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"One day, when I returned from work, Ms. Glenda and Mr. Martin from Pro-Familia were at my house. I heard what the volunteering was about, regarding the education of the men in the community, how to teach how to stop machismo, to be less violent, how to give the talks and visit the clients. They also talked about the contraceptive methods, medicines and many things that would change people's lives. The proposal seemed important to me and I accepted, since I like to work for my people," recalls José.  In 2008, the Asociación Demográfica Salvadoreña (Pro-Familia) developed a project focusing on sexual and reproductive health and the active participation of men in rural areas. It concentrated specifically on the integration of male participation in sexual and reproductive healthcare. Since 2014, the project has been integrated into the Community-Based Programme as part of the provision of healthcare for rural men.  "When I gave the talks on masculinities, they questioned me: 'Why can't you scream at home, if you're the man?' Or 'who do you think you are to say those things?', questions that I also asked myself once", says José. "Thanks to the training I have had and the support of the Pro-Familia staff, I have managed to learn and clarify my doubts. I take care of my own health, I share the responsibilities at home, I take care of my two-year-old son – before volunteering, I thought it was a woman’s job, I didn't do that."  Ensuring access to information and contraception   Educational activities in sexual and reproductive health remain a challenge, but Pro-Familia is committed to delivering their strategy. The role of the health promoter is to advocate – with other men – the use of contraception, counselling couples, and providing supplies (especially condoms) and medicines.   "I like the communication I have with the Pro-Familia staff, and the training reinforcements – they should keep it that way, because it's the way to learn and do things better in the community," he says.  "The change begins with oneself and then transmits it to others. I gather men in talks, make visits to their homes, give guidance on prevention of sexually- transmitted infections, on family planning, and how not to be violent", says José. "Older adult men are more difficult to change."  Increasing contraceptive use among men   José has seen the positive change among men in his community and those small achievements encourage him to keep going. "When men ask me about violence and condom use, I feel encouraged. For example: a co-worker uses a condom and confidently tells me that he does it because he learned from the talks he received, that motivates me to continue guiding towards new masculinities."  The Community-Based Program has a special fund for clients who are referred by promoters for a voluntary surgical contraception (VSC) procedure, so the service is free of charge for clients. In this regard, José is aware that there is still work to be done: "The issue of vasectomy is difficult with men in the community, the challenges continue."  "In the community, young people 'get to live together' [marital union] at an early age. Maybe I cannot change that, but I can help them to be better people, to respect each other. Just as I changed, so can other men," says José. 

"I decided to become a volunteer at Pro-Familia when I heard a talk the staff were giving at the Acajutla City Hall, where they explained what they were doing in the communities with the program, and they invited us to be part of the volunteer service. I liked what I could do with the men in the community. It’s been two-and-a-half years." Juan Martinez Leon is a volunteer with the Asociación Demográfica Salvadoreña (ADS/Pro-Familia) community-based programme. Juan’s remit is broad, working mainly with men to provide information on contraceptive methods and counselling to individuals and couples. He also provides contraceptive methods including the Pill, injectables and, especially, condoms. For some hormonal contraceptive methods, Juan refers his clients to Pro-Familia clinics or other public health facilities. Putting community first "I like to work for my community, despite the difficulties, and I help in four more communities for them to have the [contraceptive] methods and medicines, because they come to get me," says Juan. "I give talks on the soccer field in front of my house or I have meetings at my house. My children help me invite men to come and they also learn and admire the work." Juan visits clients at home and organizes talks – mainly with other men – to promote the importance of contraceptive use, and women and children's health. The importance of men’s health and their family group is a key element in Juan's role as a health promoter. “I like providing family planning counselling, because sometimes men don't like women using anything to prevent pregnancy. When I talk with the men of my community, people's lives change and you see the difference: you no longer see the domination over women, they let women plan, and [the woman] no longer requests the method secretly – although there are still some women who hide from their husbands. That's why we have to continue working on counselling, that's what awakens them." Changing behaviour and attitudes Juan runs informative talks on reproductive health and the prevention of STIs and HIV. "In some talks, some men have come out angry and questioned me. Who am I to tell those things? ‘Someone who has learned and who respects people's rights,’ I tell them. Now men come to ask for condoms, and even my wife confidently gives the condoms to them. She also supports me." Some men thank Juan for having "awakened their minds", and encouraged them to change to respect women and to help at home. “I think I help my community a lot. You wake them up. I like what I do, I like to help. Before there was no promoter and they had women submerged. Little by little that is changing, but only by talking to men is it achieved. I want to continue learning about sexual and reproductive health issues, it never ends. I would like to continue in training as we used to before the pandemic, and for Pro-Familia to come more often. Until God tells me, I feel that it is my obligation to attend to men or whoever seeks me to help them. That's what I'm for.”

