LATINAS AND REPRODUCTIVE HEALTH - July 25, 2000 - Seattle, Washington

Presented to:
Listening Group on Achieving Balanced Communities and Eliminating Disparities in Health

By: Luz AlvarezMartinez, Executive Director

Demographic information is important in understanding correlations to health status: The Latino population in theUnited Statesis approximately 22 million or approximately 9% of the total population with the majority inCalifornia. Over 7 million. Latinas comprise 8.6 % of the total female population. They are one of the fastest-growing and most diverse groups in the country and are expected to increase to 10.7% of the population in 2010. In 1986 half of all working-age Latinas were in the labor force. Currently the median income among Latinas is $10,099.00. Two-thirds (67.7%) of the Latino population are under thirty-five years of age; 19% of Latinamothers are under twenty years of age...one of the factors that accounts for the low educational attainment among Latinas.

Reproductive Health: The dictionary defines reproductive as 1. Of or pertaining to reproduction. 2. Tending to reproduce. And of course reproduceis defined, in the biological sense, Ato generate (offspring) by sexual means. With these definitions in mind, reproductive health is limited to girls and women that already have or will some time in the future, biologically reproduce. It excludes women that have not or will not reproduce for reasons of personal choice, physical incapacity or those women that are beyond their fertile years. This perspective is very politically charged.

Legislators and policy makers alike are focused on:

• Who is getting pregnant; the number of children being born and to whom.
• What can or cannot be taught in the schools regarding sex or family education?
• Can school clinics provide birth control and condoms to students?
• Ensuring the availability of sterilization and long-term hormonal contraceptive methods for specific populations.
• Who can legally get an abortion and who pays for it; is a Apartial birth abortion@ really murder?
• The incarceration of pregnant women that are Aendangering the health and welfare of a minor@ or their fetus.
• Can hospitals or HMO's make individual decisions on what kind of reproductive health they provide or reimburse?

These are some of the reproductive health issues women and girls face.

Policy implications are the following: In the United States, adolescent health is still viewed very narrowly. Unfortunately, it is synonymous with adolescent pregnancy, a very hot topic across the nation.  The response to the issue is one-dimensional. The Welfare Reform law of 1996 committed $850 million in public funds over a five year period solely to promote Aabstinence for anyone that is not married. This a dangerous supposition as it promotes being married as the most important issue. This can be translated to mean that as long as young sexually active or adolescent mothers are married, the problem is taken care of.  This same law rewards states that reduce out-of-wedlock births and abortions among all women.  The law and the available funding do not take into account that adolescent pregnancy is a symptom of a much larger, more complex problem.  There is no mention of comprehensive, preventive health care and of the rising incidence of Reproductive Tract Infections (RTIs) and cervical cancer in young women.

In a 1995 State-By-State Review, NARAL reported that only twenty-two states and the District of Columbia require schools to provide both sexuality and STD/HIV education. An additional fifteen states require schools to provide only STD/HIV education. Thirteen states do not require schools to provide either sexuality or STD/HIV education. Of the twenty-six states that require abstinence instruction, only fourteen also require the inclusion of other information on contraception and pregnancy and disease prevention. A number of states prohibit school health and education programs from making contraceptives available and ban or restrict discussion of abortion and sexual orientation.

The latest research shows that Latina adolescents have the highest rate of pregnancy than any other ethnic group. If Latinas are getting pregnant, there is a natural assumption that they are not practicingAsafe sex@ to protect themselves against RTIs.  The reason for the high incidence of Latina teen pregnancy is complex. Although adolescent pregnancy is not the sum total of adolescent health, it has an impact on the adolescent=s entire life. An interesting fact is that abortion in the Latina population is higher proportionally than in other ethnic communities; but Latina teens are more likely to have and keep their babies.  Latinas make up 8.4% of women 15-44 years of age, yet 13% of all abortions are performed on Latinas in that age group. Latina/o students also have the highest rate of school drop-out. There is a direct correlation of adolescent pregnancy to the socio-economic and educational status of the girls and their families. The National Latina Health Organization (NLHO) believes that there are many obstacles in our youth's pathway. Not only are they at risk for pregnancy, but are also at risk for abuse, violence, education deprivation and neglect.  Economic disparities, illegal immigration status, false and negative stereotypes, peer pressure, domestic violence, racism.....these are just some of the nameable problems our youth face. Most damaging to our youth's self-esteem is a dominant societal attitude that does not understand their cultural needs and blames them for the ills of the present economic system. Additionally, mothers who did not learn about sex and sexuality from their parents, do not educate their own children on the issues. What is more troubling is that mothers themselves do not have adequate information on how their daughters should protect themselves against pregnancy or RTIs; or how to communicate with them on matters of sex and sexuality.

