Para los Estudiantes de Comasaguas

El Salvador: Salud Reproductiva

Referencias

Recursos para Violencia

• ISDEMU - Instituto Salvadoreño para el Desarrollo de la Mujer www.isdemu.gob.sv/
• Las Dignas: http://www.lasdignas.org/, 2284-9550
• CEMUJER: http://www.cemujer.com/, 2275-7563
• ORMUSA Organización de Mujeres Salvadoreñas: Ormusa.org, Línea amiga que es 2226-5829 y 7837-7306
• Coalición mesoamericana para la educación integral en sexualidad: http://www.coalicionmesoamericana.org/
• Movimiento Salvadoreño de Mujeres: http://www.mujeresmsm.org/nuestro-trabajo.html
• Hombres Contra la Violencia: http://hombrescontralaviolencia.blogspot.com/

Como Decir No al Sexo

• No. (No necesitan dar una explicación)
• Si me quieres, esperarías hasta que me sienta que es el tiempo perfecto
• Me gustas mucho pero no estoy listo(a) para tener relaciones sexuales
• Me divierto mucho contigo y no me gustaría arruinar nuestra amistad
• Eres muy importante en mi vida, pero tener relaciones sexuales, no es la manera en que le demuestro a alguien que me agrada
• Me gustaría esperar a casarme, antes de tener relaciones sexuales
• Tú me gustas mucho, pero quiero que mi primera vez sea especial, por eso es importante que seamos pacientes y pensemos en esto cuidadosamente
• Es mi cuerpo y no me siento cómoda

10 Preguntas para su Pareja antes de Tener Sexo

1. ¿Te has hecho la prueba de Infecciones de transmisión sexual (ITS)?
2. ¿Tienes VIH/SIDA?
3. ¿Has resultado positiva a una prueba de ITS? Si es sí, ¿has tomado medicina para esa infección?
4. ¿Has tenido sexo con alguien que tiene una ITS?
5. ¿Estás teniendo sexo con alguien más?
6. ¿Cuántas parejas sexuales has tenido?
7. ¿Crees que es importante ser fiel uno al otro?
8. ¿Tienes alergia al látex o tienes problemas con usar un condón?
9. ¿Estás tomando algún anticonceptivo?
10. ¿Si la chica queda embarazada, cual es nuestro plan?

Pastillas de Emergencia - NO SON MÉTODO ANTICONCEPTIVO

• Postinor 1 o Vermagest (Levonorgestrel) 1.5 mg
• Se usa después de que falló el condón o en caso de una violación y entre 72 horas
• Si no hay pastillas de emergencia, usen 4 pastillas de planificar y esperen 12 horas
• Luego, tómense 4 pastillas mas
• Es importante ir a un doctor y obtener un método anticonceptivo apropiado

Health Clubs

Here's a post from Alisan.  The internet was being too slow to try to figure out how to officially add her to the blog!
_______________

In addition to the FIMRC initiatives that focus around providing medical and public health services to the community, a newer initiative by FIMRC started last week  involved bringing education to students in the community through helping schools establish health clubs.  The initiative was born as a result of the current field operations manager conducting needs based surveys in the local communities.  Last week, Erin, Lynn, and I along with a FIMRC staff member visited a local school where we met with the health club advisor about the health club and the future expectations of the club.  We met with the students and discussed the various leadership roles for the club and the expectations associated with the roles.  The group then nominated and elected the organization leaders.  As a group, the students then outlined the objectives of their health club and the topics that they hoped to cover throughout the course of the school year.  The students appeared to be engaged and excited about the course of the health club.

The following week, Erin and I returned to the school in Bulobi while our fellow classmates set out to initiate similar partnerships at other schools.  Understanding that FIMRC is meant to serve a supporting role to the schools and that the presence of volunteers is not always guaranteed, we aimed to promote a model that would give the students ownership over the health club and promote sustainability.  We developed and presented a model to teach the children how to take a concept from the beginning to the development of a final product.  We outlined steps from choosing a topic to learning and educating about the topic to choosing and implementing a project related to the topic.  We demonstrated the model through role-playing by presenting the topic of handwashing for which we made a “tippy tap” handwashing station to be used at the guesthouse or clinic.  Afterwards, we had the students go through the process with a topic of their choice.  The students chose nutrition as their topic and shared their knowledge on food and nutrition.  They then decided on potentially developing a school garden as their final project.  The students were able to grasp the concept of the model as something that they could use for all of the future topics without having to depend on volunteers or FIMRC.

