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Aminata Sonogo listened intently to the group of young volunteers as they explained different types of contraception, and raised her hand with questions. Sitting at a wooden school desk at 22, Aminata is older than most of her classmates, but she shrugs off the looks and comments. She has fought hard to be here. Aminata is studying in Bamako, the capital of Mali. Just a quarter of Malian girls complete secondary school, according to UNICEF. But even if she will graduate later than most, Aminata is conscious of how far she has come. “I wanted to go to high school but I needed to pass some exams to get here. In the end, it took me three years,” she said. At the start of her final year of collège, or middle school, Aminata got pregnant. She is far from alone: 38% of Malian girls will be pregnant or a mother by the age of 18. Abortion is illegal in Mali except in cases of rape, incest or danger to the mother’s life, and even then it is difficult to obtain, according to medical professionals. Determined to take control of her life “I felt a lot of stigma from my classmates and even my teachers. I tried to ignore them and carry on going to school and studying. But I gave birth to my daughter just before my exams, so I couldn’t take them.” Aminata went through her pregnancy with little support, as the father of her daughter, Fatoumata, distanced himself from her after arguments about their situation. “I have had some problems with the father of the baby. We fought a lot and I didn’t see him for most of the pregnancy, right until the birth,” she recalled. The first year of her daughter’s life was a blur of doctors’ appointments, as Fatoumata was often ill. It seemed Aminata’s chances of finishing school were slipping away. But gradually her family began to take a more active role in caring for her daughter, and she began demanding more help from Fatoumata’s father too. She went back to school in the autumn, 18 months after Fatoumata’s birth and with more determination than ever. She no longer had time to hang out with friends after school, but attended classes, took care of her daughter and then studied more. At the end of the academic year, it paid off. “I did it. I passed my exams and now I am in high school,” Aminata said, smiling and relaxing her shoulders.  "Family planning protects girls" Aminata’s next goal is her high school diploma, and obtaining it while trying to navigate the difficult world of relationships and sex. “It’s something you can talk about with your close friends. I would be too ashamed to talk about this with my parents,” she said. She is guided by visits from the young volunteers of the Association Malienne pour la Protection et Promotion de la Famille (AMPPF), and shares her own story with classmates who she sees at risk. “The guys come up to you and tell you that you are beautiful, but if you don’t want to sleep with them they will rape you. That’s the choice. You can accept or you can refuse and they will rape you anyway,” she said. “Girls have to know their rights”. After listening to the volunteers talk about all the different options for contraception, she is reviewing her own choices. “Family planning protects girls,” Aminata said. “It means we can protect ourselves from pregnancies that we don’t want”.

My name is Mariame Doumbia, I am a midwife with the Association Malienne pour la Protection et la Promotion de la Famille (AMPPF), providing family planning and sexual health services to Malians in and around the capital, Bamako. I have worked with AMPPF for almost six years in total, but there was a break two years ago when American funding stopped due to the Global Gag Rule. I was able to come back to work with Canadian funding for the project SheDecides, and they have paid my salary for the last two years. I work at fixed and mobile clinics in Bamako. In the neighbourhood of Kalabancoro, which is on the outskirts of the capital, I receive clients at the clinic who would not be able to afford travel to somewhere farther away. It’s a poor neighbourhood. Providing the correct information The women come with their ideas about sex, sometimes with lots of rumours, but we go through it all with them to explain what sexual health is and how to maintain it. We clarify things for them. More and more they come with their mothers, or their boyfriends or husbands. The youngest ones come to ask about their periods and how they can count their menstrual cycle. Then they start to ask about sex. These days the price of sanitary pads is going down, so they are using bits of fabric less often, which is what I used to see.  Seeing the impact of our work  We see cases of early pregnancy here in Kalabancoro, but the numbers are definitely going down. Most are from 14 years old upwards, though occasionally they are younger. SheDecides has brought so much to this clinic, starting with the fact that before the project’s arrival there was no one here at all for a prolonged period of time. Now the community has the right to information and I try my best to answer all their questions.

