jueves, 29 de diciembre de 2016

The day-after pill - myths and the truth

Some definitions about pregnancy, contraception and SRR


By Marco Paulini


When does a woman get pregnant? Do all the intercourses become creating a new being? How does emergency oral contraception work? Since August 22nd, 2016, Lima's First Constitutional Court instructed EOC to be distributed free in all health public stands, after the rule was suspended since 2009.


The problem was it actually could be sold in private drugstores, what generated unequitty in access and that is what court decision tried to balance.


But, what is all this process about? Before, I think it's necessary you understand some concepts and interpretations related to this issue in case you want to join the discussion, so you also do it under equity criteria.


Plus, I include you sources you can go deeper about this concepts (all my references are in Spanish, but you can find their equivalents in your language).


1. Reproductive cycle, ovulation and fertilization

every month, the female organism gets ready for a pregnancy. This preparation begins the first day of menstruation due to the ovaries make hormones such as estrogen and progesterone, mechanism ruled by the hypotalamus at the brain. Its objective is ova maturation, the preparation of uterus and the rest of the female sexual organs as well for a possible pregnancy.


The week after the menstruation begins, the ovaries will be the responsible for follicular maturation. As in every menstrual cycle 7 to 8 follicula start to grow, only one grows becoming mature between cycle's days 12 to 16, moment when ovulation happens. The Fallopian tube catches the mature ovum what begins its trip to the uterus, which has been preparing for a possible pregnancy swelling its endometrial layer (1). Once released, the ovum could b fertilized when joining to spermatozzoon during next 12 to 48 hours, if not it will begin to be disintegrated.


Human fertilization is intern, it happens inside the woman's body in other words, at Fallopian tubes to be exact.


Fertilization is probable if spermatozoons (male cells) are stored in the vagina by the intercourse at days 12 of 16of female menstrual cycle. Then, helped by the cervical mocus and stored in upper portion of the vagina, they start to raise to Fallopian tubes, those at the same time have gathered a mature ovum (female cell) .


For the fertilization (union of ovum and spermatozoon) to be produced, it's necessary that sexual contact (intercourse) between a man and a woman (except when artificial or assisted fertilization techniques are used) be made in a moment close to the ovulation (1).


It's actually easy to set that because this harmonious and almost timed working that female reproductive system does, the women are fertile every month during their reproductive lifetime, what begins in menarche (first menstruation) and ends in menopause. Then, her fertility or reproduction will be depend on mechanisms she and/or her partner adopts to begin or prevent pregnancies, facts those response to a biological sequence what occur cyclically in every woman, sequence that can not be unaware to take preventive measures and let them to God's fate neither.


2. Pregnancy

If spermatozzoon and owvum intercept, they will unite fusing their cores and formin one only cell, that starting in this point, will trek to the uterus, while it also begins a mitosis process, multiplying in number of cells.


3 to 4 days since the ovulation, the fertilized ovum will get the uterus, when it could last 2 to 3 days more for pinning up the endometrium, place where the new being will develop (1).


3Emergency oral contraception (EOC) and its action mechanism

The emergency oral contraception (EOC) is a method that offers an alternative to forced sexual relations or rapes, intercourses without prior contraceptive using, misusing or its failure (4). It's necessary to remark this method is effective only among 72 hours after having sex. It must not be used when this deadline is over.


It's proven the EOC works because unables the ovulation, at the same time it thickens the cervical mocus making the spermatozzoon not to go its way inside the uterus (5). So for example, Levonorgestrel emergency contraception pills prevent the pregnancy unallowing or delaying the ovulation, and avoid the fertilization due to its action on the cervical mocus, becoming it much thicky, so decreasing the spermatozzoon mobility with that, then its ability to join the ovum (4).


Thus, we support on updated scientific evidence to affirm that once the fertilization occured, the EOC doesn't interfere the process of fertilized ovam implantation and, neither it interferes the embryonic development of an already implantated ovum (4).


What it should be taken in mind is the EOC is a good method that allows preventing non-wanted pregnancies, and the protection of the woman's life in comsequence.


