Analysis

A Mexican NGO Meets the Community Where It’s At

IPPFWHR

The current sexual and reproductive health landscape in Mexico is one of both progress and challenges. It is one of divisions between rich and poor, between urban and rural populations, and between younger and older generations.

The current sexual and reproductive health landscape in Mexico is one of both progress and challenges. It is one of divisions between rich and poor, between urban and rural populations, and between younger and older generations.

Mexico is the second largest economy in Latin America; however, aggregate figures distort the reality of a large cohort of the population that continues to live in striking poverty. About 52 percent of Mexico’s total income is held by the wealthiest 20 percent in the country, and more than 3 percent live on less than $2 a day. Despite this reality, donor countries are graduating countries such as Mexico from foreign aid, failing to acknowledge the sharp inequalities and the still weak health systems.

At the same time, Mexico is at an advanced stage in its demographic transition. With a very young population — 18 percent are between the ages 15 to 24 and the median age of total population is 27 — the county is experiencing an increasing strain on education, health, and social welfare systems. Challenges are also emerging to improve the sexual and reproductive health of this population group. Young people are becoming sexually active at increasingly younger ages (mean of 15.9 years), but 75 percent of them do not use contraceptives at their first sexual experience. HIV/AIDS is among the top ten causes of mortality for men and women ages 25 to 34.

The marital, sexual, and reproductive behavior of young women varies greatly depending on where they live. In 2006, 29 percent of women ages 20 to 24 in rural areas reported having been married before age 18, compared with 17 percent in urban areas. Fewer urban than rural women had had a birth before age 18 (14 percent vs. 22 percent). Meanwhile, the proportion of married women who have an unmet need for contraception— that is, who are able to become pregnant, but are not using any contraceptive method, even though they do not want to have a child soon or at all—increased among this age-group, from 23 percent to 31 percent. The situation is more critical among sexually active, unmarried young women ages 15 to 24: Only 35 percent were using a contraceptive method in 2006.

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In Mexico, as in many countries throughout the region, the health and well-bring of women and youth are subject to vast geographic disparities. Those living in the relatively less developed, less urbanized, and poorer southern states have more limited access to sexual and reproductive health services and information than those living in the more developed, more urbanized areas, such as Mexico City.

As the fifth largest state of Mexico, Oaxaca is characterized by extreme geographic fragmentation. Located where the Eastern Sierra Madre and the Southern Sierra Madre come together, Oaxaca shares a common border with the states of Veracruz and Puebla (on the north), Chiapas (on the east), and Guerrero (on the west). Oaxaca’s rugged topography has played a significant role in giving rise to its amazing cultural diversity. Because individual towns and tribal groups lived in isolation from each other for long periods of time, there are sixteen groups that maintained individual languages, customs, and ancestral traditions well into the colonial era, and – to some extent – to the present day. According to many, Oaxaca is – by and large – the most ethnically complex of Mexico’s thirty-one states, and it is believed that, even today, at least half of the population of Oaxaca still speaks an indigenous dialect.

According to Conapo (Mexico’s National Population Council), Oaxaca is the third most economically marginalized state in Mexico. The state has 3.3 percent of the population, but produces only 1.5 percent of the GNP. Eighty percent of the state’s municipalities do not meet federal minimums for housing and education. While the majority of Oaxaca’s population lives in rural areas, most development projects are planned for the capital and surrounding area. About 31 percent of the population is employed in agriculture, about 50% in commerce and services, and 22 percent in industry.

While maternal mortality has decreased steadily in Mexico since the 1950s, the national numbers mask glaring inequalities, which continue to divide Mexico along lines of class, ethnicity, and geography. In Oaxaca, where 53 percent of the population lives in rural areas, indigenous women and rural communities face acute health challenges on many fronts because of abject poverty, poor education, and a dire shortage of medical staff.

In 2008, there were 57 maternal deaths per 100,000 live births in Mexico, a ratio that is five times that found in industrialized countries. Moreover, the maternal mortality ratio in the least developed region of the country (comprised of the states of Guerrero, Oaxaca, and Chiapas) is 97 maternal deaths per 100,000 live births—almost double the national average. Such regional disparities are partly due to the uneven distribution of health care resources and providers, which favors urban areas.

Despite a changing environment, local NGO Mexfam continues to provide high quality sexual and reproductive health services throughout the country. Its three-tiered approach to sexual and reproductive health — services, education and community — gives them the critical capacity to reach those most in need.

Throughout Mexico, Mexfam employs approximately 1,000 health promoters. These promoters educate community members about sexual ad reproductive health and provide a much-needed link to Mexfam’s clinical services — as well as condoms and contraception— in rural and underserved areas. As part of this work, Mexfam’s health promoters host JOCCAs — two-day local events that bring the community together for discussions and learning about sex.

