positive impact that these efforts are having on the people implementing the program themselves.- people like Silvester, from community organization Mitume Mantix, and Nerrie, a Youth Champion at Maseno University. They are the
“If I am a man, when my girlfriend tells me she wants to go for contraceptives, it’s high time for me to stop thinking she’s being unfaithful, or that she’s being promiscuous. Let us support them. I tell them (young men), ‘If you are in form one and your girlfriend is in form two, and if by bad luck you impregnate this girl, you won’t be at peace, because maybe you’ll be arrested, maybe you’ll be taken to court for these things, or rather maybe you will run away from your place, your home, so you’ll also be affecting your education… If you feel you are in an in-love relationship, support her! Go for the contraceptives, and see her through her education, so that if you meet somewhere in the future, you can enjoy your relationship.’ “ – Silvester, of CBO Mitume Mantix, an Ipas community partner
“The project has changed me in lots and lots of ways. It has provided me with a platform to develop my leadership skills and to also empower others on issues dealing with their sexual and reproductive health. Implementing Ipas’ Choice for Change project and working with the Youth Champions across Maseno University has been very fulfilling and a good learning experience regarding challenges faced by the youth on matters regarding their reproductive health. Ipas has taken me places I would have never dreamed of and provided me with invaluable experience that I wouldn’t have stumbled across on a normal day.” – Nerrie, Youth Champion with Ipas’ Choice for Change program, which seeks to increase young women’s access to contraceptives.
These and many more agents of change are the hopeful vision for a more just world that we must all invest in. For every person who has told me that Kenya has a long way to go regarding sexual and reproductive rights, I fully believe that Kenya is already well into that journey, with Ipas staff and those they work with leading the way.
As I think about arriving back home, I am filled with excitement to see family and friends, but a part of me will always remain in Kenya. It’s been one of the honors of my life to be here. Thank you, Ipas and thank you to the Ipas Liz Maguire Fellowship for Young Leaders for this incredible opportunity.
The highlight of this week was co-facilitating focus groups with Youth Champions in charge of implementing the Ipas Africa Alliance’s Choice for Change (C4C) project at two universities in Eastern Kenya on what resources they think young people need to care for their sexual and reproductive health and live their best lives. This was an activity to inform a webage that the Alliance is designing, which will link to their Nimechanuka Facebook and Twitter feeds (Nimechanuka, I am told, means “I am enlightened/empowered” in Kiswahili).
Spending time with these awesome young people reminded me of how much I miss working directly with youth, how much I love sex ed, and how full of hope and amazing ideas so many of them are. There were also several hilarious moments like when we we talked about the fear that sooo many young people have that the natural size and shape of their genitalia are abnormal. This is apparently a global concern for young folks since the youth I worked with in North Carolina and Georgia were equally worried. ALL OF YA’ PARTS ARE NORMAL. lol We had a good laugh.
After the focus groups were over, I had the honor of sitting down with two of the brilliant Youth Champions one-on-one to talk about their work to refer young women on their campuses for contraception. They had a lot to say about the work and what motivates them, and how the training and support they’ve received from the Ipas Africa Alliance has changed the way they view themselves and the importance of sexual and reproductive health and rights. They’ve generously given me permission to share their feedback and photos.
Meet Morra*. Don’t let her small stature fool you- she’s is on fire for reproductive health and rights! She’s also got great style, so we clearly hit it off! 🙂 Here’s what she had to say about her work with Ipas during our interview this week:
“They (other young women) tell me they admire my confidence and I tell them they too need to be confident. It’s important in our society where the feminine gender is considered inferior.”
What impact has the Choice for Change (C4C) program had on young people in your community?
“Through this program, youth have been able to learn facts about contraceptives. You know there’s been so much fiction and in fact, (before) if you ask a lady why she can’t go for contraceptives, people surely will tell you that, “You know, I would grow fat, I would grow thin, I would lose my shape.” But now… they are able to get the facts on importance and effects of contraceptives. And they have been able to access contraceptives in the right place from the health practitioners… They’re first advised by the health practitioner, they’re given a variety (of options) so you make a decision, an informed decision.”
What has your experience been like working with Ipas to implement C4C?
“When I first started this I was green. But you see I have gained a lot of information. Initially I was afraid of talking about contraceptives, but now I’m courageous. I can teach people. In fact, I have really gained knowledge. I have also been able to convince some other people. I have advised them on the right way to make informed decisions.”
How has the program changed you?