Lynn, along with a FIMRC Community Health Educator, visited another school in Bumwalukani.  Angela and Justin also visited a local school where they worked to establish a connection on behalf of FIMRC with the health club.  They were all met with great enthusiasm by the students and teachers who were excited to learn about methods for learning about and promoting health education with limited resources.  These relationships were founded with the help of our students and FIMRC staff and I hope to see the relationship fostered over the coming years.

On a less academic and more gross note, Lynn had to just minor surgically remove a jigger from my toe.

 - Alisan

Casa de Maternidad

Last Wednesday, I learned about an interesting option for pregnant women in a mountainous part of El Salvador called casa de maternidad. This is a house available to women who are pregnant in a small town of 74 people called Las Brisas, which stands at about 1000 meters of elevation. The roads to the town are barely drivable to say the least, so rarely do personal vehicles make it up the mountain. At the peak of the mountain, there is a coffee plantation, which has trucks driving up and down the treacherous roads daily.

Most people walk up and down that road to go to the market, doctor, or just about anything that is not available on the mountain. The hike up the mountain, which I had the pleasure of experiencing, takes about 1.5-2 hours. It is currently the dry season in El Salvador and is extremely dusty. The lack of dust free air makes the hike slightly more difficult. To venture up the mountain, one needs to take all the water they will drink for the day, since there are no stores in the small town to purchase more water. The walk down takes about 1-1.5 hours.

I hope I may have convinced you that this seems like a difficult task to undertake while pregnant. They unfortunately, do not have mid-wives in the community helping out in home pregnancies. The women need to walk up and down that mountain for prenatal care check ups, but when it gets close to the due date, women in Las Brisas can opt to go to the casa de maternidad. Approximately, 10 days before due date, women can walk over to this house, where they will stay with other pregnant women and share experiences. They will have cooking and cleaning services taken care of by staff members overseeing the house. The pregnant ladies can have family visit them everyday and even drop off food should they wish for some classic family recipes. In addition, an OB/GYN, visits them everyday to see how the pregnancy is progressing, and they are not too far from OB/GYN help in case a complication arises. When labor begins, the woman is transported to the hospital by car. All of these services are offered free of charge. The only rule is that no family members can stay over night. This is a nice option for women who live in a community were access to care is a large issue. It is a very interesting compromise to try to decrease complications surrounding delivery. 

Salud Reproductiva - El Salvador!

We have had a busy several weeks! From Pap smear campaigns to diabetes campaigns, traveling clinic with the physician, cultural events with the elderly, government-run nutrition events, and more.

One project spans almost the entirety of our stay - we have been leading a series of reproductive health classes for 4th-9th graders. Last year's group was invited to give a session on reproductive health, in response to rising rates of adolescent pregnancies. We were invited back again this year, for 4 sessions!

Our first presentation was to parents. We presented our plan -


Anatomy
Puberty
Sex
How to say 'No'
Fertilization
Embryology
Contraception
Violence in Relationships/Inappropriate Touching (for younger kids) /Rape(for older kids) 
STDs
Condom Demo

We were expecting many questions, especially as this community has religious groups traditionally very opposed to certain themes we wanted to address. But the parents thanked us for coming in to talk to their children, and we were given the green-light. Surprised, but pleased, we began to prepare. This was a reminder that you can't predict a response, positive or negative! We all want the same thing - the health and wellness of adolescents

We expanded on material created by last year's group (we especially loved their skits and the conception puppet show - thank you Julie, Angela, Steve, and Mike!) and began to expand with information from the CDC, WHO, Planned Parenthood, written resources provided by FIMRC, and other valuable websites and books.

So far we have delivered the 3 primary sessions. We prepare them in Spanish, with cultural editing from our wonderful Spanish instructor Liseth. The 4th session will be entirely devoted to student questions, which we collect at the end of each class. 

Examples of questions include "How are twins developed?", "How do you know who is the one?", "If haven't had my period for 3 months, could I be pregnant?"  "Are the condoms at the Unidad de Salud (health center) safe?" "Why is sex bad?" "When can we start having sex?" "What is gonorrhea " "What are the symptoms of HIV?" And the list goes on. We've been attempting to answer most of these questions in our 3 primary sessions, with the 4th session available for the rest of them. 

This project led to an adventure as we ventured into the community pharmacy to see what contraceptive items are available for local adolescents. 

The following are available over-the-counter in this particular pharmacy:
Male Condoms
Oral Contraceptives
Monthly progesterone shot

I held the oral contraceptives and shots in my hands and thought "It's that easy? You just walk in? No prescription at all" These over the counter products do cost money. I'm under the impression that if an adolescent went through the government, it would be possible to get free contraceptives, as well.