As I already explained, it must be paid attention to action mechanism because the EOC, as unallowing ovulation, won't display an ovum to fertilize, then there will be not a pregnancy. Also in case, that sexual relation has been happened after the ovulation, when an ovum has already been produced, this method thickens the cervical mocus as a second action mechanism, unallowing spermatozzoon and ovum encounter. So, it is proven it's not an avortive metod, bringing down the false theories which many politic authorities, influenced by their ecclesiastical colleagues, are based because here is not attempting against the life of a supposed new being, but simply conditions for the pregnancy to occur get nullified.


4. Sexual and reproductive rights (SRR) and Peruvian laws onEOC

In the other hand, each men or women has the whole right to decide on their sexuality, totally free, unattached by coercion, discrimination or violence, to decide if having kids or not, the number and spacing of them, as well as having true information with a scientific basis, and access to contraceptive methodology. In other words, to have sexual and reproductive rights (SRR), the same what were mentioned and recognized in Confference of Population and Development in Cairo, 1994, and 4th World Conference in Beijing, 1995.


Peru's Constitution doesn't mention explicitically to SRR of people, however it does recognize several rights inside or related directly to SRR of every citizen. So we find the right to dignity, free development of personality, also the right to the life, to physical and mental integrity, to fre concius, to free information, to personal intimacy for quoting someones.


Additionally on July 28th, 2005, the Family Planning technical Rule was aproved, which objective is to guarantee and standardize the attention processes on family planning inside the SRR focused from gender, setting up all person has right to enjoy the highest level of own health for allowing to enjoy own sexuality, to decide free and responsible the number and spacing of the kids, to have access with equity, without any discrimination, sexual orientation neither, to sexual health and family planning services, to the access to contraceptive methods for choosing free and volunterly, to have access to quality services of sexual and reproductive health without any type of coercion, to health institutions guard those principles to be committed.


Unfortunately, the women's SRR in Peru have not been totally recognized, as much as EOC laws have coming out behind a machismo veil, wwhich even the eecclesiastical authorities have self-allowed to give messages opposed to this contraceptive method despite Peru is a secular country, so the Church sshould not influence when ruling about issues related to sexual rights of persons.


The opposers' argument is the defense of a hypothetical being, not proven, based upon the premise of life defense.


Faith, science and machismo

despite Peruvian law fortunately begins to have a much favorable position to sexual rights, paradoxically it's still perceived there is a big number of women (not counting the men) who although recognize this contraceptive method offers a way-out before a non-wanted situation, they still see it like something attempting against the faith, prefering to accept what they had to live by God's fate, and that the woman's mission by tradition andd religion is the calling to give life despite the conditions it is given.


To us, who have a panoramic view of what happens, can affirm cathegorically this situation is just the product of the letargy and the lack of interest of Peruvian Government about recognizing and ruling on time in favor of sexual rights of people, much more women's - that the government, after paying more attention to religiosity, has come allowing laws those give to the woman a role of almost pure reproduction.


If we add disinformation to this, we have the perfect formula to continue in the chaos that non-wanted pregnancies bring themselves on. Then, we can elucidate that before such conditions, unfortunately the EOC is not an option for many of our women as a mean to protect their life, but it's not an option by own will, by pure ignorance given by the lack of information instead, because the State (almost holding hands to the Church and machismo) doesn't offer the conditions for the ownn woman to be the one who recognizes, empowers and internalizes she has sexual rights, those have not to struggle to her faith, making them to respect.


Don't lose our main focus, and this is the health of each person, translated in social health, our women's mainly, because a big amount of non-wanted pregnancies become clandestine abortion in unhealthy places those attempt against women's physical integrity, psychologic problems as well.


Let's have in mind that before rapes or any intimate relation without condom, the person exposes not only to a non-wanted pregnancy because EOC doesn't protect from sexually transmited infections nor HIV neither, due to this is not a method what avoids the contact to body secretions of the other person.


If you want to go more in-depth, I suggest go to bibliographic references I used to write this article. Remember they are in Spanish, so you can find out the equivalent in your language.

1. Saludemia. Planificación familiar. Lima: Saludemia; 2016

4. World Health Organization. Anticoncepción de Emergencia. España: Organización Mundial de la Salud; 2016.

5. Centro de la mujer peruana Flora Tristán. Anticoncepción Oral de Emergencia. Lima: Centro de la mujer peruana Flora Tristán; 2016.