“Initially, I wouldn’t advise somebody to go for contraception. The only thing I knew was you would bleed. But now I know it is not that bleeding like I thought. That bleeding is just for a short time before the body gets to be compatible with the new substance that has been introduced into the body. So it changed by perception about contraceptives and in that way, I’ve also helped change other people’s perceptions who thought the same as me. They (other young women) tell me they admire my confidence and I tell them they too need to be confident. It’s important in our society where the feminine gender is considered inferior.”
What motivates you do refer other young people for contraception?
“I was born out of wedlock. Because one, my mom wasn’t informed about contraceptives… She was the only bread winner. She told me my father left before I was born. So, at least I can help a few.”
“There’s (also) a number of drop outs on my (campus)…. I just want to reach out to any people so that they can make informed decisions. Prevent the unplanned pregnancies, the STIs, the HIV, and children who are born out of wedlock.”
How do you feel when you refer other young people for contraception?
“The feeling is incredible. I just can’t get a suitable word. But it makes me smile knowing that I have achieved my objectives (sensitization and referral). Helping the youth, especially ladies, make informed choices is just my happiness.”
If only we were all this wise in college! Can we please give this woman a standing ovation? ❤
The other young person I had the honor of talking to this week was Cleophas. Here’s a photo of him breaking down the importance of safe sex and contraception for his peers during the focus group,* and what he had to say about his work with Ipas:
“I’ve had the chance to change the lives of those other innocent students, because we have had cases of students who are procuring unsafe abortion before, but now they are able to access contraceptives so that they do not reach to that stage of unsafe abortion.”
Tell me about your work with the Ipas Choice for Change (C4C) program.
“What I do normally, I reach out to students. I attend to so many students. I do counseling, peer education…. I also do referrals to the link students to health centers that Ipas is working with. So these are just the kind of groups we are referring students to. I also do a lot of phone calls to attend to students. I do one-on-one chats. We do chats on social media. At times I even stay awake, like, throughout the night because students just keep on asking me questions.”
How confident do you feel answering the questions students ask?
“At first I didn’t feel that confident because my experience with Ipas has been gradual. It has not been so immediate that way, because the research, at first I was a bit naïve talking about matters concerning sexuality, but through the training, capacity building, networking and advocacy trainings that we were taken through, I was able to gain that confidence and I’m able to counsel and offer guidance.”
What has your experience been like working with Ipas to implement C4C?
“It has been extremely positive working for C4C as a champion, I am reaching (out) to other students and changing even my life as an individual… I know much on contraceptives and I’ve had the chance to change the lives of those other innocent students, because we have had cases of students who are procuring unsafe abortion before, but now they are able to access contraceptives so that they do not reach the stage of unsafe abortion.”
How beneficial has C4C been to your community?
“It has been extremely beneficial because since the time I came here the lives has just changed. People have just changed with Ipas…When I came here back in 2014, there was a lot of pregnant women in the community. People even branded the university… like a maternity (ward)… So, you know, that time so many students were pregnant but within a short while this pregnancy just disappears. So, it never disappeared in a positive way, you know in a good way, but people are procuring unsafe abortion. But now through the information Ipas has impacted students, and you know even when I walk along the corridors of JOOUST, there is a name a lot of students have branded me, they do call me “Ipas.” Because when they see me they see hope… When they see me, they see a solution to reproductive health (problems).”
Aren’t they AMAZING?! If there’s hope for the world, it rests on our willingness to invest in youth like Morra and Cleophas.
*Both Morra and Cleophas gave written permission to be interviewed and for their photos and names to be shared.
This past week was mostly spent in the field, traversing dusty roads in the rural towns of Kakamega County to visit intervention facilities with Ipas Africa Alliance staff. During visits, staff offer training and follow-up support to healthcare providers and community health volunteers (CHVs) who are implementing Ipas’ Choice for Change (C4C) project, which seeks to increase uptake of contraceptives among sexually active young people and lower high rates of adolescent pregnancy. The causes of these high rates are diverse and include a lack of access to education, poverty, child marriage, sexual abuse, and difficulties accessing reproductive health services due to stigma and a lack of reproductive commodities and training within the health sector (National Adolescent Sexual and Reproductive Health Policy, 2015; Godia, Alenja, Hofman & Van Den Broek, 2014). These communities are often very religious, and nearly every site visit began with a prayer asking God to guide our time together and their work in the community.
During these visits, I conducted in-depth interviews with providers and CHVs to document their experiences and feedback on the C4C project. Laying under my mosquito net at night looking over notes from this week’s interviews, I was moved by people’s commitment to the health and well-being of the women and girls they serve:
“When they (the youth) are given the service (contraception), they feel so good. Before, when they would come I would tell them, ‘this is not for you.’ But this time I tell them, ‘this is for everybody’… They come knowing there is good assistance (here), so they are happy and I am also happy.”
