Gender

A Better Health Agenda for the Americas

Latin America needs comprehensive health care solutions, not minor uncontroversial changes.
In June 2007 the Ministers of Health of all Latin American nations issued a Health Agenda for the Americas: 2008-2015, (the "Agenda") a supposedly comprehensive plan for improving the health of the people of the Americas that was anything but comprehensive. It managed to leave out many proven recommendations for improving the sexual and reproductive health of the citizens of Latin America.

Infant and Maternal Mortality

If the moral soundness of a society is measured by how it treats its children, then Latin America, while better than Africa, does not measure up. Infant mortality in Latin America is stubbornly high -- averaging 23 per 1000 live births (versus 7 in the U.S.) -- though an improvement from 81 per 1,000 live births in the years 1970-1975. Maternal mortality is far too high, with Bolivia and Peru leading at rates of 420 and 410 per 100,000 births respectively, as opposed to 17 in the U.S. Uruguay has the low at 27. The major causes of high infant and maternal mortality are well known: poverty, lack of skilled birth attendants and deficiencies in emergency medical care. There are underlying causes as well that lead to these medical emergencies, and they all fall under the rubric of sexual and reproductive health. Health experts, and mothers, know that contraception which enables intended pregnancy can improve outcomes by 1) delaying first birth until a woman has fully matured, 2) birth spacing, permitting a mother to regain her health and to fully nurture the child she has before giving birth to the next, and 3) reduction in absolute number of births, allowing the mother to give more care to the children she has. The Agenda, to its credit, called access to contraceptives "indispensable," and called for continuous care to mothers before, during and after pregnancy, for increased efforts to prevent transmission of STI's and for stronger men's roles in all these.

While a good start, this is insufficient.



Contraceptive and Fertility Rates

The issue in Latin America is not contraceptive use; it is getting the contraceptives to those at risk for unintended pregnancy. Contraceptive prevalence in Latin America is the highest in the developing world, on average, with 75 percent of women in South America and 66 percent in Central America having access to a method (the corresponding figure in Africa is 27 percent and in the U.S. 73 percent). These rates are far less in rural and poorer areas, and thus the rate of unintended pregnancy there is higher. Increase in contraceptive prevalence (the rate was 60 percent for Latin America and the Caribbean in 1998) though has not translated into birth rate or abortion rate declines. The reason is a combination of lack of contraceptive access in vulnerable populations, along with higher intended childbearing desires. In some Latin countries overall birth rates, including teen birth rates, increased during the 1990's, while in the rest of the world they declined. On average, 20 percent of teens give birth in Latin America. The fertility rate for ages 15-19 is currently 78 in South America. In 1996, the South American rate was 75, indicating a 4 percent rise since then. A comparison with the U.S. is instructive. The fertility rate for Hispanic teens in the U.S. is about 82 for 2005, or slightly higher than the overall fertility rate for teens in Latin America (about 76). The U.S. figure disguises ethnic variations among immigrant populations, with the fertility rate for teens of Mexican origin in the U.S. being 93. However, interestingly, the teen fertility rate in Mexico is 63, about a third less than for Mexican teens in the U.S. Hispanic teens in the U.S. in general have a higher fertility rate than Hispanic teens in their country of origin. The reasons could include lack of access in the U.S. to contraception or more teen sexual activity. Also Hispanic culture meeting with more prosperity in the U.S. (as well as in those Latin countries that have prospered) could have led to increased teen birth rates. There are no figures, though, that I have seen as to the intentionality of these teen pregnancies. Though adolescents especially were recognized in the Agenda as needing special attention, there was, however, no specific call for renewed sexuality education efforts and increased availability of contraceptives for adolescents. This is not dissimilar to the silence in official circles in the U.S. Government around teen sexual activity, except for calls for abstinence education.

One sure way to decrease unintended pregnancy for teens and adults alike is emergency contraception. In many Latin countries there are battles over the legality of emergency contraception, which is characterized, mistakenly, as an abortifacient. In Chile and Ecuador, cases challenging distribution of emergency contraception recently went up to their respective Supreme Courts where, alas, EC opponents prevailed. The Agenda makes no mention of emergency contraception.

Abortion

An abortion rate about 50 percent higher than the North American level predominates throughout Latin America, along with attendant maternal mortality and morbidity. This would indicate pregnancy rates are higher than the desired childbearing rates. Still, women in Latin America have about one more child than they say they want.

