In my weekly column I usually answer a question related to a women's health issue. However, I just returned from the highlands in Guatemala, where I was visiting Save the Children's programs in this portion of the country, and I wanted to share my experiences. (I am on the Save the Children board and have been trying to visit many of our national and global programs. This is the first one I've gone to in Central America.)
Guatemala is an absolutely beautiful country, blessed with gorgeous verdant mountains that dive in and out of the clouds, interrupted by rushing streams that cascade down from the peaks. Cornfields are planted in every available space (including areas that I felt were totally inaccessible). This country was once the heart of the Mayan empire. The population, currently 13 million, includes Mayan descendants, Garifuna natives and Caucasians. Although Spanish is the official language, there are 23 languages spoken in the highlands. In order to speak to those we visited, our group from Save the Children's country staff needed to translate from Eishal (the most common local language) to Spanish to English.
In 1996 Guatemala signed a peace accord, but prior to that it had a 36-year armed conflict. All of this is evident in the 11 years it has taken to develop its economy and the current widespread societal and economic disparities, extreme endemic poverty and a legacy of societal violence. Save the Children has multiple programs in this country, and is working with USAID, private sponsors and the Guatemalan government. Their programs vary from helping with food security issues (50 percent of children under the age of 5 in this country are chronically malnourished and this number increases to 70 percent in the central highlands), education, health needs, adolescent reproductive health and family planning.
I arrived in the central highlands after a brief stay in New York City, where (aside from taping the “Today” show) I joined 1,200 guests celebrating the 75th anniversary of Save the Children. We all knew why we were “honoring” Save and those given awards for their admirable work in helping create lasting change for children in need. (The honorees included Presidents George Bush Sr., Bill Clinton and Melinda Gates.) The evening was terrific and the attendees, who had already donated considerable money to support Save’s programs, left with a sense of appreciation and dedication. But the literal jump from celebratory speeches and films presented in that gorgeous tent set up at Lincoln Center to the “field,” where poverty, illiteracy, disease, and childhood and maternal death are so prevalent, was a huge shock to my sense of reality and experience.
Save the Children's impact on Guatemala
I visited schools and observed Save the Children's education programs in action. The illiteracy rate in Guatemala is 69.9 percent for those over 15 (only Nicaragua and Haiti are worse in Latin America and the Caribbean). In several areas that I visited in the highlands, more than 70 percent of the women were illiterate. Most children don't make it past the sixth grade, and 50 percent of Mayan adolescent girls don't attend school.
To help combat this problem, Save the Children has programs in 57 communities in Guatemala's rural highlands and has developed child-oriented methods of education that promote Mayan culture. In addition, their programs benefit more than 15,000 children in this area. I was wowed. Prior to the programs, children were taught by rote, not encouraged to honor their cultural traditions and were not nourished in mind or body in their schools. Absentee rates were horrific. I watched children stand up at the front of the class and take turns teaching one another under the expert guidance of young teachers who had gone through special education programs. One of the programs I attended was “respect the corn” day, where first-graders acted out Mayan traditional plays about corn, were taught how to count by sorting corncobs, made corn out of Play-Doh, and created Mayan symbols of corn, all which were hung proudly in the room. At snack time the children sit outside with their teachers and (after they washed their hands in the clean-water sinks we had created) eat plantains and drink a “milk” mixture made with soy and boiled water (many of these children have a genetic lactose intolerance). I also visited health programs. Guatemala is among the worst countries in Latin America and the Caribbean in terms of life expectancy, infant mortality and maternal mortality. Death during and right after a delivery (usually from hemorrhage) in the mid-highlands area, according to local health records from 2004, is 277 maternal deaths per 100,000 live births. (These numbers may be inaccurate since 90 percent of deliveries occur at home with a traditional birth attendant, and many births and deaths are not even recorded!) That's at least three times the national average. In the cities in this area, only 14 percent of women of reproductive age are using contraceptive methods (we don’t have numbers for rural areas).
One of the programs to help fight teenage pregnancy and lack of family spacing is called the “breaking the cycle” program. I visited one such group in a local hospital where adolescent leaders were gathered to learn about and promote education on reproductive health. There were wonderfully illustrated information booklets about deciding what one wanted to do in the future, whether sex should be postponed, and how, if one decided to do so, to engage in sex safely. I was so impressed by this group of 10 girls and two boys. The maturity, empathy and gratitude these adolescents displayed was amazing. I'm not sure I'd see the same dedication among 14- to 16-year-olds here in the U.S. There are 96 clubs like this one, and each of these adolescents then goes on to become a peer counselor to 10 to 12 other adolescents. The hope is that they too will become counselors to their friends, exponentially affecting the life and reproductive choices of entire communities. The most memorable adolescent was a 16-year-old girl. After her mother left home (she was an alcoholic and on the street “somewhere”) and her father remarried (he didn't want to have anything to do with them), this young girl had to take care of her younger brother, and despite a stipend for rent from their father, they lived alone in a shack. But this young woman was a leader in her school, a spokesperson for reproductive health and mentored 10 other teenagers. Her personal goal was to become a physician (that's the part I really loved).
