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From Anti-Natalist to Ultra-Conservative

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From Anti-Natalist to Ultra-Conservative
www.rhm-elsevier.com
A 2004 Reproductive Health Matters.
All rights reserved.
Reproductive Health Matters 2004;12(24):56–69
0968-8080/04 $ – see front matter
PII: S 0 9 6 8 - 8 0 8 0 ( 0 4 ) 2 41 3 9 - 8
www.rhmjournal.org.uk
From Anti-Natalist to Ultra-Conservative:
Restricting Reproductive Choice in Peru
Anna-Britt Coe
Program Director, Latin America, Center for Health and Gender Equity, Lima, Peru. E-mail: [email protected]
Abstract: This article examines Peru’s population policy since the 1994 International Conference
on Population and Development and assesses to what extent its policies and programmes have
affected reproductive health and rights. It is drawn from data collected during ongoing monitoring
of sexual and reproductive health policies and programmes in Peru since 1998 for the Center
for Health and Gender Equity (CHANGE). Accomplishments since 1994 in Peru demonstrate good
faith on the part of the government and foreign donors to make progress towards fulfilling the
ICPD agenda by addressing key reproductive health concerns and promoting women’s rights.
Unfortunately, this progress has not been consistent. It has been overshadowed by two periods of
anti-choice policies and interventions. The first, in 1996–97 under the Fujimori government, was
a demographic approach that used numerical targets and undue pressure on women to accept
sterilisation as the government’s main poverty reduction strategy, which led to documented abuses.
The second, in 2001–03 under the Toledo government, was a far-right approach that worked to
limit access to essential services, including emergency contraception, condoms and post-abortion
care. In spite of their contradictory nature, these two policy approaches have been the greatest
obstacles to making long-lasting improvements to reproductive health and rights in Peru.
A 2004 Reproductive Health Matters. All rights reserved.
Keywords: 1994 International Conference on Population and Development, anti-natalist
population policy, reproductive health policy and programmes, reproductive rights, anti-choice
policies, Peru, United States
F
OR women’s health advocates, the consensus forged at the 1994 International Conference on Population and Development
(ICPD) was the result of decades of hard work
to shift the focus of population policies away
from the fulfilment of demographic goals
toward the promotion of reproductive health
and rights. However, participants faced their
greatest challenge when they returned to their
home countries – ensuring that governments
adopted and met the goals set forth in the new
agenda. Concretely, governments must replace
narrowly defined fertility reduction strategies
with broader policies that work to enhance
women’s and men’s capacity to exercise their
56
rights and address their reproductive health
concerns, including but not limited to their need
for contraceptives. This has proven to be far
more difficult than expected, in part because
many governments have limited technical and
financial capacity to make and sustain the
necessary changes. These changes also imply a
long, slow process of transforming unwieldy
bureaucratic structures and programmes.
However, the greatest obstacles to promoting
the ICPD Programme of Action are policy positions that are frankly opposed to reproductive
rights. These political positions may prevent
governments from making a full-fledged commitment to achieving reproductive health and
A Coe / Reproductive Health Matters 2004;12(24):56–69
rights objectives. Peru is a telling example of
the complexities involved in developing a
reproductive health and rights agenda. Until
the early 1990s, the government gave little support to population issues and its public family
planning programme was poorly organised and
relatively ineffective.1–3 Since signing the ICPD
agreement, the Peruvian government has taken
several steps toward fulfilling reproductive
health and rights objectives.3–5 Progress has
been overshadowed, however, by two periods
of adverse policy approaches – demographic
(1996–1997) and far right (2001–2003).6–8 This
article examines Peru’s population policy since
the ICPD and assesses to what extent the policies
and measures adopted have enhanced or detracted from reproductive health and rights.
Methodology
The data are drawn from the author’s ongoing
monitoring of sexual and reproductive health
policies and programmes in Peru since 1998
for the Center for Health and Gender Equity
(CHANGE). The purpose of this monitoring has
been to assess Peru’s progress in implementing
a reproductive health and rights agenda, including commitments agreed at ICPD, and the use and
effectiveness of US foreign assistance in meeting
this goal. It has consisted of two phases.
During the first phase, primary and secondary
data were collected from key national-level
stakeholders in reproductive health policies:
women’s rights groups, reproductive health
NGOs, government institutions and international donor and technical assistance agencies.
A total of 45 in-depth interviews and 15 key
informant interviews were carried out with
stakeholder representatives in April–June 1998
and October–December 2000 (Table 1). In-depth
interviews were semi-structured using a topic
guide with open-ended questions. Key informant interviews were designed to follow up on
the same topics. Participant observation was
used at public conferences, workshops and presentations organised by key stakeholders, and
involving policymakers, programme directors
and health care providers. Direct observations
were made of service delivery in on-site visits in
Ayacucho Department. Official documents and
research studies produced by key stakeholders
were reviewed.
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A Coe / Reproductive Health Matters 2004;12(24):56–69
Information was sought on the following
issues:
! What are the priority reproductive health
issues faced by women?
! How do the government and key international donors define population policy
in Peru?
! What are the formal policies regarding population issues, family planning and contraceptive delivery, STIs and HIV, maternal mortality,
cervical cancer and reproductive rights?
