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Ethiopia

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Many Women with their children attend the clinic for sexual and reproductive services, treatment and advice. .
03 November 2022

Ethiopian refugees find help in the clinic with pink walls

It's mid-morning, and the Um Rakuba refugee camp on the southern border of Sudan is hot. There are few trees to take shade from the 40°c heat. The dusty main road is bordered on both sides by rows upon rows of huts and tents, temporary accommodation established by The United Nations High Commissioner for Refugees (UNHCR) for the tens of thousands of refugees who have fled over the border from neighbouring Ethiopia since fighting broke out between government forces and the Tigray People’s Liberation Front (TPLF) in November 2020. The severe humanitarian crisis has left more than 5 million people facing starvation.   This week, peace talks mediated by the African Union are taking place in South Africa in an aim to break the bitter impasse between the Tigray region and the Ethiopian federal governments and bring succour to the desperate people caught in the middle.      Many arrivals tell of being victims of armed groups, facing perilous situations, including looting of their houses, forceful recruitment of men and boys and sexual violence against women and girls. Refugees are arriving with little more than the clothes on their backs, fatigued and in weak conditions after sometimes days of travel.  The main road of the camp is peppered with the temporary offices of well-known charities, some providing food aid, others medical care. But there is only one clinic that has bright pink walls and welcomes women, girls, and men inside for free sexual and reproductive healthcare. The Sudan Family Planning Association (SFPA) quickly established a presence here once refugees started to arrive as they understood sexual and reproductive health is not only vital for women’s health and safety but very often overlooked by the humanitarian community. 

Young woman

2020: An unprecedented year

There are some years that become a pivotal moment in history - 2020 is one of those. IPPF has never been faced with delivering healthcare in the grip of a global pandemic. Yet our global teams have demonstrated agility, resilience, and creativity putting clients at the heart of our work to ensure the safe delivery of vital care. The pandemic has changed how we work, but not what we do. Here we acknowledge some of our amazing colleagues, clients, and partners as well as events that have shaped 2020. Expanding healthcare for factory staff Sandra is one of a team of women who work at a cashew factory in a small town in rural Ghana. Thanks to a project run in partnership by Planned Parenthood Association Ghana (PPAG) and the Danish Family Planning Association (DFPA) women like Sandra can now access contraceptive and reproductive healthcare during their working day. "It has helped me a lot, without that information I would have given birth to many children.”© IPPF/Natalija Gormalova Share on Twitter Share on Facebook Share via WhatsApp Share via Email Ensuring healthcare provision during the pandemic Malak Dirani, a midwife at the Lebanese Association for Family Health (SALAMA). “My message to healthcare workers across the world is that we are always here for people to secure their health and rights. We are on the frontline; we were always the one who people trust! We are the nation's guiding light during this difficult time, so we can, with our efforts and power support patients, overcome this crisis, and save lives.”© SALAMA Share on Twitter Share on Facebook Share via WhatsApp Share via Email COVID-19 crisis sparks innovation New approaches to reach women with safe abortion care include telemedicine and home-based provision of medical abortion. To ensure that quality abortion care can be provided to women during travel restrictions, the Cameroon National Planning Association for Family Welfare (CAMNAFAW)’s service providers travel to partner clinics in underserved areas and to clients’ homes to provide medical and surgical abortion care. This model of taking safe abortion care closer to women will continue even with easing of travel restrictions, as this has been found to be an effective and acceptable approach to increasing access.© IPPF/Xaume Olleros Share on Twitter Share on Facebook Share via WhatsApp Share via Email Getting creative on social media A watercolour entry for a social media art competition. “With our Youth Network we created an artistic competition on our Facebook and Instagram platforms on issues such as masturbation, menstruation, coming out, female genitalia, pornography. The aim is to enhance creativity and make young people reflect about sexual and reproductive health and rights in a creative way during the pandemic. The aim was also to offer something fun and positive in this difficult time.” Noemi, 24, is the co-founder and coordinator of Santé Sexuelle Suisse/Sexuelle Gesundheit Schweiz's Youth Network. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Delivering healthcare to remote communities in Fiji RFHAF Team in Kadavu performing general health checks after TC Harold. Healthcare provider, Nasi, administers an HPV shot to a client. In early April 2020, the all too familiar destruction of a Tropical Cyclone (TC) – Harold – hit the Solomon Islands, Vanuatu, Fiji and Tonga. One of the worst affected areas was the Eastern part of Fiji. Through support by Department of Foreign Affairs and Trade (DFAT), our Member Association, Reproductive and Family Health Association of Fiji (RFHAF), was quick to respond ensuring access to essential sexual and reproductive healthcare for Kadavu’s women, girls, and vulnerable groups.© IPPF/Rob Rickman Share on Twitter Share on Facebook Share via WhatsApp Share via Email Spotlight on women in leadership Executive Director, Dr Kalpana Apte, of FPA India talks about young people being a primary focus for access to healthcare and information. “Gender equality and equity is a fundamental issue that India must prioritize. India is a country of young people. That is the biggest cohort of people at this time in history. Within this group of young people, adolescent and young girls are the most marginalized group. The face of poverty in India is a young girl. Girls have fewer choices, options and opportunity. The gap between boys and girls in terms of access to sexual and reproductive health services and information is huge. Education, Health and empowerment are the three priorities for young girls.”© IPPF/Anurag Banerjee Share on Twitter Share on Facebook Share via WhatsApp Share via Email Humanitarian Youth Club, Kiribati Theta, 25, is part of the Humanitarian Youth Club set up by the Kiribati Family Health Association in her village. “I have helped the Humanitarian Youth Club to apply for financial grants from the Australian High Commission [for $1,000]. I am recognized as the smartest member who can write in English. We have learned how to design a disaster plan for the community and share our ideas on sexual and reproductive issues such as sexually transmitted infections. We discuss what we can do for the next strong tide, where we can gather as a community. For now, I want to enjoy the chance to be in our own beloved country. I won’t move until the majority have already left. I want my daughter to grow up in the same place I grew up in.”© IPPF/Hannah Maule-Ffinch Share on Twitter Share on Facebook Share via WhatsApp Share via Email Youth-led healthcare through song, dance, and poetry 17-year-old student Jumeya Mohammed Amin has been a ‘change agent’ for her community through the Family Guidance Association of Ethiopia since she was 14. "I wanted to protect girls from violence – like early marriage – and I wanted to change people’s wrong perceptions about sex and sexuality.”©IPPF/ Zacharias Abubeker Share on Twitter Share on Facebook Share via WhatsApp Share via Email Small but mighty: The Pill at 60 2020 marks the 60th anniversary of the game-changing contraceptive pill. For 60 years, “the Pill” has been approved for use in the US market, changing the face of reproductive control for millions of people since. Although taking a few years longer to become widely available to all women, the Pill was the first oral hormonal contraceptive. It allowed women to take real ownership over if and when they had children, and how many they had, giving them control over their lives in a way that had never been seen before.© Jessica Dance Share on Twitter Share on Facebook Share via WhatsApp Share via Email Being part of IPPF: What it means for Profamilia, Colombia Executive Director, Marta Royo. “For Profamilia, the value that the Federation adds is enormous. It gives us the possibility to exchange experiences and knowledge with other associations around the world, enriching our work, and allowing it to advance more quickly and with greater strength. This has allowed us to work with the most vulnerable populations in our country – from advocacy to healthcare service delivery, research, addressing issues as varied as abortion care, contraception and comprehensive sex education. Without this support, thousands of people in Colombia would not have access to any of these services.”© Profamilia Share on Twitter Share on Facebook Share via WhatsApp Share via Email Unprecedented support for women’s right to abortion care in Poland Huge numbers of people took part in protests prompted by the decision of the Constitutional Tribunal to impose a near ban on abortion on 22 October 2020. The ruling struck down the possibility for women to access abortion care on the ground of severe fetal impairment, rejecting what is the most common of the few legal grounds for abortion in the country at present. The demonstrations had a powerful impact, and on 3 November the government announced a delay in implementing its latest court ruling in response to the protests.© Marta Bogdanowicz Spacerowiczka Share on Twitter Share on Facebook Share via WhatsApp Share via Email US Election 2020 The people of the United States voted for change and progress. The reinstatement of the US Global Gag Rule in 2017 has had enormous consequences for women and girls accessing sexual and reproductive healthcare. IPPF calls on President-elect Biden to keep to his word of signing an executive order on his first day in office to repeal the harmful Global Gag Rule (the Mexico City Policy). © J. Smith/USA Share on Twitter Share on Facebook Share via WhatsApp Share via Email 16 Days of Activism Against GBV In humanitarian emergencies, women and girls may be forced to turn to survival sex work as a way of feeding themselves and their families. Without the usual healthcare available and low sexual health understanding, sex is frequently unprotected and violent, exposing them and their clients to sexually transmitted infections, including HIV. In fact, people who engage in sex work experience 10 times higher prevalence of HIV than the general population, with an average of a 12% rate of HIV infection.© Jem Milton Share on Twitter Share on Facebook Share via WhatsApp Share via Email Spotlight on sex and disability Joy & Jake talk sex and more to mark International Day of Persons with Disabilities. Joy and Jake – who are sight/visually-impaired – discuss the highs, lows, and everything in between of navigating sex, sexual health, dating, relationships and sex education, whilst living with a disability.© Bird Lime Media Share on Twitter Share on Facebook Share via WhatsApp Share via Email

