The Thula Sana Project in El Salvador

El Salvador is a small country nestled in Central America, about the size of Massachusetts, with a population of 6 million. The countryside is beautiful. It’s volcanic, has stunning beaches, and its hilly roads are drawing more tourists each and every year. Coffee used to be the main crop, but now they also grow rice, beans, corn, sugar, and harvest coconuts.

But despite the natural beauty, over half the population lives in poverty, and fifth of the population lives in extreme poverty.

Sexual and reproductive rights have a long way to go in the country. Abortion care is illegal in all circumstances, including the life of the woman. Dozens of women are serving jail sentences for alleged abortions and miscarriages. Early childbearing is almost universal, with about 70% of women giving birth before reaching 18. Violence against women is endemic, with about a quarter of all women reporting being a victim of physical or sexual violence—and regardless where you are in the world, gender-based violence is severely underreported.

Poverty, lack of autonomy, limited social networks, and low level of schooling makes it challenging for young mothers. Infants whose experience with a caretaker are negative are more likely to develop attachment insecurity. Specifically, infant attachment insecurity is a result of a poor emotional relationship that does not make them feel secure, and social studies have found a clear link between infant attachment insecurity and gender-based violence. Witnessing violence and cognitive development also have an impact.

Pro-Familia, a non-profit organization in El Salvador, is dedicated to advancing sexual and reproductive health and rights in the country. Also known as the Demographic Association of El Salvador (ADS), it has twelve clinics across the country dedicated to family planning, cancer screenings, and STI testing and treatment. The organization has trained over 1000 volunteer health promoters who are well-known and trusted in their communities. Many of them do this work at great personal risk—violence against clinic staff and outreach workers is a real possibility. Outreach staff is careful to meet with gang leaders ahead of time, gain their trust, and operate with their permission.

Recently, ADS has been working on an initiative called the Thula Sana project, with the goal of evaluating whether a community-based intervention model would be successful at lessening maternal depression and promoting secure early attachment between adolescent, first-time mothers and their infants. Community outreach workers identified over sixty families to work with and divided them into two groups, a control group and one that would receive training. Those who received training would receive two ante-natal visits and 14 post-natal visits over six months. Outreach workers do a series of exercises with mother and baby to build the mother’s confidence and train her to better recognize infant needs. 

Interestingly, outreach workers found that the role of the extended family became an obstacle. In cases where there was marriage or cohabitation with parents, the adolescent was often controlled by her mother or mother-in-law and often disempowered and scared. They concluded that cooperation of the adolescent’s mother or mother-in-law was vital, so they focused on building trust with the younger mother and the extended family.  

I visited one mother, Veronica, and her daughter Angelica. They live with her parents and her brother in a home with a dirt floor. There’s no electricity or running water, and chickens and puppies roamed in and around the home. The parents and brother work on a nearly coffee plantation. 

I’ve traveled to many remote places, and one of the things that always impacts me is the hospitality and generosity that I encounter, even in the most impoverished places. Veronica roasted fresh coffee beans, bought us pastries, and made the best coffee I have ever had. Her family had been angry when they found out she had gotten pregnant, and even angrier when her partner left to live with another woman—whom he also got pregnant. But, “you can’t abandon your family,” her mother said. 

Veronica was most appreciative of learning how to breast feed, and how to observe what her baby was doing and how to respond to her actions. Angelica lived up to her name, she was bubbly and clearly comfortable with her mother, her grandmother, and eventually, me. It was a beautiful experience. 

The second home we visited belonged to Julia and her husband, Esteban. It was made out of cinder blocks, had electricity, running water, and even a fridge. But it was in a rough area, so we had to take vehicles that were familiar to the local gangs to avoid creating suspicion. The outreach workers even wore ADS vests that identify them whenever they go into the neighborhood (in the moment, I had wished they had given me one too!)  

Julia was thankful for the training. She particularly enjoyed the encouragement to express her emotions—in Salvadoran culture, women are sometimes conditioned to suffer quietly and endure whatever is thrown their way. She was also thankful to have somebody to answer the many questions she had about child-rearing, and was so inspired by the training she decided to become a volunteer for ADS. She now organizes other mothers in neighborhoods and provides information on family planning. 

The unsung heroes of the program, though, are the outreach workers themselves. Many of them are mothers, and despite the dangers, they are fearlessly committed to their work. Their compassion, dedication, and professionalism is reflected by the affectionate bonds they created with adolescent mothers in need.