– Nellie*, Hospital Nurse
“In my village, we have been having a lot of early pregnancy, and most are below 15 years old… they don’t know that they’re pregnant and some try to procure an abortion. We even have cases of deaths secondary to abortions. If you try to inquire with the person who was accused of impregnating her, he says he doesn’t know… They call me the matron of the street children. I go up to them and talk to them. I find out if they are pregnant or could become pregnant. I counsel them on family planning.”
– Liza*, Community Health Volunteer (CHV)
As I reflected on their words, I thought about an article I’d read where Dr. Willie Parker, an abortion care provider in the United States, talked about Bible passage Luke 10:25-27 and the way in which his Christian faith compels him to help women seeking to end a pregnancy:
“… my breakthrough finally came when I listened to a sermon by Dr. Martin Luther King Jr. about what made the Good Samaritan good. The sermon that you know as the “Mountaintop Sermon,” the very last sermon that he preached on the night that he was assassinated—within that sermon, he described the very familiar story of the Good Samaritan who stopped to help someone who had been robbed and injured. Everybody passed that person by and refused to help. The Samaritan stopped and helped, and Dr. King said what made the Good Samaritan good was that person reversed the question of concern, whereas everybody else said, ‘What will happen to me if I stopped to help this person?’ The Samaritan asked, ‘What will happen to this person if I don’t stop to help him?’
As an OB/GYN seeing women, I saw myself in that story and became convinced that not only was it appropriate for me to care about the well-being of my patients, but I now had a moral imperative, if you will. It became to me more important to think about the well-being of my patients than what might happen to me for providing this care. So I had to see my religious understanding in a different way. I never had any desire to abandon Christianity.
And so what became more important to me in a conscious way was embracing the compassion and the moral obligation to respond to the need of your fellow human being than the judgment and the rigidity around interpreting isolated passage of sacred texts to leave you unable to respond to the needs of other people. And in my case, as a women’s health provider, the need that I felt most called to respond to was that of women with unplanned pregnancies when they asked me to safely end their pregnancy that they didn’t want or that they were unable to continue even if they wanted it” (Jezebel, 2017).
Half a world away, this same compassion seems to be what drives many of those on the front lines of helping Kenyan women and girls access life-enhancing and life-saving reproductive health services. This is especially critical in a context where violations of women’s and girls’ sexual agency and human dignity frequently go unpunished.
Not everyone is a Christian, nor do they need to be. Yet, the fact remains that many Christians feel God’s mandate to support people in their most vulnerable moments is what calls them to provide women and girls with access to reproductive health services- a powerful reality often left out of the pro-choice vs. anti-choice arguments. These reflections lead me to pose the questions, What if we replaced shame and stigma around adolescent sexuality, safe abortion, and contraception with a non-judgmental commitment to what civil rights activist Valarie Kaur calls revolutionary love? What would that world look like? What would that mean for the quality of life of women and girls all over the world- for all people?
We must challenge the false dichotomy between reproductive rights and Christianity. Whether it’s rural western Kenya or the rural southern U.S., we cannot ignore the role that the Christian faith has had and continues to have in shaping people’s world views on controversial topics like abortion and contraception. We must advocate for the fact that helping people who face a pregnancy they can’t continue or adamantly don’t want, is a life-affirming act. How could we argue otherwise knowing the damage to women’s and girls’ dignity and health that follows when these services are denied? In the words of the good Samaritan, “What will happen to this person if I don’t stop to help her?”
This Easter Sunday, many Christians will post pious words on social media, or talk about how grateful they are that Jesus died for the sins of all humankind. There’s nothing wrong with this necessarily, but how many of us will also have the courage to daringly live-out Jesus Christ’s legacy of revolutionary love? How many of us will do what our heart tells us is right, even when this is difficult or unpopular within our faith communities?
I deeply believe that I have a moral imperative to support this work, grounded in my love for God and the world around me. The testimonies of Christians like Nellie, Liza, and Dr. Parker assure me that I am not the only one.
*Not respondent’s real name. All respondents gave written consent to be interviewed and for their quotes to be shared.
Have your heart and mind ever been so full that you find yourself expending all of your energy on processing thoughts and feelings? That’s where I’ve been the past few days. Full of admiration for the work of my Ipas Africa Alliance colleagues and their beautiful country.
