Oriéntame: Preventing and Solving Problems Related to Unwanted Pregnancy for 25 Years in Colombia

Abstract

Abstract

For over 25 years, the Oriéntame Foundation in Bogotá, Colombia, has been providing reproductive health services to women, regardless of their socio-economic or marital status, race, age or religious affiliation. Oriéntame started by focusing primarily on unwanted pregnancy and treatment for incomplete abortion, which has contributed to the reduction of maternal mortality in Bogotá. Oriéntame now provides comprehensive sexual and reproductive health services, including sexual health education, Pap smears, gynaecological problems, STIs and sexual violence, with a continuing emphasis on unwanted pregnancy, treatment for incomplete abortion and post-abortion care. The women that come to Oriéntame, some 18,000 per year in recent years, are from all socio-economic levels, and are increasingly more informed. The services are regularly re-evaluated so as to accommodate their changing needs. There is a sliding scale of fees, so that the 40% of women patients with higher incomes subsidise the 60% with lower incomes; this also allows the clinics to be self-supporting. Services are offered in an atmosphere of respect for women and their decisions, with professional staff who are trained to take care of both the medical and emotional needs of each woman. Since 1992, Oriéntame has also been doing outreach to the slum areas of Bogotá, providing education and information, to contribute to the empowerment of the poorest inhabitants of the city.

Résumé

Depuis plus de 25 ans, la Fondation Oriéntame á Bogotá, Colombie, fournit des services de santé génésique aux femmes, sans distinction de condition socio-économique ou maritale, de race, d'âge ou de croyance religieuse. Oriéntame a commencé à travailler sur les grossesses non désirées et l'avortement incomplet, réduisant la mortalité maternelle á Bogotá. Nous fournissons maintenant des services complets de santé génésique – éducation en santé sexuelle, frottis Pap, problèmes gynégologiques, MST et violence sexuelle – en donnant toujours la priorité aux grossesses non désirées, l'avortement incomplet et aux soins après l'avortement. Les patientes de la Fondation, environ 18,000 par an, sont issues de tous les niveaux socio-économiques, et sont de mieux en mieux informées. Les services sont régulièrement réévalués afin de les adapter à leurs besoins en évolution. Les honoraires sont dégressifs, les 40% les plus aisées subventionnant les 60% aux revenus les plus faibles; les dispensaires sont ainsi financièrement indépendants. Les services sont dispensés avec un personnel professionnel formé à traiter les besoins médicaux et psychologiques de chaque femme. Depuis 1992, Oriéntame se rend dans les bidonvilles de Bogotá pour informer et éduquer les habitants les plus pauvres de la ville.

Resumen

Resumen Sobre 25 años la Fundación Oriéntame en Bogotá, Colombia, provee servicios de salud reproductiva a mujeres sin distinguir su estado civil o socioeconómico, raza, edad o religión. Su enfoque principal en el embarazo no deseado y la atención al aborto incompleto ha contribuido a la disminución de la mortalidad materna en Bogotá. Actualmente proveemos servicios sexuales y reproductivos que incluyen la educación en salud sexual, exámenes papanicolau, atención a problemas ginecológicos, ITS y violencia sexual, con un énfasis permanente en el embarazo no deseado, la atención al aborto incompleto y al post-aborto. En los últimos años, Oriéntame ha atendido anualmente a 18,000 quienes son cada vez más informadas. Se reevaluan los servicios con regularidad para poder adecuarse a los cambios en sus necesidades. Se mantiene un sistema de cobro diferenciado, el 40% de las mujeres de ingresos más altos subsidian el 60% que perciben menos, lo que permite que las clı́nicas se autofinancien. Se ofrecen los servicios con personal formado para atender tanto a las necesidades médicas como emocionales de cada mujer. Desde 1992, Oriéntame realiza además un trabajo de extensión en los barriales de Bogotá, impartiendo educación e información, contribuyendo ası́ al empoderamiento de los habitantes más pobres de la ciudad.

