Intended for healthcare professionals

Feature Family Planning

Contraceptive shortages mean Venezuela’s people face a sexual health emergency

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1197 (Published 23 March 2018) Cite this as: BMJ 2018;360:k1197
  1. Angelika Albaladejo, independent journalist, Medellín, Colombia
  1. angelikaalbaladejo{at}gmail.com

Health indicators that had improved over decades are coming undone as the country’s economic situation deteriorates, leaving people without access to reproductive, sexual, and HIV healthcare. Angelika Albaladejo reports

It is several years since Venezuela’s socialist government stopped providing free contraception—including birth control pills, intrauterine devices, and condoms—at public hospitals and through federal distribution programmes. And although pharmacies once sold subsidised contraception cheaply, low stock has led to high prices.

Venezuelans face stark shortages and rocketing prices, not just for contraception but for all necessities. A worsening economic crisis prompted by a crash in oil prices in 2014 and compounded by US sanctions, strict currency controls, and high inflation has decimated production and imports of all goods.

Under former President Hugo Chavez, Venezuela’s socialist government used growing oil wealth to fund programmes aimed at reducing poverty, eradicating hunger, and improving access to healthcare for poorer Venezuelans. But progress made over decades is rapidly backsliding.

Highest teen pregnancy and HIV rates

Everything from drugs to food is in short supply, leaving many forms of contraception impossible to find and others prohibitively expensive. The Venezuelan Pharmaceutical Federation, which represents pharmacists, estimates that stocks of contraceptives in the country have fallen by 90% since 2015.

Venezuela already had among the highest rates of adolescent pregnancy and HIV infection in Latin America before the economic collapse.12

As the country’s economic and political situation has worsened, President Nicolas Maduro’s government has largely stopped releasing public health statistics. But contraception shortages are exacerbating an already dire public health emergency and contributing to spikes in unintended pregnancies, unsafe abortions, maternal and infant mortality, and sexually transmitted diseases, sexual and reproductive health experts in the country told The BMJ.

Jorge Díaz Polanco, an investigator for the Venezuelan Health Observatory, the public health research and advocacy arm of Venezuela’s Central University, told The BMJ that the unmet need for contraception and family planning is reaching a “moment of profound crisis.”

Out of stock

Government distributed condoms and birth control have not been available in public hospitals since 2015. In private pharmacies, Venezuelans can sometimes find less trusted brands of condoms, while birth control pills and emergency contraception have been out of stock for several months.34

Health ministry officials did not respond to multiple requests for recent data and information about plans to tackle the crisis.

Shortages and high prices particularly affect young and poor people. Many Venezuelans go without. Wealthy Venezuelans are purchasing contraception on the black market online through sites such as Facebook and MercadoLibre and at open air “medical flea markets.”5

Illicit contraception typically costs more than 25 times the government set prices.4 On MercadoLibre underground resellers list birth control pills for around £20 (€23; $28) a pack and intrauterine devices for nearly £180, out of reach for most Venezuelans, who earn a minimum monthly income of 177 507 bolívares (£1.40).

Risk of misuse is high because these patients may not have consulted a doctor. The quality and safety of contraband contraception are also dubious, with many expired or improperly stored after being taken from Venezuelan hospitals or smuggled from neighbouring Colombia or Brazil.

Many people are instead opting for less effective, traditional family planning methods, especially when it comes to condoms, Jorge Luis Díaz Ramírez, a public health professor and researcher at the Central University, told The BMJ.

Risky alternatives

“The use of condoms has cultural barriers … Even before the crisis, people didn’t want them. Now that they are very expensive, quite simply, they don’t use them. They use other methods like coitus interruptus or the rhythm method, which we know are ineffective,” he said.

People are also trying “home remedies” to avoid pregnancy, such as eating papaya fruit or drinking ginger tea after having sex.6

Enrique Abache is a gynaecologist and medical director at Venezuela’s largest network of family planning clinics, known as PLAFAM, which is funded by the International Planned Parenthood Federation (IPPF). Thousands of Venezuelans from the extremes of the country are seeking PLAFAM’s services in the capital, he told The BMJ.

