Luis, a brickworker, walked into a health care clinic near his home in El Alto, Bolivia, to buy condoms. When he left, not only did he have a supply of condoms, but he had enough information about other family planning methods to convince his wife, Carmen, to return with him to find out more about the various methods.
During this second visit, the counselor gave Carmen the same information and counseling that she had given Luis. After considering their options, Carmen and Luis decided that female sterilization was the best choice for them. They returned to the clinic one week later for the procedure and then another week later for follow-up care.
The couple marveled at how easy the procedure had been. Carmen had no pain, her incisions were small, and she returned to work after only four days. Sometime afterward, Luis returned to the clinic once again, this time with his sister-in-law Maria.
AVSC believes that all clients should receive the same level of care and wide choice of contraceptive methods as Luis, Carmen, and Maria. As part of our work in Bolivia, we have been collaborating with the Ministry of Health (MOH) and the Centro de Investigación, Educación y Servicios (CIES), a nongovernmental organization, to ensure that safe, high-quality female sterilization services are widely available throughout the country.
Assistance at the Local Level
AVSC has been working with Bolivian public- and private-sector institutions since 1985 to strengthen family planning services. Since 1997, we have been providing technical assistance in five MOH hospitals in four cities--La Paz, Santa Cruz, Sucre, and Tarija. We have also been working in two CIES clinics in El Alto and Santa Cruz.
Training has been an important component of our work. Teams of doctors and nurses from each service site have been trained in the female sterilization procedure, and various staff have received training in family planning counseling, infection prevention, and contraceptive technology.
On an ongoing basis, AVSC staff provide monitoring and supervision to the providers at these sites. This support helps the providers improve their clinical skills and solve any problems they may have in providing services, such as difficulty in following proper infection prevention practices or in providing clients with counseling and information with which to make informed choices about their care.
Expanding Services to All
In 1997, the Bolivian government issued the first national norms on female sterilization. The norms limited access to the procedure to women who were age 35 or older, had five children, and were of "high reproductive risk"--those having certain medical conditions. They did not consider any social or economic conditions in offering the services.
AVSC worked with the MOH to revise the norms and to develop a procedures manual for female sterilization services. In 1998, the norms were changed. Sterilization services are no longer limited to women based on any age, parity, or medical requirements, so now more women who want the procedure can have it.
The norms now require providers to give full counseling and information to individuals considering services and to follow correct procedures in obtaining informed consent. This change is significant, because it ensures that women and men will get the information they need to make knowledgeable, voluntary choices about family planning.
The MOH and CIES, in collaboration with AVSC, are giving individuals like Luis, Carmen, and Maria greater opportunities to make their own decisions about contraception and a wider range of methods from which to choose. This is our goal for all Bolivian women and men.
Andrea Eschen is a senior director for AVSC's Latin America program. She thanks Drs. Maria Lorencikova and Gonzalo Aramayo of AVSC's Bolivia office for their assistance in preparing this article, as well as the MOH and CIES for sharing their client stories.
