#13 – Midwives Providing Safe Birth in Humanitarian Settings

 

“(Midwives) give support to women whether they are in labour or not, they are social solidarity players in the local communities, not only the providers of health services for women & newborns.” – Mohamed Afifi, UNFPA

Welcome back to The Mom Pod! In this episode Julia Wiklander connects us with midwives and advocates about maternal and newborn health in humanitarian settings, at the 31st ICM Triennial Congress in Toronto, Canada. The midwives that we meet work in Mexico, Somalia and Afghanistan and share experiences from their work and talk about the challenges they face to deliver care.

With a world in constant political change and with the largest number of displaced people in history, ensuring that every mother and every child has access to a midwife during pregnancy and birth, is a difficult promise to keep. The world needs more midwives.

“They’re not refugees, they are not citizens – they are migrants. We need to start to name this as a public health issue.” – Cristina Alonso, Midwife working in Mexico

Our conversation is also broadened by UNFPA Reproductive Health Specialist for the Arab States, Mohammed Afifi, who tells us that in the region, midwives is the cadre of health professionals that are committing to delivering care, despite conflicts that push away many of their colleagues.

Safe Birth Even Here is a Campaign run by UNFPA to raise awareness of the high rate of maternal deaths in emergency situations and increase support for services to protect the rights of the women and girls living in humanitarian and fragile settings. Johnson & Johnson is one of the partners supporting the campaign, and has committed to supporting health professionals at the frontlines of care. We speak to Joy Marini at Johnson & Johnson about why the company is investing in the health of women & children in humanitarian settings and what they are doing to ensure that midwives receive support in their important work. 

In this episode, Young Midwife Leader, Massoma Jafari from Afghanistan, interviews Jane Philpott, the Canadian Minister of Health and asks her what action Canada is taking to support midwives in Afghanistan. Philpott gives the young midwife advice and promises new connections. A meeting that hopefully sparks further engagement by the Canadian government to invest in midwives. 

Listen to the full episode here.

During the ICM Congress, Johnson & Johnson launched their new initative – the GenH Challenge. This exciting opportunity hopes to encourage midwives to see themselves as innovators with the power to help to create the healthiest generation in human history – “GenH”. The GenH Challenge is looking to discover brand new ideas from the front lines of care that can change the trajectory of health. If this sounds daunting, don’t worry! The competition welcomes ideas in their earliest stages, and it welcomes small ideas that have the potential to create great impact. You can apply any time until 4 October 2017. Full guidelines are available at www.genhchallenge.com.

See all of the Girls’ Globe LIVE coverage from the 31st ICM Triennial Congress in Toronto, Canada here

An Interview with Kate Grant and the Fistula Foundation

Girls’ Globe values the voices of the incredible organizations in our network. Over the next year, Girls’ Globe will continue to highlight the amazing work of these organizations and what they are doing to improve the health and well-being of women and children around the world. Last week, in honor of the International Day to End Obstetric Fistula we “sat down” with CEO of The Fistula Foundation, Kate Grant. Read the interview below and learn more about the they are doing to improve the the health of women around the world.

1. Earlier this week the G4 Alliance launched globally at the WHA in Geneva, Switzerland – an alliance in place to improve​ access to care in Surgery, Obstetrics, Trauma and Anaesthesia. What does this alliance hope to achieve and how is Fistula Foundation involved?

The goal of the G4 Alliance is to advocate for neglected surgical patients (i.e. those in low-resource countries) and to provide a collective voice for increasing access to safe, essential and timely surgical, obstetric, trauma and anesthesia care as part of universal health coverage. The numbers are staggering: Over two billion people lack access to basic surgical services worldwide with less than 4% of all operations being delivered to the world’s poorest countries. In fact, Africa has roughly 1% of the number of surgeons in the U.S. (Abdullah 2015). We know that far too few women in the developing world have access to timely obstetric surgery – that is why fistulas occur – and after the fact they face challenges in accessing the necessary surgery to repair their bodies which have broken by childbirth. Fistula Foundation is dedicated to ending that suffering through free, safe, and high-quality surgeries, which is why we are a proud member of the G4 Alliance and its vision to make sure all patients have access to the surgical care they need.

2. Saturday marked, the International Day to End Obstetric Fistula. Can you explain why it is so important to specifically invest in ending obstetric fistula and not just maternal health services in general?