"I started as a Pro-Family Health Promoter 30 years ago. I received a visit from Pro-Familia staff on several occasions and I was very interested in what I could do to help in my community as a volunteer, so I accepted. I was trained in sexual and reproductive health issues, and in the technique of injecting [contraceptives]", says Juana Margoth.  Since 1974, the Asociación Demográfica Salvadoreña (ADS/Pro-Familia), has been providing sexual and reproductive healthcare to marginalized communities in rural and peri-urban areas. Through their Pro-Family Health Promoter and community-based programme, the Pro-Familia teams provide information and contraceptive care and supplies to vulnerable populations. Today, the programme has around 900 health promoters throughout El Salvador.  Building relationships and trust   Juana Margoth is one of these health promoters who provides care across four local villages in Hacienda El Edén, in Sonsonate, where the Ministry of Health does not have a presence.   "I like that women know that I am here to help them, also to give advice and understand each person's problem; [to help them] to plan their family, and I like the fact that they want to do it with me," she says.  She receives a quarterly supply of contraceptives that she distributes at low prices to the women in her community.  "I make visits in the communities to the clients I already have, to see if they are okay with the [contraceptive] method, and to receive new clients. Sometimes even the same clients tell me that there is someone who needs a visit. I like that they look to me to help them – I give confidence to the clients, to their partners too. I have clients since two, five or six years ago. There is a lot of need, so I am here, until God wants it." Providing contraceptive advice Juana Margoth also highlights the importance of guiding women and men, providing counselling to clients so that they understand the different methods and contraception, and how to use it: "In other places they only give the contraceptive methods to women and do not explain [on its use]." Veronica has been a regular client of Juana Margoth’s for eight years, receiving counselling and contraceptives. "Margoth has changed our life, mine and my family’s, I have been planning with her for eight years, she is kind and always has the method I use. When I have doubts, I ask her with confidence, without shame, and I can go to her house at any time, she is always there. I don't like going to the health unit, because it costs a lot of money, and sometimes they don't have contraceptives; nowadays, with the pandemic, we have Margoth close and she never stopped treating me, it is very helpful in our community."  Responding to humanitarian disasters   As well as the community-based programme, Pro-Familia supports the network of volunteer promoter's humanitarian crises, such as natural disasters. Pro-Familia conducts a survey of needs and responds with support for reconstruction, healthcare, and food security.  "I have a lot to thank Pro-Familia for. I have learned and continue to learn with them, they are always there when I need to know something, when I run out of contraceptives and without medications [for the program]; I am also grateful because I have my prefabricated house thanks to Pro-Familia who helped me when the earthquake of 2001 happened, several years ago."