Youth dancers in Jimma, Ethiopia
30 July 2020

Youth-led sexual healthcare through dance, song, and poetry

In Ethiopia, getting young people’s attention about sexual and reproductive healthcare is no easy task. But at a youth centre in Jimma, the capital Oromia region, groups of young people are getting vital messages about sexual health and contraception out to their peers through dance, song, and poetry. Student Jumeya Mohammed Amin came here to train as a peer educator for sexual and reproductive health [SRH] three years ago, when she was 14 years old. In her community – a conservative village 20 km outside the city – early marriage and pregnancy was common, and information about SRH practically unheard of. Navigating traditional norms “Girls younger than me at the time were married. The youngest was only nine,” said Amin, who would watch her classmates have to leave their home, school, and playmates behind. In Amin’s community, to opt out of unintended pregnancies involves unsafe abortion methods such as remedies prescribed by traditional healers – which can be fatal. “I know one girl from 10th grade who was 15 years old, and she died from this in 2017,” she said. But Amin’s work educating hundreds of young people each year on sexual health has changed attitudes in her community around early marriage, unplanned pregnancy and the options available to prevent it, she says, with many of her peers now waiting to start becoming sexually active. Tackling high rates of teen pregnancy Oromia has the third highest rate of teenage pregnancy in Ethiopia, after the Afar and Somali regions, says Dessalegn Workineh, who runs the Jimma office of the Family Guidance Association of Ethiopia [FGAE], which is supported by IPPF. “In Oromia, out of this rate of teen pregnancies, almost twenty percent end up in abortion,” he said. The region also has the third lowest uptake of contraceptives among women aged 15 to 49. 17-year-old peer educator Mastewal Ephrem says that the problem comes down to a lack of information. “People don’t know about reproductive health and they need this information about how to manage their family, sex and infections,” she said. Religious and social conservatism make this difficult, especially in poor and rural areas where families receive dowries in the form of money and gifts when their daughters marry. “Because of not having confidence and not talking to people, girls are doing early marriage,” said Ephrem. Poverty and other hardships also push girls out of their family homes early and leave them in precarious situations, where they run a high risk of encountering abuse. “I see girls aged 10, 13 and 15, who live on the streets and take drugs,” said Emebet Bekele, a counsellor working at an IPPF-supported clinic in Jimma that is aimed at helping sex workers. Bekele provides counselling and testing for HIV and STIs. She talks to girls and women about the full range of free and confidential family planning services available at the clinic. “Sometimes we bring them from the streets and we test them. Most of them get pregnant,” she said. She often supports students to get safe abortion care; including girls as young as 13. Taking sexual healthcare to the streets The youth centre reaches a lot of young people in schools and directs them towards the youth centre, where there is a library and many group activities and performances to teach them about SRH. Groups of young people practice and perform short plays and dances about topics such as unsafe sex and STIs here, as well as on the streets, where they draw a crowd. Fourteen-year-old Simret Abiyu has turned what she has learned into SRH-themed poems that she pens and performs to her peers in English, Amharic and Oromo. “Sometimes I get training here and write poems about family planning and the work of FGAE and the development of the country,” she said. Healthcare and advice via the phone University student Nebiyu Ephirem, 26, is a youth leader at the centre. He has been managing the two SRH helplines – located in a quiet back office – since it started in 2017. He answers a lot of calls from young people asking about contraception or their bodies and people dealing with emergencies and tries to answer their questions or refer them to public, private or FGAE clinics across the country. “Culturally, people used not to want to discuss sexual issues. They fear discussing these openly with family, and due to religious beliefs, so people like to call me,” said Ephirem. The youth centre reaches more than 11,000 young people a year through its work at schools, and through outreach clinics located in coffee plantations, where many young people work. Currently, the youth centre uses the helpline, radio adverts and social media to inform people about sexual health. The team hopes that media campaigns can spread the message wider in order to raise awareness about young peoples’ sexual health needs.

Jumeya Mohammed Amin

"I wanted to protect girls from violence – like early marriage – and I wanted to change people’s wrong perceptions about sex and sexuality"

Seventeen-year-old student Jumeya Mohammed Amin started educating other people about sexual and reproductive health when she was 14 years old. She trained as a ‘change agent’ for her community through the Family Guidance Association of Ethiopia’s south west office in Jimma, the capital of Oromia region. Amin comes from a small, conservative town about 20km outside the city. "I wanted to protect girls from violence – like early marriage – and I wanted to change people’s wrong perceptions about sex and sexuality, because they [men in her community] start having sex with girls at a young age, even with girls as young as nine years old, because of a lack of education." "They suddenly had to act like grown-up women" "Before I started this training I saw the majority of students having sex early and getting pregnant because of a lack of information, and they would have to leave home and school. Boys would be disciplined and if they were seen doing things on campus, expelled. Girls younger than me at the time were married. The youngest was only nine. They would have to go back home and could not play anymore or go to school. They suddenly had to act like grown-up women, like old ladies. They never go back to school after marriage. My teacher chose me for this training and told me about the programme. I like the truth so I was not afraid. I heard about a lot of problems out there during my training and I told myself I had to be strong and go and fight this." "I have a brother and four sisters and I practiced my training on my family first. They were so shocked by what I was saying they were silent. Even on the second day, they said nothing. On the third day, I told them I was going to teach people in schools this, so I asked them why they had stayed silent. They told me that because of cultural and religious issues, people would not accept these ideas and stories, but they gave me permission to go and do it. Because of my efforts, people in my school have not started having sex early and the girls get free sanitary pads through the clubs so they no longer need to stay home during periods." Training hundreds of her peers "I know people in my community who have unplanned pregnancies consult traditional healers [for abortions] and take drugs and they suffer. I know one girl from 10th grade who was 15 years old and died from this in 2017. The healers sometimes use tree leaves in their concoctions.  We tell them where they can go and get different [safe abortion] services. The first round of trainings I did was with 400 students over four months and eight sessions in 2017. Last year, I trained 600 people and this year in the first trimester of school I trained 400. When students finish the course, they want to do it again, and when we forget we have a session, they come and remind me. At school, they call me a teacher. I’d like to be a doctor and this training has really made me want to do that more."

young people sit and listen to a sexual health peer educator
27 July 2020

Ethiopia: Filling the sexual health gaps for young people through a unique youth center

Every Saturday, about 40 people gather at a youth center in Mekelle to hear about a subject they don’t get taught in schools in Ethiopia, and don’t want to discuss with their parents – sexual and reproductive health (SRH). This youth center located in the Tigray region of northern Ethiopia, is run by the Family Guidance Association of Ethiopia (FGAE) – it has a playground and library at the front for studying and socializing. In the back, there is a clinic and offices where staff provide a full range of SRH services, including free contraceptives, abortion care and testing and counselling for sexually transmitted diseases (STIs). “In our country, we have a huge amount of youth and adolescents and it is very important to work with them on sexual and reproductive health,” said Mebrahtu Abadi, who manages this center in Mekelle, the capital of Ethiopia’s Tigray region. Young people at the heart of the center Ethiopia has Africa’s second largest population and according to government studies, youth makes up roughly a third of its population.  The center is aimed at people aged between 10 and 24 years old and runs a range of activities, including holding sessions in schools to bring people in for talks and services. On Saturdays, groups of young people usually do some performance art based on a particular SRH subject, and hold debates and discussions around a coffee ceremony – a traditional Ethiopian social gathering. “In these ceremonies we prepare a poem or a short drama to entertain and educate using peer to peer methods about things like HIV and other sexually transmitted diseases, contraceptives, unplanned pregnancy and abortion”, said Abadi. The youth center has 20 peer educators – 10 male and 10 female – who provide counselling to others at the center, in schools and communities. Tigray is home to about five million people and Mekelle is a large university town, so the centre also works with campus clinics and with university and school clubs focusing on sexual health education. Peer educators leading the change There is always some giggling when the group’s leader, 24-year-old engineering student Tsegay Teklehaimanot, shows how to use male and female condoms. “They laugh and they love it,” he said. The club has more than a thousand members and the work the peer educators do is voluntary, but rewarding. “I’m proud of doing that thing because I am educating my friends and my family and protecting them,” says Teklehaimanot. Biology student Gebre Haileselassie says that young people will discuss things with their peers that they would be embarrassed to ask their parents. “In this place, we talk easily and are happy to talk,” he said. “The main message and point is how to protect ourselves, because in our world now, there are a lot of diseases and infections,” he said. The peer educators often stress the risks involved with drinking and having unprotected sex, especially with strangers.  “There are so many students that don’t know how to use condoms and [what to do] if something happens,” said Teklehaimanot. Unintended pregnancies often mean female students drop out of school, and most are not aware of other options, so the peer educators provide information and refer them to counselling services. Unsafe abortion numbers drop Baraki has been working at the main FGAE clinic in Mekelle for 21 years and seen the number of unsafe abortions performed by traditional healers drop in recent years, and the number of young people coming in for comprehensive abortion care rise.  “Especially in high schools and universities it has increased,” she said. “Nowadays awareness is increasing, especially in post-abortion complications and use of contraceptives,” she said. Complications arise due to traditional healers inserting sharp, unsterile instruments into the uterus or prescribing a concoction of antibiotics, toxic tree leaves and strenuous exercise.  In rural villages however, Baraki has seen the number of safe abortion decrease “due to some changing norms”, she says, although outreach services have also dropped due to budget cuts. Contraceptive shortages in rural areas Programs to help youth in rural areas have been scaled back in recent years due to a decrease in funding for SRH services from international donors and the government of Ethiopia. Mekelle had to cut its monthly visits to twelve rural districts in Tigray to once a quarter, then completely, and other partners have also stopped doing outreach in rural areas. “Nowadays they are not there and these services that are given by them are not supported now,” said Abadi. The cuts also mean that in Tigray, there are shortages of condoms and HIV testing kits, including at the youth center. Thanks to an FGAE program to provide free SRH services and products through public and private clinics, many young people and the poor from rural areas that come to Mekelle to sell produce now go to a 24-hour private clinic located in downtown Mekelle. Clinic owner Temegen Weldegiorgis says that many students come to get contraceptives, STI testing and comprehensive abortion care here because they can’t afford to pay for services, but fear being seen by family members at public clinics. The clinic serves a lot of teenagers who know nothing about family planning and the risk of STIs, and other underserved or unreached groups that need a drop in service in the center of town, such as farmers, sex workers, people living with a disability and veterans. “They need privacy and so come and have the service here,” he said.

