A Better Health Agenda for the Americas

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.