Abortion is proscribed virtually everywhere in Latin America, except Cuba, Guyana and Mexico City. Four of the five countries of the world which prohibit abortion in all cases, even to save the mother's life, are in Latin America: Honduras, Chile, Nicaragua and El Salvador. There are about 4 million illegal abortions a year, 95 percent of which are unsafe. About 5,000 women die a year, resulting in 20 percent of all maternal deaths being from unsafe abortion.

There has been progress during the last year in decriminalization. Colombia's Constitutional Court decriminalized abortion in three cases: rape, for the life or health of the woman and for fetal deformity. The Mexico City legislature also decriminalized abortion, by a vote of 46 votes in favor and 19 against, despite a threat of excommunication.

The Agenda made no mention of de-criminalizing abortion or providing post-abortion care.

STD's and HIV/AIDS

While HIV/AIDS levels are below those of sub-Saharan Africa, HIV is still at serious levels. The prevalence rate is at or below 1 percent in every South American country, similar to most Asian countries, compared to rates of 25 percent in southern Africa. Condom use in Latin America is low -- just 4 percent of women in Brazil and Mexico report using condoms, compared with 13 percent in the U.S. according to PAHO (other sources show a higher rate of condom use of 18 percent in the U.S.).

Approximately one-third of Latin women have never had a Pap smear. In the U.S. about 84 percent of women had a Pap smear within the last three years (including 81 percent of Hispanics), indicating that Hispanic women are not disproportionately marginalized from the U.S. health care system. The Agenda made no specific recommendations for increasing condom use and the availability of Pap smears.


Violence Against Women

Violence against women is apparently more prevalent in Latin America than in the United States, though comparable and accurate statistics are hard to come by. In the U.S. there has been a steady decline in what the U.S. Department of Justice calls "intimate partner non-fatal victimization" (a gender neutral term) which had declined from 6 per 1000 persons to about 2 per 1000 from 1993 to 2005. The rate of violence against both Hispanic and non-Hispanic females in the U.S. declined as well and averaged about 4.2 per 1000 annually during the period 2001-5.

In Latin America, the few surveys that have been done show, for example, that over 40 percent of women ages 15 to 49, who have ever been in a union in Peru (42 percent) and Colombia (44 percent), have been victims of partner violence. This is a cumulative figure, but it would appear that violence against women is higher in Latin America than among Hispanics in the U.S. DHS surveys in Latin America reveal that, for instance, in Nicaragua 11.9 percent of women experienced domestic violence in the year preceding the survey.

There was not a single mention of violence against women or domestic violence in Health Agenda for the Americas: 2008-2015.


The Americas' Health Ministers' Recommendations … and Omissions

So, the Latin American Health Ministers made a less than sterling start in addressing the sexual and reproductive health needs on their citizens, leaving out sexuality education, teen access, condoms, safe abortion, emergency contraception and measures to combat domestic violence.

Not unexpectedly, they did call for increased spending on health. The region spends 6.8 percent of its GDP on health care, or about $500 per person (the U.S. figures are 16 percent and $7,600, respectively).

How to pay for increased sexual and reproductive health care? First, decriminalizing abortion will save health care dollars. So will providing preventive health care, including family planning, emergency contraception and condoms. Passing and enforcing domestic violence laws too will reduce health care expenditures.

If funds are needed, countries might consider increasing tax revenues. Latin American taxes average 18 percent of GDP (in the U.S. it is about 25 percent and about 36 percent in Western Europe.

Finally, the U.S. and other donor nations could also increase their ODA to the agreed-upon level of 0.7 percent of GDP. The U.S. ODA in 2006 was at 0.17 percent. Only three Scandinavian nations, the Netherlands and Luxembourg exceeded 0.7 percent. Having healthy neighbors is in our national interest.
Alexander C. Sanger, the grandson of Margaret Sanger, who founded the birth control movement over eighty years ago, is currently Chair of the International Planned Parenthood Council. Mr. Sanger previously served as the President of Planned Parenthood of New York City (PPNYC) and its international arm, The Margaret Sanger Center International (MSCI) for ten years from 1991 - 2000. Mr. Sanger speaks around the country and the world and has served as a Goodwill Ambassador for the United Nations Population Fund. More of his writing can be found on his website, www.alexandersanger.com