8. Petrell E. Política de anticoncepción oral de emergencia: la experiencia peruana. Simposio [Serie en internet]. 2013[Citada 2016 octubre 31]; 30 (3):m [aAround 2 screens]. Available on: http://www.scielosp.org/pdf/rpmesp/v30n3/a19v30n3.pdf


miércoles, 28 de diciembre de 2016

Píldora del día siguiente: mitos y verdades

Algunas definiciones sobre embarazo, anticoncepción y derechos sexuales y reproductivos

Por Marco Paulini Espinoza

¿Cuándo una mujer queda embarazada? ¿Todos los coitos terminan en la procreación de un nuevo ser? ¿Cómo funciona la anticoncepción oral de emergencia? Desde el 22 de agosto de 2016, el Primer Juzgado Constitucional de Lima instruyó que se distribuya gratuitamente la AOE en todos los establecimientos públicos de salud, medida que estaba suspendida desde 2009.
         
El problema era que sí podía comercializarse en farmacias y boticas privadas, lo que generaba inequidad en el acceso, y eso es lo que la decisión judicial trataba de equilibrar.

Pero, ¿de qué se trata todo este proceso? Antes creo necesario que entiendas algunos conceptos e interpretaciones relacionados a este tema, para que si te integras a la discusión, también lo hagas en equidad de criterios. Además, te incluyo fuentes en las que puedes profundizar más sobre estos conceptos.

1. Ciclo reproductivo, ovulación y fecundación.
Todos los meses el organismo femenino se prepara para un embarazo. Esta preparación inicia con el primer día de regla, gracias a que los ovarios fabrican hormonas como estrógeno y progesterona, mecanismo regulado por el hipotálamo en el cerebro. Su fin es la maduración de óvulos, así como la preparación del útero y el resto de órganos sexuales femeninos para un posible embarazo.

En la semana siguiente al inicio de la regla, los ovarios serán los responsables de la maduración folicular. Como en cada ciclo menstrual de siete a ocho folículos inician su crecimiento, solo uno crece llegando a su madurez entre el día 12 a 16 del ciclo, momento en que se produce la ovulación; la trompa de Falopio capta al óvulo maduro que inicia su recorrido hasta el útero, el mismo que se ha estado preparando para un posible embarazo engrosando su capa endometrial (1). Una vez liberado, el óvulo podrá ser fertilizado al unirse al espermatozoide durante las siguientes 12-48 horas; si no, comenzará a desintegrarse.

La  fecundación humana  es interna; es decir se produce dentro del cuerpo de la mujer, concretamente en las  trompas de Falopio.

La fecundación es probable si los espermatozoides (células masculinas) a través del coito, son depositados en la vagina entre los 12 a 16 días del ciclo menstrual femenino; es entonces que, ayudados por el moco cervical, y depositados en la porción superior de la vagina, inician su ascenso hasta llegar a las trompas de Falopio; éstas a su vez han recogido un óvulo maduro (célula femenina).

Para que se produzca la fecundación (unión del óvulo con un  espermatozoide) es necesario que el contacto sexual (coito) entre hombre y mujer (excepto cuando se utilizan técnicas de fecundación artificial o asistida) se realice en un momento cercano a la ovulación (1).

Entonces es fácil establecer que gracias a este funcionamiento armonioso y casi cronometrado que realiza el sistema reproductivo femenino, las mujeres son fértiles todos los meses durante su etapa de vida reproductiva, la misma que se inicia con la menarquia (primera menstruación) y termina con la menopausia. Entonces su fertilidad o reproducción dependerá de los mecanismos que ella y/o su pareja adopten para iniciar o prevenir embarazos, hechos que responden a una secuencia biológica que ocurre cíclicamente en cada mujer, secuencia a la que no se puede dejar de prestar atención sin tomar las medidas preventivas y menos dejar bajo “designio divino”.

2. Embarazo
De interceptarse óvulo y espermatozoide, estos se unirán, fusionando sus núcleos y formando una sola célula que, a partir de ahí, emprenderá su camino hacia el útero mientras también inicia un proceso de mitosis multiplicándose en número de células.

Pasados tres a cuatro días desde la ovulación, el óvulo fecundado llegará al útero donde podría tardar de dos a tres días más para fijarse al endometrio, lugar en que se desarrollará el nuevo ser (1).

