Analysis Law and Policy

Using the Law to Reduce Health Disparities in Peru

IPPFWHR

Peru has made major strides in recent years in regards to development, with strong economic growth and low inflation. Despite these achievements, among Peru’s more than 29 million inhabitants, great disparities persist: 54% of Peru’s population still lives in poverty, and the UNDP estimates that among those living in poverty, 19% survive on less than USD $1 a day.

Peru has made major strides in recent years in development, with strong economic growth and low inflation. Despite these achievements, among Peru’s more than 29 million inhabitants, great disparities persist: 54 percent of Peru’s population still lives in poverty, and the UNDP estimates that among those living in poverty, 19 percent survive on less than USD $1 a day.

In this context, the estimated eight million Peruvians between the ages of 10 and 24 face limited economic, educational, and creative opportunities. They also face enormous challenges in accessing the sexual and reproductive health services—such as family planning and comprehensive sexuality education—that would allow them to make a healthy transition to adulthood. According to the Ministry of Health, less than 2.6 percent of adolescents use contraception. And although overall teenage birth rates are low relative to other countries in the region, national averages mask great disparities, with less educated and poorer women more likely to have given birth.

These challenges are exacerbated by national regulations that prevent adolescents under the age of 18 from accessing condoms, birth control, pregnancy testing, and counseling at public health clinics without parental consent. Beyond legal obstacles, adolescents also face practical and social barriers to accessing services—particularly if they belong to economically, socially and culturally marginalized communities. The Ministry of Health has issued guidelines to facilitate adolescents’ access to information about family planning as part of its efforts to reduce maternal mortality, but so far, implementation of adolescent-friendly health policies has been slow.

Since the creation of these guidelines at the national level four years ago, many youth advocates in Peru have been looking for a way to accelerate implementation of youth-friendly policies and legislation. Through the Voices project, IPPF/WHR and our Peruvian Member Association, INPPARES, invested in building a strong network of 20 youth organizations to serve as watchdogs for the implementation of adolescent health policies in three regions of Peru.

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“One of the principal problems that we’re facing in Peru is that there are a lot of laws, programs, and policies in the area of sexual and reproductive health,” says Giovanna Sofía Carrillo, Voices Project Coordinator at INPPARES, “but very few of them have been applied and implemented in practice. Despite progress at the national level, major gaps persist at the local level.”

INPPARES led a concentrated effort to monitor implementation of existing norms and policies, such as comprehensive sexuality education guidelines, and hold governmental agencies and other key actors accountable. According to Carrillo, this involves more than training governments in effective youth programming in sexual and reproductive health and reproductive rights of youth in Peru.

“This project has been able to give voice to people who have traditionally been excluded from having a real voice and a visible role in the political process,” says Carrillo. “We literally cannot develop as a country without addressing the poverty and discrimination that adolescents face. Preventing unwanted pregnancy is a key part of this: if the state is serious about reducing poverty and promoting development, it has an absolute responsibility to ensure that adolescents have access to family planning services, health information and sexuality education.”

This regional-level focus has also led to increased political participation among young people. In northern Peru’s Lambayeque region, young advocates secured a meeting with government officials to discuss implementation of the youth sexual and reproductive health program. Following this meeting, a Regional Youth Council for citizen monitoring and oversight was established.

“It’s a significant achievement: people who were invisible are now being seen, they are taken into consideration by authorities at the regional and national level. The great struggle that fuels our work is to reduce disparities so that economic growth affects everyone. And to be able to say that Peru’s laws and legal frameworks are more than just symbolic commitments.”

Analysis Human Rights

Zika Increases the Already Grave Dangers of Being Young and Female in El Salvador

Kathy Bougher

The Zika virus, its potential link to microcephaly and other complications, and the inadequate government responses to it so far all bring into sharper focus the threats girls and women already face in the country.

Read more of our articles on the Zika virus here.

The arrival of the Zika virus is not the only threat to young women’s health and human rights in El Salvador. The virus, its potential link to microcephaly and other complications, and the inadequate government responses to it so far all bring into sharper focus the grave situation girls and women already face in the country. Such danger, highlighted in both government reports and the work of activists on the ground, includes sexual violence, a lack of access to medical care, and gang activity.