! What steps have been taken to develop policies that promote reproductive health and
rights in Peru? What is the relationship
between demographic goals and contraceptive delivery, including targets, fertility reduction and rhetoric vs. practice?
! What has been accomplished and what have
the constraints been?
! What are the main issues concerning health
services, including method mix, provider
biases, use of integrated and innovative
approaches, education and counselling, prevention and treatment, private vs. public
sector services?
! What more is needed to improve the promotion of reproductive health and rights in Peru?
Data were processed, categorised and analysed by the author. Hand-written notes of
observations and interviews were entered into
a computer word-processing programme. Preliminary codes were given to the data at this
stage based on the main themes and topics
identified in the information. The data were
analysed soon thereafter and preliminary codes
were revised into first-level codes. Once firstlevel codes were assigned, the data were
retrieved and sorted using the ‘‘find’’ key in the
word-processing programme. A separate wordprocessing file was created for each main topic
that emerged from retrieving and sorting the
data according to first-level codes. Data in each
file were analysed to identify patterns within
the particular theme of the first-level codes.
Patterns were given second-level codes and sorted using the ‘‘find’’ key in the word-processing
programme. A separate word-processing file
was created for each pattern that was identified
through the second-level codes. Information
and interview transcripts from different points
in time were compared for continuity and
58
change. The author presented the data in two
internal reports, July 1998 and in July 2001.
During the second phase, since 2001, I have
participated on behalf of CHANGE in a coalition
of civil society organisations in Peru, Mesa de
Vigilancia de Derechos Sexuales y Reproductivos
(Monitoring Group on Sexual and Reproductive
Rights). This entity regularly shares and collectively analyses policy information and events
on sexual and reproductive health in order to
develop appropriate advocacy responses. Simultaneously, I have documented the alliance
between far right actors in Peru and the US,
and their assault on reproductive health programmes funded by the US government in
Peru, through information obtained from key
informants, the web pages of far right organisations and internal, confidential documents.
Key priorities for women’s health in Peru
All key stakeholders repeatedly pointed to five
priority sexual and reproductive health problems in Peru, backed by quantitative and qualitative data:
! unsafe childbirth and abortion
! unwanted pregnancy
! STIs/HIV
! cervical cancer
! gender-based violence.
The maternal mortality ratio, currently estimated at 185 deaths per 100,000 live births, is
very high for the region, according to the Pan
American Health Organization. Additionally, the
national average masks the reality of far higher
numbers of maternal deaths in rural and periurban areas, and in certain Andean and Amazonian departments. Unsafe abortion accounts for
an estimated 16% of pregnancy-related deaths.9
Approximately 66 abortions occur for every 100
live births in Peru, where abortion is illegal and
safe abortions rare.10 At least 30% of all abortions result in complications.11
In Peru, 60% of all pregnancies are unwanted,
and an estimated 25% of all sexually active
women of reproductive age in Peru are not adequately protected against an unwanted pregnancy.11 Despite consistent increases over the
last decade in contraceptive prevalence rates,
access to quality information and services varies
widely according to socio-economic status, age
A Coe / Reproductive Health Matters 2004;12(24):56–69
group and place of residence.12 Adolescent girls
are particularly vulnerable as they have the least
access to contraceptive methods. Although
there are insufficient data available to present a
complete picture of the magnitude of STIs,
including HIV, evidence shows that women are
increasingly at risk of infection.13 A decade ago,
women accounted for one out of 15 people
infected with HIV; currently, they make up one
in three.14 Women of reproductive age are most
likely to die of cancer, and 48% of these deaths
are due to a gynaecological cancer, mainly cervical or breast cancer.15
Social and cultural discrimination against
women increases their risk of sexual and reproductive health problems and hampers their
ability to address them. For example, men in Peru
frequently exercise control over their female
partners’ sexuality and fertility, expecting to be
provided with sex on demand and opposing
their use of contraception or barrier methods
for infection prevention.16,17 Male control is
reinforced through intimate partner violence,
which is commonplace. A recent prevalence
study of gender-based violence found that half
of all women in Lima, and almost two-thirds of
all women in Cusco department reported having
been physically and/or sexually abused by an
intimate partner at least once in their lifetime.18
Early population policies 1980–92
Peru has a relatively short history of addressing population and reproductive health issues
through specific policies and programmes. In
1979, at the end of a decade-long military regime, the new Constitution recognised the right
of families and individuals to voluntarily regulate their fertility and proclaimed the state’s
support for responsible parenthood. The democratically elected governments that followed,
led by presidents Fernando Belaunde (1980–85)
and Alan Garcia (1985–90), were the first to
demonstrate concern for population growth
and unwanted fertility. In 1983, the Ministry
of Health (MoH) began to offer public family
planning services.2 Not long thereafter, the government established a legal and policy framework for addressing population issues by
passing the National Population Policy Law in
198519 and formulating the first National Population Programme in 1987.20
The National Population Policy Law, still in
effect, calls for promoting a balanced relationship between population size, structure and distribution, and socio-economic development.