An issue that is not being addressed by mainstream reproductive health organizations is the FDA approval of Norplant in 1990 and Depo-Provera in 1992.  Both of these contraceptives are not in the control of the user and do not protect against RTIs. The NLHO has taken a lead nationally in educating and informing policy makers and women alike on the dangerous side-effects of the drugs and the abusive and punitive use of both methods. They are the first choice methods of the majority of clinics that serve adolescents, particularly adolescents of color. Women are not given the information they need to make informed decisions on their use. Girls are often not given a choice but routinely prescribed or coerced into using Depo-Provera or Norplant because Acompliance@ is easily attainable. The focus continues to be pregnancy prevention and not educated and informed decision making and development of healthy lifestyles. There has been no research or testing conducted on women under eighteen years of age so there is no information on the short or long-term effects on them. A common side effect of both methods is irregular bleeding or amenorrhea. Osteoporosis is also a known side-effect. How can this be safe for girls whose bone structures and bodies are still developing physiologically?

While it is sometimes difficult for women to obtain Medi-Care funded abortions, sterilization services are provided by states under the Medicaid Program, and the federal government reimburses states for 90% of those expenses. In some areas of the United States, sterilization rates for Latinas are as high as 65%.

Welfare Reform also attempts to control women's reproductive behavior by punishing poor women for having children and "rewards" them for controlling their reproductive ability through insufficiently tested contraceptive devices such as Norplant and Depo-Provera. For example, the "Child Exclusion Rule" of the California Work Pays Demonstration Project Waiver Request includes a provision which contains exemptions for children conceived as a result of contraceptive failure if the contraceptive was an IUD, Norplant or sterilization. This is a form of coercion for women to use long-term or permanent methods that are not in their control. Reform such as this severely infringes upon a woman's right to make decisions regarding procreation free from governmental interference and financial constraint. Through "family-caps" policies and certain exemptions the government unabashedly infringes on a woman's reproductive liberty.

According to a March, 1998 Briefing by the Alan Guttmacher Institute (AGI), only nineteen states plus the District of Columbia mandate that schools provide sex education. Sex education is often synonymous withApregnancy prevention@ or Aabstinence@ curriculums, so there is no guarantee or requirement that accurate, quality information be provided on RTI=s or pregnancy prevention. AGI also reports that three million teens acquire an RTI each year; and that teen women are more at risk for RTIs than older women. A 1997 Kaiser Family Foundation report reveals that only 12% (one out of ten) of women between the ages of 18-44 reported that a health provider had raised the subject of STDs with them at their first visit. There is no breakdown by ethnicity, but another hard fact is that Latinas are less likely to receive preventive or regular health care than other groups. Nationally 32.4% of Latinos were uninsured in 1990. In California there are more than 6 million uninsured; over half of those are Latino. There are multiple barriers for Latina women, in particular Latina teens, in obtaining health care or information; not the least of which is language and culture. Data on Latinas of all ages is insufficient regarding sexual activity, RTIs and the decision making process adolescents use regarding initiation of sexual activity.

Abortion is still legal in this country, but just barely. There are numerous attempts to abolish it or to restrict it. Californiais one of the few states that funds abortion for indigent women and protects the right of adolescent girls to access it. There have been numerous attempts to amend the California Constitution regarding minors=rights to privacy; and there are numerous states that prohibit any abortion being performed on a minor without written consent from the minor and one parent. Since 1995Apartial birth abortion laws have been enacted in twenty-six states. Eleven have been blocked by federal or state court judges who have ruled that the laws are so broadly written that they could potentially criminalize almost all common abortion procedures , including those used early in pregnancy. State after state is legislating a ban onApartial birth abortion laws have been enacted in twenty-six states.