During the second half of last week, I attended a meeting where Ministry of Education (MOE) officials and administrators met with Choice for Change (C4C) program staff (see my last post for a description of that program). The purpose of the meeting was to bring MOE staff up to date on statistics regarding youth sexual and reproductive health (SRH) nationally and in their county, as well as the basics of the C4C program, with the hope that they will encourage teaching staff to refer youth for services as needed. This is essential, as Alliance colleagues explained that some teachers have discouraged their students from accessing contraception through the program due to the stigma around adolescents and sexual activity.
The Africa Alliance’s Health Systems Advisor, Martha Kaguara, began the meeting by asking MOE staff to share their experiences with challenges in youth SRH. The stories they shared were difficult to hear, ranging from a young girl giving birth in a latrine to the expulsion of pregnant youth from school and the lack of consequences for the young men who got them pregnant, and even instances of sexual abuse perpetrated by teachers themselves (teachers have considerable power in many areas of the country, and some abuse this power).
There were several comments that were very stigmatizing toward youth SRH, especially toward girls. But there was also a real desire in the room to find a way to address these issues. When one participant deemed the young woman who gave birth in the latrine as “negligent” other MOE staff immediately responded, essentially stating that it is the community who is negligent when youth are denied access to the information, support and the tools to prevent pregnancy. Martha responded to these heartbreaking stories with a call for action, “Are we all seeing these cases? Are they there? What are we going to do about it? It is not about talking. It must be about the way forward.” There were many head nods among attendees.
The way MOE staff became increasingly engaged with the topic throughout the day, and their excitement around collective action to improve the lives of youth in their communities were inspiring. While some for their comments reminded me of the global need to sensitize adults to become true allies, rather than judge and jury when it comes to youth SRH, I was impressed by the patience with which Martha and Moses Kidi, the Africa Alliance Youth Advisor, worked to build compassion for youth facing inadequate SRH information and resources, converting those who may have been foes to allies in this work. It is a privilege to witness this process and learn from it.
One moment that really stuck with me was the challenge to the audience made by Moses regarding our collective responsibility to link youth to services: “There are those of us who have killed clients, sending them away. You don’t know what happened to that girl. Did she seek an unsafe abortion? Did she die? We are all responsible.” The weight of that statement was palpable.
Later, he shared with me how this is a major issue that the Alliance has worked to address within health facilities as well. Facilities may turn away very sick women, and especially those suspected of having induced an abortion, as high rates of maternal death within the facility will cause them to look poorly when mortality audits are conducted by the government. Maternal death due to abortion is not captured in official data, though studies indicate incomplete abortions account for over one-third of gynaecological admissions and unsafe abortion is responsible for approximately 13% of maternal deaths in Kenya (Lema et al, 1996). In Africa- and all over the world, abortion is common. On the continent, over six million abortions are estimated to have occurred in the year 2008, with two million occurring in East Africa alone (World Health Organization, 2011; Singh, S., 2006).
As I reflect on this week, I am in awe of the commitment of my colleagues working on C4C and their determination to ensure every person has access the information and resources to prevent unintended pregnancies. I have been thinking a lot about how, although some issues, like stigma directed at pregnant youth, are global challenges, others are a direct result of oppressive forces throughout history, and the intersection of various forms of oppression. For instance, it seems grossly unjust that, to varying degrees across the globe, women of color, and particularly young black women, are faced with the highest rates of unmet need for contraception, unintended pregnancy and maternal death, including death from unsafe abortion. In Kenya, which gained its’ independence from Britain in 1963 only after much bloodshed, the maternal mortality ratio is about 363 deaths per 100,000 live births (Kenyan Demographic Health Survey, 2015). Many of these deaths are among young women, as are many of those caused by a lack of access to safe abortion. While the U.S. maternal mortality rate is much lower at 28 deaths per 100,000 live births, this rate has risen alarmingly in recent years, and black women in my country are three to four times (or in some states like Louisiana, even five times) more likely than white women to die within one year of giving birth (The Root, 2016). This is not just a matter of health, but also a matter of human rights- and specifically, reproductive rights, as the United Nations and other international organizations have pointed out (UN News Centre, 2015; WHO, 2012).
While women and girls of all colors live with the burden of various types of harm caused by the patriarchy, even if they might choose to deny this reality, far too many women of color are also burdened with the ongoing effects of colonialism and white supremacy. Some are also harmed by homophobia, transphobia and ableism. How can we, as a global SRH and rights movement do a better job of recognizing and pushing back against this- of helping to right these historic wrongs? I think one step is stating them aloud and remaining cognizant of the root causes of these injustices as we engage in this work. All women are created equal, but they are not treated as such by societies. Further, we must ensure that those leading SRH efforts like those of the Ipas Africa Alliance are representative of the communities they seek to influence, and that they genuinely seek to gain the perspectives and direction of the young people they wish to benefit.