New York Times columnist Nick Kristof has referred to women with fistulas as “ the lepers of the 21st century, among the most voiceless and shunned people on earth.” Obstetric fistula may not be the ‘sexiest’ issue out there, but as the most devastating of all childbirth injuries, it is one that deserves targeted attention and investment. Not only is a woman left incontinent and unable to control her bodily wastes, but 9 times out of 10 her baby does not survive and she is abandoned by her husband and ostracized from her community because they cannot stand her smell. Fistula is truly a symbol of global inequality and indeed should not exist. The cure is a surgery which, on average, takes 1 hour and costs $450. Doesn’t seem like much, but this 1 hour and $450 completely transform a woman’s life!

3. Are there any specific concerns or challenges that the community working towards ending fistula is currently facing?

There are a few specific challenges we face in ending fistula completely. One of the biggest challenges is a global shortage of trained surgeons. Because fistula has been nearly eradicated in high-income countries, it is no longer a relevant field of specialized training for most surgeons. The Fistula Foundation funds training programs led by international experts in nearly all of the countries in which we work. Surgeons are trained through the standard competency program developed by the International Federation of Gynecology and Obstetrics (FIGO), and we support them following their training to make sure they have the necessary resources to put their skills into practice.

Another big challenge is lack of awareness. Again, because fistula has been nearly eradicated in high-income countries, many people are simply unaware that the problem exists. It is a humiliating and isolating condition that affects the poorest and most vulnerable women in low-resource countries, many of whom don’t even know that treatment is available or are too ashamed to come forward. We fund outreach programs to help raise awareness in rural communities and identify these women who are too often hidden and ostracized from society.

4. How can the international community help to end Obstetric Fistula as a part of the post-2015 agenda.

The only way to truly end fistula is to treat existing cases while at the same time preventing new ones from occurring. In order to do that, every pregnancy and delivery must be safe – this means improving women’s access to pre-natal care and emergency obstetric services. ALL women need access to emergency obstetric care, regardless of which part of the world they come from. About half of the women who give birth in Africa each year do not have access to the emergency care they need, so that is really the key to any agenda focused on ending fistula.

Until the time comes where every pregnancy and delivery is safe, raising awareness is one of the most important factors in helping to end obstetric fistula. The issue has slowly started to creep onto the international agenda in a variety of forms, such as the Global Fistula Map we co-funded with Direct Relief and UNFPA, and the United Nations Campaign to End Fistula. In fact, in December 2014, a UN resolution was passed to intensify efforts to end fistula. Efforts like these help keep fistula on the radar – let’s keep up the momentum!

5. Can you share any news about the progress to end Obstetric Fistula?

The good news is maternal mortality rates have dropped dramatically and more women are delivering their babies with a skilled attendant present than ever before. The path to ending fistula is a long one, but we are making steady progress. Fistula Foundation has now funded more than 14,000 surgeries across 30 countries, meaning more women in more places have been able to access surgery than ever before. More surgeons are being trained than ever before as well, increasing the international capacity to reduce the global backlog of patients.

Our Action on Fistula program, a three-year, $2M initiative funded by Astellas Pharma EMEA designed to make a lasting impact on fistula treatment in Kenya, also shows promise in accelerating the progress to end fistula. It is the largest and most well-funded single program we have ever undertaken in any of the countries where we work, and we believe has the potential to be a roadmap for comprehensive fistula treatment in other countries and regions. Based on its success, we are working to establish treatment networks throughout Africa and south Asia in order to help surgeons collaborate better and ensure that women have access to timely, quality surgery.

6. How can our readers and audience get involved to help end Obstetric Fistula?

There are many ways to get involved! Become a fistula ambassador in your community or school by joining our Circle of Friends program and putting on an event. Play the game Half the Sky on Facebook, inspired by the book-turned-documentary, Half the Sky: Turning Oppression into Opportunity for Women Worldwide by Nick Kristof and Sheryl WuDunn. The game allows players to complete quests based on themes from the book that unlock real-world donations to Fistula Foundation and the surgeries we provide! Another great example is Allie Pape, a supporter recently used an opportunity on an email lottery called The Listserve to raise $2,500 and counting for Fistula Foundation. You can read more about her story on my Huffington Post page.