My name is Fatoumata Yehiya Maiga. I’m 23-years-old, and I’m an IT specialist. I joined the Youth Action Movement at the end of 2018. The head of the movement in Mali is a friend of mine, and I met her before I knew she was the president. She invited me to their events and over time persuaded me to join. I watched them raising awareness about sexual and reproductive health, using sketches and speeches. I learnt a lot. Overcoming taboos I went home and talked about what I had seen and learnt with my family. In Africa, and even more so in the village where I come from in Gao, northern Mali, people don’t talk about these things. I wanted to take my sisters to the events, but every time I spoke about them my relatives would just say it was to teach girls to have sex, and that it’s taboo. That’s not what I believe. I think the movement helps girls, most of all, to know their sexual rights, their bodies, what to do and what not to do to stay healthy and safe. They don’t understand this concept. My family would say it was just a smokescreen to convince girls to get involved in something dirty.  I have had to tell my younger cousins about their periods, for example, when they came from the village to live in the city. One of my cousins was so scared, and told me she was bleeding from her vagina and didn’t know why. We talk about managing periods in the Youth Action Movement, as well as how to manage cramps and feel better. The devastating impact of FGM But there was a much more important reason for me to join the movement. My parents are educated, so me and my sisters were never cut. I learned about female genital mutilation at a conference I attended in 2016. I didn’t know that there were different types of severity and ways that girls could be cut. I hadn’t understood quite how dangerous this practice is. Then, two years ago, I lost my friend Aïssata. She got married young, at 17. She struggled to conceive until she was 23. The day she gave birth, there were complications and she died. The doctors said that the excision was botched and that’s what killed her. From that day on, I decided I needed to teach all the girls in my community about how harmful this practice is for their health. I was so horrified by the way she died. Normally, girls in Mali are cut when they are three or four years old, though for some it’s done at birth. When they are older and get pregnant, I know they face the same challenges as every woman does giving birth, but they also live with the dangerous consequences of this unhealthy practice.  The importance of talking openly  The problem lies with the families. I want us, as a movement, to talk with the parents and explain to them how they can contribute to their children’s sexual health. I wish it were no longer a taboo between parents and their girls. But if we talk in such direct terms, they only see disobedience, and say that we are encouraging promiscuity. We need to talk to teenagers because they are already parents in many cases. They are the ones who decide to go through with cutting their daughters, or not. A lot of Mali is hard to reach though. We need travelling groups to go to those isolated rural areas and talk to people about sexual health. Pregnancy is the girl’s decision, and girls have a right to be healthy, and to choose their future.

In 2017, the Association Malienne pour la Protection et la Promotion de la Famille (AMPPF), was hit hard by the reinstatement of the Global Gag Rule (GGR). The impact was swift and devastating – depleted budgets meant that AMPPF had to cut back on key staff and suspend education activities and community healthcare provision. The situation turned around with funding from the Canadian Government supporting the SheDecides project, filling the gap left by GGR. AMPPF has been able to employ staff ensuring their team can reach the most vulnerable clients who would otherwise be left without access to sexual healthcare and increase their outreach to youth. Putting communities first Mama Keita Sy Diallo, midwife The SheDecides project has allowed AMPPF to maintain three mobile clinics, travelling to more remote areas where transportation costs and huge distances separate women from access to health and contraceptive care.“SheDecides has helped us a lot, above all in our work outside our own permanent clinics. When we go out in the community we have a lot of clients, and many women come to us who would otherwise not have the means to obtain advice or contraception,” explained Mama Keita Sy Diallo, a midwife and AMPPF board member. She runs consultations at community health centers in underserved areas of the Malian capital. “Everything is free for the women in these sessions.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email SheDecides projects ensures free access to healthcare and contraception Fatoumata Dramé, client By 9am at the Asaco Sekasi community health center in Bamako, its wooden benches are full of clients waiting their turn at a SheDecides outreach session. Fatoumata Dramé, 30, got here early and has already been fitted for a new implant. “I came here for family planning, and it’s my first time. I’ve just moved to the area so I came because it’s close to home,” she said. Bouncing two-month-old Tiemoko on her knee, Dramé said her main motivation was to space the births of her children. “I am a mum of three now. My first child is 7 years old. I try to leave three years between each child. It helps with my health,” she explained. Share on Twitter Share on Facebook Share via WhatsApp Share via Email Targeting youth Mamadou Bah, Youth Action Movement “After the arrival of SheDecides, we intensified our targeting of vulnerable groups with activities in the evening, when domestic workers and those working during the day could attend,” said Mariam Modibo Tandina, who heads the national committee of the Youth Action Movement in Mali. “That means that young people in precarious situations could learn more about safer sex and family planning. Now they know how to protect themselves against sexually transmitted infections and unwanted pregnancies.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Speaking out against FGM Fatoumata Yehiya Maiga, youth volunteer Fatoumata’s decision to join the Youth Action Movement was fueled by a personal loss. “My parents are educated, so me and my sisters were never cut. I learned about female genital mutilation at a conference I attended in 2016. I didn’t know that there were different types of severity and ways that girls could be cut. I hadn’t understood quite how dangerous this practice is. Two years ago, I lost my friend Aïssata. She got married young, at 17. She struggled to conceive until she was 23. The day she gave birth, there were complications and she died. The doctors said that the excision was botched and that’s what killed her. From that day on, I decided I needed to teach all the girls in my community about how harmful this practice is for their health. I was so horrified by the way she died.