Barriers to Access

This past Wednesday, I had the opportunity to lead a discussion on family planning with a group of graduated health promoters (those who have been serving their communities as health workers for the past four years) during their monthly meeting. I was interested to find out what, if anything, they knew about family planning methods, and what their opinions were on the subject.

A few years back, the health promoters had access to birth control methods through another, non-religious NGO that was supplying pill packs, injections, and condoms to all interested health promoters in the area. This worked well for awhile, until a woman who was unknowingly pregnant received a progesterone injection for birth control and later lost the baby due to a miscarriage. The NGO promptly recalled all birth control methods from each community and now only allows pre-screened, qualified medical professionals to administer any type of family planning. This means, of course, that the health promoters can no longer give out condoms or birth control pills, let alone Depo-Provera injections.

This would not be such a large problem if people in rural areas were willing to come into town to San Lucas and go to the government-sponsored Centro de Salud (Health Center), where all forms of birth control are free of charge. The truth, however, is that the Centro de Salud keeps lists of birth control patients organized by community, and so when you go to see the nurse for your birth control, she pulls out the list to log in your information, thereby revealing all of your neighbors who are also using family planning. Due to the small size of each community, and the gossip-loving nature of people in small towns, within days of your visit to the Centro de Salud, everybody in your community knows your business. This is especially frightening for women using the injection without their husbands' permission. If word gets to their husbands that they are using any form of birth control, violence can ensue.

On the other hand, people put a lot of trust in their health promoter, and, when it was available, used to go to their health promoters regularly for birth control because they knew that their confidentiality and privacy were safe from prying eyes.

Now that the only access to birth control comes from the Centro de Salud, health promoters can’t do much to help the women in their communities, other than encourage them to go to the Centro de Salud. But besides the lack of privacy and confidentiality at the Centro de Salud, the other reason that women don’t want to go there is because of the prerequisite pelvic exam and pap smear that they require before they give out any form of birth control. Women are afraid and skeptical of the pelvic exams because there have been rumors that the speculums are reused on more than one woman. Though I doubt these rumors are true, I don't blame them... If I had reason to believe that the un-sterilized speculum being used on me was the same one used on the previous patient, I wouldn’t be too jazzed about pelvic exams either.

In addition to religious beliefs and lack of access, misinformation is a large barrier to the use of birth control methods. For example, this past Tuesday, I tagged along with Shom and Kate, a pediatrician, to the remote village of San Martín, to see patients. One patient, a woman in her thirties who came in seeking treatment for a yeast infection, told us that she and her husband didn’t want any more children (they already have four) and so she had been using Depo-Provera for a year. Unfortunately, somehow or another the woman’s grandmother found out that she was using the birth control injections and told her granddaughter that people have died from using Depo-Provera. Frightened, the woman stopped the injections, but according to our conversation, is now unwilling to try anything else besides natural family planning, which has a pretty poor success rate. For every 100 women who practice natural family planning, 20 of them will become pregnant within a year. Woah. Double woah when you consider that less than 1 woman out of 100 gets pregnant during a year of using Depo-Provera.

It seems to me that there are two possible solutions to the lack of access to family planning. The first would be to drum up some funding so that the health promoters could provide the birth control themselves. The other would be getting the Centro de Salud to allow the community health promoters to provide a list of the women seeking a given method and the result of a current pregnancy test, the Centro could provide the method to the health promoters, the health promoters deliver it to the women and get a signature from the women that they received their method free of charge, and return the documentation to the Centro. This would protect the women's privacy and take advantage of the fact that family planning methods are free via the Centro de Salud, making the system sustainable. It would also keep family planning in the hands of the Centro de Salud so that statistics could be kept and would ensure that pregnancy testing was being done before initiating a method, maximizing safety.

The health promoters had proposed this idea to the Centro de Salud in the past, but the government health center refused to compromise and continued to insist that all women come in person to receive their preferred method of birth control (don't you just love beaurocrats?).

Shom, Kate and I have been wondering if there might be a way to reopen this issue for discussion with those who manage the Centro de Salud. Given that all entities share the common goal of improving access to family planning for women, a brainstorming session with the Centro de Salud could be fruitful, right?

I’ll keep you posted…