Among other things, the law guarantees voluntary, informed choice regarding reproduction
and contraceptive use, access to education and
health services and protection of individual
human rights. The 1987–90 National Population
Programme sought to fulfill the law’s objectives
in practical terms through specific goals and
interventions. However, only a few activities
were implemented within the MoH’s Family
Planning Programme. Most of the National
Population Programme was not implemented
due to insufficient funding and political support, compounded by Peru’s economic collapse
and ensuing political crisis.2,3
The second National Population Programme
1991–95, was formulated during Alberto Fujimori’s
first presidential term (1990–95). It sought to
reduce the population growth rate (from 2.1% to
2%), the total fertility rate (from 3.5 to 3.3)
and maternal and child mortality rates.2 It also
aimed to foster equitable socio-economic opportunities and cultural norms between women and
men. To achieve these goals, the programme proposed the multisectoral co-ordination of eight
inter-related strategies: reproductive health and
family planning, communication and information dissemination, decentralisation of the population policy, education, production of research
and statistics, advancement of women and youth,
and environmental protection.2 Nonetheless, a
series of institutional and political constraints
severely limited its implementation.1,3 For example, the National Population Council, the agency
in charge of implementation, lacked sufficient
power to carry out its functions. The public agencies responsible were not interested and were
unwilling to co-ordinate efforts due to interinstitutional rivalries.1
Furthermore, although Fujimori was initially
extremely vocal in his support for family planning, he simultaneously faced a pervasive, violent internal conflict, a weak economy and
spiralling inflation. To address these, his government desperately needed the backing of the
Catholic Church, whose officials have long
played a privileged and powerful role in Peru’s
public affairs and adamantly oppose access
to modern contraceptives. Consequently, the
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president toned down his promotion of contraception. Moreover, his government adopted a
structural adjustment programme recommended
by the International Monetary Fund of fiscal
austerity and reduced social spending.
During these years, international donor assistance to population, family planning and health
was extremely limited. UNFPA was the only
foreign donor providing financial and technical
assistance to the government. Apart from contraceptive donations to the public sector, the US
Agency for International Development (USAID)
directed all of its support to non-governmental
family planning services. Until the early 1990s,
Peru’s population policy and public health services were weak and the public family planning
programme poorly organised.1
Progress towards reproductive health
and rights: 1993–98
As preparations began for the ICPD, various
factors came together to create a favourable
policy environment for addressing unwanted
pregnancy and related reproductive health
concerns, and improving women’s rights. First,
the 1991–92 Demographic and Health Survey
demonstrated a widespread desire among
Peruvians to have fewer children and control
their fertility, yet large sectors of the population lacked the conditions necessary to fulfill
this desire.20 Second, women’s rights groups
reoriented their advocacy efforts more effectively towards policymakers, to raise awareness of how gender inequalities work against
women’s reproductive health and proposed
appropriate public policies to reduce disparities.
Third, the political and economic situation was
stabilised, allowing Fujimori’s government
greater leverage for making policy decisions
contrary to the position of the Catholic hierarchy. Finally, foreign donors decided to shift
the bulk of their investment towards strengthening government services after a UNFPA evaluation found that the public sector’s large stock
of contraceptive methods, mainly donated by
USAID, were inadequately managed and often
remained in MoH warehouses undistributed.
The confluence of these factors led the Peruvian government, in 1994, to sign the ICPD
Programme of Action and reinforce its commitment to reproductive health and rights at
60
the Beijing Conference the following year.* At
Beijing and in Peru, Fujimori openly promoted
women’s universal access to contraceptives.
Official government discourse placed this issue
within the context of social justice and reproductive rights: poor women deserved the same
opportunity as wealthier women to regulate
their fertility, and all women had the right to
control their bodies and use contraceptives if
they wished.21
For the first time, the Peruvian government
adopted measures to expand reproductive
choice and offered free contraceptive services
in public health facilities. In September 1995,
the Peruvian Congress, controlled by Fujimori’s
political alliance, legalised sterilisation. Soon
thereafter, the MoH drafted its first comprehensive reproductive health programme and the
Ministry of Education initiated an innovative
sexuality education programme in public
schools, in line with ICPD accords. For example,
on paper, the reproductive health programme
proposed addressing a range of women’s health
priorities by improving quality of care and
increasing access to services:22
‘‘The programme’s strengths include that reproductive health is conceptualised as a woman’s
right and abortion is considered a public health
problem.’’ (Programme manager, women’s rights
NGO, Lima, 1998)
In addition, government officials sought out the
expertise and involvement of civil society groups
and women’s health advocates. For example,
two women’s rights groups, Red Nacional de
Promoción de la Mujer and Movimiento El Pozo,
were among the diverse institutions that validated the new teachers’ guides for sexuality
* The official Peruvian delegation expressed two main
reservations with regard to the Platform of Action at
Beijing: abortion could not be included as a contraceptive method and sexual rights could only refer to
heterosexual relations. Peru has also ratified international treaties for women’s human rights, including
the Convention for the Elimination of all Forms of
Discrimination against Women (CEDAW, 1982), the
Universal Declaration on of Human Rights (1993), the
Inter-American Convention to Prevent, Sanction and
Eradicate Violence against Women (1996) and the
CEDAW Facultative Protocol (2001).