Plan B, Emergency Contraception, is also available in El Salvador pharmacies, although not in this community. It is called Postinor 1 and costs $15. 

It is not the largest difference between the US and El Salvador, but it stuck with me. I'd known, logically, that these items were available over the counter. But you don't realize what that means until you just walk in and buy them. What does this mean for access? For 'control'/yearly physicals? While available, are they being utilized? We've run into a variety of myths surrounding contraceptives, whether hormonal, barrier, or 'natural', and usage depends heavily on clearing some of these myths (see prior blog entry on the use of condoms)

As we give our weekly 'charlas' at the school, we've tried to keep in mind that we can't dictate culturally what is acceptable, but we can present facts as we know them and try to clarify myths surrounding reproductive health. This week, we give the same presentation to the parents, which should be educational all around!

Emily and Nabil puppeteer the sperm and the egg traveling to one another in Day 2 of "Salud Reproductiva" 

 Emily with her "Anticonceptivos" Poster!

Nabil explaining how to read a pregnancy test


Nabil's condom demonstration (in Spanish)

Adventures of the Tourist Kind:
We hiked up a volcano! Here we are about to be blown away by the wind, at the edge of the volcano crater (created by the last eruption)

Here is a panoramic shot of our view from near the top. It was 12 kilometers of uphill-downhill, but well worth it - we could see San Salvador, Guatemala, and Honduras! 

Equipo El Salvador, signing out 

The Landslide Event

Six months ago, the Bumwalukani Landslide killed at least seven people and displaced nearly eighty others. Twenty people lost their homes and many more their farmland.

In response, the community came together to help those affected. FIMRC’s Beatrice Tierney Clinic offered free medical care to 63 families for the six months following the landslide. For the past week, my classmates and I have been visiting these families to determine whether the free care should be continued past the initial period, which ends this Wednesday. All of the families initially relocated to Shelter Box emergency relief tents at the base of the mountain. Many have now moved back to the area of the landslide. We spent the day walking along narrow trails through the Bumwalukani mountainside and were able to interact with all but four of the 63 families on the list. We gathered information about their access to latrines and clean drinking water, use of the clinic, and reasons for moving back to the landslide area.

I knew very little about landslides or their impact on a community before coming to Bududa. We learned that over-farming and erosion are primary causes of landslides in Uganda and other rural, agricultural areas. After the initial disaster, the untouched land lining the landslide site is known as the “danger zone” and the chance of a second event is much greater in this area. That is why the families living in this “danger zone” were provided with emergency tents away from the site. It is also why we were shocked to find that, six months later, nearly every family whose home was not completely destroyed had moved back. When we spoke with the families, we discovered there was a common reason for this migration back to the “danger zone”: hunger. The families could not afford to continue to buy food at the base of the mountain. They moved back to the landslide site so they could once again live on their farms and gardens, close to their food source.

Tomorrow we are planning an event to provide food and soap for handwashing to the families affected. We will also be collecting their free healthcare cards. None of the families were dealing with landslide-related illnesses, though for some the cost of healthcare was large when combined with the new costs the landslide had forced on them. Fortunately, we found that most of the families had begun to find their footing again and were able to make a living. In the end, we had to balance the resources of the clinic with the families’ needs, and felt the free healthcare was no longer justified. Fortunately, the clinic model is one that provides free care to children, so access should not be too greatly affected.

Excursions!

We apologize for the lack of pictures, but finally we've found some fast internet for the day in Jinja!

Here are some pictures of our home and clinic:

Our home in the Bududa District

Beatrice Tierney Clinic, where we work every day

And after work we still have time for some weekend fun!

The group preparing to raft the River Nile in Jinja

Capsized

Down a waterfall

Elephant up close on the riverboat safari at Murchison Falls

Giraffe on the morning game drive

Dancers at the Cultural Center

These are just some pictures from the past month. Real blog post to come....

Cuidado

The following flyer was found in a pharmacy by Marloes, the Fields Operation Manager of FIMRC in El Salvador. Once she read the flyer in question, she informed the pharmacist of the error in said flyer.

 It says the following:

"Careful! Inform yourself well!

Condoms do not protect 100%!

There are more than 65 sexually transmitted diseases (STDs) that one acquires even if condoms are utilized. Some of these STDs are deadly and others are incurable.

The condom fails in 47% of the time as an anticontraceptive in adolescents in the United States. (correct reference of this JAMA Article: Steiner MJ. Contraceptive Effectiveness. JAMA. 1999;282(15):1405-1407. doi:10.1001/jama.282.15.1405.)

The Human Papilloma Virus (HPV-incurable) is found in all genital areas, and can be transmitted by anyone from skin to skin contact. The condom does not protect against HPV. (According to the American Cancer Society).

