Informing choices: expanding access to emergency contraception in Peru.

Since 1998, CHANGE has been working with colleagues in Peru to expand the reproductive health options available to women. Their work has included conducting secondary research and analysis on the constraints women face in exercising reproductive choices and advocating for donor and government policy changes to address these constraints, including expanded access to emergency contraception (EC).

In recent months, a great deal of attention has been paid to violations of women's rights to informed choice in the Peruvian health system with particular emphasis on those that occurred under the administration of former President Alberto Fujimori, resulting from pressures on health workers to achieve high rates of female sterilization, with or without consent. However, less attention has been paid to other critical reproductive health needs of Peruvian women.

Today, Peru has among the highest rates of unwanted pregnancy, unsafe abortion and maternal mortality in all of Latin America. Approximately 350,000 clandestine abortions take place annually in Peru where abortion is illegal and safe abortions rare. (1) Complications of unsafe abortion rank fourth as a cause of maternal deaths in the country. (2) Yet despite this reality conservative politicians in Peru and abroad have been conspiring to further limit women's choices by working to prevent their access to a wide range of contraceptive methods, including emergency contraception (EC) and life-saving, post-abortion care.

Poor reproductive health conditions in Peru are the result of social and cultural discrimination against women and the general failure of the public health system to address women's needs. For example, women often have little control over the frequency and timing of sexual intercourse due to economic and social dependence on men and high rates of violence and sexual coercion by intimate partners, among other factors. Studies from Peru and elsewhere now confirm that sexual violence is a major factor in unwanted pregnancy. According to a recent study on the prevalence of gender-based violence in Peru conducted by Guezmes, et al., (2002), half of all women in Lima, the nation's capital, and almost two-thirds of all women in the department of Cusco have experienced physical and/ or sexual violence by an intimate partner at least once in their lifetime. (3) The same study found that sexual violence represents a significant proportion of all violence by intimate partners, including husbands.

Lack of access to contraceptive methods, poor quality of care in health services and high rates of contraceptive failure further restrict women's choices. An estimated 25% of all sexually active women of reproductive age in Peru--approximately 850,000 women--are not adequately protected against an unwanted pregnancy. (4) Adolescent girls are particularly vulnerable as they have the least access to contraceptive methods of all women in their reproductive years. Lack of access to information and methods coupled with lack of control over sexual intercourse contributes to the heavy reliance on unsafe abortions among women in Peru.

Until relatively recently, the government of Peru gave low priority to reproductive health services. This changed somewhat in the early 1990s when government support for family planning programs began to build and international donors shifted much of their family planning funding from NGOs to investments in the public sector. During this time, Peru's Ministry of Health also invested in a significant expansion of family planning services. Emergency contraception was among the range of methods approved for distribution in government health facilities though little was done to make it available in practice.

Between 1996 and 1998, the government adopted an unofficial policy that sought to achieve demographic objectives through an aggressive campaign aimed at increasing use of modern contraceptives, particularly female sterilization. (5) Targets were set for the number of women to be sterilized, and family planning workers were expected to fulfill numeric quotas. In practice, the policy was directed at poor women with little or no formal education. This strategy resulted in violations of informed choice and poor quality of care in Peru's family planning program, which in turn led to criticism of government policies from within and outside Peru. Women's groups in Peru led the campaign for change. In early 1998, responding to both local and international pressure, the Peruvian government shifted the focus of its family planning program towards meeting individual needs.

During this period, the far right in Peru and the United States stepped up their campaigns to undermine women's access to contraception, safe abortion services and post-abortion care. Representatives of the right in both countries began working in concert in Peru, using the evidence of violations of informed choice and of poor quality of care to their own ends and intensifying their opposition to reproductive health services overall. These actors targeted the programs funded by international donor agencies such as USAID, already under siege from opponents of family planning in the U.S. Congress who seek to eliminate U.S. international assistance.

USAID-Peru responded by pressuring the Ministry of Health to eliminate EC from the national family planning guidelines, just one of several moves intended to placate anti-choice conservatives and stave off further threats of funding cuts in the U.S. Congress. This step met with little internal resistance from USAID headquarters, in part because support for EC within the agency was and remains soft, given both the external politics and the persistent belief among some within the agency that access to EC is not necessary if access to other forms of contraception is widespread. However, rather than placating the right, recent events show that the hesitancy of donors to support access to EC has further emboldened anti-choice conservatives to continue to chip away at reproductive health programs and women's rights in Peru.