Key Words:

• clandestine and unsafe abortion
• reproductive and sexual health services
• training of service providers
• Colombia

In 1977, when Dr. Jorge Villarreal and a group of gynaecologists founded Oriéntame in Bogotá as a private, non-profit organisation, it seemed an impossible dream. From that time until 2001, abortion was illegal in Colombia with no exceptions, and public policy related to sexuality, contraception and abortion was and continues to be strongly influenced by the most conservative sectors of society, including the Catholic Church.

Data from studies in the 1990s [1][2] show that 50% of all pregnancies were unwanted in Colombia, and 30% of women of reproductive age who had been pregnant reported that they had an abortion. On the basis of these data it was estimated that 350,000–400,000 women were having induced abortions each year in Colombia. In the 1970s, when effective contraceptive use was even lower than today and clandestine abortions more dangerous, Oriéntame took up the challenge to deal with and make unsafe abortion visible as a public health problem, and to make it clear that abortion was only the tip of the iceberg of unwanted pregnancy and all its related complexities and problems. A study in 1990–1991 among 602 women attending one of Oriéntame's clinics (average age 27), found that with an average of three pregnancies per woman, the average number of unwanted pregnancies was 1.8 and of abortions 1.4 per woman [3].

Before Oriéntame was founded, women who decided not to continue their pregnancies were strongly condemned both legally and socially. Society at large closed its doors to them, leaving those who survived a dangerous abortion alone, often suffering from serious morbidity and a huge amount of guilt, and without information on how to avoid a similar situation in future. Oriéntame chose to confront this situation with deep respect for women, offering them compassionate treatment for incomplete abortion with services of the highest medical and psychological quality, for fees that were affordable for all women.

This service has contributed to the reduction of maternal mortality due to unsafe abortions in the city of Bogotá. In the early 1970s, data from the main maternity hospital in Bogotá [4] indicated that abortion was the primary cause of maternal mortality, responsible for 38% of cases. In the 1990s data from the Secretary of Health of Bogotá [5] showed that unsafe abortion was the third most important cause, responsible for 8% of maternal mortality.

The objectives of Oriéntame

From the beginning, Oriéntame intended to fill the void around sexual and reproductive health services and information that women and their partners receive in Colombia. We believe that the right to sexual and reproductive health services cannot be mediated by religious beliefs or by legal or economic restrictions that threaten the health of women, especially the poorest.

With a deep belief in the right of all women to access health services, Oriéntame has found a way to help all the women who come through its doors, and reach out to others, no matter what their socio-economic or marital status, race, age or religious affiliation. Since the first day that Oriéntame opened its doors, 370,000 women have attended its three clinics in Bogotá. In the past five years the annual volume has been around 18,000 women.

From the very beginning, one of the purposes of Oriéntame was to become a model of service provision and a training centre for others in Latin America. The ESAR Foundation, a private, non-profit organization also initiated by Dr. Jorge Villarreal, is in charge of a training programme in Oriéntame's clinics for service providers who come on fellowships from other Latin American countries. The Foundation also provides technical assistance and follow-up support for the recipients of training. To date 365 Latin American health professionals and other health personnel have been trained and are working in their respective countries for the improvement of sexual and reproductive health, following the principles and the model of Oriéntame's services.

Who attends the clinics and community-based programmes

Nowadays, compared to the past, women are able to admit to unwanted pregnancies, sexually transmitted infections and domestic violence. These are problems that have stopped being invisible and unmentioned, both for society and for women themselves. Many women recognise their right to decide how many children to bear, with whom and when. In addition, most women do not want to suffer a sexual transmitted infection or a relationship problem in silence. Consequently, they look for medical services and prevention counselling that supports their health and lives, which is why they choose Oriéntame as their sexual and reproductive health provider. Women approaching Oriéntame are increasingly more informed and qualified to ask questions, reflected both in the way they ask for information and what they expect from an integrated health service. In other words, the women who come to the Foundation are more empowered now than in the past.

