What is Sexual and Reproductive Health?
Sexual and reproductive health (SRH) is a critical issue of global health that focuses on the ability “to have a satisfying and safe sex life and have the capability to reproduce and the freedom to decide if, when, and how often to do so” (United Nations High Commissioner for Refugees [UNHCR]). Sexual and reproductive healthcare focuses on services that allow for the previously mentioned goals to become possible.
Examples of sexual and reproductive healthcare include (UNHCR, 2022):
- Access to contraceptives and family planning
- Educational classes
- Access to abortion and management of abortion-related complications
- Ante and postnatal care
- Screening and treatment of cervical and prostate cancer
- Prevention and treatment of HIV and other sexually transmitted diseases
These services should be provided to all women, men, adolescents, young people, LGBTI and people who sell sex.
Where is Bolivia?
Bolivia is a low income country (LIC) located in central South America. It is landlocked and surprisingly has two capitals; however, La Paz is the administrative capital. Bolivia is often known for its varied terrains as it encompasses the Andes Mountains, the Atacama Desert and Amazon Basin rainforest. Primary languages include Spanish and several dozen indigenous languages. (Britannica, 2022).
In Bolivia there is a much larger need for implementation of policies that promote safe SRH as well as education as the country is increasingly affected by the results of poor SRH.
Harmful effects of Improper Sexual and Reproductive Healthcare
- 43% of all women aged 15-49 years old have an unmet need of proper contraceptives (Guttmacher, 2021)
- 63% for adolescents aged 15-19 do not have adequate access to contraceptives (Guttmacher, 2021)
- Without contraceptives, women may face issues of financial support, sexual violence, death of mother and/or fetus, higher rates of STIs, higher rates of teen pregnancy, etc.
- Young mothers often do not finish school
- Bolivia faces a maternal mortality rate of 155 per 100,000 live rates (UNICEF, 2021) - one of the highest in Latin America
- In Bolivia, "among women aged 15-19 in Bolivia, 35,000 give birth” but “6,000 make fewer than four antenatal care visits and 3,600 do not deliver in a health facility" (Guttmacher Institute, 2021)
- In developing countries, where sexual and reproductive health problems are a leading cause of ill health and death for women and girls of childbearing age (UNFPA, 2022).
- Impoverished women suffer disproportionately from unintended pregnancies, unsafe abortion, maternal death and disability, sexually transmitted infections (STIs), gender-based violence, and other problems related to pregnancy and childbirth. (UNFPA, 2022).
- STIs can also cause pregnancy-related complications, including stillbirth, congenital infections, sepsis and neonatal death.
- (HPV) can lead to pelvic inflammatory disease, infertility and cervical cancer, a major killer of women
Who is most commonly affected by the lack of sexual and reproductive healthcare in Bolivia?
Women Individuals of reproductive age, 15-49 years old, who are of low and middle socioeconomic backgrounds are most affected by the lack of SRH policies in Bolivia. Additionally, Bolivia has high percentage of indigenous populations who are often subjected to a lack of sexual and reproductive healthcare.
Social Determinants
- Bolivia is stricken with “widespread poverty, insufficient medical services and geographic isolation [which has] limited the availability of adequate health care (Paulson & Bailey, 2003).
- Cultural attitudes surrounding pregnancy, relationships and sexual education dictate how adolescents and mature women feel about obtaining proper sexual and reproductive healthcare
- Stark divide between the gender roles of men and women. Typically, women are “passive submissive role models” while the ideal man is often described “as strong, virile, competitive and dominant” (Derks & Heessels, 2011).
- women typically leads to women not voicing their opinions or concerns; consequently, many women feel embarrassed or ashamed for seeking care relating to sexual and reproductive issues (Edberg, 2019).
- women are traditionally expected to become mothers and raise their children; thus, pregnant adolescents are more socially accepted if they are married or marry the father of the child (Edberg, 2019)
- Single women and adolescents who are pregnant outside of a marriage are often deemed sexually promiscuous while men are expected to engage in numerous sexual behaviors.
- In the interview, Dr. Uribe stated that indigenous populations raise their daughters with the expectation to have an abundance of children to increase the family wealth; however, in modern Bolivia this increases poverty levels
The stigma is similarly seen in accessing legal abortions as well. Although “abortion is legal under certain indications [rape, incest, risk to health, and fetal malformation], health care providers can claim conscientious objection (CO) if a service conflicts with their moral, religious, or ethical beliefs”; yet, CO is not always used properly (Küng et al., 2021). Another example of inaccessible abortions is the economic incentives provided to providers which is dependent on public facilities or private practices: “providers do not receive payment for abortion services delivered in public hospitals … while providers receive most, if not all, payment for services rendered in their practices” (Küng et al., 2021). The economic incentive that is only provided for more expensive private practices deepens the disparity between Bolivian women of low and middle socioeconomic status than their high socioeconomic counterparts.
An important challenge in Bolivia’s SRH is the lack of comprehensive sex education.
