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Sexual and Reproductive Health in women of Dominica Republic
– Reported, February 15, 2012
SITUATION AT A GLANCE
Maternal Health
Maternal Mortality: 180 deaths per 100,000 live births
Births attended by skilled health personnel: 96%
Unsafe abortion as part of maternal mortality: 20% (in Santo Domingo)
Legal status of abortion: Illegal in all circumstances
Family Planning
Contraceptive prevalence: 68.9%
Percent of women sterilized: 46%
Median age of sterilization: 28
Unmet need for family planning, 15-24 year olds 29%
Adolescent pregnancy, 15-19 year olds 23%
HIV/AIDS
HIV prevalence: .8% (likely closer to 2%)
HIV prevalence among 15-19 year olds: .6% for young women; .3% for young men
Ranking of AIDS as cause of morbidity/mortality: First (for women of reproductive age)
U.S. Funding
The Dominican Republic has received considerable assistance from the United States to address sexual and reproductive health issues. Because of the countrys relatively high contraceptive prevalence rate,in 2008, the country graduated from U.S. funding for family planning programs. The Dominican Republic receives a significant amount of PEPFAR funding to address and prevent HIV/AIDS, totaling
$ 5.75 million in 2009.
Rising HIV prevalence for young women and high rates of teen pregnancy are strong indicators of the gaps in the Dominican Republics sexual and reproductive health care. Moreover, despite the fact that almost all births are attended by skilled providers, maternal mortality is alarmingly high. Along with other barriers to comprehensive, rights-based care, CHANGE found program staff expressing frustration with the U.S. requirement that only those 15 and older could learn about condoms, and found appalling conditions in a major maternity hospital.
Fortunately, the Dominican Republic has some excellent examples of comprehensive approaches to sexual and reproductive health and rights. Profamilia and Colectiva Mujer y Salud provide high quality care in a full range of services to address the needs of women and youth, including those who are HIV+. However, U.S. assistance for family planning and reproductive health has recently ended,leaving Profamilia relying more on user fees for sustainability and the Dominican government to prove its own commitment to these issues. As the government is strongly influenced by the Catholic Church.
The Case for Comprehensive: Dominican Republic
International Planned Parenthood Federation member association Profamilia is seen as a leading sexual and reproductive health care provider in the country and a leader in defending women. In one hospital,seven clinics, one mobile clinic, and 26 community distribution outlets, Profamilia provides the full range of reproductive health care family planning, maternal health, and HIV/AIDS and other STI services. They also incorporate youth-friendly outreach and programming.
Unlike other health providers, Profamilia incorporates attention to gender based violence in all levels of service with professional counseling on gender-based violence (GBV) from a rights-based approach.
They also have a model maternity hospital in Santiago that is open 24 hours a day and serves 1,000 birthing women per year. To combat stigma for HIV+ clients, their clinics do not physically separate HIV services from other sexual and reproductive health services. All users use the same entrance, lobby and lab services, regardless of the reason for seeking care. It is important to note that while this inclusive approach has been successful for Profamilia, it may not work in all settings.
The feminist NGO Colectiva Mujer y Salud (Womens Health Collective) has a strong community presence from years of outreach and education, and opened the Monte Plata health center in March 2008. This center offers family planning, antenatal care, voluntary counseling and testing,antiretrovirals, sexual education for ages 10 and up, and community outreach that includes gender violence screening and focuses on womens rights and gender equity. They base service selection on womens needs as identified by women in the community. Although the Ministry of Health provides no female condoms, Colectiva is working to train Ministry of Health personnel on their use and is working in communities to raise awareness about female condoms. However, low supplies of female condoms have been a consistent challenge to fully execute the program.
Limited Promises in the Public Health System
The contrast between the quality and breadth of care offered by Profamilia and Colectiva as compared with the Dominican Republics public health care system is striking. The only forms of contraception offered by public health outlets are birth control pills, IUDs, condoms, Depo Provera, and sterilization.The public sector also suffers from a lack of integration between services. In a study exploring provision of family planning to postpartum women, the authors note that while 97 percent of women entering the hospital for labor had indicated interest in using family planning postpartum, only 12 percent received a method before leaving the hospital. For postabortion care clients, the situation was even worse: only 12 percent even received counseling on family planning, and just 9 percent received a method before leaving.In contrast to Profamilias approach, the public health system provides care to those living with HIV and AIDS through separate clinics sometimes attached to hospitals although with separate entrances called Integrated Attention Units (UAIs). However, despite their name, UAIs and hospitals have no referral system between them. Moreover, UAIs have no gynecologists on staff and provide no services for contraception or GBV . They do not have any youth-friendly counselors or other staff and they have little outreach to communities.
Impact of U.S. Policy on SRHR in the Dominican Republic
While the U.S. has funded some excellent SRHR programming, including those of Profamilia, advocates and program implementers reported frustration with some U.S. policies. The PEPFAR policy that restricts condom promotion among youth to those 15 and over interferes with effective HIV and pregnancy prevention among younger adolescents. While this is true around the world, it is a particular problem in the Dominica Republic, where the government recently lowered the official age for onset of contraceptive need from 15 to 10 due to the high incidence of pregnancy and STIs among younger teens.U.S. policy simply does not fit the Dominican reality in this respect.
Another U.S. policy that has had a major impact on the Dominican Republic is the Mexico City Policy (Global Gag Rule). Until President Obamas recent repeal of the Global Gag Rule, Profamilia was unable to publically advocate for liberalization of the countrys abortion laws, which prohibit abortion under all circumstances. As the countrys largest nongovernmental sexual and reproductive health care provider, their absence from participating in advocacy around the high rate of unsafe abortion and resulting maternal mortality has potentially been costly, as the Dominican government has recently approved a constitutional change that defines life as protected beginning from the moment of conception.
With the ending of U.S. family planning and reproductive health assistance, there is great concern about the sustainability and accessibility of comprehensive, rights-based sexual and reproductive health care in the Dominican Republic. Given the quality of care issues within the public health system, the danger is that the Dominican Republic will end up with a two-tier system: a rights-based, comprehensive system for those who can afford it and a low quality, non-integrated system for those without resources.
Credits: Center for Health and Gender Equity USA
More information at:
http://www.genderhealth.org/files/uploads/change/publications/dominicanrepubliccasestudy.pdf
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