Youth leader Nebiyu Ephirem, 26, has been staffing the phones at a hotline for young people who have questions about sexual and reproductive health since it started in 2017

"I'm a volunteer here, so it’s mental satisfaction I get from doing this"

Youth leader Nebiyu Ephirem, 26, has been staffing the phones at a hotline for young people who have questions about sexual and reproductive health (SRH) since it started in 2017 in Ethiopia’s Oromia region.  The helpline has two phones and is free, anonymous and open six days a week. The helpline is aimed at people aged 17-26 who are curious about SRH but are too shy or afraid to ask others about topics such as contraception, menstruation, and diseases.  The hotline also advises people dealing with emergencies following unprotected sex and issues such as unintended pregnancy and concerns over sexually transmitted infections (STIs), by referring people to their nearest clinic.  About 65 to 70 percent of the callers are female. Ephirem also trains other people about SRH and how to educate more young people about this. Being on call for his community  “Most days, I get about 30 to 40 calls and on a Saturday, around 50. People ask about contraceptive methods like pills and emergency contraceptives and depo provera [three-month injectable contraceptive], about the spread of STIs and HIV and how to prevent it, and about menstruation and sanitation. I give my suggestions and then they come and use Family Guidance Association of Ethiopia (FGAE) services, or I refer people to clinics all over the country. There are seven FGAE clinics in this area and dozens of private clinics. Young people need information about STIs before they come to the clinic, and when they want a service they can know where the clinics are. Most of them need information about menstruation and contraception. They fear discussing this openly with family and due to religious beliefs, so people like to call me. Culturally, people used to not want to discuss sexual issues. We took the information from IPPF documents and translated them into the two local languages of Oromia and Amharic, with the help of university lecturers. After four years, even the religious leaders did this training. We have trained university students, teachers and many more people to be trainers and 30 of them graduated. They [the people who dropped out] did not want to hear about the names in the local language of body parts. Most of the ones who stayed were boys and girls, but now we have women doing this. [At first], they were laughing and said: ‘How could you talk like this? It’s shameful. But slowly, they became aware. They now talk to me, they discuss things with their parents, families, even teachers at school and friends.” Lack of sex education  There is no sex education in Ethiopia’s national curriculum but youth groups and activists like Ephirem and his colleagues go into schools and teach people through school clubs. “This year [2019] up to June we trained 16,000 people and reached 517,725 adolescents and young people aged 10 to 24 through the helpline, social media – Facebook, Twitter and YouTube – workshops, radio talk shows and libraries.” A banner in Jimma town promotes the helpline and its number 8155, as does Jimma FM radio.  “The target for reaching people in school was 5,400. We achieved 11,658. The most effective way to reach people is at school. At the coffee plantation sites we reach a lot of people.”  The minimum family size around here is about five and the maximum we see is 10 to 12. In our culture, children are [considered as a sign of] wealth and people think they are blessed [if they have many]. When we go to schools to teach them, there are kids that already have kids. But after we teach them, they generally want to finish education and have kids at 20-25-years-old. We tell people they have to have kids related to the economy and to their incomes and we calculate the costs to feed and educate them. I’m a volunteer here, so it’s mental satisfaction I get from doing this. I get 1000 Ethiopian Birr [roughly USD 30] per month for transport costs. I am also studying marketing at university and want to become a business consultant.”

Midwife Rewda Kedir examines a newborn baby and mother in a health center outside of Jimma, Ethiopia

"Before, there was no safe abortion"

Rewda Kedir works as a midwife in a rural area of the Oromia region in southwest Ethiopia. Only 14% of married women are using any method of contraception here.  The government hospital Rewda works in is supported to provide a full range of sexual and reproductive healthcare, which includes providing free contraceptives and comprehensive abortion care. In January 2017, the maternal healthcare clinic faced shortages of contraceptives after the US administration reactivated and expanded the Global Gag Rule, which does not allow any funding to go to organizations associated with providing abortion care. Fortunately in this case, the shortages only lasted a month due to the government of the Netherlands stepping in and matching lost funding. “Before, we had a shortage of contraceptive pills and emergency contraceptives. We would have to give people prescriptions and they would go to private clinics and where they had to pay," Rewda tells us. "When I first came to this clinic, there was a real shortage of people trained in family planning. I was the only one. Now there are many people trained on family planning, and when I’m not here, people can help." "There used to be a shortage of choice and alternatives, and now there are many. And the implant procedures are better because there are newer products that are much smaller so putting them in is less invasive.” Opening a dialogue on contraception  The hospital has been providing medical abortions for six years. “Before, there was no safe abortion," says Rewda. She explains how people would go to 'traditional' healers and then come to the clinic with complications like sepsis, bleeding, anaemia and toxic shock. If they had complications or infections above nine weeks, Rewda and her colleagues would send them to Jimma, the regional capital. "Before, it was very difficult to persuade them to use family planning, and we had to have a lot of conversations. Now, they come 45 days after delivery to speak to us about this and get their babies immunised," she explains. "They want contraceptives to space out their children. Sometimes their husbands don’t like them coming to get family planning so we have to lock their appointment cards away. Their husbands want more children and they think that women who do not keep having their children will go with other men." "More kids, more wealth" Rewda tells us that they've used family counselling to try and persuade men to reconsider their ideas about contraception, by explaining to them that continuously giving birth under unsafe circumstances can affect a woman's health and might lead to maternal death, damage the uterus and lead to long-term complications. "Here, people believe that more kids means more wealth, and religion restricts family planning services. Before, they did not have good training on family planning and abortion. Now, women that have abortions get proper care and the counseling and education has improved. There are still unsafe abortions but they have really reduced. We used to see about 40 a year and now it’s one or two." However, problems still exist. "There are some complications, like irregular bleeding from some contraceptives," Rewda says, and that "women still face conflict with their husbands over family planning and sometimes have to go to court to fight this or divorce them.”

a midwife attends to a pregnant woman in a clinic - Ethiopia
16 July 2020

Delivering healthcare to women in rural Ethiopia

In a room that is bare but for a few beds, Kuzema Abba Naga is resting after giving birth hours before to her tenth child, and now she thinks, her last. Before coming from her village to this remote and rural government health center in the Kebele district to give birth, Naga never knew it was possible to choose when or whether to have a baby. “I am 38 years old and I had my first baby at age 15,” she said. “This is my first baby for eight years.” Naga named the baby Nejat, which translates to ‘liberation’, after giving birth and discovering the contraception options available to her, she decides to have an IUD fitted immediately. Lack of access to contraception in rural areas This is the first time midwife Rewda Kedir has fitted a woman who has just had a baby with an IUD, though it is not uncommon to meet women coming from rural areas who have never heard about family planning. When they do, many are interested in it, even if they have to fight their husbands to use it or they are forced to hide it from them. “They want contraceptives to space out their children,” said Kedir. “Sometimes their husbands don’t like them coming in to get family planning, so we have to lock their appointment cards away. Their husbands want more children and some think that women who do not keep having their children will go with other men,” she said. Kedir says that most women prefer using the contraceptive implants because they feel few side effects, are long-lasting, easy and painless to have fitted and to conceal. “Here, people believe that more kids means more wealth, and religion restricts family planning services,” she said. “Only 28 percent of women aged 15 to 49 use modern contraceptives,” says Dessalegn Workineh, who manages the Family Guidance Association of Ethiopia’s south west area office in Jimma. Expanding contraceptive access in Ethiopia  With support from the Family Planning Association of Ethiopia (FGAE), who work with the Ethiopian government, clinics in remote rural areas like this one can now provide a full range of sexual and reproductive health (SRH) services for free.  Having all the products and services available and under one roof makes it easier to reach people who might really benefit from help with family planning.  In Oromia, 43 percent of women give birth at a health facility. Kedir finds a lot of women coming in for maternal and post-natal health services who she speaks to about family planning, end up staying or returning to get family planning services.   “Before, it was very difficult to persuade people to use family planning and we had to have a lot of conversations. Now, they come 45 days after delivery to speak to us about this when they get their babies immunised,” she said.  Staff at the clinic also provide family counselling to try and encourage men that contraception is a good idea for the whole family. “We tell them that continuously giving birth can affect the mother’s health and might lead to maternal death, damage the uterus and lead to long-term complications,” said Kedir. A number of staff at the clinic have been trained on family planning and can answer queries and deliver services, “So when I’m not here, people can help.” “The implant procedures are better because there are newer products,” said Kedir, who sits next to a handmade poster with the options for contraception glued on that still has the older, match-sized implants and the new, thinner implants. Providing comprehensive abortion care The clinic also provides comprehensive abortion care and for the past six years, medical abortions. This involves taking a pill rather than having vacuum aspiration or surgery, and is helping to stop women turning to unsafe abortion methods. “Before, there was no safe abortion. People would go to traditional healers and then come here with complications like sepsis, bleeding, anaemia and toxic shock,” said Kedir.  “The good thing is that the women that have [safe] abortions get proper care and the counselling and education has improved,” said Kedir. In Ethiopia, these services are vital “to save mothers from dying due to cases of unsafe abortion,” says Workineh. “Working on comprehensive abortion care reduces complications and therefore maternal mortality,” he added. Kedir says women still have to fight their husbands to get access to family planning and cases can end up in court or divorce. But the cases of complications resulting from unsafe abortion have plummeted.  “We used to see about 40 a year. Now it’s one or two,” she said.