- Latin American culture traditionally correlates parental discussions regarding sex with their children as an authorization to engage in sexual intercourse; consequently, children receive little to no sexual education from their families (Edberg, 2019).
- The lack of in-home sex education is reflected in the school systems as some adults who are expected to teach sex education did not receive any themselves.
- This cycle of misinformation and lack of knowledge strengthens the taboo subject of sex leading to embarrassment and shame.
- Dr. Uribe mentions the widespread myths and rumors about birth control methods as a difficult challenge to overcome
- The majority of conversation about sexual and reproductive health focuses on women. Men are almost entirely excluded from the discussion
As Bolivia moves towards the future, it is imperative that misinformation be dispelled through proper education to combat the traditional perspective of SRH so that future generations do not repeat the same cycles of embarrassment and shame and can live healthy sexual and reproductive lives.
Abortion in Bolivia
Although “abortion is legal under certain indications [rape, incest, risk to health, and fetal malformation], health care providers can claim conscientious objection (CO) if a service conflicts with their moral, religious, or ethical beliefs”; yet, CO is not always used properly (Küng et al., 2021).
Another example of inaccessible abortions is the economic incentives provided to providers which is dependent on public facilities or private practices: “providers do not receive payment for abortion services delivered in public hospitals … while providers receive most, if not all, payment for services rendered in their practices” (Küng et al., 2021). The economic incentive that is only provided for more expensive private practices deepens the disparity between Bolivian women of low and middle socioeconomic status than their high socioeconomic counterparts.
*For more information about challenges please see Dr. Uribe's interview located below
Interventions
Historical
Despite the immense need for sexual and reproductive healthcare and policies, there were historical actions taken as well as a move towards new policies and law that strengthen this section of public health. In 1990, Bolivia turned away from its pronatalist stance and established a National Reproductive Health Program to provide SRH to all women (Paulson & Bailey, 2003). Moreover, the recognition that maternal mortality was a serious problem in Bolivia allowed for measures to be taken for these numbers to decrease
Current
Additionally, programs such as CIES and Tú decides have become more popular in Bolivia. These organizations work with individuals to provide educational classes, a wide variety of sexual and reproductive healthcare services, and put together fundraisers for those who cannot afford their healthcare. Another local intervention, is the Center of Empowerment for Young Mothers. This organization was created by CFHI with the help of Dr. Cecilia Uribe de Chavez. The center provides a safe place for young mothers to leave their children while they pursue their education or continue working. In addition, the center provides educational classes for the mother with the promise she partakes in at least one form of anti-contraception.
Additionally, programs such as CIES and Tú decides have become more popular in Bolivia. These organizations work with individuals to provide educational classes, a wide variety of sexual and reproductive healthcare services, and put together fundraisers for those who cannot afford their healthcare. Another local intervention, is the Center of Empowerment for Young Mothers. This organization was created by CFHI with the help of Dr. Cecilia Uribe de Chavez. The center provides a safe place for young mothers to leave their children while they pursue their education or continue working. In addition, the center provides educational classes for the mother with the promise she partakes in at least one form of anti-contraception.
Learn more at:
Legal Interventions
The Inter-American Court of Human Right case: I.V. v. Bolivia. The decision of this case “held Bolivia responsible for the forced sterilization of a Peruvian refugee, I.V., and recognized the importance of personal autonomy as a constitutive element of personality” (“I.V. v. Bolivia,” 2021). By bringing SRH and bodily autonomy to the forefront of politics, the I.V. v. Bolivia decision could potentially change the way SRH is perceived from a law and political standpoint.
Interview with Dr. Cecilia Uribe de Chavez November 9, 2022
Dr. Cecilia Uribe de Chavez is a pediatrician in a small town named La Paz, Bolivia. Additionally, Dr. Uribe works in an hospital in El Alto. She is the medical director for CFHI La Paz and has worked with Children and Family Health International (CFHI) to create the Center for Empowerment of Young Mothers. During our interview, Dr. Uribe focuses on the challenges and interventions in sexual and reproductive healthcare.
Unfortunately, the COVID-19 pandemic severely impacted SRH and rights.
According to global surveys, the following were greatly impacted by the COVID pandemic:
- Prioritization in health service at the expense of SRH
- Lack of political will
- Suspension of sexual education
- Access to contraceptives, were just some common themes amongst countries (Endler et al., 2020).
The pandemic either pushed SRH backwards or made all progress stationary, including in Bolivia.
The Future
As Bolivia progresses into the future and moves away from the pandemic, it is essential that all progress should be continued as well as new policies created.
The Guttmacher Institute declares “if all needs were met for contraceptives for women aged 15- 49: unintended pregnancies would drop by 77%, abortions would drop by 77%, unsafe abortions would drop by 77%, and maternal deaths would drop by 83%” (Guttmacher Institute, 2021).