"I remember that I joined Pro-Familia on July 1, 2011. I had many fears and questions at that time, because I did not know about sexual and reproductive health issues, and had no experience working with contraceptive methods. It was something completely new for me, but I really wanted to learn," says Elga.  Elga is one of the Community Health Workers in the Asociación Demográfica Salvadoreña’s (Pro-Familia) Community-Based Program team. She remembers that when she first started her training, she felt that her role was small and unimportant – but over the time she learned and gained in confidence, understanding the positive impact she was having in the local communities.  "I found the reason to live, I found a purpose: knowing people’s situations, their difficult situations, that is special for me. Feeling they miss me when they spend days without seeing me because I am in different communities, that is something important, it means they value my work."  Sharing knowledge and experience   Elga believes that she has gained a lot personally. "I have learned a lot about women's rights; I apply everything about sexual and reproductive health in my personal life, I do not allow abuse by my partner and I teach my son to respect people. I learned to use contraception for my own benefit," she says.  Communication was very difficult for Elga. She considered herself shy and was very quiet. Today she talks with people, in front of large groups of students in schools, expresses her ideas and provides counselling.  "I enjoy what I do, I prepare to visit the volunteer promoters, to train them and resolve any doubts or questions that arise. They are very intelligent, and I intend to have the best volunteers. I enjoy visiting families in the community, having the opportunity to give family planning counselling, work on the prevention of cervical and breast cancer, work with young people, help them to change their lives, to find new paths, free from violence, just as I found my purpose."  Communities benefit from access to care  She admires the work of Pro-Familia, as no other organization has permanent programs and subsidized healthcare, which is of enormous benefit to the local community.  Elga has seen many clients since she started volunteering. She recalls encouraging a woman to come to the cervical screening clinic: "The lady had never had a cervical screening. I gave her counselling and a referral so that she could come to the Pro-Familia clinic. Her result was cervical dysplasia – level 1, I followed her until she received the treatment. Now, every time she sees me, she thanks me for guiding her and inviting her to the clinic," Elga says with joy.  She also remembers the first time she suggested a vasectomy to a client. "First, I made the reference to the women client, but because of health reasons she could not be sterilized, and she was very sad because using hormonal methods also affected her health. So I decided to give counselling to the client's partner, who agreed to a vasectomy. The intervention was successful, and he is well, and grateful to me and to Pro-Familia", she recalls.  The issues of sexual and reproductive health and contraceptive care are still taboo in many communities. Changing attitudes to improve the lives of individuals and families remain a vital focus. Counselling is key to recognizing that health and contraceptive care are fundamental rights, and to eliminate myths and beliefs that prohibit the use of contraception. Volunteers like Elga remain integral to this process to bring about positive change for the future. 

"I am a volunteer health promoter by inheritance. First, my mother volunteered with Pro-Familia for 15 years, when she resigned to go to the United States. I learned to volunteer when I was little, because I saw how my mother did it", Alicia recalls.  The community spent some years without a volunteer health promoter after Alicia’s mother left. During that time, women came to Alicia to encourage her to contact the Asociación Demográfica Salvadoreña’s (ADS/Pro-Familia)to bring back the programme to the Santo Domingo village, 90 minutes outside of San Salvador. In the absence of a local public health facility, Alicia decided to become a Pro-Familia volunteer to support her community.  "When my mother left, I agreed to collaborate just to promote the cervical screening clinic, but Pro-Familia suggested that I be a volunteer, like my mother, and I accepted. Today, it’s been two years. They have trained me at home on sexual and reproductive health issues, counselling, home visits and the use of brochures, and I also learned to inject." Changing people’s lives   Alicia is an entrepreneur with a strong spirit of care towards her family and community. Every day she attends her small business that provides the community with basic products.   "I help change people's lives; the women are happy and grateful, because they no longer go to Guazapa to buy contraceptive methods. Pro-Familia trains me and I coordinate with other institutions in the community – such as the church – to help people", she says.   Alicia says that counselling is a crucial part of her work: "Counselling is very important, women learn to use [contraceptive] methods and stop thinking that it is a sin. I help them to understand that family planning is a right. I had a case of a client where the husband was the one who decided which method to use and make her change it very often. One day I explained to him about the benefits of using only one family planning method, the effects of changing very often on her menstruation and that she had the right to decide whether or not to change. He understood and thanked me for taking the time to speak to him; from that day on the client keeps one family planning method and the husband respects her decision." Alicia dreams of having a larger place for her clients, or to have a table to administer the injectable, but despite the limited space she enjoys her work. "I like it and I am happy to know that I can help. Many users come at night to pick up their methods because they work out of house and I take care of them with great pleasure, when they miss their appointment, I look after them, I speak to them by phone or I send them a WhatsApp message."  Ensuring trust and confidence       Ruth Séfora Manzano has known Alicia for several years before she had children."I like Alicia because she is a respectful person, she likes to help people, she gives me confidence, and you can trust your personal things to her because she doesn't tell anyone. She looked after me when I got pregnant and she also cares about my daughter. She guides me on how taking care of myself and the baby – she is a kind person, that's why I plan with her, and if I need other medicines I also buy them from her. I also like it because it is close to my house. She gives me the shots, and I don't have to go elsewhere – I am grateful for her help and Pro-Familia's." 