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Using dance and comedy to talk about sex Abdoulaye Camara, Head of AMPPF dance troupe Abdoulaye’s moves are not just for fun. He is head of the dance troupe of the AMPPF’s Youth Action Movement, which uses dance and comedy sketches to talk about sex. It’s a canny way to deliver messages about everything from using condoms to taking counterfeit antibiotics, to an audience who are often confused and ashamed about such topics. “We distract them with dance and humour and then we transmit those important messages about sex without offending them,” explained Abdoulaye. “We show them that it’s not to insult them or show them up, but just to explain how these things happen.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Determination to graduate Aminata Sonogo, student Sitting at a wooden school desk at 22, Sonogo is older than most of her classmates, but she shrugs off the looks and comments. She has fought hard to be here. “I wanted to go to high school but I needed to pass some exams to get here. In the end, it took me three years,” she said.At the start of her final year of collège, or middle school, Sonogo got pregnant. She went back to school in the autumn, 18 months after Fatoumata’s birth and with more determination than ever. At the end of the academic year, it paid off. “I did it. I passed my exams and now I am in high school,” Sonogo said, smiling and relaxing her shoulders. She is guided by visits from the AMPPF youth volunteers and shares her own story with classmates who she sees at risk of an unwanted pregnancy. Share on Twitter Share on Facebook Share via WhatsApp Share via Email AMPPF’s mobile clinic offers a lifeline to remote communities Mariame Doumbia, midwife “I work at a mobile clinic. It’s important for accessibility, so that the women living in poorly serviced areas can access sexual and reproductive health services, and reliable information.I like what I do. I like helping people, especially the young ones. They know I am always on call to help them, and even if I don’t know the answer at that moment, I will find out. I like everything about my work. Actually, it’s not just work for me, and I became a midwife for that reason. I’ve always been an educator on these issues in my community.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Trust underpins the relationship between AMPPF’s mobile team and the village of Missala Adama Samaké, village elder and chief of the Missala Health Center Adama Samaké, chief of the Missala Health Center, oversees the proceedings as a village elder with deep trust from his community. When the mobile clinic isn’t around, his center offers maternity services and treats the many cases of malaria that are diagnosed in the community. “Given the distance between here and Bamako, most of the villagers around here rely on us for treatment,” he said. “But when we announce that the mobile clinic is coming, the women make sure they are here.” Share on Twitter Share on Facebook Share via WhatsApp Share via Email Contraceptive choice Kadidiatou Sogoba, client Kadidiatou Sogoba, a mother of seven, waited nervously for her turn. “I came today because I keep getting ill and I have felt very weak, just not myself, since I had a Caesarean section three years ago. I lost a lot of blood,” she said. “I have been very afraid since the birth of my last child. We have been using condoms and we were getting a bit tired of them, so I am looking for another longer-term type of contraception.”After emerging half an hour later, Sogoba clutched a packet of the contraceptive pill, and said next time she would go for a cervical screening.Photos ©IPPF/Xaume Olleros/Mali Share on Twitter Share on Facebook Share via WhatsApp Share via Email

With three children to raise on her own, Liljana’s health was the last thing on her mind but she could no longer ignore the feeling that something was wrong. Through speaking to her friends, she learnt about the  Albanian Centre of Population and Development (ACDP) clinic. “First, I had the gynaecological visit and after that, for 1 minute, the doctor did the VIA test. The response was immediate, but positive. I was so scared. The doctor was able to calm me down by explaining everything very simply. Everything was going to be all right because this disease was 100% curable.” Liljana underwent treatment for pre-cancerous lesions for two weeks, but the results of the test were still positive. The doctor suggested cryotherapy. “I decided to do cryotherapy, which is very simple and very comfortable. It was the best decision I have made in my life. After two years, I am completely recovered. I am very grateful to the ACDP clinic, they saved my life.” What is VIA & Cryotherapy? Show more + Visual inspection of the cervix with acetic acid (VIA) is a process of screening and examining the cervix. Pre-cancerous lesions on the cervix will turn white when the acid is applied.  This simple procedure can be done in a clinic setting without the use of a laboratory and allows for immediate treatment of any pre-cancerous lesions with cryotherapy. Cryotherapy is a gynaecological treatment that freezes and destroys abnormal, pre-cancerous cervical cells. Cryotherapy is not a treatment for cervical cancer. VIA has the potential to revolutionize cervical cancer prevention efforts, particularly in low resource settings, because it eliminates the need for laboratories, transportation of specimens and provides immediate test results.   VIA needs less equipment and fewer specialists than traditional cervical cancer screening methods like Pap tests. Results from VIA are available immediately so women can be screened and treated in one single visit.  A happier & healthier life Now Liljana is having routine checks following the advice of the doctor and maintains regular contact with the clinic. “I know that whenever I need advice, I can call the doctor or the nurse and always get a response.” Liljana told all her friends about the VIA procedure and recommended many of them to the clinic in Tirana. Since her successful treatment, Liljana has noticed the relationship with her children has also improved. “My 15 years daughter says that now I smile more than before. She has noticed that before the test I was sad, because I was thinking bad things about my life. This experience has helped me also to talk openly with my daughter about the reproductive and sexual life and teach her to take care of herself. The other two are boys, 13 and 10 years old, but I promise I will talk to them about the importance of having a healthy reproductive and sexual life.”