And more Venezuelans are turning to sterilisation. Between 2012 and 2016, the number of Venezuelan women being sterilised rose by 23%, PLAFAM reports.7

Failing public health system

The harms to health from contraception shortages are being compounded by the country’s failing public health system. Hospitals can no longer ensure safe operating conditions, security from violence, or even provide basic drugs such as antibiotics, while doctors and nurses are fleeing the country.89

It is difficult to estimate the true effect on sexual and reproductive health. However, doctors and researchers who spoke to The BMJ agreed that there could be a link with rising rates of unintended and adolescent pregnancies, unsafe abortions, maternal and infant mortality, as well as HIV/AIDS infections and deaths.

Regionally, 75% of all unintended pregnancies in Latin America and the Caribbean are the result of an unmet need for modern contraception, according to the Guttmacher Institute, an international sexual and reproductive healthcare research and advocacy organisation. A third of adolescents in the region are sexually active, want to avoid pregnancy, but don’t have access to birth control.10

The United Nations Population Fund (UNFPA), the intergovernmental organisation’s reproductive health and rights agency, has worked with Venezuela’s government in recent years to design a national plan for preventing and reducing adolescent pregnancies through a combination of comprehensive sexual education, public awareness campaigns, and increased access to contraception.

Jorge González Caro, UNFPA Venezuela’s national representative, told The BMJ that, although the Venezuelan government has approved the plan, which was finalised in November 2017, there has not yet been the political momentum or funding to implement it. González Caro added that government stipends provided to pregnant women might also be having “a counterproductive effect on preventing adolescent pregnancies.”

Díaz Polanco, from the Venezuelan Health Observatory, said that one in three pregnant women in Venezuela is aged under 19, and these girls account for one in three maternal deaths because adolescent pregnancies have higher complication rates.11

The World Health Organization estimates that there were 95 maternal deaths per 100 000 live births in Venezuela in 2015; the regional average is 68.112 Infant and child mortality rates, though reduced in recent decades, also seem to be rising.13

Venezuela has released no official statistics on Zika since 2016, when the health ministry confirmed nearly 17 000 cases.14 Venezuelan doctors estimated 500 000 cases nationwide, however.15 The Pan American Health Organisation recently estimated 200 000 cases in the Americas since 2015.16 Only a few cases of babies born with Zika related microcephaly and women seeking abortion because of these complications have been documented in Venezuela. González Caro said that UNFPA’s most recent donation of condoms and intrauterine devices was made during the Zika crisis in an attempt to stem these pregnancies.

Clandestine abortions and sexually transmitted diseases

Abache told TheBMJ that his clinics are starting to receive more patients with complications after clandestine abortions. Venezuela, like most countries in the region, heavily restricts access to abortion, which is illegal except when the mother’s life is at risk.17 Every year, more than 760 000 women are treated for complications resulting from unsafe abortions in Latin America and the Caribbean.18

Sexually transmitted diseases may also be on the rise. According to the health ministry’s last official statistics from 2013, every year an estimated 11 000 Venezuelans—2500 of whom are children—become infected with HIV. At that time, about eight Venezuelans were dying from AIDS every day.

Since then, as rates of HIV and AIDS have dropped in other countries in the region, Venezuela has returned to epidemic levels not seen since 30 years ago, before the government made treatment free in 1999.19

Jhonatan Rodríguez, the president and founder of the non-profit organisation StopVIH, told The BMJ that the Venezuelan government has not provided public sexual education programmes since 2005. “The HIV situation in Venezuela is out of control. There aren’t tests, there aren’t condoms, and there aren’t antiretroviral medicines,” he said. Many Venezuelans with HIV have been forced to flee the country.

Violence against women

The problems are compounded by the prevalent violence against women and cultural taboos that exist in most Latin American countries. Sexual health education is key, and Abache emphasised that within Venezuela’s “conservative society” it should “focus on men and their responsibility . . . and not put all of the responsibility on women.”

González Caro of UNFPA said that reducing adolescent pregnancies is particularly important because young pregnant women often “enter a cycle of precarious work, poverty, and violence,” which has “grave repercussions” for the country’s development.

But the Venezuelan government has shown little capacity to improve access to healthcare or education. “We are living a humanitarian emergency that is the direct result of public policies from a government which hasn’t demonstrated a will to attend to public health,” StopVIH’s Rodríguez said.

The 2018 budget for Venezuela’s health ministry falls well short of what’s needed, but President Maduro refuses to accept international humanitarian aid and has blocked donations of drugs.20

Civil society groups like PLAFAM and StopVIH, as well as international donors such as the IPPF, are using international support to provide services the state cannot or will not offer. “We need help. If we don’t open our doors to help, more of our people are going to die every day from health complications,” Rodríguez said.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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