El Salvador’s health ministry recently recommended that because of the virus, women contemplating pregnancies should take measures to postpone their pregnancies for at least two years. However, as Rewire reported, feminists responded that the recommendation is inadequate. It does not address the realities in El Salvador, they said, a country where 31 percent of all pregnancies registered with the El Salvador Ministry of Health in 2014 occurred among girls and women ages 10 to 19. Because of a number of societal restrictions, many of these girls may not have a choice in whether to put off pregnancy. 

A November 2015 report from the United Nations Population Fund (UNFPA) and the Salvadoran Ministry of Health (MINSAL) gives the most up-to-date details so far about this large segment of the population, especially where issues of relationships, pregnancies, and reproductive rights are concerned. Although the report was released before news of Zika became widely recognized, it describes interconnected systems of coercion and abuse any strategies to address the virus must take into account.

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The UNFPA and MINSAL report stemmed from two stark figures in a National Health Survey in 2014: One out of every three women ages 20 to 49 in the survey had a pregnancy before the age of 18. One out of four lived in a relationship with a man, married or unmarried, before the age of 18.

These numbers, notes Minister of Health Violeta Menjívar in the 2015 report’s introduction, reflect the environment young women must often navigate in El Salvador:

The relationships as well as the early pregnancies are the result of circumstances beyond the control of the girl and the adolescent, and they impede her from making key decisions about her life adequately. The situation of violence in the family and in the society places girls and adolescents in situations in which their rights are violated. The relationships and pregnancies before age 17 are a product of the social violence that they suffer daily, and which is not taken on as such by the society or the State. 

Using interviews with girls between the ages of 10 and 17 who had a live birth in 2012 at a Ministry of Health facility, the authors of the 2015 report attempted to flesh out the stories behind those statistics. The majority of the relationships, it found, were “not among peers,” meaning an age difference of three years or less. Rather, two-thirds of the girls had a male partner at least four years older at the time they gave birth, and 18 percent had a partner at least 10 years older.

This, the report states, creates “very unequal power” in the relationships, which leaves the girls and young women with “very little margin with which to make decisions about their lives.”

The study recognizes the problematic and conflicting laws in the country that criminalize some of these relationships but legalize others. For unmarried individuals, for example, any sexual relation with a minor younger than 15 years old is a crime. But there are still laws in effect in the penal code, it says, that “permit marriage under the condition that the girl or adolescent is pregnant or [they] have children in common, and there exists the express permission of the parents or guardians.”  

The study also shows that “one of every ten relationships was formalized through marriage, including some with girls ages 10 to 12.”

The report also highlighted the inadequate medical services many of the girls received. In the case of the 10-to-12-year-old group, 20 percent had no postpartum care, even though, as the report says, they are the most vulnerable to obstetric complications. Half the girls and young women who gave birth in 2012 were not using contraceptives at the time of the study in 2015. By that time, 29 percent had already had a second pregnancy or were pregnant.

Girls and adolescents with histories of sexual violence, as self-reported in the interviews, comprised 37 percent of the interviewees overall, but two-thirds of girls ages 10 to 12 in 2012. One out of five of the girls who were 10 to 12 years old in 2012 had their first sexual relation with a family member, which constitutes the crime of aggravated sexual aggression. Though the report did not discuss individuals’ experience with the justice system, feminist groups that collect data on violence against women say that few police reports are ever filed of crimes like these—and if they are, there is rarely any follow-up.

“Sexual aggressions committed against girls and adolescents take place in an environment of social permissiveness around assaults, abuse and deception, fed by neglect, violence and poverty,” wrote Menjívar in her introduction.

“The fact that a girl of 10, 11 or 12 years of age is pregnant or finds herself in a relationship, that she leaves school, that she does not have access to services to protect her, et cetera, should be considered a national priority especially, when the persons who should protect them, and the institutions that should guarantee their rights, permit that these rights be violated,” she continued.

Right now, local health educators say that combating this problem is not a national government priority—and their own community-based work reinforces the report’s conclusions. Zuleyma Lovo, psychology student and leader from the activist group Jóvenes Voceras y Voceros en Derechos Sexuales y Reproductivos, gave workshops in rural communities and in middle schools on sexual and reproductive health—until increasing gang violence caused the program to be suspended in late 2015.

