Among the social and economic changes that have swept Latin America during the last generation, the evolution of women's reproductive behavior is one of the most striking. As recently reported in this publication and elsewhere, fertility rates in Latin America have dropped by half since the 1960s, from an average of six children per woman to just over three today, and further declines are likely. This trend has cheered advocates of women's development, since declining fertility is associated with better education levels among women and greater female participation in the workforce.
These fertility trends also seem to indicate that most Latin American women have access to effective contraceptive methods that allow them to control the number and spacing of their children. Indeed, the statistics appear to show that the gap between women's reproductive goals and their actual reproductive experience is finally disappearing.
Unfortunately, the reality behind the statistics is more complex and less encouraging. While most Latin American women are attempting to limit their fertility, a high proportion of them still do not have access to the information, the services and the contraceptive methods necessary to do so safely and consistently. As a result, many of these women continue to give birth to children that were not planned or desired. And under the relentless financial pressure of feeding, clothing and educating their existing children, too many Latin American women resort to abortion.
According to a comprehensive study released last year by the Alan Guttmacher Institute, a New York-based reproductive research group, approximately 30 percent of all pregnancies in the region end in abortion. This rate is comparable to that of China and is among the highest rates in the world's developing regions, the study notes.
The study finds that Latin American women are having an average of 1.2 abortions during their reproductive years. Even more troubling is the fact that many of these abortions are being performed in dangerous conditions by untrained practitioners. An estimated 800,000 Latin American women each year are hospitalized because of hemorrhages, infection or other complications of unsafe abortions, according to the study.
Claudio de Moura Castro, who heads the IDB's Social Programs Division, says the difficulty of obtaining a professional abortion in some countries leads many low-income women to knowingly perform dangerous procedures on themselves in order to guarantee admission to a hospital emergency room where a full abortion can be performed. "These incidents take a terrible toll on women's health and add very substantial costs to medical systems that are already overburdened," Castro says. "And it can all be traced to the lack of access to family planning methods."
Castro said further evidence of the shortage of contraceptive options can be seen in the unusually high prevalence of female surgical sterilization in several of the region's countries, and particularly in Brazil. "Where women are able to choose from a variety of affordable contraceptives, they generally do not opt for sterilization in such high numbers," he said.
Contraceptive deficit----------------------
So while conditions for Latin American women are undoubtedly improving, the figures on abortion and sterilization show that the supply of effective family planning falls far short of demand. "The basic underlying cause of abortion in the region is the lack of access to information and family planning services," says Mayra Buvinic, chief of the IDB's Women in Development Unit. Figures compiled by the United Nations Population Fund (UNFPA) back up her claim. According to the UNFPA's 1997 State of the World's Population Report, the percentage of women in Latin America who would like to control their fertility but are unable to because they lack effective contraceptives ranges from a low of 17 in Colombia to a high of 43 in Bolivia. In other Latin American countries, an average of around 25 percent of women claim to have an "unmet need" for effective contraception.
The problem is especially serious among adolescent women, according to Buvinic. For example, between the 1980s and the 1990s, fertility among teen-age women actually increased in Brazil and Colombia. "Any increase in fertility among adolescent women is particularly alarming," she says, "because they suffer the most severe consequences from unwanted pregnancy."
New approaches-----------------
Though it may seem obvious, the scope of this problem is underscoring the urgency of providing traditional "indirect" solutions to the unmet need for family planning.
"Increasingly, reproductive health experts are referring to education, employment and self-esteem as the most powerful and the most effective contraceptives of all," says Clotilde Charlot, a social development specialist in the IDB's Women in Development Unit who previously managed a large reproductive health program for working women in Haiti. "Unless low-income women are given the opportunity to develop marketable skills, generate income, and enhance their self-esteem, family planning service providers won't achieve sustainable success in reducing unplanned pregnancies."
While it will take years for many of the women who most need contraception to see these kinds of improvements, Buvinic sees encouraging signs on the family planning services front, based in part on a minor revolution that has taken place in the reproductive health field over the last decade. In the past, family planning services tended to focus narrowly on the distribution and promotion of contraceptive methods, according to Buvinic. In many countries such services were provided by a single government agency or small, non-profit institutions. Other aspects of reproductive health, such as prenatal and postnatal counseling or problems related to sexual health and sexually transmitted diseases, were often not addressed by family planning services at all.
The result was that most individuals received only fragmentary information and assistance with their reproductive health needs, leaving many questions unanswered and leading to ineffective family planning practices.
Buvinic says that today, health experts are advising that all areas related to reproductive health, including those that affect men, should be addressed in an integrated manner. This focus attempts to address the totality of a person's physical, social and psychological needs when it comes to sex and reproduction. Instead of relying exclusively on the medical profession, it advocates coordinated efforts by educators, social service providers, psychologists and politicians.
The IDB is promoting this integrated approach to reproductive health in a number of countries, according to Buvinic. The health services component of a $60 million loan to Bolivia's Social Investment Fund approved in 1995, for example, includes specific targets to increase the number of women receiving information or training about contraception from 35 percent to 60 percent. But this goal is part of a broader program to increase access to prenatal care and reduce infant and maternal mortality.
In Mexico, a $500 million Program of Essential Social Services partly funded by the IDB combines annual targets for expanding family planning services with a nutrition and counseling program for pregnant and lactating women.
In Venezuela, the Association for Alternative Sex Education (AVESA), an NGO devoted to sex education for teen-agers, is using a $500,000 technical cooperation grant from the IDB to fund an innovative public information campaign aimed at adolescents from low-income households. The campaign includes short radio announcements and newspaper inserts with candid information on avoiding pregnancy and sexually transmitted diseases. AVESA is also taking its educational materials to 60 schools and youth organizations that already work with disadvantaged youth.
These projects, along with several other efforts funded by the IDB, reflect the beginnings of a fundamental shift in the way family planning services are being delivered throughout Latin America. "I am convinced that the concept of integrated reproductive health services has been adopted by the leadership throughout the region," says the IDB's Buvinic. "Now the challenge is to implement it."