The women that come to Oriéntame are from all socio-economic levels. The Foundation has set a sliding scale of fees for services, so that the 40% of women patients with higher incomes subsidise the 60% with lower incomes. This also allows the clinics to be self-supporting, and when there has been more income than costs in some years, the money has been invested in community-based programmes in the slum areas of Bogotá, primarily for single mothers who are heads of household and their children. Oriéntame has a special interest in reaching this population group, because they have the greatest sexual and reproductive health problems and needs. Women with higher incomes are important to Oriéntame too, not least because they are advocates for the clinics, but they do have good medical insurance and can if they wish go to private doctors. Women with low incomes, on the other hand, have in most cases no access at all to qualified service providers, much less for heavily stigmatised conditions like unwanted pregnancy or incomplete abortions.

The services

Each time a woman comes to Oriéntame, the consultation has two purposes: the short-term need for diagnosis, treatment and healing and the longer-term need for prevention of future sexual and reproductive health problems.

In the early years, Oriéntame's services were almost exclusively dedicated to providing high quality, compassionate treatment of incomplete abortions and post-abortion contraception, but very soon women's other needs were recognised, which resulted in the more comprehensive management of undesired pregnancy. This includes counselling and referral for adoption, support for single pregnant women who have been thrown out of their homes, work or schools because they are pregnant. Today, comprehensive sexual and reproductive health services are provided, including sexual health education, pregnancy testing, family planning, screening for early detection of uterine and cervical cancer, counselling and treatment for gynaecological problems, menopause, infertility, STIs and sexual violence, with a continuing emphasis on unwanted pregnancy and treatment for incomplete abortion and also post-abortion care.

Over the years the services offered by the foundation have regularly been re-evaluated so as to accommodate the changing needs of women. For example, women's partners are now often involved in counselling sessions, adolescents are given special emphasis as they are more open about sexuality and sexually active, and technical changes have been introduced in the services to address the needs of women who are coming with incomplete abortions earlier in pregnancy than in the past. Oriéntame's goal is to create a humane atmosphere that prevents emotional and physical scars, and also prevents future undesired pregnancies.

The Foundation has been carrying out community-based programmes in the slum areas of Bogotá since 1992. These programmes were felt to be necessary because, in spite of the subsidised fees, many low-income women did not know about the Foundation and thus were not coming for consultations in the numbers we would have liked to see. Oriéntame first contacted public assistance programmes, which are attended by large numbers of women from these areas, to enlist their support to organise educational talks and workshops on reproductive health issues. The talks are given by social workers who have very close contact with the community, focusing primarily on family planning, STIs, unwanted pregnancy and sexual violence. At the suggestion of women who have attended these activities, we have also become involved during the last five years in the organisation of social development programmes for single women heads of household, which include basic education and vocational training, provision of primary and basic reproductive health services, empowerment and self-development activities and support for sponsorship programmes for their children. It is Oriéntame's hope that through this channel, women can be helped with other reproductive and sexual health needs and that by going to the community, where women and teenage girls can more easily attend, our clinical services will become better known and used as well.

The most important components and characteristics of the services that Oriéntame provides, making it different from other public or private health service providers, are as follows:

•	They are centred around the needs of the women attending: every suggestion, criticism and complaint is taken account of and evaluated, in order to improve the programmes.
•	They are based on respect for women's decisions and on providing emotional support and information, so as to empower the decision-making process. Informed choice is not a common practice in health services in Colombia but it has been part of Oriéntame's work from the very beginning.
•	A user-friendly atmosphere, making each room as comfortable and unclinical as possible, so that women feel they are in a friendly and caring place and not a sterilised or cold environment.
•	It includes prevention as a key component. Each consultation is seen as an opportunity to educate and to prevent future sexual and reproductive health problems from occurring. Informational brochures and educational videos are also commonly used.
•	Women who receive clinical services and those in community-based programmes are followed up as far as possible in order to ensure their needs have been met.
•	Affordable fees for all women. No woman is ever denied services on the basis of inability to pay.

The staff and continuing education

The Oriéntame team comprises 120 people, of whom 16 are doctors, 19 counsellors, 11 nurses, 6 social workers and 68 support personnel, including front desk staff, cleaners, administrative assistants, keeping records and statistics and filing, and security and customer service staff. It is the doctors, nurses, counsellors and social workers who have the most direct contact with the women who come in.