 HPV causes 99.7% of cervical cancer cases.

Cervical cancer is the #1 cause of death in Salvadorian women.

Protect yourself with the only solution.
'Stay faithful to your partner all of your life."

Where to begin... Let's breakdown this flier line by line.

"Careful! Inform yourself well! Condoms do not protect 100%! There are more than 65 sexually transmitted diseases (STDs) that one acquires even if condoms are utilized. Some of those STDs are deadly and others are incurable," up until here everything is a true statement.

This next statement is problematic, "The condom fails 47% of the time as an anticontraceptive in adolescents in the United States." 47% of the time is not an accurate description of the facts. What are they quoting? If one pulls the JAMA article, the following statement is found, "for example, adolescent women who are not married but are cohabiting experience a failure rate of about 47% in the first year of contraception use, while the 12 month failure rate among married women aged 30 and older is only 8%."

Dr Steiner's article is a commentary paper and not the original or primary source of quoted research. The original paper by Fu et al goes on in the abstract to conclude that, "Levels of contraceptive failure vary widely by method as well as by personal and background characteristics. Income's strong influence on contraceptive failure suggests that access barriers and the general disadvantage associated with poverty seriously impede effective contraceptive practice in the United States." Here is the correct citation of the primary research paper: Haishan Fu, Jacqueline E. Darroch, Taylor Haas and Nalini Ranjit. Contraceptive Failure Rates: New Estimates from the 1995 National Survey of Family Growth Family Planning Perspectives , Vol. 31, No. 2 (Mar. - Apr., 1999), pp. 56-63. The correct failure rate is as follows, 18/100 will become pregnant if condoms are used incorrectly or inconsistently in the first year of use and 2/100 will become pregnant if used perfectly (James Trussell, Contraceptive failure in the United States, Contraception, Volume 83, Issue 5, May 2011, Pages 397-404).

Now the flyer jumps to a new topic about HPV: "The Human Papilloma Virus (HPV-incurable) is found in all genital areas. And can be transmitted by anyone from skin to skin contact. The condom does not protect against HPV. (According to the American Cancer Society)." Though it can be transmitted by contact, the condom does decrease the risk of transmitting the disease. The correct quote from the American Cancer Society is as follows:

"Condoms can help prevent HPV, but HPV may be on skin that’s not covered by the condom. And condoms must be used every time, from start to finish. The virus can spread during direct skin-to-skin contact before the condom is put on, and male condoms do not cover the entire genital area, especially in women. The female condom covers more of the vulva in women, but has not been studied as carefully for its ability to prevent HPV. Condoms are very helpful, though, in protecting against other infections that can be spread through sexual activity."

Skipping to this statement: "Cervical cancer is the #1 cause of death in Salvadorian women." This was a shocking statement for me to believe, because after being here for a few weeks, I have encountered many patients with diabetes and hypertension. I gathered from being in the clinic that the leading cause of death in the country was due to cardiovascular events. When I looked it up, cervical cancer is the leading cause of cancer death in Salvadorian women. Cardiovascular events are the leading cause of death for men and women. Cardiovascular event deaths count for 25% of death that are non-communicable, while all of cancers account for 12% of deaths. 

The last statement is the most confusing line: "Stay faithful to your partner all of your life." They are implying at this point that men should not cheat on their wives, because if they do cheat and use condoms, they can still cause their wife to have cervical cancer. The holy union of matrimony is symbolized by the wedding bands in the condom wrappers.

At one glance this flyer is about decreasing the rate of cervical cancers, but at another it is to discourage men from cheating on their wives. The CDC states the following about being faithful and cervical cancer:

"People can also lower their chances of getting HPV by being in a faithful relationship with one partner; limiting their number of sex partners; and choosing a partner who has had no or few prior sex partners. But even people with only one lifetime sex partner can get HPV. And it may not be possible to determine if a partner who has been sexually active in the past is currently infected. That's why the only sure way to prevent HPV is to avoid all sexual activity."

It is disheartening to see an advertisement against the use of condoms by twisting quotes from respected sources such as JAMA and ACS to support their cause. This flyer neglects to mention all the positives of condom use,  such as decreasing the risk of sexually transmitted diseases such as HIV, chlamydia and gonorrhea.

If the purpose of this flyer is to decrease mortality from HPV, it should first promote the vaccine against the deadly virus. The vaccine is one of the best preventative measures that one can take to decrease the risk of cervical cancer, but also warts. The article should represent condoms accurately, with both risks and benefits, so that patients can make an informed decision regarding their use. 

