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El Control: Birth Control in Latin America

El Control: Birth Control in Latin America

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El Control: Birth Control in Latin America

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  1. El Control: Birth Control in Latin America Dara Mendelsohn University of Rochester School of Medicine SHSP Scholar 2010-11 © AMSA National Sexual Health Scholars Program

  2. Learning Objectives • Discuss common birth control methods used in different Latino countries • Contextualize uses of specific birth control methods in particular countries • Organize popular forms of birth control on a country-to-country basis

  3. Demographics

  4. International Conference on Population and Development (ICPD) in Cairo (1994) “Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents.”

  5. International Foreign Aid Agencies • USAID • United Nations Population Fund (UNPF) • International Planned Parenthood Federation (IPPF) • Population Council

  6. Birth Control (el Control de Natalidad or Anticoncepción) • Use of drugs, chemicals, devices, surgery or behavior in an attempt to prevent unintended pregnancy • ‘Mode of operation’ distinguishes between hormonal, mechanical, surgical, and behavioral methods of contraception

  7. Hormonal Contraceptives in U.S. • “The Pill” (La Píldora) • Daily oral contraceptive pill (COCP) • Progestin-only or estrogen and progestin combinations • “Morning-After-Pill” Emergency Contraceptive (La Piladora de Día Después) • U.S. brand names include ella, Plan B One-Step, Plan B, and Next Choice • Vaginal ring • 2-inch diameter soft vaginal ring that is worn inside the vagina for 3 weeks at a time • NuvaRing • Combined Injectable Contraception (Inyectable) • Monthly injection of progestin-, estradiol-only, or in combination • U.S. brand names include Depo-Provera, Cyclofem, Novafem, Mesigyna, Lunelle • Contraceptive implant • Inserted under skin • U.S. brand names include Norplant, Jadelle, Implanon • Contraceptive “patch” • Transdermal patch applied to the skin • Ortho Evra

  8. The Pill (La Píldora) • Costa Rica: 25.6 (%) • United States: 16.3 • Puerto Rico: 15.5 • Nicaragua: 13.5 • Dominican Republic: 13.4 • Honduras: 11.3 • El Salvador: 5.5 • Mexico: 4.7 • Guatemala: 3.4

  9. Clinical Trials of the Pill in Puerto Rico • During the 1950s, George Pincus and John Rock conducted several studies on the effects exogenous progesterone and estrogen on ovulation and fertility, which ultimately led to the development of the drug as a contraceptive • After the success of the preliminary Boston trials for the Pill in 1954 and 1955, Rock and Pincus still needed to conduct a large-scale human trial in order for the drug to receive FDA approval • RockPincus • Given the strong legal, cultural, and religious opposition to birth control in the U.S. in the 1950s, the researchers decided to conduct their clinical trial in Puerto Rico

  10. Clinical Trials of the Pill in Puerto Rico • First trial conducted in 1956 at a clinic in Rio Pedras, a brand new housing project outside of San Juan • Pharmaceutical company G.D. Searle provided the pills for the trial • Dr. Edris Rice-Wray, a faculty member of the Puerto Rico Medical School and medical director of the Puerto Rico Family Planning Association, was in charge of the trials

  11. Clinical Trials of the Pill in Puerto Rico • Rock selected a high dose (10 mg) of Enovid, the company’s brand name for their synthetic oral progesterone, to ensure that no pregnancies would occur while test subjects were on the drug • Dr. Rice-Wray reported that the Pill was 100% effective when taken properly, but 17% of women in the study complained of nausea, dizziness, headaches, stomach pain, and vomiting • She suggested that 10-mg dose caused “too many side reactions to be generally acceptable”

  12. Clinical Trials of the Pill in Puerto Rico • Rock and Pincus dismissed Rice-Wray's conclusions, believing many of the complaints were psychosomatic • Pincus and Rock took no action to assess the root cause of the side effects • Pill was FDA-approved for contraceptive use in 1960

  13. La Píldora • The Pill is currently the most popular form of birth control in the U.S. and Costa Rica, but it is one of the least popular in Mexico • While birth control pills in the U.S. are available only with a prescription, they are sold over-the-counter (OTC) in pharmacies in several countries in Latin America • Should the pill be sold OTC in the U.S.?