In an interview with Rewire, she affirmed the frequent incidents of violence and sexual abuse among the students she knew, and the many young girls who lived with older men:

At the school we asked for anonymous written comments, and in addition to questions about our talks, the girls would tell us about the physical, sexual, and emotional violence they experienced at home. Many think they can escape it by leaving home and living with a man, almost always a man who is older. But, the same dynamics repeat themselves, the violence, the abuse, the control.

This coercion extends to the control of pregnancy planning. “The men decide whether or not the women can use contraceptives. The men almost never agree to use condoms,” she said.

“Then the Ministry of Health arrives and tells women to abstain or to keep from getting pregnant,” she added.  

This is not the only situation, advocates say, in which adolescents have difficulty accessing contraceptives. Lovo, and Noel Gonzalez, health educator and national director of Voceros y Voceras, described the difficulties the young people they serve face when attempting to obtain birth control available at no cost from local health centers operated by the government. Such clinics are the providers for the majority of poor people, both urban and rural; those who can pay for private pharmacies tend to have more options.

Gonzalez explained that the centers are directed to offer “youth-friendly” services, but that is rarely the case. Frequently, Gonzalez said, the young people he’s interacted with are met with “judgmental, prejudice-laden treatment and a lack of confidentiality” from the time they walk in the door. When young people do request contraceptives, he said, they are often told, “You’re too young. It won’t matter. You’re just going to get pregnant, anyway.” As a result, Gonzalez said, “many never go back.”

Clinics, Gonzalez said, often have limited supplies of certain kinds of birth control. “They only have the three-month injections, which have more side effects for young women,” noted Gonzalez. In its 2014 report On the Brink of Death: Violence Against Women and the Abortion Ban in El Salvador, Amnesty International found that “these clinics have … been associated with provision of fewer options and poorer levels of service for young women including denial of services and discriminatory treatment.”

And if that contraception fails, Lovo noted, women have few options: Abortion is 100 percent illegal in all cases in El Salvador. “Pregnant women who are abused or whose partners deserted them might be considering interrupting their pregnancies, but they are afraid to talk about it because of the strong religious biases against abortion,” she said.

All this is worsened, Lovo explained, by the threat of gang violence, which shut down her project in 2015. “They murdered a woman leader in one community, and we can’t go back there,” she said.  

El Salvador, by many rankings, is one of the most dangerous countries in the world. Contributing factors are complex, but gangs and organized crime play large roles.

Gangs claim territories, which makes access to some health clinics a dangerous matter. Gonzalez elaborated, “The gangs stop you and ask you for your [identification], and if you live in the area of a rival gang, they won’t let you into their area. That can be where the clinic is.” A young person with the resources can take a bus to a distant clinic, but most don’t have that option.  

Working as a health promoter is also dangerous: Some, Gonzalez said, have been murdered by gangs as they move from one community to another. He also explained that gangs kidnap or threaten to kidnap young women from their families and rape them, which has caused families to relocate within the country or to leave the country in order to protect their daughters. Some health clinics are reluctant to report rapes when women come to them for fear of reprisals from gangs.  

Violence and poverty work together to curtail school attendance, including access to sexual education. Rates of students who leave their school out of fear have doubled in the past five years. In some cases, schools have closed as families flee to other regions of the country or leave the country altogether. Lovo noted that independently run sexual education programs such as hers have been effective but small, and limited by safety concerns.

Various projects and programs to improve matters have been written at the ministerial level and partially implemented, but have not met their goals. A proposed law on sex education in the schools has stalled in various committees.

The potential risks and impacts of the Zika virus interact with and exacerbate the chronic dangers of being young and female in El Salvador. Any efforts to deal with Zika need to recognize those contexts, and to work on making the country safer for girls and women beyond the threat of the virus alone.

Analysis Abortion

In Louisiana, a New Law, and a Worsening Reproductive Health-Care Crisis

Teddy Wilson

Access to reproductive health-care services in Louisiana is limited. There are only five clinics that provide abortion care in the state—and that number is soon expected to fall to two once a new law signed by Republican Gov. Bobby Jindal goes into effect.