A Coe / Reproductive Health Matters 2004;12(24):56–69
education.23 Three women’s rights organisations, Movimiento Manuela Ramos, Centro de
la Mujer Peruana Flora Tristán and CESIP,
worked with the social marketing agency,
APROPO, to train schoolteachers in using the
new guides. 24 Women’s groups, including
Manuela Ramos, Flora Tristán and Consorcio
Mujer, participated in the Working Group on
Gynaecological Cancer that later devised the
first national plan to address this issue.3,15
Government measures also emphasised equal
opportunities for women and men. In each
branch of government, a public agency was
set up to advance gender equity – a Ministry
for the Promotion of Women and Human
Development (PROMUDEH), a Congressional
Committee on Women and a Public Ombudsman on Women’s Rights. In addition, laws
advancing gender equity were passed, including
one that recognised domestic violence as a
crime (1997) and another that allowed pregnant adolescents to finish secondary school
(1998).25,26 Finally, at the initiative of women’s
rights groups, a Tri-Party Commission was
formed in 1997 to monitor the implementation
of the ICPD PoA, which included representation
from government institutions, donor agencies,
NGOs and universities:
‘‘Its main achievements include prioritising
what areas of the ICPD PoA to monitor (all
related to reproductive health), creating a database of what activities each member institution
is carrying out to address the priorities, and
developing a system of indicators to monitor
improvements in these areas.’’ (Programme
officer, donor agency, Lima, 2000)
Foreign donors also stepped up their support.
Between 1994 and 1998, USAID provided
US$85 million in population funding alone,
three-quarters of all foreign assistance to Peru
for such activities.27 During this same period,
UNFPA gave almost US$14 million and the UK
Department for International Development
(DFID) contributed US$7 million. Although their
assistance remained centred on family planning, donors initiated the arduous task of redefining their own policies, moving towards a
more comprehensive and user-centred approach
to reproductive health. Prior to the ICPD, their
programmes had sought mainly to achieve demographic objectives, without taking into consider-
ation local context or needs. The assumption
was that as long as contraceptive methods are
offered, women will automatically request and
use them, which ignored the broader conditions
that place women at a disadvantage for enjoying
their sexuality and controlling their fertility.
Donor objectives in Peru shifted to focus on
preventing unwanted pregnancies, improving
women’s health and protecting individual
rights.27–33 In addition, they addressed other
critical needs. For example, USAID funded the
MoH to strengthen the STD/AIDS Control Programme, develop services tailored to adolescent
needs, and lead a multisectoral working group
to design the first National Prevention Plan
on Gynaecological Cancer.28–30 DFID funded
the expansion of post-abortion care to 43 hospitals and medium-sized facilities nationwide.31
Finally, donors directed funding for improvements to the broader social conditions to enable
women to exercise reproductive choice. For
example, UNFPA led efforts to develop a multisectoral population policy that would contribute
to reducing poverty, social discrimination and
gender inequities.32,33 Donors also worked to
foster civil society participation in policy by
channelling assistance to national women’s
groups, such as Manuela Ramos, Flora Tristán,
and Red Nacional, to conduct advocacy campaigns and promote government accountability.
Re-emergence of a demographic
approach: 1996–97
Despite these advances, in 1996 the government
failed to approve an official National Population
Policy, but it did return to a demographic focus
early that year without making this information
public. The policy shift emerged as a response to
mounting international and domestic pressure to
address deepening socio-economic disparities.
Despite macro-level economic growth, marketoriented economic policies implemented during
Fujimori’s first term did not yield a decline in
poverty or an increase in employment.3 The Fujimori government then made contraceptive services the core component of its mass poverty
relief programme.3,34
‘‘The fertility rate among poor women is 6.9
children – they are poor and are producing more
poor people. The president is aware that the
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government cannot fight poverty without reducing poor people’s fertility. Thus, demographic
goals are a combination of the population’s right
to access family planning and the government’s
anti-poverty strategy.’’ (Programme manager, MoH,
Lima 1998)
The demographic rationale was that with fewer
dependants the economic status of the poor
would improve. The policy was to increase the
use of modern contraceptives, especially sterilisation, largely among poor, disenfranchised
women with little or no formal education.6,7 To
achieve this goal, the government family planning programme focused on scaling up sterilisation services in an effort to meet a presumed
large, latent demand. Previously, women could
obtain sterilisation only if they had a health risk,
four or more children, or were above a certain
age, and they needed spousal permission.35
According to the MoH, the total number of
sterilisations performed annually within its
facilities rose from less than 15,000 prior to
1995 to 67,000 procedures in 1996 and approximately 115,000 in 1997.* However, interviews
with donor representatives revealed that the
MoH did not have enough adequately trained
medical personnel or appropriate equipment to
make good quality sterilisation services that
widely available in such a short period of time.
Health care workers did not have the necessary
counselling skills and were unable to provide
quality information prior to procedures. As a
main strategy, sterilisation campaigns were carried out in which surgical teams were dispatched
for one day at a time to perform procedures in
rural and isolated areas.6,7 This practice jeopardised service quality as well as follow-up care.