Following a public scandal that exposed government responsibility in carrying out widespread corruption, election fraud and human rights abuses, Fujimori secretly fled the country in late 2000, and his ruling political party disbanded. A transitional government took office and brought with it a strong concern for promoting human rights, including full support for universal access to quality reproductive health services. Given this favorable political climate, a group of Peruvian NGOs--headed by the Flora Tristan Peruvian Women's Center-launched a communication initiative to increase awareness of the existence of emergency contraception among young people in the capital city of Lima, using television and radio, print materials and a website to provide university students with accurate information on how to gain access to and use EC. The campaign also included information on how to use NGO-run hotlines and how to access services offered by Peruvian NGOs to populations throughout the country. The initiative led to increased demand for EC among vulnerable women and built a base of evidence for ongoing policy and program responses to help women avoid unsafe abortion.

During this time, efforts were also intensified to obtain government commitment to distribute EC through public sector services. Taking its cue from local women's groups, CHANGE used this opportunity to advocate strongly for USAID support for reintroduction of EC in the public health system. As a result of these efforts, USAID provided technical assistance to the Ministry of Health to revise the national family planning guidelines to include EC among the methods offered by public health facilities. Approved in July 2001, the guidelines provide the legal basis for the distribution and use of this method in the country. USAID also supported development by the Ministry of Health of a protocol for service providers for distribution of EC to clients. Unfortunately, the final version was not approved before the transitional government left office at the end of July.

A second political shift occurred when the newly-elected government headed by Alejandro Toledo came to power at this time. It included many staunch conservatives strongly opposited to reproductive rights. The first Minister of Health, Dr. Luis Solari, was a local leader of the right-wing Catholic organization Soldiers of Life. During his six-month tenure as Minister, Solari filled key posts with anti-choice activists. In early 2002, he returned to his previous seat in the Peruvian national congress and was replaced by the equally conservative Vice-Minister of Health, Dr. Fernando Carbone. While the Ministry of Health leadership has repeatedly stated that it will continue to offer contraceptive methods, it has moved quickly and proactively to advance an agenda against reproductive health and rights on various fronts, including the mass media, the Congress and the Ministry itself.

For example, Solari published an article in the largest Peruvian daily newspaper arguing that EC acts as an abortifacient. Carbone has attempted to remove the IUD from the Ministry's method mix on the basis that it, too, is an abortifacient while at the same time touting the effectiveness of the Billings method in the protocol for contraceptive services. In addition, at a Peruvian congressional event in June 2002, a representative from the Ministry of Health claimed that all contraceptive methods--except for abstinence and the rhythm method--were abortifacients. Finally, in July conservative members of Congress joined Minister Carbone in proposing to outlaw female and male sterilization, ostensibly as a strategy to rectify the abuses that occurred under the Fujimori government. Such political moves go hand and hand with those in the U.S. Congress which similarly seek to limit women's access to all forms of family planning in addition to safe abortion services. Carbone regularly uses Bush's anti-abortion language to justify his policies, and he maintains close ties to U.S. Congressman Chris Smith. On a recent trip to Peru, Mr. Smith was eager to challenge USAID's role in supporting EC, despite U.S. laws that permit the inclusion of EC in U.S.-funded international programs.

These moves have obvious implications for reproductive rights on numerous levels. A year after its inclusion in the family planning guidelines, for example, emergency contraception is still not offered by government health facilities. Continued attacks on reproductive choice have once again caused certain actors--including international donors--to shy away from this issue, fearing that this will only further jeopardize available contraceptive services. For example, despite consistent verbal commitments to expanding access to EC in Peru, USAID has yet to translate this into concrete and sustained support either through the public or private sector.

However, some inroads are now being made as alternative strategies to increasing access are adopted by NGOs and by at least one government agency. APPRENDE, a local social marketing NGO, began to market and distribute Postinor 2, a dedicated EC product, in July 2002. In addition, other NGOs, including Flora Tristan, APROPO, INPPARES and Kalpa are expanding their communication initiative to two additional departments of Peru. (6) The Ministry of Women and Social Development has signed an agreement for both financial and technical assistance from the Catalyst Project (sponsored by USAID) and Flora Tristan, which includes training the personnel of the Emergency Women's Center (CEM) to develop a module for counseling victims of sexual abuse on emergency contraception. This represents only a partial victory: since the CEMs are not authorized to deliver medical services per se, they cannot distribute the actual method.