Correction: A version of this article incorrectly noted that HB 388 will require the implementation of a forced 24-hour waiting period on surgical abortion in Louisiana. In fact, such a waiting period is already in place; HB 388 will require the implementation of a forced 24-hour waiting period on medication abortion. We regret the error.

It’s a muggy late May morning in New Orleans’ Broadmoor neighborhood, and dozens of area residents are lined up in the rain for a health-care fair at the Rosa Keller Library and Community Center. For many of the people who live in Broadmoor—a predominantly low-income community of color—this is their only access to health care.

LaToya Cantrell, who represents the residents of Broadmoor on the New Orleans City Council, walks through a crowded hallway, stopping every few feet to converse with constituents and say hello to neighbors. She also gets her blood sugar tested.

Cantrell explains to Rewire that the community center only exists today because of intense rebuilding efforts in the months and years after Hurricane Katrina. Broadmoor was one of the neighborhoods worst hit by flooding in the city, with waters reaching as high as ten feet throughout much of the area. In the districts that include Broadmoor, more than three out of every four homes were damaged or destroyed. Some city leaders wanted to turn the neighborhood into a green space rather than rebuild.

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Then president of the Broadmoor Improvement Association, Cantrell helped organize the neighborhood rebuilding effort. Three years after the storm, 79 percent of all the homes in the neighborhood had been restored.

“I’ve been on the ground working as a community organizer long before I was on the city council,” said Cantrell. “We worked as a community to make sure this community center was here for the neighborhood—a neighborhood the city wanted to turn into a park.”

Still, nearly a decade after Katrina, signs of the storm and the subsequent breach of the city’s levies remain in Broadmoor, in the form of abandoned homes and apartment buildings. These are signs that are largely absent from other, more affluent areas of the city.

Many residents see the inattention by lawmakers in Baton Rouge to rebuilding lower-income neighborhoods post-Katrina as one of a number of indications that political agendas in the state are often pursued without consideration for how they may affect low-income communities and communities of color.

The state’s record on health care, and reproductive health care in particular, also illustrates this view.

Louisiana has some of the worst health-care outcomes of any state in the country, and these outcomes have remained steady for the last two decades. The state also has among the highest share of residents without health insurance.

The Louisiana legislature has on multiple occasions blocked the expansion of Medicaid that was made available to states under the Affordable Care Act. If enacted, Medicaid expansion in the state would be expected to cover 240,000 additional people, with all of the cost of expansion covered by the federal government for the first three years. (The federal government would pay 90 percent of the cost after that.)

In states that have expanded Medicaid under the health-care reform law, the rate of uninsured citizens has declined by an average of 2.5 percentage points between 2013 and the first quarter of 2014. Meanwhile, states like Louisiana that have not expanded Medicaid saw uninsured rates drop by an average of just 0.8 percent.

A December 2013 study by the Kaiser Family Foundation, which found that Medicaid expansion would significantly increase health coverage for low-income people of color across all states, also shows a significant racial disparity among the percentage of individuals in Louisiana who are uninsured. While 16 percent of white people in the state are uninsured, 25 percent of people of color are without health insurance. Racial disparities are also evident in the share of people at or below 138 percent of the federal poverty line ($15,856 for an individual in 2013)—the group of people who would eligible for Medicaid under the expansion—with 48 percent of white people who are uninsured being eligible, compared to 63 percent of people of color.

The state’s reproductive and sexual health outcomes paint an even worse picture. According to data from the Guttmacher Institute, in 2008 there were 65,300 births in Louisiana and of those 36,400 were unintended. Among unintended births in Louisiana, 80.4 percent were paid for by public insurance programs. Only Mississippi, with 83.2 percent, had a higher percentage of unintended births paid for by the state.

A 2012 annual report by the Louisiana Department of Health and Hospitals found that from 2008 to 2012, the state ranked in the top five each year for cases of chlamydia, gonorrhea, and syphilis. One-third of sexually transmitted diseases in the state were reported among people ages 15 to 19.