Public officials privately determined annual
numeric goals and corresponding targets for
programme personnel.6,7,36 To fulfil obligatory
targets, many local and regional health facilities
undertook measures that did not comply with
obtaining informed consent. For example, temporary methods such as injectable and oral
* The 1996 DHS found that 5.9% of all women of
reproductive age currently used sterilisation as a contraceptive method (9.5% of married women). The
2000 DHS found that 7.5% of all women of reproductive age currently used sterilisation, and 12.3% of all
married women.2
62
contraceptives were intentionally withheld to
promote sterilisation. Blatant deception, economic incentives and threats were also used.6,7
‘‘We were required to perform a certain number of
sterilisations each month. This was obligatory
and if we did not comply, we were fired. Many
providers did not inform women that they were
going to be sterilised – they told them the procedure was something else. But I felt this was
wrong. I preferred to offer women a bag of rice to
convince them to accept the procedure and
explained to them beforehand what was going to
happen.’’ (Physician, former MoH service provider, Ayacucho Department)
‘‘Both the public sector and civil society recognise the demand for family planning services.
The government responded to this by massively
extending services. But in the process, these services used coercion and abuse, violating individual
rights. Sterilisation should be available, but not be
prioritised. Sterilisation was prioritised by the
government for economic reasons rather than to
meet a demand for the service.’’ (Programme
manager, women’s rights NGO, Lima, 1998)
‘‘The government argued that programmatic
goals were necessary for projecting and estimating how much stock and supplies were going to
be needed. There are valid numeric goals for
reproductive health, such as reducing the maternal mortality rate, reducing the prevalence of
STIs and increasing the number of people who
are adequately informed. But achieving a certain number of sterilisations is not a valid goal.’’
(Programme manager, women’s rights NGO,
Lima, 1998)
These practices contradicted Peru’s constitutional and legal protections, producing discrepancies between policies and their application.
Moreover, the MoH did not (and still does not)
have any institutional mechanism to provide
redress to anyone mistreated by the public health
system or to sanction clinic managers and providers who commit abuses. Although the Public
Ombudsman on Women’s Rights is charged
with investigating human rights violations
committed by public institutions against women,
it was in the process of establishing itself and
its role while these abuses were taking place. In
addition, while it can make recommendations,
A Coe / Reproductive Health Matters 2004;12(24):56–69
it has no authority to ensure the recommendations are adopted or to take action against
rights violations.
As the government’s demographic focus
was incompatible with the current objectives
of international donors in Peru, the donors pressured the Peruvian government behind closed
doors to change its strategy. Some donors,
including USAID, refused to support any activities related to sterilisation, while continuing to
fund other aspects of the family planning programme. Other donors continued funding the
family planning programme because:
‘‘It is not a justifiable option to work apart from
the MoH because it has a large network of
facilities and good people working for it. There
are a lot of problems, but our role is to help the
MoH do what it is intended to do.’’ (Programme
officer, Donor agency, Lima, 1998)
Civil society organisations also became concerned when they learned about the problems
with sterilisation, but obtaining concrete evidence to formulate a critique of government
practices was blocked by the covert nature of
the policy and the sharp contrast with the public
discourse. Early critiques centred on the numeric
goals being so high that they were bound to lead
to abuses.34 Next, women’s organisations, specifically the Centro de la Mujer Peruana Flora
Tristán and the Comité de América Latina y el
Caribe para la Defensa de los Derechos de la
Mujer (CLADEM), gathered evidence from
women on the use of coercion and other abuses
in sterilisation services.6,37 They sent their findings and concerns to the Public Ombudsman on
Women’s Rights, which began to receive and
investigate alleged complaints of abuses in mid1997. The breaking point occurred in December
1997 when one of Peru’s major daily newspapers, La República, reported their own investigative findings on the government’s policy.38
Re-endorsement of reproductive health
and rights: 1998–2001
In early 1998, a heated debate erupted when the
general public learned of the full extent of
the Fujimori government’s demographic policy,
the systematic violations of informed consent
and poor quality of care in sterilisation services.
Women’s groups opposed the policy while
advocating for the protection of individual
rights to reproductive health information and
services.39 In January, the Public Ombudsman
released a report of its investigation into alleged
cases of rights violations and recommended a
series of reforms to the family planning
programme.7 Civil society organisations, medical and professional associations and foreign
donors backed the report’s findings and pressured the Peruvian government to adopt the
reforms. In March 1998, the MoH agreed to
reform sterilisation services* and make changes
to the broader family planning programme.
Most importantly, it eliminated numeric goals
for contraceptive use, which led to discontinuation of sterilisation targets. Based on ongoing
monitoring the Public Ombudsman said the blatant violations that occurred in 1996–97 were
largely halted after the policy shift in 1998.40 y
All stakeholders interviewed explained that
the remaining problems in contraceptive delivery centred on subtler forms of violation of
informed choice. Counselling and information
provision were weak or absent from contraceptive services.41 As part of the reforms, the
family planning programme developed and
published a manual on counselling methodology and increased training, particularly of
nurse–midwives, who deliver approximately
70% of contraceptive services. UNFPA, USAID
and DFID gave full technical and financial
support to these reforms. In 1999, after a
thorough review by women’s health advocates,
professional associations and donor agencies,42
the MoH approved new national guidelines for
delivering family planning services, which were
distributed to health facilities throughout the
country and providers.43
*Reforms included new counselling guidelines and
consent form, two counselling sessions for candidates,
a 72-hour waiting period between the second counselling
session and sterilisation, 24-hour hospitalisation after
surgery for those with difficult access to services and
certification of qualified health facilities and physicians.