peer educators doing outreach work with sex workers providing them with information on their sexual health and contraception
03 July 2020

Providing a safe space for sex workers in Ethiopia

At a small clinic in a quiet, residential neighborhood, ten women are preparing to hit the streets for a day of potentially life-saving work; by donning white coats and filling their handbags with condoms. These peer educators are former or current sex workers who teach others how to protect themselves from sexually-transmitted infections (STIs) and unintended pregnancy. Their mission is to educate sex workers about STIs, HIV and contraceptives, distribute condoms and persuade people to access the full range of services at a confidential clinic in Jimma, the capital of Ethiopia’s Oromia region. “It’s very difficult to convince sex workers to come to the clinic,” said Meseret Girma*, a 25-year-old peer educator. “Some sex workers tend to have no knowledge, even about how to use a condom,” she said. A safe space for underserved populations The Jimma confidential clinic was set up in 2014 to help at-risk and underserved populations like sex workers receive free and bespoke services that include HIV and STI testing, treatment and counselling, contraceptives and comprehensive abortion care. The peer educators work as volunteers and receive 2,000 Ethiopian Birr (about USD 60) per month for travel costs.  Their work is challenging, and they travel in pairs for safety because some people do not welcome their messages. “When we try to tell people about HIV we can be insulted and told: ‘You are just working for yourself and earn money if you bring us in.’ They sometimes throw stones and sticks at us,” said 25-year-old Melat Tesfaye*.  They also have a hard time persuading women that the staff at the confidential clinic are friendly towards sex workers and will keep their information private. “They have had bad experiences at other clinics so they fear coming in, or they are scared about being tested for HIV,” said Gueba. “In other clinics, they don’t keep people’s HIV status confidential. Doctors and nurses discuss it in public,” she said. But a lot of sex workers ask questions about HIV and what to do if they test positive. Working with people living with HIV The Oromia region ranks sixth out of eleven regions for HIV prevalence rates but has the greatest number of people living with HIV due to its large population, says Dessalegn Workineh, who manages the Family Guidance Association of Ethiopia’s (FGAE) south west area office in Jimma. “There is a need to work on awareness raising on HIV and AIDS,” he said, particularly among women. Another confidential clinic operates in the nearby region of Gambella, where HIV prevalence is high. “A 2016 study shows that only 17 percent of women in Oromia were aware of HIV, compared to 35 percent men,” and in the capital Addis Ababa where 42 percent of women and 52 percent of men knew about HIV, he said. Reaching sex workers Getting information to women often involves going out to find them. “I once found a woman who did not know her status who came in and found out she was positive. She had a young child and blessed me afterwards. It really saves lives,” says Gueba.  Peer educators focus on areas with a lot of hotels and bars and also broker's houses, where sex workers find clients. At one broker’s office in Jimma, Gueba and Tesfaye speak to half a dozen sex workers about staying safe by using contraceptives. It’s the first time 21-year-old Jamila has heard about condoms. “I never used a condom before and it’s interesting to hear that,” she said. “Now I think I can keep myself from getting diseases.” Eighteen-year-old Ameya had left her family and village 100km away for the first time to find a job cooking, cleaning or waitressing, and had arrived at the broker’s house a day before. “I’m interested in the family planning methods and I think I might use them now. Maybe the Depo-Provera [contraceptive injection],” she said. Lydia, 22, met the peer educators when she turned to sex work a year ago. She knew nothing about condoms or family planning and returned for further counselling.   “I never tested for HIV and did not use contraception and now I test every three months and use Depo-Provera and condoms,” she said. “We are happy when we meet these people and we tell them our stories, the difficulties sex workers face and how they can protect themselves,” says Tesfaye. Men will offer to pay double or triple to not use a condom and brokers routinely take new girls’ virginity and have sex with them, often without using condoms, until they get clients. In Jimma and other regions, budget issues and reallocations mean that outreach services to sex workers have been cut in recent years.  “We had to decrease our catchment area and services by around 30 percent,” said the clinic’s manager Eremiah Getachew, who used to have 20 peer educators but had to let ten of them go.  The Global Gag Rule This followed fears that Ethiopia’s ten confidential clinics would have to close after Donald Trump re-instated the Global Gag Rule in 2017, which does not allow any US funding to go to organizations with links to abortion care.  Emergency funding from the Netherlands kept the clinics open, but some services changed.  “We have 61 clients in Gambella on ART [anti-retroviral treatment for HIV] and we could have lost them. In Jimma, we could have lost 120 clients on ART,” said Workineh. The Jimma clinic was also forced to stop giving sex workers sanitary products, soap and water purification tablets. It currently serves about 400 sex workers per month, rising to 600 during coffee harvesting, when more people come to the city. Gueba sees the effect that outreach has and wishes there was more funding for it. “I do this because it saves other people’s lives. Even if we didn’t get paid transport costs, I would still go and do it,” she said. “This is a really important job. And we need the world to know about it.”

portrait of Emebet Bekele is a former sex worker turned counsellor

“I used to be a sex worker, so I have a shared experience with them"

Emebet Bekele is a former sex worker turned counsellor, who works at the Family Guidance Association of Ethiopia (FGAE) run, confidential clinic in Jimma, Oromia. The clinic was set up in 2014 to help at-risk and underserved populations such as sex workers. The clinic provides free and bespoke services that include HIV and STI testing, treatment and counselling, contraceptives and comprehensive abortion care.  Counselling sex workers In her new role, Emebet counsels others about HIV and treatment with anti-retroviral drugs, follows up with them and monitors their treatment. Emebet tries to be a role model for other girls and women who are sex workers to adopt a healthier lifestyle “The nature of the sex work business is very mobile, and they often go to other places when the coffee harvest is good, so I tell them about referrals and take their phone numbers so I can keep counselling them”. “The difficult thing is sex workers using alcohol and drugs with ARVs [anti-retrovirals], which is not good and also means that they forget to take their medication. The best thing is that I know and understand them because I passed through that life. I know where they live so I can call them and drop medicine at their homes.” Bekele regularly tests sex workers and every month, “a minimum of five out of a hundred, maximum ten” test positive for HIV.  An increase in HIV cases Over the last five years, her reports show an increase in the number of HIV cases due to more sex workers coming in or changing clinics to attend the confidential clinic. Partly because the staff are friendly towards sex workers, who often report facing stigma in other public hospitals or being turned away when staff hear what they do. At the confidential clinic, people can walk-in any time, which better suits the sex worker lifestyle, but crucially, the service is confidential. “The ARV clinics in government hospitals are separate so everyone knows you have HIV. Also, people will see others crying and say that they have HIV,” says Bekele. A shared experience  “I used to be a sex worker, so I have a shared experience with them. When I came to this clinic I taught people about this place and the services and I counsel and train them. I didn’t have any knowledge about sex work so I also got infected. When I got knowledge, I decided I wanted to do something to help others.” “Sometimes clients add extra money for sex without condoms and sometimes sex workers have been drinking and don’t notice their clients have not used condoms. To have sex using a condom usually costs about 300 Ethiopian Birr [roughly USD 7] but it can go as low as 50 Birr [USD 1.20] or 20 Birr [USD 0.50], whereas sex without using a condom costs 200 to 300 Birr more or even up to 1000 Birr [USD 24].” When Bekele was a sex worker, she would take home about 7,000 to 8,000 Birr per month [roughly USD 170 to 190], after paying job-related expenses such as hotels, as well as for substances like alcohol to get through it. As a counsellor, she now gets 2,000 Birr to cover her travel costs.  “I have already stopped and I’m now a model for these girls. I have financial problems but life is much more than money.” “I see girls aged 10, 13 and 15 who live on the streets and take drugs. Sometimes we bring them from the streets and test them. Most of them are pregnant and I help them.” “This project is useful for our country because there aren’t any others helping sex workers and if there are ways to help them, we save many lives and young people. If you teach one sex worker, you teach everyone, from government to university staff and anyone who goes to see them, so I save many lives doing this job.”