Incarceration of pregnant women:According to the Center for Reproductive Law and Policy, twenty-two states have attempted to incarcerate pregnant women that are believed to be using or abusing drugs. The women being targeted are those using public clinics, who are for the most part women of color and poor. Twenty-one of those states have rejected criminal prosecution. South Carolina is the only state that has started prosecuting women. It is important to note that most states do not have adequate or any drug prevention programs available,even when women ask for them.

Availability of Reproductive Services: At the state level AB160 would have legislated every health care service plan that provides coverage for outpatient prescription drug benefits to provide coverage for a variety of FDA approved prescription contraceptive drugs. In 1998, Governor Wilson of California, attempted to insert a Aconscience clause@ that would allow clinics, hospitals or employers to refuse to provide contraceptives because they may have conflicting religious beliefs. Why should a clinic or hospital director=s personal beliefs infringe on women=s access to contraceptives?

The NLHO conducted informal surveys asking adolescents, young adult women and mature women of all ages what specific information/content they would like in a reproductive health conference. Their overwhelming response was that they needed basic information on physical development, menstruation, how to protect themselves against unwanted pregnancies and Reproductive Tract Infections (RTIs). For older and younger women alike, there were also concerns regarding pre-menopausal symptoms and the onset of menopause; another life event that is just beginning to be openly discussed.

I want to present a more holistic and encompassing approach of women=s life spectrum of sex and sexuality. From pre-adolescence, through puberty, womanhood through menopause and beyond. Young girls need to have information and an understanding of their developing and changing bodies; and that the onset of menstruation is a life event to be celebrated and not cursed. Girls should be provided with the education, skills and support they need to increase their health awareness in order to make healthful life decisions for themselves regarding sex and sexuality and peer pressure; and increase their understanding and awareness of sexual activity that is at risk for pregnancy and RTIs.

There is an urgent need to re-define or re-discover and reclaim a holistic, indigenous health perspective that is our true culture. I am talking about what we had before the Spanish invasion. A culture that requires equality of women and men and works toward an environmental and ecological balance of mother earth. A culture and tradition that celebrates young women=s puberty, menstruation and coming of age; and that respects and reveres elders.  A culture that does not differentiate, compartmentalize or separate the body, mind and spirit; and that accepts sex and sexuality as a natural process of life.

A most vital issue is the processes and procedures; and rules and regulations that some state and federal Health and Human Services Departments use to fund non-profit and for profit organizations. The NLHO believes that it is of extreme importance that prevention programs and curriculums for Latinas, and other ethnic groups, should be developed and administered by culturally-based organizations. When programs are developed within the communities that they serve, there is a higher likelihood of its successful practical application. Programs that are developed by individuals or organizations that do not understand the cultural experience of Latinas, are outside the community, in an academic setting, or without community involvement, do not usually include an evaluation for its cultural success. The quantitative success may be there, but not the qualitative.  One is as important as the other. There must be cultural competency within the organization providing the program, not just the individuals implementing the program.  Even if staff is culturally competent and the organization is not, the organization is still the entity that makes the final decisions. I have seen several situations where program staff has been overridden and blocked from doing what is best for the community because the organization did not have the cultural understanding to see the importance of the intervention.

A practice that is very detrimental is the awarding of grants using the criteria of  the lowest dollar total amount and the lowest responsible bidder meeting the RFP standards.  An extremely important question is, what is the correlation between having the lowest bid and providing a quality program? This criteria does not provide a level playing field for smaller organizations such as the NLHO. It completely skews it and gives advantage to organizations with larger budgets and cash flow; and that can absorb some program expenses.  Non-profits are always struggling to offer fair and competitive salaries to their staff; and to cover all of the costs of programs.  The process of granting funding to the lowest bidder sabotages this effort.

Recommendations:

• That we develop a holistic approach to health, in this case reproductive health, that encompasses access to quality health, information and education about sex and sexuality that is culturally relevant and in our language.
• Curriculums or programs must address youth development issues.
• Women need safe and affordable birth control methods that are in their control.
• We need access to abortions and to early prenatal care for all women/girls so we can have healthy babies.
• We must have freedom from all reproductive abuses.
•  We need information available to make knowledgeable, healthful decisions so that we are not left with abortion as our only choice; true informed consent.
• There must be cultural competency requirements for funding so that programs are relevant and meaningful to the population being served.