The results of the program are inspiring. When compared to the control group, the intervention proved to create stronger bonds between mothers and their infants. It provided adolescent mothers with parenting skills, improved their communication, and taught them tools to deal with conflict management and stress. Most importantly, the feedback from the mothers who participated was overwhelmingly positive. There was also little opposition from gang members to the program, even though one of the long-term goals of the program is to reduce violent tendencies. 

ADS receives no funding from the Salvadoran government, nor does it receive foreign aid. It does receive funding from the International Planned Parenthood Federation (IPPF), and ADS would like to expand the program across El Salvador. The positive results from the project inspired other non-profits within the IPPF network to get involved in similar efforts to prevent gender-based violence. Iniciativas Sanitarias in Uruguay, for example, is working with public health authorities to train midwives using the Thula Sana methodology. Most exciting are the plans in the works to scale up the intervention to encourage secure attachment between infant and primary care giver, a factor that plays an unfortunate role in long-term chances of gender-based violence.  

Profamilia Colombia

I paid a visit last week to the Profamilia clinic in Cartagena, Colombia. The waiting rooms were full of women seeking education and clinical services. The clinic offers full sexual and reproductive health care, including GYN surgery, tubals, vasectomies and surgical and medical abortions (85% of women choose medical abortion). They see about 3,000 patients a month. The staff was dedicated, hard working and focused on providing what the clients need.

I met two dozen youth educators, 3 boys and the balance girls – we clearly need more boys in the mix. There were outgoing, ebullient and knowledgable, ready to give answers to teens who need answers.

Go Argentina

No, not for the World Cup, but for the vote today in the lower house of its Congress to decriminalize abortion up to 14 weeks gestation. The vote was 129-125. The bill next goes to the Senate. It will be close. We are ready and actively lobbying.

IPPF Member Association in Kenya Reducing Services Due to Global Gag Rule

Kenyan Clinic Rejects Trump Abortion Policy, Loses $2 Million In U.S. Aid

On Jan. 23, 2017, President Trump signed an executive order that bans U.S. aid to any health organization in another country that provides, advocates or makes referrals for abortions.

The full impact of the order won’t be felt until September. That’s when the U.S. government fiscal year comes to an end. At that point, every international organization that does not comply with the order will be excluded from U.S. funding, says Marjorie Newman-Williams, president of Marie Stopes International, an organization that provides contraception and safe abortion in dozens of countries.

But health groups that aren’t complying with the policy are already feeling the effects. The U.S. has pulled the plug on funds that had been previously allocated but not yet spent prior to the Trump order. “Marie Stopes can talk about its own sad stories of programs that have had to close,” says Newman-Williams. Its outreach services, which were funded by USAID in countries like Uganda, Kenya, Senegal, Madagascar, Pakistan and Myanmar, have already stopped, she says.

That’s the case for Family Health Options Kenya, Kenya’s oldest provider of sexual and reproductive health services. FHOK disagreed with the terms of the “Mexico City” policy, which has been reinstated by every Republican president since Ronald Reagan first issued it.

In October 2017, $640,000 that was in a four-year pipeline for ongoing work was lost because the funds, which came from the President’s Emergency Plan for AIDS Relief, were discontinued. Since then, $1.56 million more has been lost because FHOK was unable to renew project funds and bid for future U.S. funding, says Amos Simpano, director of clinical services. FHOK says that amounts to nearly 60 percent of the organization’s funding.

On a visit to Washington, D.C., this spring, Melvine Ouyo, an FHOK reproductive health nurse, sat down with NPR to discuss the effects of losing that much funding. One of the organization’s 14 clinics has closed down, and a clinic in Kibera, Nairobi’s largest slum and where Ouyo works, could be next. FHOK has also ceased outreach services to underprivileged communities, which it estimates has affected more than 76,000 women and young girls to date.

Though abortion is legal under Kenyan law if the health or well-being of the mother is at risk, some pregnant women and girls who now lack access to medical care because of the funding cuts are resorting to unsafe measures out of desperation. They visit “curtain clinics,” she says — secret spaces run by people who aren’t nurses or doctors — or use household items like crochet needles to terminate their pregnancies.

The loss of funding has also jeopardized essential services that are unrelated to abortion — like cancer screening of reproductive organs, treatment for HIV, postnatal care and vaccinations for diseases.

