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.

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.” 

I left Somaliland when I was 9 years old with my mother, brother, uncles, aunts and cousins. It was the civil war and we were lucky enough to reach Canada as refugees. I remember that time as a pleasant, warm, loving time where my cousins and I had a lot of freedom to play, walk to school and daydream. I am from Somaliland so of course I am part of the 97-98% or so of girls who undergo the female genital cut. I think it happened when I was around seven years old. I remember being restrained. I remember strangers being around and I remember peeing standing up and it burning. These memories don’t come up often and they don’t cause me pain. It’s a distant, childhood event. A cousin and a niece my age were there and we went through it together and afterwards our mothers and aunts took care of us. I grew up, went to school, questioned the world and my role in it for a time, got married, had kids and eventually went back to Somaliland. There I met Edna Adan Ismail and asked to volunteer with her. She opened her office, hospital and life to me and I became immersed in the maternal health issues of the women in my home country. The effort to end FGM Most were not as lucky as I had been. Because of FGM/C (female genital mutilation/circumcision), most had experienced recurring infections and difficulties in child birth. Some had formed cysts, some became infertile, and some had obstetric fistula. But few linked these problem to the cutting. At SOFHA (Somaliland Family Health Association) we’ve been working to help women (and men) understand these links and get the help they need. That’s only a part of the work. The effort to end FGM/C in Somaliland goes back almost 40 years. FGM/C programs and projects have been happening for at least the last 25 years. We’re now at the point where it’s recognized as a legitimate, critical, health and social issue. We’re on the cusp of a law against the practice and I have personally witnessed a transformation among the individuals who engage in this work. NGO and government staff tasked with working on FGM/C used to go into communities apologetically, “Sorry but we have to talk to you about this ‘issue’, we know it’s unpleasant but bear with us” to “I have 2 daughters and I have not cut them. This is a terrible practice and we must stop it now”. It fills me with great joy to see young women and men taking this personal stance and doing it confidently and proudly. But it’s not easy for most people to do this. It certainly wasn’t for me. This is personal. This is private. Before I got into the work I might have said, “What business is it of yours anyway? Do you really want me digging into your private life? Into your past and history? I am not a victim. I may be a survivor but not in the way you think and not for the reasons you imagine. I am bigger than this. This doesn’t define me.” Dignity, bravery, respect And it may not define most Somali women. I think that’s what confuses many people. Maybe it’s because it happens in childhood and those memories are lost or hidden or maybe because mothers and grandmothers have such good intentions or maybe because it’s so universal within the community? That’s why it’s a completely different experience for a young Somali girl born and brought up somewhere else. The experience is very personal and it varies from person to person. Dignity, respect and bravery are guiding principles for our work on female genital mutilation. In Somaliland, a dynamic young generation connected to the world through the internet, and integrated multi-pronged FGM/C programming, is helping us to influence a generation of Somalis to abandon the cut and break the cycle. It’s still some distance away but we see the end in sight. Words Amal Ahmed, the executive director of our Member Association in Somaliland (SOFHA)