The flyer instead is an attempt to address another issue entirely - fidelity. This is a complicated issue, and condom use is tied to it, but we are having a hard time seeing that change will be affected by fear of condoms. Setting aside the issue of infidelity in a relationship, one should always use condoms with more than one sex partner.

Condom use is surrounded by myths:

Small holes exist in condoms that allow HIV to pass

Only prostitutes or those who sleep with prostitutes use condoms

Condoms cause cervical cancer

We can add a new one to the list, today - condoms are ineffective, so you might as well not use them, so you might as well not cheat.

Information can be twisted for an organization's agenda. As we continue our education sessions on Reproductive Health with adolescents (more on this later!), we need to keep in mind all of the cultural beliefs surrounding condoms, and the barriers to their use. It's a reminder of the importance of evidence-based medicine, focusing on giving best patient care, rather than allowing personal beliefs to influence how we advise patients.



--Nabil with edits by Angie

Family Planning in Bumwalukani

Once every other month an international family planning organization visits the Bumwalukani clinic to provide education and various birth control services.  They start their day at the clinic teaching women in a large group about the benefits of planning a family and how different forms of birth control work.  Then the women are checked in, receiving pregnancy tests, blood pressure checks, and discussion about their family situations and which form of birth control might be right for each of them.  We got to observe the nurse injecting about ten Implanons (progesterone-containing birth control implants) in a row; it was like a birth control factory (in a good way).  The system they have is great and allows them to be super efficient. 

We missed most of the individual patient education and discussion, but luckily one woman came later asking for an IUD.  We were very excited to be able to observe this procedure, but the nurses were meticulous about discussing the risks, benefits, and alternatives about the procedure (aka obtaining informed consent).  After getting to know the woman’s story, they decided an IUD was not right for her, and she decided to get an Implanon instead.  It was disappointing to us to not be able to see a different kind of procedure, but it was very reassuring that they were so thorough in their counseling that they were able to discover certain contraindications to the procedure. 

The most exciting part of the day was the tubal ligations.  In the days leading up to the visit from this family planning group, we had heard that they perform tubal ligations in the office in the pavilion down the hill from the clinic.  Just to paint a picture for you, the pavilion is covered, but totally open to the air.  There are some tables and benches set up for various patient groups.  There’s also an 8 x 12 room which transforms from an office for HIV education to a prenatal exam room to an operating theater for the family planning doctor.  Unfortunately on this particular day, we couldn’t rely on Umeme (the power company) to come through with enough electricity to light up the “operating room,” so the doctor decided it would be better to move the surgeries outside of the room, but still under the pavilion.  So we were observing our first open-air surgeries under local anesthesia – yes, LOCAL anesthesia.  In other words, they were doing what would be considered major surgery in the US with only anesthesia to the skin overlying the internal organs they were working on.  So the lidocaine numbed the two-centimeter area of skin that they would be cutting. They carefully sliced through the muscle and peritoneum (the lining of most abdominal organs), reached into the woman’s pelvis with a blunt hook to trace the outline of her uterus so they could follow it across to her fallopian tubes and grab them.  At this point the women would curl their toes or scrunch up their faces in pain.  No one made a peep.  I could look around and in one view see the mountains, a river, a farm, a cow, children playing, and a fallopian tube – probably not a view I will ever have again. They tied off each one, snip-snip, three skin-sutures, and done.  Even more impressive, after performing this major surgery with only anesthesia to the skin, the women were sent on their way to walk through the mountains to their homes with only Panadol (Tylenol), for their post-op pain. 

I thought about all the patients we’ve seen in Flint with medically-enabled addictions to narcotic pain-killers and wondered if either extreme is better.  I wish we could follow up with these patients to see what complications they experience, if their pain is controlled or how that pain might interfere with their lives.  I wonder how the clinicians here compute the risk-benefit equations they are presented with every day.  For example, is it better for these women to suffer the complications of a sixth, seventh, tenth pregnancy or suffer the pain of a hook grabbing the delicate tubes where those pregnancies begin?  Should they have to tolerate the burden of adding another mouth to feed to their over-burdened families or tolerate the risk of an infection that could take them away from those hungry mouths?  I think we are all trying to maintain humble spirits when we confront these dilemmas and think about all the medical and social disparities that contribute to them.  We are learning how to problem-solve in totally new ways and provide care with limited resources.  Almost every day my eyes become (sometimes painfully) more open to a new world of pathology, social inequities, and systemic deficiencies that all contribute to a patient’s health. While I feel stressed at having to think about problems I have never encountered, I am grateful for the skills I am developing and the perspective I am gaining from these experiences.