Eleanor* is a mother of three children, she lives in Vlora, a city in south Albania. Eleanor and her children rely on her husband's modest income to survive. She is only too aware that her economic situation is a major barrier for her to access healthcare. Most treatments are referred to the capital, Tirana, or are at private clinics; incurring costs she simply cannot afford. When she heard about the Aulona Centre offering free PAP tests, she booked an appointment. “I have always admired women who take care of their health. Taking care of ourselves is decisive for our family wellbeing, children and relatives. But in our areas, it is difficult to get proper services, especially for reproductive health”, she says. Eleanor’s first pap smear was in 2012, the results came back negative. The doctor informed her that she had to come back in 3 years for another test.  In 2015 she returned to the center, convinced that the results would again be negative. The results came back positive. “I remember the doctor underlining my name with red pen. She said to go to Tirana for further treatment because they had better equipment and staff there.” The encouragement from the staff of Aulona center helped Eleanor decide on her next steps.  “While making my decision, I had this vision of my name underlined with red colour, which was an alert sign. So I contacted a doctor in Tirana and had the surgery in 2016. Nowadays I feel much better and I am clean from signs of cancer.” From a client to an activist  Her experience with Aulona center has made Eleanor an ardent activist of reproductive health for women. “Every cousin in my family knows about my case. I encourage them to have a PAP screening although they don’t have any concern. For some of them is a matter of shame, because they think if you don’t have any problem, why you should expose intimate parts of your body to the doctor? I challenge them asking what it is more difficult: when the doctor says: Madam, you have few years to live left or just booking a visit? They listen to me more now because they see I recovered.” Through her activism, Eleanor has recently become aware of the VIA testing method and is enthusiastic about it. “The most wonderful thing about this new method [VIA] is that I don’t have to wait 3 weeks for the response. I recall the waiting period for the second test with my eyes attached to the telephone screen. Why are they not calling? Is there anything wrong with my results? VIA avoid all this anxiety, and you can start the therapy immediately.”   Eleanor feels confident about her knowledge on sexual and reproductive health. Her own experiences allows her speak more openly with her 20-year-old old daughter, reminding her of the importance of regular screening. “The disease does not ask if you are rich or poor. I could have let myself at risk, but when interventions are at the right time, they save lives.” What is VIA & Cryotherapy? Show more + Visual inspection of the cervix with acetic acid (VIA) is a process of screening and examining the cervix. Pre-cancerous lesions on the cervix will turn white when the acid is applied.  This simple procedure can be done in a clinic setting without the use of a laboratory and allows for immediate treatment of any pre-cancerous lesions with cryotherapy. Cryotherapy is a gynaecological treatment that freezes and destroys abnormal, pre-cancerous cervical cells. Cryotherapy is not a treatment for cervical cancer. VIA has the potential to revolutionize cervical cancer prevention efforts, particularly in low resource settings, because it eliminates the need for laboratories, transportation of specimens and provides immediate test results.   VIA needs less equipment and fewer specialists than traditional cervical cancer screening methods like Pap tests. Results from VIA are available immediately so women can be screened and treated in one single visit.  *Name has been changed

Scrolling through her social media page, 21-year-old Artemisa Seraj stumbled across a post from the Aulona Center offering seminars and workshops on sexual and reproductive healthcare for young people and students. Feeling like she had the opportunity to learn something about a subject that she and her friends rarely discuss, she decided to attend one of the seminars. “I found the information very interesting because we don’t talk very much about these things with my friends. It is still a taboo. On the other hand, we know that the sexually transmitted infections are being spread among youngsters, but we don’t know how to protect ourselves.” The first seminar went so well, Artemisa decided that she wanted to become a volunteer. “I like very much to pass the information on to others. So, I discussed with the Enela, the director of the center, to become a volunteer and here I am today.” Empowering women & girls Since becoming an activist Artemisa is now even more passionate about the importance of comprehensive sexuality education (CSE) for young people, gender equality and women’s rights. “I have known many other girls and women in our outreach activities that have no information about their reproductive and sexual life. Especially, girls from rural areas are the most deprived of this kind of information. The health centers have no staff or adequate equipment for gynaecological visits. Aulona center has high standards of friendly services for teenagers and youngsters, so you feel safe and not prejudiced against. Confidentiality is very high here and the doctors are very qualified. In the young groups, you feel like a community, you can speak openly about your concerns.”  Artemisa hopes that by distributing information to women and girls, it is empowering them as well giving them an opportunity to fight for their own rights. “I do think that even a single person can contribute to the improvement of the situation regarding CSE. It is an instinct now, whenever I meet a woman, I talk about the center.  My greatest satisfaction as an activist is seeing them coming to the center for a [health] visit or for counselling, because this means that my work has paid off. I do this work because I believe every girl and woman’s life counts.”