In San Catarina Minas, I had the opportunity to see one of Mexfam’s JOCCAs in action. In the middle of this small town an hour south of the city of Oaxaca, the school gymnasium was packed with hundreds of community members, young and old. After opening the session with a traditional Oaxacan dance, Mexfam went to work. They divided up the participants into groups according to age and Mexfam health promoters and staff led discussions with each group about sexuality and health. At the end of the JOCCA, each group presented a skit or poster it had created on the topic of their choice to the larger group.

Walking through the gymnasium and listening to snippets of the group discussions afforded a rare insight about the evolving nature of sexuality: while we often discuss sexuality education in the context of youth development, too often we forget the fact that the need for accurate and complete information is one that remains with us throughout our lives. Among the 12-year-olds, I heard questions about masturbation and dating, while a group of middle-aged women shared strategies on how to initiate the topic of condom use with their husbands.

The JOCCAs have been so effective at disseminating accurate information and facilitating access to sexual health services that the Ministry of Health in Oaxaca has begun to replicate Mexfam’s JOCCA model in other communities throughout the state. As a result, the state of Oaxaca has seen a 25 percent decrease in teen pregnancy over the last five years.

Perhaps most importantly, the JOCCAs have been invaluable at creating a climate where sexual and reproductive health and rights can be discussed openly across gender and age lines. One Mexfam health educator said it best:

“When it’s time for your child to start brushing their teeth, you don’t immediately send them to the dentist; you give them the tools and information they need to learn to take care of themselves. Learning about sexuality and how to protect yourself needs to become a part of what you learn at home, a natural part of your community.”

Ultimately, she told me, she would like to see topics like correct condom use as prevalent in household discussions as the importance of brushing your teeth or washing your hands.

Mexfam’s high-quality sexual and reproductive health services provides rural and marginalized populations lifesaving health care to which they would not otherwise have access. Although obstacles remain, Mexfam is a leading advocate meeting the vital needs of the most vulnerable Mexicans.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

News Abortion

Study: United States a ‘Stark Outlier’ in Countries With Legal Abortion, Thanks to Hyde Amendment

Nicole Knight Shine

The study's lead author said the United States' public-funding restriction makes it a "stark outlier among countries where abortion is legal—especially among high-income nations."

The vast majority of countries pay for abortion care, making the United States a global outlier and putting it on par with the former Soviet republic of Kyrgyzstan and a handful of Balkan States, a new study in the journal Contraception finds.

A team of researchers conducted two rounds of surveys between 2011 and 2014 in 80 countries where abortion care is legal. They found that 59 countries, or 74 percent of those surveyed, either fully or partially cover terminations using public funding. The United States was one of only ten countries that limits federal funding for abortion care to exceptional cases, such as rape, incest, or life endangerment.

Among the 40 “high-income” countries included in the survey, 31 provided full or partial funding for abortion care—something the United States does not do.

Dr. Daniel Grossman, lead author and director of Advancing New Standards in Reproductive Health (ANSIRH) at the University of California (UC) San Francisco, said in a statement announcing the findings that this country’s public-funding restriction makes it a “stark outlier among countries where abortion is legal—especially among high-income nations.”

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The researchers call on policymakers to make affordable health care a priority.

The federal Hyde Amendment (first passed in 1976 and reauthorized every year thereafter) bans the use of federal dollars for abortion care, except for cases of rape, incest, or life endangerment. Seventeen states, as the researchers note, bridge this gap by spending state money on terminations for low-income residents. Of the 14.1 million women enrolled in Medicaid, fewer than half, or 6.7 million, live in states that cover abortion services with state funds.

This funding gap delays abortion care for some people with limited means, who need time to raise money for the procedure, researchers note.

As Jamila Taylor and Yamani Hernandez wrote last year for Rewire, “We have heard first-person accounts of low-income women selling their belongings, going hungry for weeks as they save up their grocery money, or risking eviction by using their rent money to pay for an abortion, because of the Hyde Amendment.”

Public insurance coverage of abortion remains controversial in the United States despite “evidence that cost may create a barrier to access,” the authors observe.

“Women in the US, including those with low incomes, should have access to the highest quality of care, including the full range of reproductive health services,” Grossman said in the statement. “This research indicates there is a global consensus that abortion care should be covered like other health care.”

Earlier research indicated that U.S. women attempting to self-induce abortion cited high cost as a reason.

The team of ANSIRH researchers and Ibis Reproductive Health uncovered a bit of good news, finding that some countries are loosening abortion laws and paying for the procedures.

“Uruguay, as well as Mexico City,” as co-author Kate Grindlay from Ibis Reproductive Health noted in a press release, “legalized abortion in the first trimester in the past decade, and in both cases the service is available free of charge in public hospitals or covered by national insurance.”