y
Between 1998 and 1999, the Ombudsman investigated
157 cases of violations of informed choice and quality of
care standards in MoH family planning services: 9
occurred before 1995, 112 between 1996 and 1997, 29 in
1998, and 1 in 1999.40
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PROMUDEH sought feedback from women’s
rights organisations, donor agencies and professional associations on its draft National
Population Plan for 1998–2002. With these suggestions incorporated, the policy reflected key
elements of the ICPD Programme of Action.44
For example, in the earlier draft, the fertilityrelated goal had a demographic target of 2.5
births per woman, whereas in the final version,
the goal was to reach a ‘‘total fertility rate
compatible with individual reproductive intentions’’. The policy asserted that ‘‘reproductive
health programmes should provide the widest
array of services possible, without any type of
coercion’’. In addition, the policy had a multisectoral approach, touching on population and
poverty, gender inequity, sexual and reproductive health and education, environment and
development and youth and adolescent needs.
Efforts to advance reproductive health and
rights in Peru moved slowly due to several
obstacles, including the rise of the far right as
a political force in Peru. When the problems in
sterilisation services came to light in 1998,
Catholic Church officials, leaders of rightwing
lay Catholic groups and ultra-conservative
policymakers used the evidence of abuses to
advance their own agenda, calling for an immediate end to government-sponsored family planning services. They also targeted international
donor agencies, particularly USAID, by working
in concert with US anti-choice counterparts in
the US Congress. For example, current Peruvian
congressman Héctor Chávez Chuchón began to
collaborate with the US organisation, Population
Research Institute (PRI), in its effort to discredit
US bilateral assistance for reproductive health in
Peru. PRI claimed that USAID had funded the
abuses, and a congressional investigation was
ordered on USAID involvement in Peru’s
sterilisation abuses, which threatened to cut off
US assistance to them.*
USAID subsequently demonstrated that its
funding in Peru was not supporting these
abuses. Nonetheless, over the next few years,
these same far right actors sought to discredit
and harass USAID’s reproductive health programmes in Peru based on sterilisation abuses.45
Moreover, the far right in both countries continued to gain ground and soon dominated both
governments. Then, renewed political upheaval
arose over the government’s involvement in
widespread corruption, election fraud and human
rights abuses in mid-2000. Fujimori fled the
country and his ruling political party disbanded.
Notwithstanding, the transitional government
that took office for nine months worked to
promote human rights, including women’s
rights, and the MoH leadership supported reproductive health services already in place.
BRUCE GILDEN / MAGNUM PHOTOS
Development of a far right policy
approach: 2001–03
Between 2001 and 2003, progress in promoting
reproductive health and rights in Peru was
Protestors demand justice outside the Presidential
Palace, Lima, Peru, 2000
64
*The chief counsel of the Subcommittee on International
Operations and Human Rights of the House International
Relations Committee sent staff members to Peru to
investigate the allegations and called on women who had
registered complaints and representatives from the MoH
and USAID/Peru to testify before the Subcommittee.
A Coe / Reproductive Health Matters 2004;12(24):56–69
overshadowed when newly-elected President
Alejandro Toledo assumed office and appointed
several ultra-conservatives to top government
posts. For example, although the first Health
Minister, Dr Luis Solari, only served in this position for six months, he filled key posts in the
Ministry with opponents of reproductive choice,
and left his colleague Dr Fernando Carbone at
the helm of the MoH. Solari and Carbone both
worked in concert with sympathetic legislators
and with far right actors in the US such as
Congressmen Chris Smith and Henry Hyde and
US anti-choice groups, such as PRI and Human
Life International.
The far right approach was not specific to
Peru but part of a global fundamentalist movement of extremist groups from different religions, including Catholic, evangelical Christian
and Muslim. According to a recent analysis of
this period, the far right in Peru sought to apply
strict interpretations of religious doctrine to
broad-based public policies, with little regard
for scientific or evidence-based interventions
and no respect for individual choice. For example, all sexual relations – other than those
between married heterosexual couples for the
purpose of procreation – were characterised as
immoral and sinful. Policy proposals stressed
abstinence as the exclusive means to prevent
STI/HIV transmission and natural methods for
family planning. The far right position also held
that an ideal family model, in which women’s
only role is motherhood, must be preserved at
all costs.8 Rather than promote gender equality
and women’s rights, policy proposals sought to
reinforce women’s subordination.
The three ministries responsible for social
policy, MoH, MoEd and PROMUDEH (now
MIMDES), removed all objectives and strategies
designed to advance gender equity and sexual
and reproductive health from existing and new
policy documents. For example, the MoH’s
Health Policy Guidelines for 2002–12 contain
no reference to gender inequity. Moreover, the
Ministry of Education stopped providing sexual
education and the MoH refused to make public
any information on the family planning and
gynaecological cancer programmes. The MoH
eliminated its STI/AIDs control programme and
put HIV prevention in a ‘‘Risk Reduction’’
programme that included malaria, dengue and
other diseases.