The criteria for selection and ongoing evaluation of the staff have to do with their technical skills and ability and, equally importantly, their compassion and ability to relate to the problems and crises of others. Each person that works for the institution, from the doorman to the doctors, has received special training in the technical, practical and ideological aspects of unwanted pregnancy and abortion, appropriate to the job each is doing.

In addition, all personnel receive continuing education through workshops and talks, given either by external specialists or specialists from within the foundation. For example, during 2001 there was a medical update on STIs, specifically looking at modes of transmission and treatment, and a discussion of new strategies for providing services to adolescents, based on the results of research [6] presented to the staff, which helped in the creation of a special waiting room for teenagers, and shedding new light on counselling for teenagers. These activities help to improve the quality of the services being offered. Furthermore, the recent changes in the Colombian Penal Code were also analysed and discussed, which now allow a judge to decide not to punish a woman who has aborted a pregnancy if it results from rape or non-consensual insemination, depending on the circumstances surrounding the case.

Following the line of constant improvement, there are also evaluation forms filled in by each patient, in which they assess all aspects of the services. Staff analyse the results to see where improvements can be made, such as in waiting times. Educational sessions for staff are also partly determined through the suggestions of clinic users, to help us respond better to their needs.

These activities and strategies for selection and training of personnel have resulted in their having a strong commitment to their work, which has been sorely tested and fully proven at times when the clinic has been threatened with closure or shut down, following political pressure by conservative groups, which usually happens after the topic of decriminalisation of abortion is raised publicly. The staff have courageously decided to continue their work at these times, even at the risk of their personal, professional and social status.

Conclusion

This model of service delivery has worked well for over 25 years, proving that even in countries where there are legal, economic and social restrictions, it is possible to provide services of the highest quality at reasonable costs, where women's rights are respected, and to make the services affordable for all women. In addition, Oriéntame has made it possible for women to find information that allows them to manage their lives from a more empowered position, thus helping create a more equitable and respectful society, including for women. It is the institution's hope that 25 years from today, there will be legal, affordable and professional reproductive and sexual health services for all the women in Colombia, Latin America and the world as a whole.

IN MEMORIAM Dr Jorge Villarreal Mejia

With sadness, we communicate the death in Bogota on 8 December 2001 of our much loved teacher and friend Dr. Jorge Villarreal, Colombian doctor, pioneer in sexual and reproductive health, founder of ESAR (Foundation for Education in Reproductive Health) and defender of women's rights. Many people associated with the field of health will recall Dr. Villarreal's presentation in 1993 in the Andean Safe Motherhood Conference held in Santa Cruz de la Sierra, Bolivia. In that event, as in so many others in Latin America and internationally, Dr. Jorge Villarreal jolted people's consciences and provided a vital impulse to public debates concerning abortion, unwanted pregnancy, sexual rights and women's reproductive rights. We remember Dr. Villarreal as an upright and courageous man, with a moral quality of transparency, who did not tolerate hypocrisy. He dared to say and demonstrate in practice what many people-peers of his own generation, and younger colleagues – alluded to only timidly, or silenced for fear of social sanctions. The regret we feel at losing Dr. Villarreal, our wise and beloved friend, is mixed with our awareness of the richness of having known him. He accompanied us, personally and from far away, in a series of initiatives linked to his life's cause: women's human rights, and a more just form of medical practice, put to the service of Latin America's most needy populations. We will keep his work alive through our commitment to continue transmitting, here and elsewhere, the teaching and example of Dr. Jorge Villarreal Mejı́a, mentor and friend, defender of women's rights.

CDD-Bolivia, Catholics for a Free Choice; CISTAC, Project for Participatory Advocacy in Sexual Rights; FCI-Bolivia, Family Care International; Working Group on Unwanted Pregnancy and Abortion, La Paz; PROMESA, Programme for Medical Trainers in Health; WI Ñ AY, Private Voluntary Medical Association

La Paz, 10 December 2001

International Human Rights Day