When Blanca started volunteering with the Asociación Demográfica Salvadoreña’s (ADS/Pro-Familia), she committed to her new role with enthusiasm. Her thoughts were about how the women of La Loma village would benefit from being able to access contraceptive methods close to home.  "Many women walk up to an hour-and-a-half from the villages of the Guazapa Hill to receive family planning services, or to receive counselling," 61-year-old Blanca Edith Mendoza Ramos says proudly.   Her house is a cosy and special place for the clients. "I have been a Pro-Familia volunteer for 29 years. When I started, I had already had my five children. I was busy at home, but when the Pro-Familia staff explained to me about working in my community, I trusted it was important to support women. I have learned a lot and I continue to do so. I have received training that helps me to be a better person, to have knowledge and to give good advice; I have received many people from Pro-Familia in these years, and always with great responsibility", she says.  A confidential and cosy place    To ensure her clients’ confidentiality, Blanca has created a private room with a sofa where she provides counselling and administers injectable contraceptive methods. By creating a private space, Blanca has built up trust in the community and women prefer to go to her for contraception and advice.  "I am proud to help in my community. I visit clients to see if they have any side effects, when they do not come to receive their method, to know if they are well, or to recruit new clients who are encouraged to use a family planning method, because their families are already very large." Although the public health facility provides free healthcare, women from other local communities prefer to see Blanca because she is closer and offers confidential personalized care.   "The Health Unit is not close, so women prefer to plan with me. They come with confidence to apply their method. On their first visit, I ask them a few questions about their health, and if everything is okay, they plan with me. I think that family planning is important for the spacing of the children and that it is not only the use of methods, but also communication with the couple", reflects Blanca. 

Women around the world have faced multiple barriers to accessing safe abortion care during the COVID-19 pandemic including the de-prioritization of sexual and reproductive healthcare, overwhelmed health systems and restrictions on movement. The COVID-19 crisis has sparked innovation among IPPF Member Associations who responded swiftly by developing new approaches to reach women with safe abortion care including telemedicine and home-based provision of medical abortion. Strong evidence generated from this work supports the continuation and strengthening of these approaches beyond the end of the pandemic. Cameroon Cameroon National Planning Association for Family Welfare (CAMNAFAW) To ensure that quality abortion care can be provided to women during travel restrictions, 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.Photo: IPPF/Xaume Olleros/Cameroon Share on Twitter Share on Facebook Share via WhatsApp Share via Email Guinea Association Guinéenne pour le Bien-Etre Familial (AGBEF) Building on lessons learned during the Ebola crisis in Guinea, AGBEF quickly took measures to prevent infection in its clinics to continue providing sexual and reproductive healthcare, including surgical and medical abortion, in a safe environment. AGBEF donated protective materials to communities, including hand-washing stations, face masks and antibacterial gel, alongside messaging on infection prevention. This community visibility reassures clients they can safely attend AGBEF clinics for abortion and contraceptive care.Photo: AGBEF/Guinea Share on Twitter Share on Facebook Share via WhatsApp Share via Email India Family Planning Association of India (FPA India) FPA India and partners advocated to have sexual and reproductive healthcare, including abortion, recognized as essential by the government, which meant FPA India could continue healthcare delivery during the national lockdown. To reduce in-person clinic visits, FPA India established teleconsultation and counselling for abortion care, and is continuing to provide in-clinic care for both medical and surgical abortion. Photo: IPPF/Alison Joyce/India Share on Twitter Share on Facebook Share via WhatsApp Share via Email Nepal Family Planning Association of Nepal (FPAN) FPAN and partners advocated for interim approval of home provision of medical abortion and telemedicine for abortion counselling during COVID-19. FPAN is now implementing these approaches, ensuring continued access to abortion care in Nepal, where many people live in remote locations with limited mobility, which has been further restricted by COVID-19 lockdowns. Photo: FPAN/Nepal Share on Twitter Share on Facebook Share via WhatsApp Share via Email Pakistan Rahnuma – Family Planning Association of Pakistan (Rahnuma-FPAP) Rahnuma-FPAP and partners successfully advocated for the government to class sexual and reproductive healthcare as ‘essential’, which enabled the team to continue providing post-abortion care during the pandemic. Rahnuma-FPAP expanded its telemedicine and home-based provision for menstrual regulation counselling and post-abortion care. These new approaches have ensured continued access to services for clients unable to reach clinics.Photo: Rahnuma-FPAP/Pakistan Share on Twitter Share on Facebook Share via WhatsApp Share via Email Palestine Palestinian Family Planning and Protection Association (PFPPA) In response to the government-mandated closure of its clinics, PFPPA quickly established a toll-free call centre which provides consultations, counselling, referrals and follow-up, including consultation for abortion care through a harm reduction approach, ensuring that women are provided with accurate information. Due to its success, PFPPA is exploring options for continuing this healthcare delivery model beyond the pandemic, with the aim of keeping it free of charge for users.Photo: SAAF/Samar Hazboun/Palestine Share on Twitter Share on Facebook Share via WhatsApp Share via Email Sudan Sudan Family Planning Association (SFPA) Following a nation-wide shutdown in April, SFPA  established  a call centre to increase access to healthcare, including abortion and contraceptive counselling and referrals.  