Health Ministers Solari and Carbone worked
to impede access to services and information on
modern contraceptives, the use of condoms to
protect against STIs and HIV, and to treat complications from unsafe abortion. Specific steps
included directives discrediting critical reproductive technologies, spreading dis-information
in the mass media, and blocking the distribution
of needed supplies. For example, in early 2002,
Carbone attempted to remove the IUD from the
MoH protocol for contraceptive services on
the basis that it was an abortifacient, while at
the same time touting the effectiveness of the
Billings method.46 He also deterred the use of
manual vacuum aspiration for post-abortion
care, despite it being the safest available method
for treating incomplete abortion and miscarriage.46,47 In late 2002, health officials launched
a dis-information campaign on condoms, characterising them as totally ineffective in preventing STIs and HIV because they contain
spermicides. Around this same time, the monitoring efforts carried out by the Public Ombudsman’s office uncovered evidence of barriers
imposed by health services to prevent women
from obtaining contraceptive methods.48 Evidence from two recent studies confirm the negative impact of these policies, including decreases
in access to and use of modern contraceptives
and increased reliance on ‘‘natural’’ methods
and unsafe abortion.10,49
International donors have effectively been
prevented from supporting reproductive health
and rights in Peru since 2001. This has been
compounded by the fact that both USAID and
UNFPA have been under siege by reproductive
rights opponents in the US Congress. The Bush
Administration itself has been working actively
to undermine reproductive health programmes
such as Peru’s globally,50 and US foreign policy
for Peru has changed from prioritising democracy and human rights to the war on drugs.
Pursuing this goal has required Peru’s full cooperation with the US State Department to
design and implement an aggressive counternarcotics strategy with little local input.51 USAID
has also reshaped its entire development portfolio
in seven coca-growing states.52 Confidential
sources report that US officials in Peru have
expressed willingness to sacrifice reproductive
health assistance to appease the right and maintain good relations with the Toledo government.
65
A Coe / Reproductive Health Matters 2004;12(24):56–69
In fact, USAID/Peru has limited its support for
interventions to address unwanted pregnancy
and unsafe abortion. Emergency contraception
is a clear example. In 1992, emergency contraception was approved in Peru, though not distributed.* However, after USAID/Peru was first
attacked by the far right in early 1998, officials
responded by pressuring the MoH to remove
emergency contraception from the approved
list. In 2001, when the transitional government
was in office, civil society organisations convinced health officials to reincorporate emergency contraception, for which USAID provided
technical assistance.53
However, USAID’s support for emergency
contraception was short-lived.54 Under Toledo,
health ministers Solari and Carbone refused to
make it available in public heath clinics, claiming it was abortifacient. This not only blocked
USAID/Peru’s support for public provision but
also had a chilling effect on their support to
the NGO and private sectors to integrate emergency contraception into their programmes.
USAID/Peru has also refused to lend seed money
needed to market Postinor-2, an emergency
contraceptive product distributed by the social
marketing organisation, Apprende, since 2002.
US anti-choice pressure also remains high. In
2002, on a visit to Peru, US Congressman Chris
Smith threatened USAID officials, ‘‘You better
not be funding emergency contraception here.’’54
Finally, political appointees at USAID in Washington have withdrawn institutional backing for
emergency contraception, even if technical staff
continue to favour the method. So although it
remains an approved method in Peru and in the
US, USAID/Peru will not support it.
HIV/AIDS organisations and progressive medical associations, Toledo publicly resolved to back
family planning policies according to the World
Health Organization guidelines. He also replaced
ultra-conservative cabinet members, including
Health Minister Carbone, with professionals
who endorse evidenced-based policies regarding
reproductive health and rights.
Not surprisingly, far right leaders, particularly in the congress, continue to put intense
pressure on the MoH to limit access to reproductive health services and technologies. Ultraconservatives joined forces to have Chávez
Chuchón appointed to the chair of the Congressional Health Committee for 2003–04. However,
the current health minister, Dr Pilar Mazzetti, a
neurologist appointed to the post in February
2004, is standing firm to reverse the far right
policies in the MoH, taking concrete steps to
improve sexual and reproductive health services, information and education and engage
with civil society. For example, in July 2004,
the MoH launched a new ‘‘Programme of Integrated Care in Sexual and Reproductive Health’’
and approved new national guidelines for
services.55 In addition, Dr Mazzetti responded
resolutely to the dis-information campaign
launched by the far right against emergency
contraception, based on the scientific evidence
that the method is not an abortifacient, and
announced that it will at last be distributed in
MoH services.55 Finally, Dr Mazzetti met with
15 organisations from the Mesa de Vigilancia en
Derechos Sexuales y Reproductivos, to discuss
ways in which this civil society coalition can
help promote sustainable public policies in
sexual and reproductive health.
Current context
Conclusion
During his first two years in office, President
Toledo avoided publicly declaring his government’s position on reproductive health and
rights. In July 2003, after consistent pressure
from women’s groups, reproductive health and
In spite of their contradictory nature, the demographic and far right policy approaches share
an important characteristic: they are clearly
not compatible with gender equality or reproductive rights and hinder progress towards
achieving these goals in concrete ways. Under
the demographic approach, many health care
providers throughout Peru were pressured to
perform sterilisations under inadequate conditions and without complying with standards
of informed consent, or lose their posts. Meanwhile, under the far right approach, health
*The following methods are also approved: IUD, male
condom, oral contraceptives, injectables, Norplant,
male and female sterilisation, vaginal suppositories,
and rhythm/calendar and Billings methods. The diaphragm and the female condom have still not been
incorporated into the method mix.