These statistics demonstrate the apparent need for contraceptives as well as their influence on SRH. Furthermore, Guttmacher Institute states “every $1 spent on contraceptive services beyond the current level would save $5.62 in the cost of maternal, newborn, and abortion care” (Guttmacher Institute, 2021). While we may not know the future actions and policies that will be incorporated, it is imperative that Bolivia start by providing access to contraceptives to all women to develop a stable foundation for SRH and rights.
Special Thanks
Special thanks to: Sam Wey, Kaegon Matlock, and Olivia Soto-Allioson for interpretation and subtitles. Dr. Moira Rogers for her guidance and connection. Dr. Anastacia Kohl and Dr. Sharrah Lane for Spanish translation. Dr. Cecilia Uribe de Chavez for taking the time to answer my questions. Naya Villarreal for editing and advising throughout the semester.
Work Cited
Adding it up: Investing in sexual and reproductive health in Latin America and the Caribbean. Guttmacher Institute. (2021, May 14). https://www.guttmacher.org/regions/latin-america-caribbean/bolivia
Child Family Health International (CFHI). (n.d.). Young children. Young Mother's Empowerment Center. Retrieved from https://www.cfhi.org/young-mothers-empowerment-center-emj.
CIES. (n.d.). Cies educational classs. Salud Sexual, Salud Reproductive, Salud Integral. Retrieved from https://www.med.unc.edu/oia/wp-content/uploads/sites/613/2022/10/Presentacio%CC%81n-CIES-U.pdf.
CIES. (n.d.). Cies Educational class in classroom with chalkboard. Institutional Brochure - CIES Sexual, Reproductive, & Comprehensive Health. Retrieved from https://www.med.unc.edu/oia/wp-content/uploads/sites/613/2022/09/Brochure-CIES-2022-FINAL-version-ingles.pdf.
Data Warehouse. UNICEF DATA. (2021, March 29). https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq=BOL.MNCH_MMR.&startPeriod=1970&endPeriod=2022
Derks, S., & Heessels, M. (2011) Battered women venerating a vicious Virgin: Reconsidering Marianismo at a Bolivian pilgrimage shrine, Culture and Religion, 12:3, 303-316, DOI: 10.1080/14755610.2011.605156
Edberg, J. (2019). Stigma of Adolescent Pregnancy and Motherhood in Bolivia: Examining how pregnant and mothering adolescents experience stigma in the city of Cochabama, Bolivia. Lunds Universitet.
Encyclopædia Britannica, inc. (2022). Bolivia. Encyclopædia Britannica. Retrieved from https://www.britannica.com/place/Bolivia
Endler, M., Al-Haidari, T., Benedetto, C., Chowdhury, S., Christilaw, J., El Kak, F., Galimberti, D., Garacia-Moreno, C., Gutierrez, M., Ibrahim, S., Kumari, S., McNicholas, C., Flores, D.M., Muganda, J., Ramires-Negrin, A., Senanayake, H., Sohail, H., Temmerman, M., & Gemzell-Danielsson, K. (2020, November 11). How the coronavirus disease 2019 pandemic is impacting sexual and reproductive health and rights and response: Results from a global survey of providers, researches, and policy makers. Obstetrics & Gynecology. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.14043
I.V. v. Bolivia. Global Freedom of Expression. (2021, June 3). https://globalfreedomofexpression.columbia.edu/cases/i-v-v-bolivia/
Küng, S.A., Wilkins, J.D., de León, F.D., Huaraz, F., & Pearson, E. “We don’t want problems”: reasons for denial of legal abortion based on conscientious objection in Mexico and Bolivia. Reprod Health 18, 44 (2021). https://doi.org/10.1186/s12978-021-01101-2
McFarren, P. J. (2022) Bolivia. Location of Bolivia. Bolivia | History, Language, Capital, Flag, Population, Map, & Facts | Britannica https://www.britannica.com/place/Bolivia
Muñoz, C. (2021). [Photograph] A woman protests access to abortion with a sign that reads in "Niñas, no madres" or "Girls, not mothers". Girl’s Ordeal Exposes Bolivia’s Failure on Reproductive Rights.
Paulson, S., & Bailey, P. (2003). Culturally Constructed Relationships Shape Sexual and Reproductive Health in Bolivia. Culture, Health & Sexuality, 5(6), 483–498. http://www.jstor.org/stable/4005380
Stieglitz, J., Blackwell, A. D., Raúl, Q. G., Edhitt, C. L., Gurven, M., & Kaplan, H. (2012). Modernization, Sexual Risk-Taking, and Gynecological Morbidity among Bolivian Forager-Horticulturalists. PLoS One, 7(12)https://doi.org/10.1371/journal.pone.0050384
Tú Decides. (n.d.). Tú Decides class. Tú Decides. Retrieved from https://www.redtudecides.com/.
United Nations Population Fund. (2022, April 4). Sexual & Reproductive Health. United Nations Population Fund. Retrieved from https://www.unfpa.org/sexual-reproductive-health#readmore-expand
United Nations High Commissioner for Refugees. (n.d.). Sexual and reproductive health. UNHCR. https://www.unhcr.org/en-us/reproductive-health.html
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