Finally, civil society efforts in which CHANGE actively participates are advocating strongly on behalf of EC. The Monitoring Group on Citizen's Health Rights, an ad-hoc reproductive rights coalition, has repeatedly sent and published letters to the Ministery of Health, demanding that it fulfill the national family planning guidelines by making EC accessible. The Advisory Committee on Emergency Contraception has petitioned the Ombudsman to investigate the Ministry's lack of fulfillment of the national family planning guidelines for not distributing EC. Advocates consistently emphasize the scientific evidence demonstrating that EC is not an abortifacient, the method's endorsement by the international medical community, including the WHO and the International Federation for Obstetrics and Gynecology, and the reproductive right of women to access this method.

One measure of the success of these efforts to both protect women's rights generally and expand access to EC in particular is that the Ministry of Health has yet to attempt to eliminate EC from the national family planning guidelines, as many speculated would happen early in the Toledo government. The government has instead punted by claiming that it must assess whether EC violates the Peruvian constitution which protects life from the moment of conception. Accordingly, the Ministry of Health solicited the opinion of the Peruvian Medical Board. The task was initially delegated to the Peruvian Society for Obstetrics and Gynecology which promptly declared its support of the use of EC up to 48 hours after an act of intercourse. Dissatisfied with this response, the Ministry pressured for the Medical Board to direct the decision to its Committee on Ethics, and so far, no further decision has been made.

To date, persistent advocacy and high-quality information campaigns have limited the damage done to reproductive choice in Peru by the far right in Peru and the U.S. and have succeeded in making progress in a difficult environment. Nonetheless, the advocacy movement cannot be left to shoulder this task alone. International donors to reproductive health--USAID, UNFPA, and DfID--have a critical role to play and a responsibility to assume that role. Despite the opposition within the public sector, there are several ways that donors can help expand access to EC within the country. First, they can fund the distribution of the method through alternative sources of health information and services. For example, various NGOs across the country receive donor funding to deliver reproductive health education and services and have a proven track record: technical and financial assistance should be directed to these NGOs to effectively integrate EC provision into their programs. (Note that the prohibitions established by the Mexico City Policy, otherwise known as the Global Gag Rule, do not include EC).

Second, donors can provide the critical seed money needed to ensure that Postinor 2 is marketed effectively nationwide and made available at pharmacies and through the private sector in Peru. Third, donors should continue to seek means to making EC available within the public sector such as at police stations that provide specialized services for victims of sexual assault. As the process of decentralization moves forward and local governments have greater control over health services, donors should develop agreements with local health officials to integrate EC provision.

Finally, donors should direct funding to strengthen NGO capacity to conduct advocacy in favor of making EC accessible. Reproductive health advocacy groups desperately need funds for development and execution of a cohesive strategic plan to promote and protect sexual and reproductive rights in the face of conservative opposition. Key strategies would include ongoing efforts to increase media coverage, raise public awareness, and pressure government officials regarding the need for expanded access to EC, all of which will require additional resources for staff and for strengthening coordination between and among networks throughout the country. In this context, CHANGE's goal is to strengthen and expand well-informed advocacy, public pressure and engagement with governments and donors to promote reproductive health and rights in Peru and specifically to dramatically increase access to emergency contraception. It is a difficult battle given the degree of opposition among the conservative right to enabling women to choose when and with whom to bear a child and one that is likely to continue to be waged for years to come. It is nonetheless an essential battle as the lives of literally thousands of women hang in the balance.

Notes

(1.) Delicia Ferrando, El aborto clandestine en el Peru. Hechos y cifras (Lima, Peru: Centro de la Mujer Peruana Flora Tristan and Pathfinder International, 2002).

(2.) INEI: Instituto Nacional de Estadistica e Informatica, National Demographic and Health Survey 2000 (Lima, Peru: INEI, 2001).

(3.) Ana Guezmes, Nancy Palomino and Miguel Ramos, Violencia Sexual y Fisica contra las Mujeres en el Peru. Estudio multicentrico de la OMS sobre la violencia de pareja y la salud de las mujeres (Lima, Peru: Centro de la Mujer Peruana Flora Tristan, Universidad Peruana Cayetano Heredia, Organizacion Mundial de la Salud, 2002).

(4.) Delicia Ferrando, Op cit.

(5.) Sterilization on demand was legalized in 1995.

(6.) APROPO (Support for Population Programs) is a private company that specializes in social marketing of reproductive health products and information. INPPARES is the Peruvian affiliate of the International Planned Parenthood Federation. Kalpa is a non-governmental organization that focuses on adolescent and youth development.

The author is Senior Program Associate at the Center for Health and Gender Equity in Takoma Park, Maryland USA. This article was disseminated electronically by CHANGE, September 10, 2002. For more information, visit CHANGE's website: www.change.org.