66
A Coe / Reproductive Health Matters 2004;12(24):56–69
care providers were discouraged from delivering modern contraceptives, condoms and postabortion care. These policy approaches are
the greatest obstacles to making real and
long-lasting improvements to sexual and reproductive health and rights.
Acknowledgements
I am grateful to the following people for
reviewing this article: Marı́a Cristina Arismendy,
formerly with UNFPA/Peru; Susana Chávez,
Centro de la Mujer Peruana Flora Tristán; Milka
Dinev, Pathfinder International Peru; Dr Ana
Güezmes, Observatorio del Derecho a la Salud,
Consorcio de Investigación Ecónomica y Social;
and Dr Luis Távara, Sociedad Peruana de
Obstetricia y Ginecologı́a. I also want to thank
colleagues who read the full report: Frescia
Carrasco, Movimiento Manuela Ramos; Federico
León, formerly Population Council Peru; Richard
Martin, USAID/Peru; Shira Saperstein, Moriah
Fund; and Alicia Yamin, international consultant. The views expressed in this article are those
of the author alone. I also appreciate helpful
insights and guidance from Jodi L Jacobson and
Rupsa Mallik, CHANGE.
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Résumé
Cet article examine la politique démographique
du Pérou depuis la Conférence internationale
de 1994 sur la population et le développement
et évalue dans quelle mesure ses politiques et
programmes ont influencé la santé et les droits
génésiques. Il s’inspire de données recueillies
lors du suivi des politiques et programmes de
santé génésique au Pérou mené depuis
1998 pour le Centre for Health and Gender
Equity (CHANGE). Les progrès enregistrés depuis
1994 prouvent la volonté du Gouvernement
péruvien et des donateurs étrangers d’avancer
vers les objectifs de la Conférence en s’attaquant
aux principales préoccupations en matière
de santé génésique et en protégeant les droits
des femmes. Malheureusement, ces progrès
n’ont pas été réguliers et ont été éclipsés par
deux périodes de politiques et d’interventions
opposées à l’avortement. La première, en
1996–1997, sous le gouvernement de Fujimori,
était une approche démographique qui
utilisait des objectifs numériques et faisait
pression sur les femmes pour leur faire accepter
la stérilisation comme principale stratégie
gouvernementale de réduction de la pauvreté,
ce qui a conduit à des violations avérées. La
deuxième, en 2001–2003, sous le gouvernement
Toledo, était une approche d’extrême droite qui
souhaitait limiter l’accès aux services essentiels,
notamment la contraception d’urgence, les
préservatifs et les soins après avortement. Malgré
leur nature contradictoire, ces deux approches
ont constitué les principaux obstacles à des
améliorations durables de la santé et des droits
génésiques au Pérou.
Equity. Lima: USAID/Peru,
15 June 2001.
54. Coe A. Informing Choices:
Expanding Access to Emergency
Contraception in Peru. Takoma
Park MD: Center for Health and
Gender Equity, 2002.
55. Aseguran que debate por la
AOE ya terminó. Diario Perú 21.
18 July 2004. p.14.
Resumen
En este artı́culo se revisa la polı́tica de población
del Perú desde la Conferencia Internacional
sobre la Población y el Desarrollo, celebrada en
1994, y se evalúa hasta qué punto sus polı́ticas y
programas han afectado la salud y los derechos
reproductivos. Se basa en los datos recolectados
mediante un monitoreo continuo de las polı́ticas
y los programas de salud sexual y reproductiva
en Perú, el cual se inició en 1998 para el Centro
para la Salud y la Equidad de Género (CHANGE).
Los logros alcanzados en Perú a partir de 1994
demuestran la buena voluntad del gobierno y
los donantes extranjeros de hacer avances
hacia el cumplimiento de la agenda de la CIPD
abordando los aspectos clave respecto a la salud
reproductiva y promoviendo los derechos de las
mujeres. Desgraciadamente, los avances no han
sido constantes. Se han visto eclipsados por dos
perı́odos de polı́ticas e intervenciones en contra
del derecho a decidir libremente. El primero,
durante 1996–97 bajo el gobierno de Fujimori,
fue un enfoque demográfico que utilizó metas
numéricas y ejerció presión indebida sobre las
mujeres para que aceptaran la esterilización
como la principal estrategia del gobierno para
disminuir la pobreza, lo cual propició abusos
que han sido documentados. El segundo, en el
perı́odo 2001–03 bajo el gobierno de Toledo, fue
un enfoque de extrema derecha que se propuso
limitar el acceso a los servicios esenciales,
incluida la anticoncepción de emergencia, el
condón y la atención postaborto. A pesar de su
naturaleza contradictoria, estas dos polı́ticas han
sido los mayores obstáculos al logro de avances
duraderos en el campo de la salud y los derechos
reproductivos en Perú.
69
Fly UP