Many Women with their children attend the clinic for sexual and reproductive services, treatment and advice. .
03 November 2022

Ethiopian refugees find help in the clinic with pink walls

It's mid-morning, and the Um Rakuba refugee camp on the southern border of Sudan is hot. There are few trees to take shade from the 40°c heat. The dusty main road is bordered on both sides by rows upon rows of huts and tents, temporary accommodation established by The United Nations High Commissioner for Refugees (UNHCR) for the tens of thousands of refugees who have fled over the border from neighbouring Ethiopia since fighting broke out between government forces and the Tigray People’s Liberation Front (TPLF) in November 2020. The severe humanitarian crisis has left more than 5 million people facing starvation.   This week, peace talks mediated by the African Union are taking place in South Africa in an aim to break the bitter impasse between the Tigray region and the Ethiopian federal governments and bring succour to the desperate people caught in the middle.      Many arrivals tell of being victims of armed groups, facing perilous situations, including looting of their houses, forceful recruitment of men and boys and sexual violence against women and girls. Refugees are arriving with little more than the clothes on their backs, fatigued and in weak conditions after sometimes days of travel.  The main road of the camp is peppered with the temporary offices of well-known charities, some providing food aid, others medical care. But there is only one clinic that has bright pink walls and welcomes women, girls, and men inside for free sexual and reproductive healthcare. The Sudan Family Planning Association (SFPA) quickly established a presence here once refugees started to arrive as they understood sexual and reproductive health is not only vital for women’s health and safety but very often overlooked by the humanitarian community. 

Young woman

2020: An unprecedented year

There are some years that become a pivotal moment in history - 2020 is one of those. IPPF has never been faced with delivering healthcare in the grip of a global pandemic. Yet our global teams have demonstrated agility, resilience, and creativity putting clients at the heart of our work to ensure the safe delivery of vital care. The pandemic has changed how we work, but not what we do. Here we acknowledge some of our amazing colleagues, clients, and partners as well as events that have shaped 2020. Expanding healthcare for factory staff Sandra is one of a team of women who work at a cashew factory in a small town in rural Ghana. Thanks to a project run in partnership by Planned Parenthood Association Ghana (PPAG) and the Danish Family Planning Association (DFPA) women like Sandra can now access contraceptive and reproductive healthcare during their working day. "It has helped me a lot, without that information I would have given birth to many children.”© IPPF/Natalija Gormalova Share on Twitter Share on Facebook Share via WhatsApp Share via Email Ensuring healthcare provision during the pandemic Malak Dirani, a midwife at the Lebanese Association for Family Health (SALAMA). “My message to healthcare workers across the world is that we are always here for people to secure their health and rights. We are on the frontline; we were always the one who people trust! We are the nation's guiding light during this difficult time, so we can, with our efforts and power support patients, overcome this crisis, and save lives.”© SALAMA Share on Twitter Share on Facebook Share via WhatsApp Share via Email COVID-19 crisis sparks innovation New approaches to reach women with safe abortion care include telemedicine and home-based provision of medical abortion. To ensure that quality abortion care can be provided to women during travel restrictions, the Cameroon National Planning Association for Family Welfare (CAMNAFAW)’s service providers travel to partner clinics in underserved areas and to clients’ homes to provide medical and surgical abortion care. This model of taking safe abortion care closer to women will continue even with easing of travel restrictions, as this has been found to be an effective and acceptable approach to increasing access.© IPPF/Xaume Olleros Share on Twitter Share on Facebook Share via WhatsApp Share via Email Getting creative on social media A watercolour entry for a social media art competition. “With our Youth Network we created an artistic competition on our Facebook and Instagram platforms on issues such as masturbation, menstruation, coming out, female genitalia, pornography. The aim is to enhance creativity and make young people reflect about sexual and reproductive health and rights in a creative way during the pandemic. The aim was also to offer something fun and positive in this difficult time.” Noemi, 24, is the co-founder and coordinator of Santé Sexuelle Suisse/Sexuelle Gesundheit Schweiz's Youth Network. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Delivering healthcare to remote communities in Fiji RFHAF Team in Kadavu performing general health checks after TC Harold. Healthcare provider, Nasi, administers an HPV shot to a client. In early April 2020, the all too familiar destruction of a Tropical Cyclone (TC) – Harold – hit the Solomon Islands, Vanuatu, Fiji and Tonga. One of the worst affected areas was the Eastern part of Fiji. Through support by Department of Foreign Affairs and Trade (DFAT), our Member Association, Reproductive and Family Health Association of Fiji (RFHAF), was quick to respond ensuring access to essential sexual and reproductive healthcare for Kadavu’s women, girls, and vulnerable groups.© IPPF/Rob Rickman Share on Twitter Share on Facebook Share via WhatsApp Share via Email Spotlight on women in leadership Executive Director, Dr Kalpana Apte, of FPA India talks about young people being a primary focus for access to healthcare and information. “Gender equality and equity is a fundamental issue that India must prioritize. India is a country of young people. That is the biggest cohort of people at this time in history. Within this group of young people, adolescent and young girls are the most marginalized group. The face of poverty in India is a young girl. Girls have fewer choices, options and opportunity. The gap between boys and girls in terms of access to sexual and reproductive health services and information is huge. Education, Health and empowerment are the three priorities for young girls.”© IPPF/Anurag Banerjee Share on Twitter Share on Facebook Share via WhatsApp Share via Email Humanitarian Youth Club, Kiribati Theta, 25, is part of the Humanitarian Youth Club set up by the Kiribati Family Health Association in her village. “I have helped the Humanitarian Youth Club to apply for financial grants from the Australian High Commission [for $1,000]. I am recognized as the smartest member who can write in English. We have learned how to design a disaster plan for the community and share our ideas on sexual and reproductive issues such as sexually transmitted infections. We discuss what we can do for the next strong tide, where we can gather as a community. For now, I want to enjoy the chance to be in our own beloved country. I won’t move until the majority have already left. I want my daughter to grow up in the same place I grew up in.”© IPPF/Hannah Maule-Ffinch Share on Twitter Share on Facebook Share via WhatsApp Share via Email Youth-led healthcare through song, dance, and poetry 17-year-old student Jumeya Mohammed Amin has been a ‘change agent’ for her community through the Family Guidance Association of Ethiopia since she was 14. "I wanted to protect girls from violence – like early marriage – and I wanted to change people’s wrong perceptions about sex and sexuality.”©IPPF/ Zacharias Abubeker Share on Twitter Share on Facebook Share via WhatsApp Share via Email Small but mighty: The Pill at 60 2020 marks the 60th anniversary of the game-changing contraceptive pill. For 60 years, “the Pill” has been approved for use in the US market, changing the face of reproductive control for millions of people since. Although taking a few years longer to become widely available to all women, the Pill was the first oral hormonal contraceptive. It allowed women to take real ownership over if and when they had children, and how many they had, giving them control over their lives in a way that had never been seen before.© Jessica Dance Share on Twitter Share on Facebook Share via WhatsApp Share via Email Being part of IPPF: What it means for Profamilia, Colombia Executive Director, Marta Royo. “For Profamilia, the value that the Federation adds is enormous. It gives us the possibility to exchange experiences and knowledge with other associations around the world, enriching our work, and allowing it to advance more quickly and with greater strength. This has allowed us to work with the most vulnerable populations in our country – from advocacy to healthcare service delivery, research, addressing issues as varied as abortion care, contraception and comprehensive sex education. Without this support, thousands of people in Colombia would not have access to any of these services.”© Profamilia Share on Twitter Share on Facebook Share via WhatsApp Share via Email Unprecedented support for women’s right to abortion care in Poland Huge numbers of people took part in protests prompted by the decision of the Constitutional Tribunal to impose a near ban on abortion on 22 October 2020. The ruling struck down the possibility for women to access abortion care on the ground of severe fetal impairment, rejecting what is the most common of the few legal grounds for abortion in the country at present. The demonstrations had a powerful impact, and on 3 November the government announced a delay in implementing its latest court ruling in response to the protests.© Marta Bogdanowicz Spacerowiczka Share on Twitter Share on Facebook Share via WhatsApp Share via Email US Election 2020 The people of the United States voted for change and progress. The reinstatement of the US Global Gag Rule in 2017 has had enormous consequences for women and girls accessing sexual and reproductive healthcare. IPPF calls on President-elect Biden to keep to his word of signing an executive order on his first day in office to repeal the harmful Global Gag Rule (the Mexico City Policy). © J. Smith/USA Share on Twitter Share on Facebook Share via WhatsApp Share via Email 16 Days of Activism Against GBV In humanitarian emergencies, women and girls may be forced to turn to survival sex work as a way of feeding themselves and their families. Without the usual healthcare available and low sexual health understanding, sex is frequently unprotected and violent, exposing them and their clients to sexually transmitted infections, including HIV. In fact, people who engage in sex work experience 10 times higher prevalence of HIV than the general population, with an average of a 12% rate of HIV infection.© Jem Milton Share on Twitter Share on Facebook Share via WhatsApp Share via Email Spotlight on sex and disability Joy & Jake talk sex and more to mark International Day of Persons with Disabilities. Joy and Jake – who are sight/visually-impaired – discuss the highs, lows, and everything in between of navigating sex, sexual health, dating, relationships and sex education, whilst living with a disability.© Bird Lime Media Share on Twitter Share on Facebook Share via WhatsApp Share via Email