  14. Morning-After Pill (La Píldora de Día Después) • Also known as Pastillas Anticonceptivas de Emergencia (PAE) • Either 1 or 2 pills containing higher doses of estrogen and progestin than found in Pill • Taken up to 72-120 hours after unprotected sex • The morning-after-pill is a controversial topic in many countries in Latin America • It is illegal to sell the morning-after pill in Costa Rica

  15. La Píldora de Día Después • Alterna (Mexico) • Evital (Dominican Republic) • Glanique (Mexico, DR) • Imediat N (DR) • Impreviat (DR) • Ladiades (Mexico) • Next Choice (Puerto Rico) • Postday (Mexico, DR) • Postinor-1 (El Salvador, Guatemala) • Postinor-2 (Mexico) • PPMS (Nicaragua) • Pregnon (DR, Honduras) • Prikul (Nicaragua) • Seguidet (DR) • Silogin (Mexico) • Vika (Mexico)

  16. La Píldora de Día Después in Mexico • In 2009, Mexican Supreme Court upheld decision 10-1 that the “morning-after-pill” should be available over-the-counter in drug stores across Mexico and that it should be offered to rape victims in the hospital as one of the expected medical services • Costs of the “morning-after-pill” range from 60-80 pesos ($4.67-$6.23 USD) • Criticism from Mexico’s Catholic Church leaders

  17. La Píldora de Día Después

  18. Inyectable • Nicaragua: 23.4 (%) • El Salvador: 22.5 • Honduras: 13.8 • Guatemala: 9.0 • Costa Rica: 5.9 • Mexico: 5.0 • Dominican Republic: 4.2 • Puerto Rico: 2.7 • United States: 1.4

  19. Mechanical Contraceptives • Condoms (el preservativo) • Diaphragms (la diafragma) • Intrauterine Devices (el depositivo intrauterino) • Sponges (la esponja)

  20. Preservativos • United States: 11.7 (%) • Costa Rica: 10.9 • Puerto Rico: 8.8 • Mexico: 6.4 • El Salvador: 4.6 • Nicaragua: 3.8 • Honduras: 2.9 • Guatemala: 2.3 • Dominican Republic: 1.9

  21. Preservativos and the Dominican Republic (1.9) • From the mid-1990s to 2003, the demand for condoms in the Dominican Republic was largely met by contraband from a Haitian branch of the Population Services International (PSI), a USAID-supported project • In an attempt to encourage sustainability by the IPPF-sponsored NGO, Profamilia, and the Dominican government, USAID stopped funding these condoms altogether for 5 years

  22. Preservativos and the Dominican Republic • USAID resumed supplying condoms to the Dominican Republic in 2003 through a targeted condom social marketing project • Developed condom brand name, Panté, which is now hugely popular and accounts for 65% of the market share • “Por Amor a la Vida, Usa Condón” (For the Love of Life, Use a Condom) • Condoms are designated to be sold at locations where concentration of sex workers are high, like small corner stores and pay-by-the-hour motels, which are required by law to have two free condoms in each room • At 10 pesos for a pack of four ($0.28 USD), Panté are the cheapest brand in the Dominican Republic • International Planned Parenthood Federation (IPPF) branch, Profamilia, buys the condoms directly from suppliers and markets the next cheapest brands, Escudo and Protector, at a pack of three for 20 pesos (about $0.57 USD)

  23. Preservativos and the Dominican Republic • Why does the Dominican Republic have one of the lowest rates of male condom use? • Not due to a lack of information • National surveys worldwide have found high levels of awareness of male condoms (Gardner, et al. 1999) • Low condom use is likely a result of various social and contextual factors including the nature of partnerships, power dynamics, communication, and cultural beliefs

  24. Diafragma • Dominican Republic: 0.6 (%) • Mexico: 0.4 • Costa Rica: 0.3 • Puerto Rico: 0.2 • United States: 0.2 • Guatemala: 0.1 • El Salvador: 0.0 • Honduras: 0.0 • Nicaragua: 0.0

  25. Dispositivo Intrauterino (DIU) • Mexico: 11.6 (%) • Costa Rica: 6.9 • Honduras: 6.6 • United States: 5.1 • Nicaragua: 3.4 • Dominican Republic: 2.1 • Guatemala: 1.9 • Puerto Rico: 1.2 • El Salvador: 0.8

  26. Surgical Methods • Tubal ligation (la ligadura de trompas) or occlusion for women • Vasectomy (vasectomía) for men • Permanent

  27. La Ligadura de Trompas • Dominican Republic: 47.4 (%) • Puerto Rico: 38.5 • El Salvador: 32.1 • Mexico: 27.3 • Nicaragua: 24.3 • United States: 23.6 • Costa Rica: 21.4 • Honduras: 21.2 • Guatemala: 16.8

  28. Sterilization Regret • Regret rate following sterilization in the Dominican Republic was roughly 17% (compared to 7% in U.S.) • According to PC 1996 study, substantial proportions of sterilized women in DR were younger than 30, had three or fewer living children, and had the operation before they had used any other method of contraception • Sterilization in Dominican Republic distributed equally across all socioeconomic levels (Loaiza, 1995) • Not class issue

  29. Vasectomía • United States: 12.5 (%) • Puerto Rico: 5.3 • Guatemala: 1.0 • Mexico: 0.6 • Costa Rica: 0.5 • Nicaragua: 0.4 • El Salvador: 0.3 • Honduras: 0.3 • Dominican Republic: 0.0