As we know, obstetric fistula is often a ‘hidden’ condition that far too few people know about. Follow us on Twitter at @Fistula_Fdtn and be sure to tweet us using the hashtags #EndFistula and #FistulaDay and let us know what YOU are doing to help end fistula and raise awareness. Or, make a donation in honor of someone you love, or take our #nopresentspledge, a pledge you can take multiple times a year to let friends and family know that instead of gifts, you’d prefer they make a donation in your name to give the gift of health to a woman in need instead.

The 2014 State of the World’s Midwifery Report: A Summary

Since the establishment of the Millennium Development Goals (MDGs) 14 years ago, global leaders, organizations, and nations have been working to reduce child mortality and to improve maternal health around the world.

Unfortunately, a major barrier in reaching the health-related MDGs is the fact that not everyone has access to quality health care services – whether at a hospital or a clinic. In sub-Saharan Africa, women are 100 times more likely to die as a result of pregnancy or childbirth than a woman in an industrialized country. Around the world, 289,000 women die from childbirth complications annually, nearly 3 million newborns die in the first month of life and 2.6 million newborns are stillbirth each year.

Enter: The midwife.

Midwife: An educated, accountable health professional who possesses the skills and experience to support mothers and babies through the pregnancy, delivery and recovery stages of birth. – UNFPA

Infographic c/o UNFPA
Infographic c/o UNFPA

Educated midwives have the capability to perform nearly 90 percent of the essential care for women and newborns before, during and after delivery. Midwives teach communities (men and boys included) about important family planning techniques and products and thereby help to decrease the risk of unwanted pregnancies. In fact, investing in an educated and well-trained midwifery workforce has the potential to yield a 1,600 percent (16-fold) return on investment due to the economic benefits that arise from improved maternal and newborn health. As a result, investing in an educated midwifery workforce can single-handedly help to improve gender equality, empower women and enhance economic development.

To expand on the importance of midwives, the United Nations Population Fund (UNFPA) recently launched the State of the World’s Midwifery (SOWMy) report.

The 2014 SOWMy aims to do the following:

  • Provide an evidence base on the state of the world’s midwifery to support policy dialogue between governments and their partners;
  • Accelerate progress on the health MDGs;
  • Identify developments in the three years since the SOWMy2011; and
  • Inform negotiations for and preparation of the post-2015 agenda.

Additionally, the report highlights the importance of four key factors – the Availability, Accessibility, Acceptability, and Quality of midwifery care. It argues that countries and health systems must address each aspect of care in order to provide women and newborns with the lifesaving care they need and deserve.

Availability

Image c/o UNFPA
Image c/o UNFPA

Shockingly, the 73 countries profiled in the report account for 96 percent of all maternal deaths, 91 percent of all stillbirths and 93 percent of all newborn deaths, yet have only 42 percent of the world’s midwives, nurses and doctors. Even worse, no one country had a sufficient number of educated midwives and health workers to support the health of mothers and infants. The SOWMy stresses that, in order to attract others to a career in midwifery, midwives must be properly compensated for their lifesaving work.

Accessibility

Image c/o UNFPA
Image c/o UNFPA

Aligning with the United Nations Declaration of Human Rights’ assertion that “everyone has the right to life, liberty, and the security of person,” the SOWMy states that all mothers should have access to trained midwives, regardless of their ability to pay. The report urges countries to adopt a “minimum services benefits package” that guarantees a baseline of care for reproductive, maternal and newborn health.

Acceptability

Although maternal and newborn health centered policies accelerate progress, sustainable change comes from the bottom-up – from behavior change and societal acceptance. We must work together to dispel the myths and common preconceptions about midwives that inhibit women and girls from seeking their care.

Quality

Perhaps most importantly, the quality of midwife care and training must be addressed in order to most effectively decrease maternal mortality rates. Countries must recognize midwifery as a regulated profession in order to eliminate educational and infrastructural gaps – gaps that currently serve as huge barriers to the supply of skilled midwives.

Progress and Next Steps

Thanks to the first SOWMy report in 2011, the world has finally realized the incredible importance of skilled midwives. In the past three years alone, serious improvements have been documented among profiled countries:

  • 45 percent reported taking action to improve midwife retention in rural areas;
  • 71 percent reported improvement in data collection and accountability;
  • 28 percent have increased recruitment and deployment of midwives;
  • 18 percent have prepared plans to establish regulatory bodies or associations; and
  • 20 percent have a new code of practice and/or regulatory framework.