Hatixhe Gorenca is a nurse at the Albanian Centre of Population and Development (ACPD) clinic in Tirana. She joined the center in 2013 with 39 years of experience working in gynaecology. During her time as a nurse, she has seen vast improvements in access and services for cervical cancer screenings. However, she says that there is a considerable number of women in rural areas that face difficulties in accessing healthcare, and some that cannot access it at all. Rural women & access “The ACPD clinic is crucial for these [rural] women, because the healthcare we offer through gynaecological visits, includes counselling, pap smears, colposcopies and recently VIA tests and cryotherapy. Services that are totally missing in their areas. What they appreciate most is the mobile clinic in the outskirts of Tirana, because they have an opportunity to meet with doctors and to get information about their health status. We do approximately 17-18 visits per day and the number is always increasing”, Hatixhe says.  The clinic has developed a reputation for offering youth-friendly healthcare and information. The confidential and open approach of the clinic is providing access for girls to comprehensive sexual education at an early age, without fear of discrimination or embarrassment. When the clinic first introduced VIA testing in 2017, as an alternative way for the screening of cervical cancer, it was welcomed by the women. “The reason is that compared to pap smears, VIA gives an immediate response on the health of the cervical cells,”  Hatixhe explains. “The other reason is economical. Many of the women we work with have no health insurance, as such they cannot benefit from the free tests at maternity hospitals. Furthermore, some of them are vulnerable women and they feel safe when they can get free information and healthcare at our clinic.” What is VIA & Cryotherapy? Show more + Visual inspection of the cervix with acetic acid (VIA) is a process of screening and examining the cervix. Pre-cancerous lesions on the cervix will turn white when the acid is applied.  This simple procedure can be done in a clinic setting without the use of a laboratory and allows for immediate treatment of any pre-cancerous lesions with cryotherapy. Cryotherapy is a gynaecological treatment that freezes and destroys abnormal, pre-cancerous cervical cells. Cryotherapy is not a treatment for cervical cancer. VIA has the potential to revolutionize cervical cancer prevention efforts, particularly in low resource settings, because it eliminates the need for laboratories, transportation of specimens and provides immediate test results.   VIA needs less equipment and fewer specialists than traditional cervical cancer screening methods like Pap smears. Results from VIA are available immediately so women can be screened and treated in one single visit.    ACDP outreach activities enable the staff to give the information where the women are: in the streets, in their workplace, in their homes. Hatixhe has witnessed a growing interest in women regarding their reproductive health in recent years. The number of women that walk through the clinic doors is proof of that. During the 2016-2017 over 3,000 women received healthcare services from the clinic.  Encouraging other women  “I myself am learning a lot in the clinic”, Hatixhe says. “VIA test was a new technique even for me, but it is so simple, I can now train the staff at the health centers. I can tell you that they are very enthusiastic and responsive because VIA is very easy to apply. Since many health centers have no gynaecological bed for their visits or low capacities to apply PAP tests which require specialized personnel, VIA is much more suitable for their conditions, because it can be done by the nurses or midwifes themselves.” Hatixhe is impressed by the reaction of women taking VIA tests. “As a nurse with long experience in the health sector, I have received many thanks from patients, but the hugs we get from these women are heartfelt. After 2-3 years of coming and going to different institutions, finally, they have found a method which can detect pre-cancer cells, get treatment for it and now they are totally healthy.”  Hatixhe says that many women have been encouraged to book a VIA test through hearing about it from a friend or relative who had a positive experience at the clinic. “After the first visit, the women return with other women who are interested to do the tests. This is wonderful.”