There were also other outstanding programs in reproductive health. I visited a village with no running water where 85 families lived. (Just to get there required a two-hour ride on a rutted mud road up what I would have considered an inaccessible mountain.) The women averaged 10 to 12 births during their reproductive life (that is if they even made it through these years, since maternal mortality is so high). At least one in seven of their infants dies before the age of 5. We met with a group of 12 women, including a traditional birth attendant who wanted to thank us for Save the Children’s program in reproductive health. Until our program had reached them over a year ago, these women had no means of spacing their children, nor did they have any knowledge about contraception. The women, as early as 12 or 13 years of age, would deliver stunted and often premature infants. If the baby did not cry and breathe immediately they did not know how to resuscitate it. For those babies who “made it,” the next risk of death came once their mothers stopped breast-feeding a year later (often because they were pregnant again or had already delivered another baby). These 1-year-olds couldn’t compete for food and were severely malnourished. They often died of simple and treatable disorders like pneumonia and diarrhea. The fact that there was no running water also meant the lack of any essential hygiene. The women, children, men and animals all slept on the same earth floor and drank the same polluted water. They barely subsisted on corn and beans.
But (here's where you and I see hope) these women in the community had formed a committee and met with trainers to learn about reproductive health and the one birth control method that worked in the area: Depo-Provera. Their smiles and need to express their gratitude made me and my cohorts forget about the surrounding dirt and conditions. We were women discussing what women want for their children and their families.
What is Depo-Provera?Now to the medical information part: This injectable progestin has become a staple for birth control and family planning in the developing world and it is also used in the U.S., especially by younger women who can’t or don’t want to remember to use daily birth control such as oral contraceptives in a consistent manner. It works by preventing ovulation. Depo-Provera is now called Depo-Provera CI (contraceptive injection). It is provided in a single-use syringe or bottle and contains a type of a progestin called medroxyprogesterone, which is a derivative of progesterone. It is injected into the arm or buttocks once every three months. Depo-Provera is used only for the prevention of pregnancy but will, for some women, also control heavy bleeding — after a year, 55 percent of women did not get their period. In a country where there's severe iron deficiency and no nutritional way to make up for the blood lost during pregnancy, this is a very positive attribute. Depo-Provera's failure rate approaches zero (which is fabulous), but its efficacy depends on getting an injection every three months.
The manufacturers of Depo-Provera don’t want it to be given to women who could be pregnant, so they suggest using it in the first five days of a normal menstrual period and five days post-partum if a woman isn't breast-feeding. If a woman is exclusively breast-feeding, they recommend giving it six weeks after delivery. Fortunately, Depo-Provera can be given to nursing moms and it doesn't appear to affect the development, growth or health of the baby. It also doesn't affect the amount, quality or composition of the milk.
Like with any other medication, though, there can be side effects. These need to be weighed against the side effects of having multiple, unwanted and nonspaced pregnancies in women who are malnourished and may not be able to care for or feed their infants. The side effects may include bone loss with long-term use, and this could have an impact on the development of osteoporosis. (Keep in mind, though, that we have no idea what the rate of osteoporosis is in these indigenous populations, so the data put out by the manufacturer is relative to our population in the Western world.) Most women using Depo-Provera also have a change in their menstrual bleeding, which can initially be irregular and unpredictable but in most cases becomes less or nonexistent with long-term use. Depo-Provera doesn’t protect against STDs and there is concern regarding clotting and pulmonary embolism. Finally, there can also be weight gain related to this form of contraception. In studies carried out in women in the Western world, the “average woman” whose initial body weight was 136 pounds gained 5.4 pounds after one year. After four years the average weight gain was 13.8 pounds. Again, when talking about indigenous women who are severely malnourished in places like rural Guatemala, this isn't seen to be a major issue.
The good news, at least in the developing world, is that Depo-Provera has a prolonged contraceptive effect that can last longer than three months. It's 100 percent effective, however, only if you take it every three months. A large U.S. study found that 68 percent of women who stopped the shot conceived within 12 months after their last injection of Depo-Provera, and 93 percent of women within 18 months. The median time to get pregnant after stopping this contraception was 10 months (longer than with the Pill, an IUD, IUS or barrier methods). So when I counsel a patient in my practice in Los Angeles, I tell her it may take longer to conceive when she stops taking Depo-Provera. This is usually not an issue for women in rural areas in the developing world.
Finally, Depo-Provera has not been shown to significantly increase the risk of breast cancer or ovarian cancer, but since it doesn't protect against STDs like HPV, it will not decrease the risk of cervical cancer.
Dr. Reichman’s Bottom Line: Reproductive health and family planning are an essential part of the work that needs to be done in the developing world. I just witnessed some amazing programs created by Save the Children in Guatemala that create lasting and positive changes in the lives of children and their families. The fact that I can participate in this organization is truly an honor. You can go to savethechildren.org for more information — you too will be amazed by their programs in the U.S. and throughout the world.
Dr. Judith Reichman, the TODAY show’s medical contributor on women’s health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, “Slow Your Clock Down: The Complete Guide to a Healthy, Younger You,” which is now available in paperback. It is published by William Morrow, a division of .
PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.