An unexpected outcome of the new call centre is that it has reached an increased number of young women who regularly call to discuss their reproductive health and rights. SFPA  is working  towards institutionalizing this model for continuation beyond the pandemic.Photo: SFPA/Sudan Share on Twitter Share on Facebook Share via WhatsApp Share via Email Togo Association Togolaise pour le Bien-Etre Familial (ATBEF) ATBEF adapted its mobile application ‘Infos Ado Jeunes’, adding a toll-free teleconsultation service for young clients to use to access abortion consultations and pre- and post-abortion counselling. This app has given young clients ongoing access to care when they face challenges travelling to clinics. It has also eased overall client flow in clinics at a time when social distancing is being implemented.Photo: ATBEF/Togo Share on Twitter Share on Facebook Share via WhatsApp Share via Email

Félicité Sonhaye ATBEF Regional Coordinator The Association Togolaise pour le Bien-Être Familial (ATBEF), has led a pioneering programme training community health workers to administer contraception in the rural areas where they live. “The injection is used more than any other method. Around 60% of women use it,” said Félicité Sonhaye, ATBEF Regional Coordinator for Togo’s Plateaux region, which covers Ilama. “Women appreciate the reliability and long-lasting effects of the injection, which allow them to stop worrying about unexpected pregnancies”, Sonhaye added. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Sossou Sagna Ilama village chief Men like Sossou Sagna, have great influence and respect within Togo’s rural communities. As Ilama’s village chief his approval was required for the ATBEF community project to take root. “I sent my own wife to seek family planning. The lady helped us and it worked really well. I also went with my older brother’s wife and she was very satisfied. Every member of this community is now aware that having a large family drives them towards poverty. Ignorance was the reason why we had so many children per family here before. Now with the family planning advice we have received, spacing births has become a reality and the reduction of the number of children per family.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Abla Abassa Community health worker Abla is a community health worker, and spends her days cycling around Ilama’s dusty streets visiting households that have signed up to an innovative programme providing contraception in hard-to-reach places. “Before, people didn’t have a lot of information about contraception. With the project the community is now able to space their births. I have seen the number of children per family going down. That’s contraception but also the increasing cost of living, and the fact that everyone wants to send their children to school.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Essivi Koutchona Client Facing prohibitive costs of school fees and food prices for six children, Essivi Koutchona, began using the contraceptive injection after deciding with her husband they did not want another child. She has received the injection every three months and has not experienced any side effects. “The community health worker passed by our house one day and explained the method and a bit about the possible side effects. We agreed as a couple that we wanted me to start using the injection.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Edem Badagbo Client 33-year-old Edem is a widowed father of three children. Edem hopes to have a vasectomy within the next month or so. His wife died following the birth of their third child but he is adamant he wants to follow through with a procedure they agreed upon before her death. “My wife agreed with the idea. I was scared when I first heard of it, but that’s because there was so little information available. When I came to the ATBEF clinic I received a lot more detail and that’s when I decided to do it. I have three children. That’s enough.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Yaori Ajossou Vasectomy client Yaori Ajossou, a retired soldier, heard about vasectomy while listening to an ABTEF awareness raising campaign on the radio. It prompted him to take on the responsibility for family planning in his marriage. “Before I had the idea that maybe I'd want to have more children, but after the campaign, and after my wife had talked a little bit about her health problems, I thought, well, maybe it's better to put the brakes on. I was about to retire. Why carry on having children? Six children is already a lot. It's already maybe too many.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Dede Koussawo Client 34-year-old Dede visits the ATBEF clinic in Lomé, Togo with her husband, Edem. “We do this together if his schedule permits it. I asked and he accepted. It's not typical (for men to come). Before the pregnancy, I was taking the pill. Before the first I was taking the pill and I used an IUD after my son's birth and after my daughter's birth as well. We've been really happy with the family planning we've got here so we decided to come here for Prescillia’s birth as well.