The funding policy — called the “global gag rule” by its critics — is meant to discourage abortion. But a Stanford University study makes the case that restricting family planning funds can lead to more abortions. Researchers analyzed survey data in 20 African countries between 1994 and 2008 and found that rates of induced abortions rose sharply in countries that were most affected by the rule. A report by Population Action International found that when the policy was in effect between 1984 and 1992, “there was no evidence that the policy reduced the incidence of abortion.”

Ouyo was in the United States to attend Capitol Hill Days, a conference around reproductive rights that is hosted by Population Connection Action Fund. When she sat down with NPR, she said the decision not to comply with the Trump order was made by the International Planned Parenthood Federation, of which FHOK is a member organization. “It was a worthwhile decision, though it has negative consequences,” she says.

This interview has been edited for length and clarity.

Tell me about how this has affected the clinic you work at in Kibera.

We had to lay off six staff [out of 10] just to be able to sustain the clinic. We also have not been able to acquire any [new] equipment in the past several months because of a lack of funding. We have not improved any of our equipment [such as autoclaving machines used to sterilize equipment]. It means we are still just operating from where we were last year.

What health problems do you see going unaddressed?

Because we have not been able to provide outreach services, which basically serve disadvantaged communities, we cannot provide screening services for HIV and AIDS and be able to initiate treatment for those who test positive, and provide health education [for prevention]. It means that people in these communities will live without any precaution. A child who requires immunization and [whose] parents may not be able to afford transport to facilities [could] get communicable diseases — measles, TB, diphtheria, hepatitis. And if one gets it, they infect another and another in the community.

Who are some of the people that rely on your clinic?

There was a young orphan girl, about 10 years old, who was sleeping at her uncle’s [home] after she lost her parents. And the uncle persistently sexually abused her. And when she got pregnant at 13 years, this is a pregnancy from incest, she would not just carry on the pregnancy. So this girl comes to you suicidal. What do you do as a professional? She had already attempted unsafe abortion. She had taken herbs given [to her] by friends. Her friends referred her to us and she was able to access safe abortion services.

With the funding loss, what is FHOK doing to survive?

We have to put a small fee on the services we are providing. It has caused the clients to shy away from seeking care. At the Kibera clinic, we are charging half a dollar, because it is within the slum and we know the clientele we are dealing with. And still, not all will be able to pay. We feel the pain of not being able to provide those services.

Other countries, like the Netherlands, have started raising funds to help international organizations that are suffering because they did not agree to the terms of the Trump order. The Dutch government created a funding initiative called “She Decides” and has raised about $200 million from governments, foundations and philanthropists. Are you receiving funding from elsewhere?

The main alternative that FHOK started was to start charging the client. We receive a reduced grant [by about $99,000] from the International Planned Parenthood Foundation.

What does it feel like for you right now?

It feels painful knowing that someone would benefit from your education, your passion, your career and you cannot do that. It kills your morale.

How do you cope, knowing that your health clinic isn’t as effective today?

Just like the previous years when we had the global gag order, I still have this hope that I have to hold on, to press on. I am hopeful that someone will hear my cry.

Thank you Cecile Richards

Cecile Richards stepped down today after 12 years as President of Planned Parenthood Federation of America.

It is a sign of my age that I have known many of her predecessors: giants like Alan Guttmacher and Faye Wattleton, and, dare I say, my grandmother.  To be great leader in our movement, and Cecile certainly was one, takes, above all, authenticity. This on top of all the skills required to raise the money, speak the speeches, lobby the lobby-able. You have to inspire, and this takes authenticity. A potential believer, supporter, donor can spot an actor, someone who is putting on an act to get on your good side, to get in your wallet, to get your vote. Cecile spoke from her life’s experiences, much as my grandmother did and Faye Wattleton did. She was the real thing.

I thank her for carrying the torch so boldly and so effectively for so long.

There are Two Choices with Abortion: Safe or Unsafe

From the just released report from Guttmacher

Notably, abortion rates are similar in countries where abortion is highly restricted and where it is broadly legal: The abortion rate is 37 per 1,000 women in countries where abortion is prohibited or permitted only to save the life of the pregnant woman, and 34 per 1,000 women in countries where abortion is not restricted as to reason. Legal restrictions do not eliminate abortion. Rather, they increase the likelihood that abortions will be done unsafely, as they compel women to seek clandestine procedures. Indeed, abortion tends to be safer in countries where it is broadly legal and in countries with a high gross national income.