3. Anticoncepción Oral de Emergencia (AOE) y su mecanismo de acción.
El anticonceptivo oral de emergencia (AOE) es un método que brinda una alternativa ante las relaciones sexuales forzadas o violaciones sexuales, coito sin uso previo de anticonceptivo, mal uso o falla de este (4). Es necesario acotar que este método es eficaz solo en las primeras 72 horas posteriores al acto sexual; fuera de este tiempo, no se debe usar.

Está demostrado que la AOE funciona gracias a que impide la ovulación, a su vez espesa el moco cervical haciendo que el espermatozoide no avance su camino hacia el interior del útero (5). Así por ejemplo las píldoras anticonceptivas de emergencia de levonorgestrel previenen el embarazo impidiendo o retrasando la ovulación, y evitan la fertilización de un óvulo por su efecto sobre el moco cervical, volviéndolo más espeso, y con eso se disminuye la movilidad del espermatozoide, por lo tanto también su capacidad de unirse al óvulo (4).

Entonces nos respaldamos en evidencia científica actualizada para afirmar que una vez ocurrida la fecundación, la AOE no interfiere con el proceso de implantación del óvulo fecundado y que tampoco interfiere el desarrollo embrionario de un óvulo ya implantado.

Lo que se debería tomar en cuenta es que la AOE es un buen método que permite la prevención de embarazos no deseados y, como consecuencia, la protección de la vida de la mujer.

Como ya se explicó, se debe prestar atención al mecanismo de acción, ya que la AOE al impedir la ovulación, no dispondrá un óvulo que fecundar, por lo tanto no habrá embarazo; además, de ser el caso que la relación sexual haya ocurrido posterior a la ovulación donde ya se produjo un óvulo, este método como segundo mecanismo de acción espesa el moco cervical, impidiendo que espermatozoide y óvulo se encuentren; entonces queda demostrado que no es un método abortivo, trayendo al suelo las falsas teorías en las que muchas autoridades políticas influenciadas por sus homólogas eclesiásticas se basan, pues aquí no se está atentando contra la vida de un supuesto “nuevo ser” sino que simplemente se anulan las condiciones para que el embarazo ocurra.

4. Derechos sexuales y reproductivos (DSR) y legislación peruana sobre AOE.
Por otro lado, cada mujer u hombre tiene todo el derecho a decidir sobre su sexualidad, con total libertad, sin verse sujeta(o) a coerción, discriminación o violencia; a decidir sobre si tener o no tener hijos, el número y espaciamiento de estos, así como a tener información veraz y con base científica y acceso a metodología anticonceptiva. Traducido todo esto, a tener Derechos Sexuales y Reproductivos (DSR), los mismos que se mencionaron y reconocieron en la Conferencia sobre Población y Desarrollo en el Cairo, 1994 y la Cuarta Conferencia Mundial sobre la Mujer en Beijing, 1995.

La constitución política en nuestro país no hace mención explícita a los DSR de las personas, sin embargo sí reconoce una serie de derechos que están inmersos o relacionados directamente con los DSR de cada ciudadano: así encontramos el derecho a la dignidad, al libre desarrollo de la personalidad, además del derecho a la vida, a la integridad física y mental, a la libertad de conciencia, a la libertad de información, a la intimidad personal por citar algunos.

Asimismo, el 28 de julio de 2005, queda aprobada la norma técnica que tiene como objetivo garantizar y estandarizar los procesos de atención en planificación familiar en el marco de los DSR con enfoque de género, estableciendo que toda persona tiene derecho a disfrutar del más alto nivel de su salud para que le permita disfrutar de su sexualidad; a decidir libre y responsablemente el número y el espaciamiento de sus hijos; a tener acceso con igualdad y sin discriminación alguna incluida la orientación sexual a los servicios de Salud Reproductiva y Planificación Familiar; al acceso a métodos anticonceptivos para realizar una elección libre y voluntaria; a tener acceso a servicios de calidad en salud sexual y reproductiva sin ningún tipo de coacción; a que las instituciones de salud velen porque se cumplan estos principios.