Youth dancers in Jimma, Ethiopia
30 July 2020

Youth-led sexual healthcare through dance, song, and poetry

In Ethiopia, getting young people’s attention about sexual and reproductive healthcare is no easy task. But at a youth centre in Jimma, the capital Oromia region, groups of young people are getting vital messages about sexual health and contraception out to their peers through dance, song, and poetry. Student Jumeya Mohammed Amin came here to train as a peer educator for sexual and reproductive health [SRH] three years ago, when she was 14 years old. In her community – a conservative village 20 km outside the city – early marriage and pregnancy was common, and information about SRH practically unheard of. Navigating traditional norms “Girls younger than me at the time were married. The youngest was only nine,” said Amin, who would watch her classmates have to leave their home, school, and playmates behind. In Amin’s community, to opt out of unintended pregnancies involves unsafe abortion methods such as remedies prescribed by traditional healers – which can be fatal. “I know one girl from 10th grade who was 15 years old, and she died from this in 2017,” she said. But Amin’s work educating hundreds of young people each year on sexual health has changed attitudes in her community around early marriage, unplanned pregnancy and the options available to prevent it, she says, with many of her peers now waiting to start becoming sexually active. Tackling high rates of teen pregnancy Oromia has the third highest rate of teenage pregnancy in Ethiopia, after the Afar and Somali regions, says Dessalegn Workineh, who runs the Jimma office of the Family Guidance Association of Ethiopia [FGAE], which is supported by IPPF. “In Oromia, out of this rate of teen pregnancies, almost twenty percent end up in abortion,” he said. The region also has the third lowest uptake of contraceptives among women aged 15 to 49. 17-year-old peer educator Mastewal Ephrem says that the problem comes down to a lack of information. “People don’t know about reproductive health and they need this information about how to manage their family, sex and infections,” she said. Religious and social conservatism make this difficult, especially in poor and rural areas where families receive dowries in the form of money and gifts when their daughters marry. “Because of not having confidence and not talking to people, girls are doing early marriage,” said Ephrem. Poverty and other hardships also push girls out of their family homes early and leave them in precarious situations, where they run a high risk of encountering abuse. “I see girls aged 10, 13 and 15, who live on the streets and take drugs,” said Emebet Bekele, a counsellor working at an IPPF-supported clinic in Jimma that is aimed at helping sex workers. Bekele provides counselling and testing for HIV and STIs. She talks to girls and women about the full range of free and confidential family planning services available at the clinic. “Sometimes we bring them from the streets and we test them. Most of them get pregnant,” she said. She often supports students to get safe abortion care; including girls as young as 13. Taking sexual healthcare to the streets The youth centre reaches a lot of young people in schools and directs them towards the youth centre, where there is a library and many group activities and performances to teach them about SRH. Groups of young people practice and perform short plays and dances about topics such as unsafe sex and STIs here, as well as on the streets, where they draw a crowd. Fourteen-year-old Simret Abiyu has turned what she has learned into SRH-themed poems that she pens and performs to her peers in English, Amharic and Oromo. “Sometimes I get training here and write poems about family planning and the work of FGAE and the development of the country,” she said. Healthcare and advice via the phone University student Nebiyu Ephirem, 26, is a youth leader at the centre. He has been managing the two SRH helplines – located in a quiet back office – since it started in 2017. He answers a lot of calls from young people asking about contraception or their bodies and people dealing with emergencies and tries to answer their questions or refer them to public, private or FGAE clinics across the country. “Culturally, people used not to want to discuss sexual issues. They fear discussing these openly with family, and due to religious beliefs, so people like to call me,” said Ephirem. The youth centre reaches more than 11,000 young people a year through its work at schools, and through outreach clinics located in coffee plantations, where many young people work. Currently, the youth centre uses the helpline, radio adverts and social media to inform people about sexual health. The team hopes that media campaigns can spread the message wider in order to raise awareness about young peoples’ sexual health needs.

Jumeya Mohammed Amin

"I wanted to protect girls from violence – like early marriage – and I wanted to change people’s wrong perceptions about sex and sexuality"

Seventeen-year-old student Jumeya Mohammed Amin started educating other people about sexual and reproductive health when she was 14 years old. She trained as a ‘change agent’ for her community through the Family Guidance Association of Ethiopia’s south west office in Jimma, the capital of Oromia region. Amin comes from a small, conservative town about 20km outside the city. "I wanted to protect girls from violence – like early marriage – and I wanted to change people’s wrong perceptions about sex and sexuality, because they [men in her community] start having sex with girls at a young age, even with girls as young as nine years old, because of a lack of education." "They suddenly had to act like grown-up women" "Before I started this training I saw the majority of students having sex early and getting pregnant because of a lack of information, and they would have to leave home and school. Boys would be disciplined and if they were seen doing things on campus, expelled. Girls younger than me at the time were married. The youngest was only nine. They would have to go back home and could not play anymore or go to school. They suddenly had to act like grown-up women, like old ladies. They never go back to school after marriage. My teacher chose me for this training and told me about the programme. I like the truth so I was not afraid. I heard about a lot of problems out there during my training and I told myself I had to be strong and go and fight this." "I have a brother and four sisters and I practiced my training on my family first. They were so shocked by what I was saying they were silent. Even on the second day, they said nothing. On the third day, I told them I was going to teach people in schools this, so I asked them why they had stayed silent. They told me that because of cultural and religious issues, people would not accept these ideas and stories, but they gave me permission to go and do it. Because of my efforts, people in my school have not started having sex early and the girls get free sanitary pads through the clubs so they no longer need to stay home during periods." Training hundreds of her peers "I know people in my community who have unplanned pregnancies consult traditional healers [for abortions] and take drugs and they suffer. I know one girl from 10th grade who was 15 years old and died from this in 2017. The healers sometimes use tree leaves in their concoctions.  We tell them where they can go and get different [safe abortion] services. The first round of trainings I did was with 400 students over four months and eight sessions in 2017. Last year, I trained 600 people and this year in the first trimester of school I trained 400. When students finish the course, they want to do it again, and when we forget we have a session, they come and remind me. At school, they call me a teacher. I’d like to be a doctor and this training has really made me want to do that more."

young people sit and listen to a sexual health peer educator
27 July 2020

Ethiopia: Filling the sexual health gaps for young people through a unique youth center

Every Saturday, about 40 people gather at a youth center in Mekelle to hear about a subject they don’t get taught in schools in Ethiopia, and don’t want to discuss with their parents – sexual and reproductive health (SRH). This youth center located in the Tigray region of northern Ethiopia, is run by the Family Guidance Association of Ethiopia (FGAE) – it has a playground and library at the front for studying and socializing. In the back, there is a clinic and offices where staff provide a full range of SRH services, including free contraceptives, abortion care and testing and counselling for sexually transmitted diseases (STIs). “In our country, we have a huge amount of youth and adolescents and it is very important to work with them on sexual and reproductive health,” said Mebrahtu Abadi, who manages this center in Mekelle, the capital of Ethiopia’s Tigray region. Young people at the heart of the center Ethiopia has Africa’s second largest population and according to government studies, youth makes up roughly a third of its population.  The center is aimed at people aged between 10 and 24 years old and runs a range of activities, including holding sessions in schools to bring people in for talks and services. On Saturdays, groups of young people usually do some performance art based on a particular SRH subject, and hold debates and discussions around a coffee ceremony – a traditional Ethiopian social gathering. “In these ceremonies we prepare a poem or a short drama to entertain and educate using peer to peer methods about things like HIV and other sexually transmitted diseases, contraceptives, unplanned pregnancy and abortion”, said Abadi. The youth center has 20 peer educators – 10 male and 10 female – who provide counselling to others at the center, in schools and communities. Tigray is home to about five million people and Mekelle is a large university town, so the centre also works with campus clinics and with university and school clubs focusing on sexual health education. Peer educators leading the change There is always some giggling when the group’s leader, 24-year-old engineering student Tsegay Teklehaimanot, shows how to use male and female condoms. “They laugh and they love it,” he said. The club has more than a thousand members and the work the peer educators do is voluntary, but rewarding. “I’m proud of doing that thing because I am educating my friends and my family and protecting them,” says Teklehaimanot. Biology student Gebre Haileselassie says that young people will discuss things with their peers that they would be embarrassed to ask their parents. “In this place, we talk easily and are happy to talk,” he said. “The main message and point is how to protect ourselves, because in our world now, there are a lot of diseases and infections,” he said. The peer educators often stress the risks involved with drinking and having unprotected sex, especially with strangers.  “There are so many students that don’t know how to use condoms and [what to do] if something happens,” said Teklehaimanot. Unintended pregnancies often mean female students drop out of school, and most are not aware of other options, so the peer educators provide information and refer them to counselling services. Unsafe abortion numbers drop Baraki has been working at the main FGAE clinic in Mekelle for 21 years and seen the number of unsafe abortions performed by traditional healers drop in recent years, and the number of young people coming in for comprehensive abortion care rise.  “Especially in high schools and universities it has increased,” she said. “Nowadays awareness is increasing, especially in post-abortion complications and use of contraceptives,” she said. Complications arise due to traditional healers inserting sharp, unsterile instruments into the uterus or prescribing a concoction of antibiotics, toxic tree leaves and strenuous exercise.  In rural villages however, Baraki has seen the number of safe abortion decrease “due to some changing norms”, she says, although outreach services have also dropped due to budget cuts. Contraceptive shortages in rural areas Programs to help youth in rural areas have been scaled back in recent years due to a decrease in funding for SRH services from international donors and the government of Ethiopia. Mekelle had to cut its monthly visits to twelve rural districts in Tigray to once a quarter, then completely, and other partners have also stopped doing outreach in rural areas. “Nowadays they are not there and these services that are given by them are not supported now,” said Abadi. The cuts also mean that in Tigray, there are shortages of condoms and HIV testing kits, including at the youth center. Thanks to an FGAE program to provide free SRH services and products through public and private clinics, many young people and the poor from rural areas that come to Mekelle to sell produce now go to a 24-hour private clinic located in downtown Mekelle. Clinic owner Temegen Weldegiorgis says that many students come to get contraceptives, STI testing and comprehensive abortion care here because they can’t afford to pay for services, but fear being seen by family members at public clinics. The clinic serves a lot of teenagers who know nothing about family planning and the risk of STIs, and other underserved or unreached groups that need a drop in service in the center of town, such as farmers, sex workers, people living with a disability and veterans. “They need privacy and so come and have the service here,” he said.

