Reproductive health care in Latin America

A Canadian physician reports

By Rosana Pellizzari

Emergency contraception, the use of hormones to prevent pregnancy after unprotected or forced intercourse, has been available in North American and Europe for more than 30 years.

In Canada, it is the standard of care for victims of sexual assault. It is now recommended for any couple relying on condoms, in case of breakage or slippage, as their method of birth control. If given within 5 days of unprotected intercourse, it can prevent most pregnancies. If given to a woman already pregnant, it will cause no harm to the developing fetus. It is not an abortificient but in fact, prevents recourse to abortions.

Yet, in Latin America, where I am now working, the Catholic Church does its best to prevent access of millions of women and couples to this effective form of birth control. Instead, it helps to promote myths and misconceptions about emergency contraception, so that providers and potential users believe it is either immoral or illegal to offer it to a woman, even in the case of rape.

In countries such as Costa Rica, levonorgestrel, the best form of emergency contraception, is not registered or available. Emergency contraception, commonly called the “morning-after pill”, can utilize either a single hormone, such as levonorgestrel, or a combination product, such as ovrol, or many other of the pills used for birth control by women. Two ovrol pills, followed by a second dose 12 hours later, can prevent 80 to 90% of pregnancies if taken up to five days post-coitally. The sooner they are taken, the better. The levonorgestrel product, marketed as “Plan B” in Canada, has the advantage of being more effective and causing fewer side effects. In addition, the drug can be taken as a single dose, rather than being split into two, which makes it much easier to use.

A recent study done in Ontario showed that having the product available through pharmacists, without the need for a medical prescription, prevented approximately 400 pregnancies, and 200 abortions over a 12 month period.

According to the International Federation of Obstetricians and Gynecologists (FIGO), it is unethical for a physician to withhold emergency contraception from a patient. In its 2002 ethical guidelines, the Federation states “Early access to hormonal emergency contraception improves its success rate and therefore decreases health risks. Therefore, at a public policy level, the medical profession should advocate that emergency contraception be easily available and accessible at all times to all women”.

On January 21st of this year, Mexico, despite immense opposition by the Catholic Church, made emergency contraception part of its Ministry of Health standards of care in reproductive health. But the church’s tactics, its denunciations, have been noted in other Central American countries, and, although unsuccessful in Mexico, send a strong and intimidating message to advocates for women’s health elsewhere. In Costa Rica, where a coalition of government representatives and NGO’s have been meeting for the purpose of ensuring that Costa Rican women get access to emergency contraception, advocates attribute the Catholic Church’s close ties to the ruling “Unidad Social Christiana” government as the main barrier. Recently, the Catholic Church hierarchy was successful in closing down the government’s adolescent sexual health promotion campaign. This, in spite of the fact that 21% of all births in Costa Rica in 2003 were to teenaged mothers.

Despite church opposition, the Costa Rican Commission on Sexual and Reproductive Health and Rights, set up by decree following the Catholic Church’s attempt to prevent access to vasectomies and tubal ligations, has decided to hold a national forum on contraception on March 24th and 25th in San Jose, the capital city.

The University of Toronto has made it possible for two Canadian physicians to present lessons learned from Canada, with the hope that Costa Rican health professionals can build upon international experience to hasten the introduction of emergency contraception into protocols and standards of care here.

Currently, in Central America, only Nicaragua and El Salvador have levonorgestrel products registered, but many still have not made access to emergency contraception part of their reproductive and sexual health care. For women living in these countries, unplanned and unwanted pregnancies, including those resulting from sexual violence, continue to put women’s lives and well-being at risk.

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