Por desgracia en nuestro país, los DSR de las mujeres no han sido plenamente reconocidos, al punto que la legislación sobre AOE se ha venido dando tras un velo de machismo, en el que hasta las autoridades eclesiásticas se han permitido dar mensajes en contra de este anticonceptivo, pese a que Perú es un país laico, y como tal la iglesia no debería influir al momento de legislar sobre temas relacionados con los derechos sexuales de las personas.

El argumento de los opositores es la defensa de un ser hipotético, no demostrado y bajo la premisa de “defensa de la vida”.

Fe, ciencia y machismo
Pese a que la legislación peruana por fin comienza a tener una postura más favorable a los derechos sexuales, paradójicamente aún se percibe que hay un gran número de mujeres (sin contar a los varones) que si bien reconocen que éste método anticonceptivo ofrece una salida ante una situación no deseada, todavía lo ven como algo que atenta a la fe, prefiriendo aceptar lo que por “designio divino” les tocó vivir, y que por tradición y religión la misión de la mujer es el llamado a “dar vida” pese a las condiciones en que ésta se dé.

Para quienes tenemos una visión panorámica de lo que sucede, podemos afirmar categóricamente que esta situación no es más que el producto del letargo y la falta de interés del Gobierno Peruano en reconocer y legislar a tiempo a favor de los derechos sexuales de las personas, más aun el de las mujeres; que el Gobierno al haber prestado mayor atención a la “religiosidad” ha venido permitiendo que se legisle dándole a la mujer un valor casi de mera reproducción.


Si a esto le sumamos la desinformación, tenemos la fórmula perfecta para seguir en el caos que los embarazos no deseados traen consigo; entonces, podemos dilucidar que ante tales condiciones, por desgracia ,para muchas de nuestras mujeres no es una opción el uso de la AOE como medio de protección de su vida; pero no es una opción por voluntad propia, sino por mero desconocimiento que se da por falta de información , porque el Estado (casi de la mano de la iglesia y el machismo) no ofrece las condiciones para que sea la propia mujer quien reconozca, se empodere e interiorice que tiene derechos sexuales, que no tienen que entrar en conflicto con su fe y los haga respetar.

No perdamos de vista nuestro principal enfoque, y este es la salud de cada persona, traducida en salud social, principalmente la de nuestras mujeres, pues un gran número de embarazos no deseados terminan en abortos clandestinos en lugares insalubres que atentan a la integridad física de las mujeres, además de los problemas psicológicos.

Tengamos en cuenta que ante violaciones sexuales o cualquier relación íntima sin uso de preservativo, la persona no se expone solo a un embarazo no deseado, pues, la AOE no protege de las infecciones de transmisión sexual ni el VIH, ya que no es un método que evite el contacto con los fluídos corporales de la otra persona.

Si deseas profundizar más, te sugiero visitar las referencias bibliográficas que usé para escribir este artículo:
1. Saludemia. Planificación familiar. Lima: Saludemia; 2016
4. Organización Mundial de la Salud. Anticoncepción de Emergencia. España: Organización Mundial de la Salud; 2016.
5. Centro de la mujer peruana Flora Tristán. Anticoncepción Oral de Emergencia. Lima: Centro de la mujer peruana Flora Tristán; 2016.
8. Petrell E. Política de anticoncepción oral de emergencia: la experiencia peruana. Simposio [Serie en internet]. 2013[Citada 2016 octubre 31]; 30 (3):m [Alrededor de 2 pantallas]. Disponible en: http://www.scielosp.org/pdf/rpmesp/v30n3/a19v30n3.pdf



viernes, 23 de diciembre de 2016

Risky teenage Love (Somewhere Piura Andes)

Risky teenage Love (Somewhere Piura Andes) By Marco Paulini

PACAIPAMPA, Peru – It seems to be a typical soap-opera scene: passion overflows two teenagers, who not worryiing about place and time, decide to make love. Around, green mountains, shiny blue sky, beautiful Andean birds tweetts are the whole romantic picture.

But that scene does not come out from the mind of a drama’s screenwriter or producer, where sex is key part of magic formula. It is a reality with risky consequences for their lives and the lives of whoever they meet or will meet.


In bellavista de Cachiaco, a village at Piura Andean Range, Peruvian Northwestern, 14-15 year-old teenagers have already started their sexual life on their romantic landscapes or when they could go beyond, “to the city”, looking for best life conditions.


