Rolling the dice with women's lives: accomplishments and challenges in the battle over reproductive health in Latin America.

THE MAIN ISSUES CONCERNING reproductive fights in Brazil and in other Latin American countries are, as elsewhere, defined in the political field and involve many different actors and institutions. They involve key democratic and rights-based issues for both women and men. The bottom line is that human reproduction is largely the responsibility of women whose bodies are rarely our own, but rather are imbedded in cultural values, religious dogmas and governmental policies.

Reproductive health issues are part of the human rights agenda and their normative parameters are stated by countries' constitutions and legislation and by international treaties and conventions. The application of such human rights principles is complex. In Brazil it depends on coordinated public policies at three levels (federal, state and municipal), each of which is often dominated by different political parties.

Budgetary allocation, efficient resource administration and political will are key elements for the implementation of good policy. From a public health perspective, access is directly related to service availability and quality and to the social, economic and educational status of the population. Improvements in income distribution, wages, education and sanitation reflect directly on reproductive health, particularly in the case of unequal societies, such as Brazil and most other Latin American countries. The rates of unwanted pregnancy are much higher among low-income women and the age of the first pregnancy decreases in relation to the years of schooling. In Brazil the rates vary from 3-7 children for women with up to three years of schooling down to 1.6 for those with eight years or more. Race and ethnicity are also major variables to be taken into account when designing public policies, since black and indigenous women are most affected by the lack of access to services, education and information.

In order to discuss the main issues and challenges concerning reproductive rights in Brazil and other Latin American countries, it is necessary to adopt a broader perspective, taking into account socioeconomic indicators, laws and the legislature, public policies and the executive, the judiciary and its jurisprudence, as well as institutions such as families, churches, political parties, the media and medical associations, and actors such as civil society organizations, particularly women's rights movements. The dynamic between all these groups, as well as broader national and international players, determines what issues are at play in any country at any given moment.

SOLID GROUNDING

In terms of basic principles, the 1988 Brazilian Constitution is a landmark. Written after the overthrow of the military regime that ruled the country for 21 years, it involved many civil society organizations, with the National Council for Women's Rights playing a leading role. The Constitution places human rights at its core and affirms the states' responsibility to provide information about and the means to exercise reproductive choices (Article 227, Paragraph 7).

The 1988 Constitution sets the parameters for equality between men and women by denying that a man is the head of the family. This is important because unequal and hierarchic family relations play a key role in shaping the reproductive choices women have. Issues related to gender and intergenerational power within the family (regulated or not by formal marriage) have a crucial influence in reproductive and sexual health policies and programs. This is particularly so in certain Latin American countries where a strong patriarchal tradition remains in spite of recent legal advances. Patterns of family interaction, for instance, can prevent an adolescent girl from accessing family planning services.

Although this text is focused mainly on Brazil, other Latin American countries and particularly those of the other Southern Cone states (Argentina, Chile, Paraguay and Uruguay) face similar challenges in regard to reproductive health and rights.

The political history of Argentina, Chile and Uruguay is similar in that they all went through military dictatorships and then experienced democratic governments beginning from the mid-1980s or early 1990s. In all these countries, the Catholic hierarchy plays a key role in preventing access to reproductive rights, in opposition to women's movements. There has, however, been some progress recently in these countries.

From an individual perspective, the different cycles of female and male reproductive life--from childhood to puberty on to adulthood and then to menopause or andropause--can be affected by different reproductive issues.

From a public policy perspective, various national and local health departments decide which issues are major, depending on their impact on public health.

From a political perspective, issues become important if they play a key part on a political agenda or become a defining issue for institutions such as churches or other political constituencies. They can also become temporarily important due to the media, when a national campaign gains traction or sometimes as a result of international events, such as the international UN conferences in the 1990s.

The women's movement in Latin America has usually adopted a more holistic approach, considering reproductive health and rights as an integral issue to everything it does. The movement understands that consent and free choice are vital in all aspects of our lives. Conception and contraception, safe abortion and safe delivery, sterilization and treatment for infertility, unwanted pregnancy, sexual violence, safe sex, STDS and HIV/AIDS, cervical and breast cancer and menopause are all part of the health and human rights agenda.

This perspective does not mean, however, that women's health advocates do not prioritize and highlight specific issues, such as abortion, emergency contraception or sexual violence at specific times.

In Brazil, where there are some 57 million women of fertile age, two issues are currently considered as priorities for the women's movement: maternal mortality and morbidity, and abortion. These issues are also viewed as such in other Latin American countries. The former is a key part of the government's agenda; the latter has always been a major theme for religions (especially the Catholic hierarchy) and a central issue in the agenda for women's reproductive health and rights advocates.

Maternal mortality is a major issue in women's reproductive lives. As the murder of a woman by her partner is often the tip of an iceberg when considering recurrent domestic violence and the lack of access to law enforcement measures, maternal mortality can be seen in the same way, with many concurrent factors also playing a role, including unwanted pregnancy, lack of prenatal and obstetric care, unsafe abortion and sexual violence, among others.

According to the WHO, maternal mortality could be avoided in more than 90 percent of cases. It affects mostly poor women with young teens being most vulnerable. In Latin America, according to data from the Pan American Health Organization, it is the fourth leading cause of mortality for girls and women aged 10-19 years old. Adolescents are more vulnerable to high blood pressure during pregnancy, to anemia and STDS and to the consequences of unsafe abortion. Their vulnerability is increased if they are low income, do not have access to quality care during pregnancy and birth and do not have adequate social and emotional support. Women over the age of 40 are also at high risk.

A crucial issue regarding maternal mortality is the lack of solid data. The under-registration of maternal deaths as well as a lack of clarity in specifying the causes hides its real impact and importance in most Latin American countries. In Brazil, government estimates of maternal mortality are as high as 134.7 per 100,000 children born alive. The Health Ministry estimates that 3,000 maternal deaths occur yearly that could have been avoided. (In the US, for example, the maternal mortality rate is around 12 per 100,000 live births).

Abortion is also a major issue and is closely tied to the debate around the separation between church and state. In Latin America, defending the state from religious influence is crucial to making some advances in this arena. The Catholic hierarchy as well as some evangelical churches play a leading role in systematically impeding progess, as they seek to influence the executive, the legislative and the judiciary. While they claim public support, recent polls--from Catolicas por el Derecho a Decidir and the Comission on Citizenship and Reproduction--do not back up this assertion.

In fact, education is often the key factor in distinguishing those in favor of expanding or maintaining the current legislation--allowing abortion in cases of rape or risk to a woman's life--from those in favor of total prohibition.

The fact that abortion is illegal means that it is usually performed in unsafe conditions, leading to maternal mortality as well as other serious health issues. Some 1,400,000 abortions are performed annually in Brazil. In one study, 20.8 percent of those who died as a result of pregnancy had undergone an abortion. In the whole of Latin America, there are an estimated 10,000 deaths per year due to unsafe abortion.

Besides the fact that unsafe abortion is a public health issue for women in Latin America, its legalization has always been a major issue in the women's agenda, as a central element of the right to choose when and if to have children, a pillar of the reproductive health and fights agenda. The actions taken to face these major challenges, maternal mortality and abortion, vary from country to country but are central to the women's rights movement and NGOS in Latin America.

JACQUELINE PITANGUY is a sociologist and the director of the Brazilian NGO, CEPIA--Citizenship Rights, Information and Action. She is also a board member of the Commission on Citizenship and Reproduction and former president of the National Council of Women's Rights of Brazil.