Youth leader Nebiyu Ephirem, 26, has been staffing the phones at a hotline for young people who have questions about sexual and reproductive health since it started in 2017

"I'm a volunteer here, so it’s mental satisfaction I get from doing this"

Youth leader Nebiyu Ephirem, 26, has been staffing the phones at a hotline for young people who have questions about sexual and reproductive health (SRH) since it started in 2017 in Ethiopia’s Oromia region.  The helpline has two phones and is free, anonymous and open six days a week. The helpline is aimed at people aged 17-26 who are curious about SRH but are too shy or afraid to ask others about topics such as contraception, menstruation, and diseases.  The hotline also advises people dealing with emergencies following unprotected sex and issues such as unintended pregnancy and concerns over sexually transmitted infections (STIs), by referring people to their nearest clinic.  About 65 to 70 percent of the callers are female. Ephirem also trains other people about SRH and how to educate more young people about this. Being on call for his community  “Most days, I get about 30 to 40 calls and on a Saturday, around 50. People ask about contraceptive methods like pills and emergency contraceptives and depo provera [three-month injectable contraceptive], about the spread of STIs and HIV and how to prevent it, and about menstruation and sanitation. I give my suggestions and then they come and use Family Guidance Association of Ethiopia (FGAE) services, or I refer people to clinics all over the country. There are seven FGAE clinics in this area and dozens of private clinics. Young people need information about STIs before they come to the clinic, and when they want a service they can know where the clinics are. Most of them need information about menstruation and contraception. They fear discussing this openly with family and due to religious beliefs, so people like to call me. Culturally, people used to not want to discuss sexual issues. We took the information from IPPF documents and translated them into the two local languages of Oromia and Amharic, with the help of university lecturers. After four years, even the religious leaders did this training. We have trained university students, teachers and many more people to be trainers and 30 of them graduated. They [the people who dropped out] did not want to hear about the names in the local language of body parts. Most of the ones who stayed were boys and girls, but now we have women doing this. [At first], they were laughing and said: ‘How could you talk like this? It’s shameful. But slowly, they became aware. They now talk to me, they discuss things with their parents, families, even teachers at school and friends.” Lack of sex education  There is no sex education in Ethiopia’s national curriculum but youth groups and activists like Ephirem and his colleagues go into schools and teach people through school clubs. “This year [2019] up to June we trained 16,000 people and reached 517,725 adolescents and young people aged 10 to 24 through the helpline, social media – Facebook, Twitter and YouTube – workshops, radio talk shows and libraries.” A banner in Jimma town promotes the helpline and its number 8155, as does Jimma FM radio.  “The target for reaching people in school was 5,400. We achieved 11,658. The most effective way to reach people is at school. At the coffee plantation sites we reach a lot of people.”  The minimum family size around here is about five and the maximum we see is 10 to 12. In our culture, children are [considered as a sign of] wealth and people think they are blessed [if they have many]. When we go to schools to teach them, there are kids that already have kids. But after we teach them, they generally want to finish education and have kids at 20-25-years-old. We tell people they have to have kids related to the economy and to their incomes and we calculate the costs to feed and educate them. I’m a volunteer here, so it’s mental satisfaction I get from doing this. I get 1000 Ethiopian Birr [roughly USD 30] per month for transport costs. I am also studying marketing at university and want to become a business consultant.”

Midwife Rewda Kedir examines a newborn baby and mother in a health center outside of Jimma, Ethiopia

"Before, there was no safe abortion"

Rewda Kedir works as a midwife in a rural area of the Oromia region in southwest Ethiopia. Only 14% of married women are using any method of contraception here.  The government hospital Rewda works in is supported to provide a full range of sexual and reproductive healthcare, which includes providing free contraceptives and comprehensive abortion care. In January 2017, the maternal healthcare clinic faced shortages of contraceptives after the US administration reactivated and expanded the Global Gag Rule, which does not allow any funding to go to organizations associated with providing abortion care. Fortunately in this case, the shortages only lasted a month due to the government of the Netherlands stepping in and matching lost funding. “Before, we had a shortage of contraceptive pills and emergency contraceptives. We would have to give people prescriptions and they would go to private clinics and where they had to pay," Rewda tells us. "When I first came to this clinic, there was a real shortage of people trained in family planning. I was the only one. Now there are many people trained on family planning, and when I’m not here, people can help." "There used to be a shortage of choice and alternatives, and now there are many. And the implant procedures are better because there are newer products that are much smaller so putting them in is less invasive.” Opening a dialogue on contraception  The hospital has been providing medical abortions for six years. “Before, there was no safe abortion," says Rewda. She explains how people would go to 'traditional' healers and then come to the clinic with complications like sepsis, bleeding, anaemia and toxic shock. If they had complications or infections above nine weeks, Rewda and her colleagues would send them to Jimma, the regional capital. "Before, it was very difficult to persuade them to use family planning, and we had to have a lot of conversations. Now, they come 45 days after delivery to speak to us about this and get their babies immunised," she explains. "They want contraceptives to space out their children. Sometimes their husbands don’t like them coming to get family planning so we have to lock their appointment cards away. Their husbands want more children and they think that women who do not keep having their children will go with other men." "More kids, more wealth" Rewda tells us that they've used family counselling to try and persuade men to reconsider their ideas about contraception, by explaining to them that continuously giving birth under unsafe circumstances can affect a woman's health and might lead to maternal death, damage the uterus and lead to long-term complications. "Here, people believe that more kids means more wealth, and religion restricts family planning services. Before, they did not have good training on family planning and abortion. Now, women that have abortions get proper care and the counseling and education has improved. There are still unsafe abortions but they have really reduced. We used to see about 40 a year and now it’s one or two." However, problems still exist. "There are some complications, like irregular bleeding from some contraceptives," Rewda says, and that "women still face conflict with their husbands over family planning and sometimes have to go to court to fight this or divorce them.”

a midwife attends to a pregnant woman in a clinic - Ethiopia
16 July 2020

Delivering healthcare to women in rural Ethiopia

In a room that is bare but for a few beds, Kuzema Abba Naga is resting after giving birth hours before to her tenth child, and now she thinks, her last. Before coming from her village to this remote and rural government health center in the Kebele district to give birth, Naga never knew it was possible to choose when or whether to have a baby. “I am 38 years old and I had my first baby at age 15,” she said. “This is my first baby for eight years.” Naga named the baby Nejat, which translates to ‘liberation’, after giving birth and discovering the contraception options available to her, she decides to have an IUD fitted immediately. Lack of access to contraception in rural areas This is the first time midwife Rewda Kedir has fitted a woman who has just had a baby with an IUD, though it is not uncommon to meet women coming from rural areas who have never heard about family planning. When they do, many are interested in it, even if they have to fight their husbands to use it or they are forced to hide it from them. “They want contraceptives to space out their children,” said Kedir. “Sometimes their husbands don’t like them coming in to get family planning, so we have to lock their appointment cards away. Their husbands want more children and some think that women who do not keep having their children will go with other men,” she said. Kedir says that most women prefer using the contraceptive implants because they feel few side effects, are long-lasting, easy and painless to have fitted and to conceal. “Here, people believe that more kids means more wealth, and religion restricts family planning services,” she said. “Only 28 percent of women aged 15 to 49 use modern contraceptives,” says Dessalegn Workineh, who manages the Family Guidance Association of Ethiopia’s south west area office in Jimma. Expanding contraceptive access in Ethiopia  With support from the Family Planning Association of Ethiopia (FGAE), who work with the Ethiopian government, clinics in remote rural areas like this one can now provide a full range of sexual and reproductive health (SRH) services for free.  Having all the products and services available and under one roof makes it easier to reach people who might really benefit from help with family planning.  In Oromia, 43 percent of women give birth at a health facility. Kedir finds a lot of women coming in for maternal and post-natal health services who she speaks to about family planning, end up staying or returning to get family planning services.   “Before, it was very difficult to persuade people to use family planning and we had to have a lot of conversations. Now, they come 45 days after delivery to speak to us about this when they get their babies immunised,” she said.  Staff at the clinic also provide family counselling to try and encourage men that contraception is a good idea for the whole family. “We tell them that continuously giving birth can affect the mother’s health and might lead to maternal death, damage the uterus and lead to long-term complications,” said Kedir. A number of staff at the clinic have been trained on family planning and can answer queries and deliver services, “So when I’m not here, people can help.” “The implant procedures are better because there are newer products,” said Kedir, who sits next to a handmade poster with the options for contraception glued on that still has the older, match-sized implants and the new, thinner implants. Providing comprehensive abortion care The clinic also provides comprehensive abortion care and for the past six years, medical abortions. This involves taking a pill rather than having vacuum aspiration or surgery, and is helping to stop women turning to unsafe abortion methods. “Before, there was no safe abortion. People would go to traditional healers and then come here with complications like sepsis, bleeding, anaemia and toxic shock,” said Kedir.  “The good thing is that the women that have [safe] abortions get proper care and the counselling and education has improved,” said Kedir. In Ethiopia, these services are vital “to save mothers from dying due to cases of unsafe abortion,” says Workineh. “Working on comprehensive abortion care reduces complications and therefore maternal mortality,” he added. Kedir says women still have to fight their husbands to get access to family planning and cases can end up in court or divorce. But the cases of complications resulting from unsafe abortion have plummeted.  “We used to see about 40 a year. Now it’s one or two,” she said.