  30. Latino Gender Roles • Machismo • Having an unusually high or exaggerated sense of masculinity • Attitude that aggression, strength, sexual prowess, power and control is the measure of someone's manliness • Marianismo • Subservient, chaste, pure, dependable, loyal, emotional, kind, docile, compliant, passive

  31. Behavioral Contraception • Abstinence (abstinencia) • Abstaining from sex • Coitus interruptus • Withdrawal or “pulling-out” of penis prior to ejaculation • ‘Rhythm’ or calendar method (ritmo or método de la ovulación) • Refraining from intercourse during the woman’s supposed fertile period based on the schedule of her menstrual cycle

  32. Abstinencia • 100% effective in prevention of STDs and unintended pregnancies • Supported by the Catholic Church • Difficult to maintain

  33. Coitus Interruptus • Honduras: 5.8 (%) • United States: 4.5 • El Salvador: 2.6 • Guatemala: 2.3 • Puerto Rico: 2.1 • Costa Rica: 1.8 • Dominican Republic: 1.5 • Nicaragua: 1.0 • Mexico: 0.4

  34. El Ritmo • Puerto Rico: 8.2 (%) • Costa Rica: 6.5 • Guatemala: 6.3 • Mexico: 3.8 • El Salvador: 3.7 • Honduras: 3.1 • Nicaragua: 1.7 • Dominican Republic: 1.3 • United States: 1.2

  35. United States • Total fertility rate: 2.0 • Female Sterilization: 23.6% • The Pill: 16.3% • Male Sterilization: 12.7% • Condoms: 11.7% • IUD: 5.1% • Coitus Interruptus: 4.5% • Injectable: 1.4% • Rhythm: 1.2% • Diaphragm: 0.2%

  36. Mexico • Total fertility rate: 3.1 • Female sterilization: 27.3% • IUD: 11.6% • Male condom: 6.4% • Injectable: 5.0% • Pill: 4.7% • Rhythm: 3.8% • Vasectomy: 0.6% • Coitus Interruptus or Diaphragm: 0.4%

  37. Puerto Rico • Total fertility rate: 2.1 • Female sterilization:38.5% • The Pill: 15.5% • Male condom: 8.8% • Rhythm: 8.2% • Vasectomy: 5.3% • Injectable: 2.7% • Coitus Interruptus: 2.1% • IUD: 1.2% • Diaphragm: 0.2%

  38. Dominican Republic • Total Fertility Rate: 3.2 1. Female sterilization: 47.4% 2. The Pill: 13.4% 3. Injectable: 4.2% 4. IUD: 2.1% 5. Condoms: 1.9% 6. Coitus Interruptus: 1.5% 7. Rhythm: 1.3% 8. Diaphragm: 0.6% 9. Vasectomy: 0.0%

  39. Costa Rica • Total fertility rate: 2.1 1. The Pill: 25.6% 2. Female Sterilization: 21.4% 3. Male Condom: 10.9% 4. IUD: 6.9% 5. Rhythm 6. Injectable: 5.9% 7. Coitus Interruptus: 1.8% 8. Vasectomy: 0.5% 9. Diaphragm: 0.3%

  40. Honduras • Total fertility rate: 5.2 • Female sterilization: 21.2% • Injectable: 13.8% • Pill: 11.3% • IUD: 6.6% • Coitus Interruptus: 5.8% • Rhythm: 3.1% • Condoms: 2.9% • Vasectomy: 0.3% • Diaphragm: 0.0%

  41. Nicaragua • Total fertility rate: 4.6 • Female sterilization: 24.3% • Injectable: 23.4% • Pill: 13.5% • Condoms: 3.8% • IUD: 3.4% • Rhythm: 1.7% • Coitus Interruptus: 1.0% • Vasectomy: 0.4% • Diaphragm: 0.0%

  42. El Salvador • Total fertility rate: 3.9 • Female sterilization: 32.1% • Injectable: 22.5% • The Pill: 5.5% • Condoms: 4.6% • Rhythm: 3.7% • Coitus Interruptus: 2.6% • IUD: 0.8% • Vasectomy: 0.3% • Diaphragm: 0.0%

  43. Guatemala • Total fertility rate: 5.1 • Female sterilization: 16.8% • Injectable: 9.0% • Rhythm: 6.3% • Pill: 3.4% • Condoms or Coitus Interruptus: 2.3% 7. IUD: 1.9% 8. Vasectomy: 1.0% 9. Diaphragm: 0.1%

  44. Your Patient • ¿Usted y su pareja están tratando tener hijos en este momento? • “Are you or your partner trying to have children at this time?” • ¿Si no, qué hacen ustedes para prevenir un embarazo? • “If no, what do you do to prevent a pregnancy?”