Access to reproductive health-care services in Louisiana is limited. There are only five clinics that provide abortion care in the state—and that number is soon expected to fall to two once a new law signed by Republican Gov. Bobby Jindal goes into effect.

HB 388 requires abortion providers to obtain admitting privileges at a hospital within 30 miles of the clinic where they perform abortions. The law also requires the implementation of a forced 24-hour waiting period on medication abortions, and will greatly reduce the number of abortions a doctor must perform in a given year to be considered an abortion provider in the state.

The law is modeled after a Texas law that has forced several abortion clinics to close in the state—and is expected to close many more—contributing to a reproductive health-care access crisis in the Rio Grande Valley and East Texas. In response to the reduction in access to reproductive health care in Texas, activists have worked to provide funding for low-income women to access such services.

Similar efforts are already underway in Louisiana. The New Orleans Abortion Fund, which works with the Women’s Healthcare Center in New Orleans, has so far helped more than 150 women pay for abortion care. The fund receives requests for help from women from all demographic and socioeconomic backgrounds, but most are younger, low-income women of color who already have families.

In interviews with Rewire, fund volunteers shared their experiences speaking with women looking for help to pay for abortion services. For most of these women, the fund is their last resort. Many had resorted to borrowing small sums of money from family and friends or selling household items.

The fund is gearing up for the fact that after September 1, when HB 388 goes into effect and the New Orleans clinic is expected to close, women in the area who may today be able to scrape together the $400 or $500 it can cost for an abortion procedure will be faced with the costs associated with traveling hundreds of miles away to Shreveport to receive abortion care at one of the two abortion clinics that is expected to remain open. This may put safe, legal abortion care out of reach for many women.

A new Planned Parenthood facility that intends to provide abortion care is being built in New Orleans, but whether or not it is able to provide abortions will depend on whether any of its doctors can get admitting privileges at a local hospital—not at all a sure bet in a state where admitting privileges are notoriously hard to secure for physicians who provide abortions.

“Affluent women are going to be able to travel the additional 300 miles to Shreveport, but poor women will not be able to make those long distances,” Amy Irvin, a New Orleans Abortion Fund board member, told Rewire. She said she worries that women in the state will start resorting to potentially unsafe procedures as was common before Roe v. Wade legalized abortion in the United States in 1973.

“There’s already anecdotal evidence here in New Orleans that the abortion pill is being sold on the street,” said Irvin. “Women don’t necessarily know who they’re buying it from, and they’re certainly not getting the information they need to use it properly and safely.”

Sylvia Cochran, who operates the Women’s Healthcare Center, told Rewire that she hears the same stories from her patients. “We are seeing women now who are buying medication off the street because they cannot afford an abortion,” said Cochran. She shared a story about a patient who had bought cytotec off the street and took the pills thinking they would cause her to miscarry. The woman ended up in the emergency room, but the pregnancy was still intact. “She was then talking about buying more pills off the street,” she said.

In addition to the Women’s Healthcare Center, Cochran operates the Delta Center in Baton Rouge, which is also expected to have to close when HB 388 is implemented.

Kathaleen Pittman is the administrator of Hope Medical Group in Shreveport, which is expected to remain open after the new law takes effect. Originally Hope cared for women in what is known as the Ark-La-Tex—the region that includes northwestern Louisiana, northeastern Texas, and southwestern Arkansas. Because of anti-choice laws being passed in Louisiana and other states, the service area of the clinic has grown. “We’re seeing more and more women from Texas, Mississippi, Arkansas, and south Louisiana,” said Pittman.

Pittman said having clinics shut down in southern Louisiana would be “devastating” for women across the region. “My biggest concern would be for women who could not get to us, [who] would try and take matters into their own hands,” she said. “I think more hospitals will be seeing cases or situations that were seen prior to Roe v. Wade.”

“What we tell them is anything you do is probably going to harm you more than the pregnancy, and we do everything we can to get them here,” said Pittman. “While we’re not being overwhelmed with these stories, I expect it to increase.”

Despite these warnings, Sylvia Cochran of the Women’s Healthcare Center holds no hope that the current state of reproductive health care in the state and the coming crisis she foresees will change policymakers’ minds. “They don’t care,” she said. “For them it’s political.”

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