If we aim to ensure every person has access to the tools to prevent pregnancy and end a pregnancy safely, we must admit this reality. It must be about the way forward for youth- and for all of us.
Today marks the end of my second day of the Ipas Maguire Fellowship at the Ipas Africa Alliance in Kenya and I am still STOKED. Monday was spent meeting many new and friendly faces and getting acclimated with the support of the Alliance’s amazing HR staff. Today, I celebrated my birthday with the most delicious surprise birthday cake, something I was not at all expecting, being so new to this office. I was pretty moved. I mean, who does that for someone they barely know? Apparently the Alliance Office does ❤.
In the afternoon, I traveled to Kiambu County to shadow Choice for Change (C4C) Program staff. C4C is an Alliance program that promotes uptake of long-acting reversible contraceptives (LARC) among adolescents and young people by 1) Improving service delivery at health facilities through provider training in values clarification, youth-friendly services and LARC placement (basically, how to provide LARC to youth and be nice about it!), 2) Activating community groups to mobilize them in favor of promoting and/or referring for the use of contraception, with a focus on LARCs and safer sex via condom use, among the young people in their county, and 3) Working with county health officials and other stakeholders to advocate for the inclusion of reproductive health funding in county budgets.
The program ‘s slogan is Maisha Poa, Future Poa, Chaguo Langu– Swahili for “Good life, Good future, My Choice”. I love that it embraces reproductive autonomy, a pillar of sexual and reproductive health and rights. The program aims to reach girls with information about contraceptives, especially the benefits of LARC, from age 10 up through age 24- taking into account the realities of the young people they aim to reach and the need to inform girls of the options available to them well before they are sexually active. While many adults may be loath to admit that someone as young as 14 may need LARC, there is undoubtedly a need to equip very young women with more discreet options and less user-dependent methods of preventing pregnancy, especially given the reality of early sexual activity and power imbalances in too many sexual relationships. While the program doesn’t address gender inequality directly, it’s beyond argument that programs like these help facilitate women’s and girls’ access to opportunities toward self-fulfillment by delaying childbearing.
Kiambu County is in the Nairobi Metropolitan Region, and hosts beautiful stretches of green farmland. 14% of girls aged 15-19 years have given birth in this county, which is lower than the national level of 18% (Kenya National Bureau of Statistics, 2010). This rate is still pretty high, and county health officials are eager to see it come down. Side note: I think one of the things that felt incredibly ironic today, was the fact that many Kenyan health leaders seem to want everyone in their country to have a basic level of access to medical care, whereas my leaders largely seek to strip it away from anyone they see as undeserving. I’m over-simplifying here, but I think the overall point is still valid and shameful in a country with a GDP as high as that of the U.S.
Anyhow, on this visit, the Alliance’s Youth Program Advisor, Moses Kidi, gave an overview of the program to Kiambu County Community Health Workers (CHWs). Peppering his explanation of the program’s comprehensive Community Referral Strategy with anecdotes about the unfair burden carried by too many young girls, particularly those born into poverty, who have been denied access to information and reproductive healthcare, Moses makes a compelling argument for working to improve the life chances of women and girls. He described the story of a girl who was forced to sleep with her uncle as he paid school fees for her and her siblings. If there wasn’t a way to remove her from that situation immediately, LARC might be her only option for delaying pregnancy, but adult judgement at her request for contraception would likely shut-down her down and squander the one chance to help her from within the healthcare system. He also made a strong economic argument for the program, highlighting the negative impact overpopulation can have on a country’s economic growth. The CHWs seemed to identify strongly with his arguments, and shared some of their own.
I could see that promoters seemed genuinely interested and committed to this work, and a visit later in the day to a sub-county hospital (mid-level hospital) and dispensary (primary care clinic) provided evidence that their work is paying off. At the first facility, the number of patients seeking family planning services has nearly doubled since it became an official intervention site just about six months ago. The provider there shared with me that Implanon is most popular among young women, and that having LARC prevents young girls from having to return to the facility regularly, which is important as her community may speak poorly of her, assuming that her frequent visits are for contraception. While the program doesn’t address abortion directly, any person who appreciates real (not alternative) scientific research, can agree that this program prevents unwanted pregnancies, abortions and, given that safe, legal abortion is still out of reach for the vast majority of Kenyan women, girls and people with female reproductive organs, I have no doubt that it’s saving lives. One would think that anti-choice folk would be gaga over a program like this… but that’s another post!