To ensure the availability, accessibility, acceptability and quality of maternal and newborn health care, policymakers, organizations and communities must champion all aspects of midwifery in the post-2015 agenda and let it be known that not only do midwives matter, but midwives save lives.

Learn more:

Cover image c/o UNFPA

Girls must be central to the Post 2015 Agenda

The health and status of women and girls are inextricably linked to the well-being and prosperity of families, communities, and economies. Yet today, nearly 15 years on from the launch of the MDGs, progress on reproductive health lags seriously behind. Approximately 800 women and girls die every day from complications related to pregnancy or childbirth, and 99 percent of these occur in developing countries.

Infographic c/o Women Deliver

Additionally, over 222 million women have an unmet need for modern contraception. Investing in the sexual and reproductive health and rights of women and girls has never been more critical. The largest-ever cohort of young people is entering their reproductive years, and their access to sexual and reproductive health information and services will have enormous implications for the trajectories of their lives. Advancing the reproductive health of women and girls also pays enormous dividends for development – poverty rates go down, education rates go up and greater prosperity follows.

As the 58th session of the UN Commission on the Status of Women is underway in New York, USA discussions and negotiations are taking place to shape the post-2015 development agenda.   Hence, now is the time to ensure that sexual and reproductive health and rights is a priority in the post-2015 agenda. I think it is essential that we realise that when we talk about sexual reproductive health and rights we are talking about young women and girls.

As a young woman and youth advocate, I am committed to ensuring that young women and girls are central to the Post 2015 agenda. I say this as the Post 2015 agenda must address the most marginalised populations and as girls and young women are two of these key populations they need to be part of the decision making process. In order to do this young women and girls must be empowered and engaged in meaningful participation. Meaningful engagement of young women can be understood as a series of empowering moments that move in the direction of the ‘decision-making table.’ She can advise, share, sing or cry her opinions on political reforms, policies, programmes and development initiatives that directly affect her and will allow for effective use of resources, both human and natural.

3773613115_9e7ca225d0_b
Image c/o Flickr Creative Commons

In a world where ‘one in three women will be beaten or raped in her lifetime,’ successful and sustainable change will require transformative leadership. This means leadership that will challenge and change the status quo and the systems and structures that perpetuate discrimination, inequality and denial of human dignity. In order for this to happen young women and girls need safe spaces to be themselves, share experiences, access information and discuss ‘taboo’ subjects without fear or judgement.

At the World YWCA (where I am lucky enough to work), we have developed a model of safe spaces which has emerged from our programming on sexual reproductive health and rights in Sub-Saharan Africa. Globally there is a frightening unmet need for family planning and as the world’s population saws we must ask ourselves what are we doing to address this? Sub-Saharan Africa has the highest adolescent fertility rate in the world, with girls under the age of 16 years of age facing four times the risk of maternal mortality than women over the age of 20. In Mexico 42% of young men and 26% of young women between 15 and 19 years have had a sexual relationship; only 47% of these young men and 15% of young women had used a condom during their first sexual intercourse. The HIV and AIDS rates are increasing in Eastern Europe. In Nepal 86% of married adolescents aged 15-19 are not using a modern contraceptives, every 4 hours one girl died from pregnancy relation complications. This is a global issue! The lack of adequate, accessible and youth friendly sexual and reproductive health services not only affect the educational and economic opportunities of present and future generations, but threaten their very survival.

Young people, particularly young women, must be educated and empowered on their own sexual reproductive health and rights. Without access to non-judgmental, confidential and evidence-based sexual and reproductive health information and services, young women remain vulnerable to unwanted pregnancies, unsafe abortion and sexually transmitted infections. Many young women are confronted with the consequences of early and forced marriage and child bearing.

Girls' Globe blogger Marcia Banasko at CSW58 in New York City
Girls’ Globe blogger Marcia Banasko at CSW58 in New York City

If we are to achieve a world of peace, equality and justice, we must be accountable to the world’s 860 million young women. We are more than a statistic – we are a valuable asset to nations, a critical population group for achieving sustainable human development and our voices must count in shaping the future of humanity. It is essential gender equality is retained as a stand-alone goal and that gender is mainstreamed across all the targets.