Profile for my Princeton class

His Past Became His Present, And His Future
by Brooke C. Stoddard ’69

Alex Sanger grew up in Mt. Kisco, N.Y., in Westchester County. His father was a surgeon, one of three children of renowned social reformer and feminist crusader Margaret Sanger. Alex’s mother was also a physician. Alex had three older brothers as well as a younger brother and younger sister. His father was Princeton Class of 1931 and rowed on the Lightweight Crew. The elder Sanger was a keen supporter of Princeton football and Princeton rowing, and, in fact, years later, the Princeton Rowing Association, when it began fostering women’s crews, named a shell for him — appropriately it became the boat of the women’s varsity.

On account of the elder Sanger’s interest in Princeton sports, the Sanger family often found itself on autumn Saturdays in Palmer Stadium rooting for the Tigers, impressions not lost on the young Alex.

After middle school, Alex went to Andover in Massachusetts and played “middling” hockey. An older brother was in the Princeton Class of 1965, so it’s no surprise Alex applied. He was accepted. He quickly set himself to Freshman and JV Hockey at Baker Rink and majored in History.

“I loved history,” Alex says. “I never felt the pull of another major.” A course that captivated him was James Ward Smith’s Philosophical Foundations of Democracy, which delved into the rights of individuals and their abilities to make their own decisions. At about the time he had to come up with a thesis topic, his legendary grandmother died, aged 87. At the time, Alex was abroad and learned much he had not known about Margaret Sanger from the obituary in The Times of London. “My father did not talk a great deal about her,” Alex says. “And for most of my growing up, my grandmother lived in Tucson. She’d come East to visit in the 1950s but cross-country travel was more troublesome then and generally we’d see her only once a year.”

But the obit in The Times had struck a chord. Alex suggested to the head of the History Department that he write his thesis on his grandmother. The notion met stiff headwinds. “This is history?” came the reply. “She died last year.” Barely beneath the surface was the view that women’s history was not quite History.

Deliberations ensued until the notion narrowed to researching Margaret Sanger’s efforts during 1910-1917, a formative period during which, despite distribution of contraception being illegal in many states and little discussed elsewhere, she established in Brooklyn the first Planned Parenthood office. Moreover, during this period, Margaret Sanger was connected to the Progressives and Radicals of the day.

But who to advise Alex? Eric Goldman, the Department’s only scholar of the 20th century, had just left to join the Lyndon Johnson administration. The Department head’s solution as articulated to Alex: “We have a new man. His period is the Civil War and Reconstruction. That’s about as close as I can get you.” This was James McPherson.

Alex did not often meet with Professor McPherson, who admitted to Alex that the Progressives were “a bit after my time.” But Alex strove on. “I think I was really one of the first persons to actually write women’s history,” he says now. “There was a ghosted ‘autobiography’ of my grandmother, but in a way, I was plowing new ground. There was no Women’s History. No one had really written on a progressive women’s movement.”

McPherson gave Alex a 1 on the thesis along with the compliment, “I learned so much from this.”

“The obituary and the thesis changed my life,” Alex says. Indeed it began a trajectory upon which Alex still remains. This includes a professional life dedicated to women’s rights not only in the United States but also around the world, and he is also working on a work based on his grandmother. Alex is weaving in material little known, indeed cloaked, during Margaret Sanger’s lifetime. For example, during the World War I era, when Margaret Sanger was working to establish offices for disseminating reproductive health information, she was also moving among persons who many were calling dangerous radicals, including Big Bill Haywood, Elizabeth Gurley Flynn, and Emma Goldman. She minimized these relationships so as not to jeopardize her work spreading education about contraception and family planning.

As graduation loomed, Alex felt the anxieties over the Vietnam conflict more than most — one of his older brothers had been killed in the fighting. Alex’s first move, though he knew his draft board had him in its sights, was to Washington, D. C., where he went to work for the Democratic National Committee. Hubert Humphrey had recently lost the election and the party was reeling from the riot-scarred ’68 convention in Chicago. The liberal wing of the party wanted a way of selecting delegates that better reflected the nation’s populations of women and minorities. “We were making significant change,” Alex recalls of his DNC days, “even rewriting state law to make the delegate selection process more inclusive.”