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Mensah Awity Teacher and ABTEF youth club coordinator in Tohoun Mensah Awity is a teacher at a local school in Tohoun. He also coordinates the ABTEF youth club where they provide information and opportunities for the students to talk about sexual health, pregnancy, contraception. “At the beginning it was difficult for the club. Now teachers have started accepting the ideas and some pupils behave much better so it’s hard for them to keep condemning it. There are three girls who gave birth and who came back to school afterwards. At the beginning it was tough for them but we explained to the students that they shouldn’t be treated differently. The rate of pregnancy has definitely gone down at school.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Emefa Charita Ankouy Youth activist and student “I'm studying for a degree in English and I'm a young activist volunteer with the IPPF youth movement. We promote, we try to help young girls who are in education to have more information about sexual health and reproduction to help them to adopt a method to avoid a pregnancy. They don't have enough information about sexual health and reproduction. I think it's because of that that they've become pregnant. They want to have sex quite early. There is pressure and there's a lack of communication between the students and their parents. Here in Togo sex is taboo for everyone, above all for parents.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Evedoh Worou Community Health Worker, Ilama “The ones who prefer the pill are young students or apprentices. Often, they take it to reduce PMS, and it regulates their period. Sometimes women will forget to take the pill, which means the injection is preferred as it’s just once for three months. The women here have more autonomy and they now have the space to earn money themselves for the household as a result of the programme. At the beginning, there were some reservations among the men in the community but after our awareness campaigns, more and more of them accompany women for family planning.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Photography by Xaume Olleros for IPPF

  Every three months, Mawoula Dahide meets a community health worker in her village in central Togo to receive a single contraceptive injection and then carries on with her busy day. Dahide, 20, has a two-and-a-half year old son and a husband living in the capital and juggles an apprenticeship in tailoring with caring for her child. After recovering from the birth, Dahide tried the injection and immediately felt relief, knowing she would decide when she got pregnant again. “I want to use it for a couple of years and then maybe we will think about having another child,” she said.   Lack of access  Until 2013, Dahide and the other women living in the village of Ilama had no access to regular contraception at all, and its use was sometimes regarded with suspicion, and even fear. In her community, the average age of a mother’s first pregnancy is around 16, and women might bear a total of six or seven children compared to the national average of 4.7, according to local health workers. That trend is changing with a pioneering programme run by the Association Togolaise pour le Bien-Être Familial (ATBEF), which has trained community health workers to administer contraception in the rural areas where they live. ATBEF has focused their distribution of contraceptives within poor and rural communities, and with mobile outreach clinics that go to villages with no trained health workers. The unmet need for contraception in Togo stands at 34% of the population, and in rural communities, this is even higher.  The association contributes a fifth of overall contraception cover to couples in Togo, a West Africa nation of 7.8 million people. There is a clear favourite among the methods offered, which include male and female condoms, the pill, and the contraceptive injection. “The injection is more used than any other method. Around 60% of women use it,” said Félicité Sonhaye, ATBEF Regional Coordinator for Togo’s Plateaux region, which covers Ilama. Women appreciate the reliability and long-lasting effects of the injection, Sonhaye added, which allow them to stop worrying about unexpected pregnancies.   From client to advocate Dahide has become an advocate for the method among her peers within her community. “My friends are getting the injection as well. I was the first to start using it and it was great, so I told them about it,” she said. Another convert to the injection is Ilama’s village chief, Sossou Sagna. The father of seven agreed with his wife they didn’t want anymore children.  “I sent my own wife to seek family planning. The lady helped us and it worked really well. I also went with my older brother’s wife and she was very satisfied,” Sagna noted in the cool of the shade.  “My wife chose the three-month injection,” he added. Sagna had not anticipated some of the wider effects of increasing contraceptive use within the community, which have become prevalent over the last couple of years. “Every member of this community is now aware that having a large family drives them towards poverty,” he said. Families have more money to spend feeding and educating their children in an economy where the cost of living keeps rising. Villagers who see Sagna attending family planning sessions are also convinced that rumours about contraception making them ill are untrue. “Ignorance was the reason why we had so many children per family here before. Now with the family planning advice we have received, spacing births has become a reality and the reduction of the number of children per family,” he added. The gains of the ATBEF rural programme will now go even further with the imminent introduction of Sayana Press, a contraceptive injection that women can self-administer.   Learn more about some of the most popular contraception methods available and if they are right for you    Photography by Xaume Olleros for IPPF