peer educators doing outreach work with sex workers providing them with information on their sexual health and contraception
03 July 2020

Providing a safe space for sex workers in Ethiopia

At a small clinic in a quiet, residential neighborhood, ten women are preparing to hit the streets for a day of potentially life-saving work; by donning white coats and filling their handbags with condoms. These peer educators are former or current sex workers who teach others how to protect themselves from sexually-transmitted infections (STIs) and unintended pregnancy. Their mission is to educate sex workers about STIs, HIV and contraceptives, distribute condoms and persuade people to access the full range of services at a confidential clinic in Jimma, the capital of Ethiopia’s Oromia region. “It’s very difficult to convince sex workers to come to the clinic,” said Meseret Girma*, a 25-year-old peer educator. “Some sex workers tend to have no knowledge, even about how to use a condom,” she said. A safe space for underserved populations The Jimma confidential clinic was set up in 2014 to help at-risk and underserved populations like sex workers receive free and bespoke services that include HIV and STI testing, treatment and counselling, contraceptives and comprehensive abortion care. The peer educators work as volunteers and receive 2,000 Ethiopian Birr (about USD 60) per month for travel costs.  Their work is challenging, and they travel in pairs for safety because some people do not welcome their messages. “When we try to tell people about HIV we can be insulted and told: ‘You are just working for yourself and earn money if you bring us in.’ They sometimes throw stones and sticks at us,” said 25-year-old Melat Tesfaye*.  They also have a hard time persuading women that the staff at the confidential clinic are friendly towards sex workers and will keep their information private. “They have had bad experiences at other clinics so they fear coming in, or they are scared about being tested for HIV,” said Gueba. “In other clinics, they don’t keep people’s HIV status confidential. Doctors and nurses discuss it in public,” she said. But a lot of sex workers ask questions about HIV and what to do if they test positive. Working with people living with HIV The Oromia region ranks sixth out of eleven regions for HIV prevalence rates but has the greatest number of people living with HIV due to its large population, says Dessalegn Workineh, who manages the Family Guidance Association of Ethiopia’s (FGAE) south west area office in Jimma. “There is a need to work on awareness raising on HIV and AIDS,” he said, particularly among women. Another confidential clinic operates in the nearby region of Gambella, where HIV prevalence is high. “A 2016 study shows that only 17 percent of women in Oromia were aware of HIV, compared to 35 percent men,” and in the capital Addis Ababa where 42 percent of women and 52 percent of men knew about HIV, he said. Reaching sex workers Getting information to women often involves going out to find them. “I once found a woman who did not know her status who came in and found out she was positive. She had a young child and blessed me afterwards. It really saves lives,” says Gueba.  Peer educators focus on areas with a lot of hotels and bars and also broker's houses, where sex workers find clients. At one broker’s office in Jimma, Gueba and Tesfaye speak to half a dozen sex workers about staying safe by using contraceptives. It’s the first time 21-year-old Jamila has heard about condoms. “I never used a condom before and it’s interesting to hear that,” she said. “Now I think I can keep myself from getting diseases.” Eighteen-year-old Ameya had left her family and village 100km away for the first time to find a job cooking, cleaning or waitressing, and had arrived at the broker’s house a day before. “I’m interested in the family planning methods and I think I might use them now. Maybe the Depo-Provera [contraceptive injection],” she said. Lydia, 22, met the peer educators when she turned to sex work a year ago. She knew nothing about condoms or family planning and returned for further counselling.   “I never tested for HIV and did not use contraception and now I test every three months and use Depo-Provera and condoms,” she said. “We are happy when we meet these people and we tell them our stories, the difficulties sex workers face and how they can protect themselves,” says Tesfaye. Men will offer to pay double or triple to not use a condom and brokers routinely take new girls’ virginity and have sex with them, often without using condoms, until they get clients. In Jimma and other regions, budget issues and reallocations mean that outreach services to sex workers have been cut in recent years.  “We had to decrease our catchment area and services by around 30 percent,” said the clinic’s manager Eremiah Getachew, who used to have 20 peer educators but had to let ten of them go.  The Global Gag Rule This followed fears that Ethiopia’s ten confidential clinics would have to close after Donald Trump re-instated the Global Gag Rule in 2017, which does not allow any US funding to go to organizations with links to abortion care.  Emergency funding from the Netherlands kept the clinics open, but some services changed.  “We have 61 clients in Gambella on ART [anti-retroviral treatment for HIV] and we could have lost them. In Jimma, we could have lost 120 clients on ART,” said Workineh. The Jimma clinic was also forced to stop giving sex workers sanitary products, soap and water purification tablets. It currently serves about 400 sex workers per month, rising to 600 during coffee harvesting, when more people come to the city. Gueba sees the effect that outreach has and wishes there was more funding for it. “I do this because it saves other people’s lives. Even if we didn’t get paid transport costs, I would still go and do it,” she said. “This is a really important job. And we need the world to know about it.”

portrait of Emebet Bekele is a former sex worker turned counsellor

“I used to be a sex worker, so I have a shared experience with them"

Emebet Bekele is a former sex worker turned counsellor, who works at the Family Guidance Association of Ethiopia (FGAE) run, confidential clinic in Jimma, Oromia. The clinic was set up in 2014 to help at-risk and underserved populations such as sex workers. The clinic provides free and bespoke services that include HIV and STI testing, treatment and counselling, contraceptives and comprehensive abortion care.  Counselling sex workers In her new role, Emebet counsels others about HIV and treatment with anti-retroviral drugs, follows up with them and monitors their treatment. Emebet tries to be a role model for other girls and women who are sex workers to adopt a healthier lifestyle “The nature of the sex work business is very mobile, and they often go to other places when the coffee harvest is good, so I tell them about referrals and take their phone numbers so I can keep counselling them”. “The difficult thing is sex workers using alcohol and drugs with ARVs [anti-retrovirals], which is not good and also means that they forget to take their medication. The best thing is that I know and understand them because I passed through that life. I know where they live so I can call them and drop medicine at their homes.” Bekele regularly tests sex workers and every month, “a minimum of five out of a hundred, maximum ten” test positive for HIV.  An increase in HIV cases Over the last five years, her reports show an increase in the number of HIV cases due to more sex workers coming in or changing clinics to attend the confidential clinic. Partly because the staff are friendly towards sex workers, who often report facing stigma in other public hospitals or being turned away when staff hear what they do. At the confidential clinic, people can walk-in any time, which better suits the sex worker lifestyle, but crucially, the service is confidential. “The ARV clinics in government hospitals are separate so everyone knows you have HIV. Also, people will see others crying and say that they have HIV,” says Bekele. A shared experience  “I used to be a sex worker, so I have a shared experience with them. When I came to this clinic I taught people about this place and the services and I counsel and train them. I didn’t have any knowledge about sex work so I also got infected. When I got knowledge, I decided I wanted to do something to help others.” “Sometimes clients add extra money for sex without condoms and sometimes sex workers have been drinking and don’t notice their clients have not used condoms. To have sex using a condom usually costs about 300 Ethiopian Birr [roughly USD 7] but it can go as low as 50 Birr [USD 1.20] or 20 Birr [USD 0.50], whereas sex without using a condom costs 200 to 300 Birr more or even up to 1000 Birr [USD 24].” When Bekele was a sex worker, she would take home about 7,000 to 8,000 Birr per month [roughly USD 170 to 190], after paying job-related expenses such as hotels, as well as for substances like alcohol to get through it. As a counsellor, she now gets 2,000 Birr to cover her travel costs.  “I have already stopped and I’m now a model for these girls. I have financial problems but life is much more than money.” “I see girls aged 10, 13 and 15 who live on the streets and take drugs. Sometimes we bring them from the streets and test them. Most of them are pregnant and I help them.” “This project is useful for our country because there aren’t any others helping sex workers and if there are ways to help them, we save many lives and young people. If you teach one sex worker, you teach everyone, from government to university staff and anyone who goes to see them, so I save many lives doing this job.”