But there was little chance of outpacing the draft board. Alex joined the Air National Guard and served six months on active duty. Released, he was not settled on a career but nonetheless took the law and business boards. He scored well enough to be admitted to a joint JD-MBA program at Columbia, which he finished in four and a half years.

The degree led to a position in the Wall Street law firm White & Case, where Alex practiced trust and estate law. Working nights, he earned an advanced tax degree from NYU.

But in the 1980s, the long reach of Margaret Sanger and the women’s rights movements began to tell. Alex recalls a quote from Jane Austen: “Everything happens at parties.” Between acts at the Lincoln Center one night in 1984, Alex was introduced to Mimi Coleman, then the chair of Planned Parenthood of New York City (PPNYC). She persuaded Alex to serve on the board. He did for six years, upon which he was elected President and CEO.

Almost as soon as Alex took over PPNYC, it was involved in a Supreme Court case – Rust v. Sullivan – challenging the Bush Administration “gag rule,” which forbad counselors at federally supported clinics like Planned Parenthood from discussing abortion. The case went against the women’s rights groups 5-4. But in 1992, President Clinton overturned the order and invited Alex to the Oval Office as part of the recognition of the reversal.

Throughout the 1990s and as head of the largest Planned Parenthood affiliates in the United States, Alex traveled the nation to other affiliates. “Everywhere I went, I was impressed by the quality of the connection to the community and the devotion to the patients who came to the clinics. The women were treated not only professionally, but also with compassion and respect. I was very proud of our people.” Alex lobbied local, state and federal authorities. The work was not without foibles and rough patches. He debated anti-abortion advocates on Fox News – watching him on television one day during a debate, which could get graphic, his 10-year-old son asked his mother, “should I be watching this?” Alex was even known to be called away from family Sunday brunches by media reporters for commentary if a prominent clergy preached in the morning against abortion.

Alex retired from his directorship of PPNYC in 2000 but began volunteering full time for the International Planned Parenthood Federation (IPPF), which promotes sexual and reproductive health around the world. “It’s fabulously rewarding and important work,” Alex says. He took time to write a book, Beyond Choice: Reproductive Freedom in the 21st Century and talked in a hundred cities on his book tour.

Even today Alex travels for IPPF, meeting staff and giving talks. But in 2012, new work cropped up. He was asked to join the board of a foundation established by Ohio businesswoman Virginia B. Toulmin founded the year before. The board determined that much good with the foundation’s money could be had increasing opportunities for women, and especially in the performing arts, where, outside of acting, women are woefully under-represented. For example, of classical symphonies performed by major U. S. orchestras in the 2014-5 season, only 1.8% were composed by women. Choreographers are most entirely men, as are living opera composers. Alex’s work with the Toulmin Foundation has offered seed and production money for women-written operas, symphonies, ballets and plays, including one in the works at the McCarter Theater. The last five years’ effort has been so prodigious that The Washington Post has run stories about it. One of the operas funded, As One by Laura Kaminsky, last year surpassed Turandot and Barber of Seville to be the 14th most produced opera in the United States. “The performing arts have a long way to go offering opportunity to women creators of ballet, plays, operas and symphonies,” says Alex. “We are trying to change the culture of how women are treated. This is such vital work, and I feel very blessed to be able to participate and help.”

Since the Weinstein Hollywood scandal broke in October, 2017, Alex’s work has been exceptionally timely. “It’s long overdue that women are treated more respectfully in this field and that men are called to account,” he says. “Women deserve the opportunity to excel and to work as professionals without harassment and hindrances. The Toulmin Foundation looks closely at the theaters, orchestras and others that are candidates for our funds. We look to see if they have policies for reporting and dealing with sexual harassment.”

Even with the Toulmin Foundation work (Alex says he has three jobs: the Toulmin Foundation; the IPPF; and an in-progress work based on Margaret Sanger), Planned Parenthood still looms large. Its centenary anniversary was 2016 (dating from the opening of the Brooklyn office). The reproductive rights organization founded by Margaret Sanger in the New York City borough now works in 171 countries. In many of these, it is not just a source of sexual and reproductive rights and health care, it is a major national provider of primary care, delivering the likes of inoculations, education, clinical work and more to children and men as well as to women.

“As is often said, ‘We have come a long way, but there is still a long way to go,'” Alex remarks.

As has been noted in various ways: “A good life is a life helping others.” You might say that many are indebted to Alex. But his parting words are, “Princeton set me on my path. My debt to the University is immeasurable.”

Below: PAW story about Alex