Abla Abassa lives in the village of Ilama, population 2,000, in rural central Togo. After waking up early each morning to prepare for the day ahead, she sits down to map out her route. Abassa is a community health worker, and spends her days cycling around Ilama’s dusty streets to visit households who have signed up to an innovative programme that provides contraception in hard-to-reach places. The village is an hour by bumpy dirt track from the regional capital of Atakpamé, and few residents have the time or money to travel into town on a regular basis to refill prescriptions. For years, that meant the women of the community had just one form of protection against pregnancy: avoiding sex altogether. In 2013, Abassa became one of 279 community health workers in the Plateaux region funded by the Association Togolaise pour le Bien-Être Familial (ATBEF), working in two districts where the unmet need for contraception was greatest. Today, Abassa has three different clients, but can deal with as many as five a day. The health worker meets women on their own or with their husbands, and conversation flows about village life before she administers a contraceptive injection, or leaves behind a small pile of condoms.   Reaching those in need She begins the day a few doors down at the home of Essivi Koutchona, a mother of six who has used the contraceptive injection for the last two-and-a-half years. “The community health worker passed by our house one day and explained the method and a bit about the possible side effects,” Koutchona said. “We agreed as a couple that we wanted me to start using the injection”.   Koutchona’s husband, Konou Aboudou, credits Abassa and the ATBEF with improving his marriage, which he said was strained by the rhythm [calendar] method and supporting many young children at once. “Now we can better understand and support our wives. We avoid adultery and pregnancies are planned,” he explained. “Before, people didn’t have a lot of information about contraception. With the project we have undertaken with ATBEF since 2013, the community is now able to space their births,” Abassa said, adding the couple had told her they wished the programmed has started years ago. Togo currently has a fertility rate of 4.7 children per woman, according to the United Nations Statistics Division, but is trying to bring that number down.    Battling misinformation The government faces entrenched attitudes about the value of a large family, and misinformation spread about contraception. A community health worker has two roles: safely providing contraception, but also reassuring women that many of the rumours they have heard that the injection or pill will make them sick are false. “I tell them that side effects come from the product, so if they have an irregular period it’s not because they are ill,” Abassa said, adding it had taken much persuasion over the last five years to reach the point where she was now trusted. Abassa’s next client preferred to meet at the health worker’s home for some privacy. At 45, Adjo Amagna is still having periods and wants to avoid any chance of another pregnancy. “I think I want to go for the injection. I have never used contraception before so I think I will do it for three months to see how it goes,” she said.  After the death of her fifth child, the only baby she had with her second husband, Amagna wants to focus on caring of the four children she has left. She sat down with the health worker and was passed condoms, femidoms and the pill, while Abassa explained how the injection works. After a half hour chat, Amagna agreed to begin the injection on her next visit.   Changes within the community  On the way to see Mawoula Dahide, a 20-year-old with one child, her last client of the day, Abassa reflected on the changes she has seen in the community since her job began. “I have seen the number of children per family going down,” she said. “That’s contraception but also the increasing cost of living, and the fact that these days everyone wants to send their children to school.” The prevalence of contraceptive use was at 17% before the programme began, but with the focus on rural communities this has risen to 23% nationwide, even though not all areas of Togo are covered by dedicated health workers yet. We met Dahide in a quiet corner as she took a short break from an apprenticeship in tailoring.  “It’s pretty tough balancing my son and my apprenticeship. If I had waited to have a kid before starting it would have been a lot easier,” she admitted. “My husband is studying at the university in Lomé so I only see him during the holidays and maybe a few weekends during term time.” Younger women like Dahide are sometimes harder to reach, said Abassa, and have a greater unmet need for contraception in a community where many have their first child around the age of 16. “Some of the young women can’t educate their own children because they had to drop out of school themselves,” the health worker explained, adding her focus was always on recruiting more teenagers to her cause. As she heads home for the day, Abassa waved to clients and neighbours, while wondering who might be on her doorstep looking for advice when she gets there.   Photography by Xaume Olleros for IPPF