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.