For Information:

World YWCA Global Call for Act: The Future Young Women Want

UNFPA Launches Advocacy Platform for Post-2015 Development Framework

Cover image courtesy of Flickr Creative Commons.

Sexual Violence in Conflict

Strong Women
Photo: Courtney Wenduki (Creative Commons licensing)

Violence against women is a global issue and constitutes various human rights violations. Annually, the 25th of November marks the International Day for the Elimination of Violence against Women and this special day also marks the beginning of the global campaign – 16 Days of Activism. The theme for this year’s campaign, “From Peace in the Home to Peace in the World: Let’s Challenge Militarism and End Violence against Women” highlights the impact of militarization and sexual violence during conflict. During armed conflict it is now said that it is more dangerous to be a woman than a soldier, due to the strategy of sexual violence as a weapon of war. The Rwandan genocide memorial notes that 500,000 women were raped during 100 days of conflict (IPU, 2008).

The consequences of sexual violence are devastating and destroy whole communities, ripping through the fabric of humanity.

As we witnessed, World AIDS Day, December 1st, also served as a reminder of the millions of women and girls who have been infected through rape in conflict. Many women and girls are subjected to rape including gang rape, forced marriages with enemy soldiers, sexual slavery, and other forms of violence (being forced to witness others being raped, mutilations, etc.). Many have fled their homes, have lost their families and livelihoods, and may have little or no access to health care. All these factors create conditions in which women’s and girls’ vulnerability to HIV is disproportionately increased.

Sexual violence is a security, public health and human rights issue and the horrific physical, emotional and psychological damage and suffering of sexual violence in each country is unique.

In Syria for instance, the threat of sexual violence was a major contributor to displacement as families fled in an attempt to get girls and women safe. As I wrote previously in a blog about Syria women and girls continue to suffer indiscriminately through war and conflict as brutal killings, rape and sexual assault and harassment destroy the fabric of families and whole communities. The UN High Commissioner for Refugees has reported that rape and sexual assault are now being used as a weapon of war in Syria. Unfortunately, this had the unintended consequence of early and forced marriages as parents married their daughters off to older men in an attempt to keep them safe.

Over the course of 2013, various global commitments have been made to eradicate sexual violence in all circumstances with a strong focus on sexual violence in conflict. The G8 Foreign Ministers’ pledged to work to eradicate sexual violence in conflict and develop an international protocol on the investigation and documentation of rape and other forms of sexual violence in conflict. Furthermore, the UN Security Council adopted Resolution 2106 to strengthen efforts to end impunity for perpetrators of sexual violence and during the 68th UN General Assembly 137 countries endorsed the Declaration of Commitment to End Sexual Violence in Conflict, proposed by the UK government.

But is this enough, what’s next? How do these Declarations and Resolutions translate to the women and girls, men and boys on the ground?

In the Congo alone, tens of thousands of women and girls have been the victims of sexual violence. Militias use rape as a weapon of war, destroying communities and in many cases even the police and security forces who are supposed to protect civilians are perpetrators themselves. This is a global scenario as testimonies of rape and sexual assault by protectors such as police and aid workers particularly in refugee camps are tragically common.  As many as 64,000 women and children were raped and sexually assaulted in Sierra Leone, over 40,000 during the Bosnia and Herzegovina war, 4,500 in a single province in the Congo in just six months and everyday hundreds of women and children are raped in Darfur.

These are not just the acts of individual soldiers, but organised military operations.

Fortunately, there are organisations working in partnership with governments, local communities, legislators, victims/survivors and perpetrators to eradicate sexual violence and bring about healing and justice. For example, Raise Hope For Congo– a campaign of the Enough Project organisation which aims to end genocide and crimes against humanity- is addressing sexual violence in conflict at the root cause. The campaign supported by the US Government has four key objectives:

  1. Increase prevention of and protection against Sexual Gender Based Violence (SGVB) for vulnerable populations.
  2. Reduce impunity for perpetrators of SGBV.
  3. Improve the capacity of the security sector to address SGBV.
  4. Increase access to quality services for survivors of SGBV.

Although, there are mountains to climb to achieve peace with real justice in this world, we can each start by raising our voices for the voiceless. Sexual violence in conflict is a crime against humanity that for too long the world has been silent about and neglected the millions of women, girls, men and boys who have been victims.

Now is the time to act.

