Family Planning

I was talking today with the grandmother of Estefany, my goddaughter. She is 40-years-old and just found out she is 4 months pregnant with her 11th child. She wants me to come with her to her ultrasound visit with Rafael because she’s embarassed. Initially I thought the embarrassment was a male-female thing but she explained that she was embarrassed that she had so many children and he would judge her for it.

She explained to me that she’d wished to have stopped having children after her 8th child. At that time, she began using depo provera injections and continued for 5 years. Depo provera is the “non-natural” family planning method of choice around here. Methods from condoms to pills to depo to IUDs are offered free via the Centro de Salud and surgery for males or females is offered at minimal charge (materials only) at the National Hospital in Solola. A pap smear is required prior to obtaining the methods. I never heard of condoms being used here (but once did get hearty laughter at the suggestion) nor seen one or its wrapper amongst the trash that lines all the streets and paths. They just aren’t used. I also haven’t heard of anyone using an IUD (though I know Rafael discourages the option as he had the experience of delivering a baby who had an IUD imbedded in its cheek -- not the most confidence-inspiring experience). Pills have been prescribed to some for irregular periods but not that I know of for “planificacion”. Some feel that pills sterilize women. Male surgery is absolutely not accepted but female sugery is, if a c-section happens to be needed. Even then, rumors are rampant of people getting pregnant after having had the surgery. Are the stories true (are the surgeons not very reliable)? Or do people spread these stories to scape goat after yet another unwanted pregnancy or, given the distrust of western medicine, is one failed tubal ligation enough to discredit the whole concept? Despite depo being the “method of choice” it is still very poorly accepted. I have heard numerous complaints of severe headaches, abdominal pains, and stomach “swelling” with depo use. Dr. Tun seems to have a low threshold as well for labeling it as “not tolerated” in a given patient. When my neighbor went off of depo and bled for 6 days straight, Rafael labeled it off limits for her in the future. I had told her it was not uncommon to have a heavy first period after stopping the depo but she was sure she would die, she told me.

In talking to Estefany’s grandmother, I realized this was a common fear. She said the medicine hadn’t sat well with her because her period didn’t come; she was blocked off and all the “suciedad” (dirtiness, as the menstrual blood is often called) stayed inside. Her abdomen got bigger and bigger over the last year and she could barely walk. She was fortunate enough, as she says, to have heard a natural medicine man in the plaza talking about how family planning methods will kill you; particularly depo because you will bleed to death when you finally go off of it. He explained to her that all the periods build up inside and they will have to come out; he’d seen it before and many women had died of the bleeding. He told her to stop the injections immediately, sold her several herbs and said that in 15 days, at the most, her period would come but it would be heavy and she should pray to the good Lord because she quite likely could die. She took the herbs and, “cabal” (exactly), on the 15th day, all that dirtiness started coming out but in fountains. She bled for a month. She said she had to be hospitalized and get many bags of vitamin water (lactated ringers) to save her life. She took a year to recover her strength. She got pregnant twice more, both difficult pregnancies. Her last baby was “puro ratoncito” (a little rat, meaning premature and small). That child is still very malnourished at 1.5 years. She attributes all of her current health problems and this unhealthy last baby to the depo. She explained to me that the depo left her “damaged”. Her pregnancies used to be easy, pain free. After the depo, she had swelling and back aches, and abdominal pains with her pregnancies. (This brings up another interesting and challenging issue in caring for patients here: given that they so distrust western medicine, anything you pressure them to do, including things as simple as placing as IV, can forever be thought of as the reason for any future problem. I’ve certainly kept this in my mind as I try to push things through with Herlyn’s heart evaluation and surgery).

I listened for over an hour to her tell this story. She felt passionate about how terrible the depo was for people and that, if not for God bringing her to this naturalist in the town square, she would have continued the depo and died. She is sure her current suffering is because of the medicine and is determined that other women know how dangerous it is. Estefany’s mom, only 22, has 3 kids and would like to slow down the baby-making. But her mom definitely won’t let her get injections. She did use depo for a short while and, as grandmother tells it, became very pale and weak and could barely get out of bed. On stopping the injections she quickly recovered to her normal self. She’s not doing any family planning now despite wanting to and despite being extremely poor and barely making ends meet to care for her family of four.

I commented that I was surprised the depo had caused so many problems in the women here because it’s widely used in the US and Europe and I haven’t heard of these particular experiences. I did explain (and wondered if the doctors ever did) that not getting a period is normal and the blood does not build up inside. I also explained that irregular bleeding for up to a year afterwards is pretty common but excessive bleeding, like she described, is extremely rare. She said she wonders if we (in the US) get special medicines. She doesn’t know if they just get sent the bad stuff because it’s cheap or because her government wants the Maya people dead. She added, at the end, that maybe Mayans had different body systems than white people and this medicine wasn’t for them. That certainly is insightful; I doubt depo has ever been tested in a Mayan population. It might sound crazy that they could be so different as to not tolerate a natural hormone like progesterone but it’s hard to cast away the theory when it’s true that medications are often only tested in white people and, certainly, other treatments have been shown to have different effects in different races. Or is the power of suggestion strong enough to account for this?

I asked her about the pill. Her first question for me was if it would be ok to dissolve the pill first so you didn’t have to swallow it. I could tell this wasn’t an issue of trouble swallowing pills but, somehow, a sense that it would be less toxic if dissolved first. I said I thought that would be fine if all of it was taken. She was really excited to learn that a period would come each month (despite explaining that, at first with the depo she had been thrilled not to have her period … less laundry!).

Having talked with several adult women who have large families, I have learned that many, many did not want as many children as they had. They either hadn’t ever heard anything about how to prevent pregnancies (Angel’s case) or they heard horror stories like this. We gringos, myself included, quite commonly ask why poor people have so many kids when they can’t even take care of the ones they have. Family planning is an easy, responsible solution to a problem that keeps people impoverished and cheats the kids that have already been born. Sometimes I feel like family planning is as far upstream as we can get. Imagine if families had just two kids each. Our development and relief services would go so much farther; hopefully become less needed. Our schools could teach better, there’d be more food on the table, there might be money to cure an illness, parents could work while grandparents cared for kids, disease wouldn’t spread so quickly if 5 family members weren’t crowded into one bed. But maybe family planning isn’t as easy and obvious a solution to people who have so have repeatedly fallen victim to attempts at extermination by their government, to people whose doctors fail to explain how a medicine works and likely side effects, to women whose husbands equate birth control with cheating, to women whose religious leaders and grandparents equate birth control with a rejection of gifts from God. How can we tackle this issue?