Take Action!

Motherhood in Childhood: State of the World Population Report 2013

UNFPA2
Girls in Rajasthan, India learning to read.
© Mark Tuschman/Educate Girls India

Today, the United Nations Population Fund (UNFPA) released its State of the World Population 2013 report under the title “Motherhood in Childhood – Facing the challenge of adolescent pregnancy”. The comprehensive report addresses the important issue of pregnancy in adolescence, which is often the result of multiple factors including poverty, gender-based discrimination, violence against girls, inability to keep girls in school and child marriage.

In developing countries, 20,000 girls under 18 give birth every day – but adolescent pregnancy is a problem in developed countries too. According to the report, there are 680,000 births to adolescent mothers in developed countries every year. Nearly half of them occur in the United States, where family planning and sexual and reproductive services have been the target of much heated debate.

Adolescent pregnancy carries negative consequences to girls’ lives and future prospects. Girls who become mothers at a young age often see their education interrupted or totally halted, have harder time finding meaningful job opportunities, and particularly in the context of low- and middle income countries often face long term health consequences such as fistula. Risk of maternal death is notably higher for younger girls than older women – in developing countries, an estimated 70,000 adolescents die each year as a result of complications during pregnancy and childbirth, and account for as many as 3.2 million unsafe abortions annually.

Source: SWOP 2013
Source: State of the World Population 2013

One of the most important messages in the report is that interventions aimed at decreasing adolescent pregnancies must move away from seeing the girl as the cause and blame of the issue. Instead they should focus more on the underlying structural and societal causes that leave girls vulnerable and powerless, and place them at a higher risk of becoming pregnant. Adolescent pregnancy is often not a result of choice, but lack there of – young girls get pregnant because their rights to education, protection, family planning, sexual and reproductive health services, information and self-determination are violated. As UNFPA notes, adolescent pregnancy is both a cause and consequence of violation of girls’ rights as citizens, as individuals, as females – and as children. Adolescent girls get pregnant because systems, institutions, governments and legislations have failed to protect them, and the focus of changing the situation must be in fixing those structural failures, not placing the blame on girls.

Source: SWOP 2013
Source: SWOP 2013
Source: State of the World Population 2013
Source: State of the World Population 2013

This year, the theme of the International Day of the Girl Child was Innovating Girls’ Education, and UNFPA’s State of the World Population Report also highlights the importance of girls’ education in decreasing and preventing adolescent pregnancy. Schools can offer safe and protective environments for girls, prepare them for adulthood by equipping them with the necessary skills and knowledge to remain in control over their own lives, and provide them with crucial sexual and reproductive health education for avoiding unwanted pregnancies. Education also decreases the risk of child marriage, which can often be the cause behind unwanted pregnancies in adolescence. Education alone is not enough, but it is a huge part of the puzzle. The report calls for a more holistic approach to tackling unintended pregnancy in adolescence through stronger partnerships across sectors, and most importantly in collaboration with adolescents themselves – both girls and boys.

Life-skills class, Ethiopia © Mark Tuschman/Planned Parenthood Global
Life-skills class, Ethiopia
© Mark Tuschman/Planned Parenthood Global

Let’s let girls be girls and finish childhood before becoming mothers, and ensure that our societies provide them with the opportunity to choose when and with whom to start a family, how many children to have, and how to space them. Motherhood should always be a choice, and never the result of poverty, coercion, violence or misinformation. We cannot expect to see sustainable development and progress when millions of girls cannot reach their full potential because of early, unintended and unsafe pregnancies. There are 580 million adolescent girls in the world, and we cannot afford to lose any of them to preventable maternal deaths, or waste their potential because we as individuals, communities and governments failed to protect them and their rights. By investing in adolescent girls, we are investing in a better future for the entire humanity. That seems like an investment worth making.

Tell us what you think is the most important or most successful way to decrease girls’ risk of adolescent pregnancy!  You can Tweet us @GirlsGlobe, connect with us on Facebook or leave a comment with your thoughts!

Follow the discussion on Twitter with #SWOP2013 and @UNFPA

All images courtesy of UNFPA.

Featured image: Sixteen-year-old Usha Yadab, class leader for Choose Your Future, a UNFPA-supported programme in Nepal that teaches girls about health issues and encourages the development of basic life skills. © UNFPA/William Ryan