But what about protection when they have sex?
  While I was working there, I asked directly san Francisco de Asis High school’s students.

We Do Not Protect
Bellavista de Cachiaco is a village 10 hours away by pick-up from Piura City, previous stop in Pacaipampa town, located deep below a valley at Andean Range, 5729 feet height. It became known because it is the birthplace of Corazón Serrano cumbia band creators, although it is also the Western gateway to enter Huarinjas lakes.

But what I look for has no magic neither mysticism. I want to know if sexually active boys and girls, at least, are protecting with a method apparently available for them – condoms.


Beginning this Annual Course, we applied a poll, being careful about informing its objective and looking for 57 both sexes teenagers to participate anonymusly and volunteeerly for free.


We found just 2 in each 25 know what a condom is and how it works, but the worst was 11 of these 25 have a negative attitude about it.


Condom is a barrier contraceptive. That means it unallows semen containing spermatozoons gets physical contact to an ovum.
No physical contact, no fecundation. So, no pregnancy.

Also, this method is suggested to avoid diverse sexual transmitted infections (STI) contagion, including HIV/AIDS.


If I Get Pregnant, It’s For Love 
Poll we applied showed that students who started their sexual life are 15 to 16 years old, in majority.

Our research also showed 64.9% of teenagers ignore they can get pregnant during penetration without condom even not having an orgasm.
Majority of this percentage are male teenagers (38.6%).
40.4% ignore they have to look for a contraceptive method before the intercourse. 52.6% does not preview neither pay attention on the possibility of a pregnancy before it happens.

54.4% assumes if pregnancy would occurs during teenage does not matter because “it’s product of love.”


Tales, Myths and Legends About Condom 
On student’s poll(males are majority), it is evident that 47.4% believes using condom threatens trust the couple has on their relationship, 52.6% thinks it limits sexual pleasure, 54.4% opine using it does not could provide them safety neither pleasure, and 64.9% believes continous using of condom causes sexual impotence in long term (.36.8% are males).

Our poll in Bellavista de Cachiaco shows 70.2% asked teenagers opine condom protects them from majority of STI, but 50.9% does not know it avoids contact to couple’s secretions during intercourse.

In doubting position, we find out 54.4% who has wrong conception that condom protects them from absolutely all STI.

50.9% does not know totally five steps proposed by World Health Organization (
WHO) to use it right, and 56.1% ignores condom does not protect if it is used just few before ejaculation, number represented in its majority by male teenagers. 23% believe wearing a condom just before ejaculation is safe.

Don’t You Have Condoms? It Doesn’t Matter! 
Data gotten in Bellavista de Cachiaco clarify 28.1% of teenagers would have sex with another one else simply “because he/she likes her/him,” even if they do not have a condom at that moment. Notoriously we observed women are who have a major negative attitude about this fact.

42.1% of this population do not pay attention before a intercourse, they must look for information to avoid STI, that they do not care using condom as protecttion if they have sex with his girlfriend/her boyfriend.


38.6% unknow they can infect from any STI during their first sexual experience if they do not use condom, and they speak it out advising their friends that it is not necessary to use it during their first sexual experience.


Conclusions
First – Evaluating knowledge on condom physiology as contraceptive method and protection against STI, more than a third part of teenagers in Bellavista de Cachiaco unknow how it works.
Second – In general terms, an elevated percentage of teenagers in Bellavista de Cachiaco unknows how to use a condom correctly, including five steps proposed by WHO.
Third – Majority of teenagers in Bellavista de Cachiaco is negatively proned to use a condom as protection against STI, as well as contraceptive method, that leads them to risky behaviors and situations turning them into a vulnerable population and –literally- unprotected before non-wanted pregnancy.
Fourth – Myths and believes before condom using are still present in more than a half of Bellavista de Cachiaco population, and unfavorable attitudes those lead on, are result of an unapproppriated information from adults, society, who are in charge of guiding and teaching teenagers.
In brief, if almost nobody knows how it is used, then almost nobody will have a possitive attitude about condoms. , It is practically unprotected sex. And this is the discussion point to empower or to improve any prevention strategy.
Do not give up on the debate.

Marco Paulini is a proffessional obsthetrician who lives in Sullana, Peru. He produced this report base don a research available in Spanish by writing at factortierra@gmail.com . Edited and translated by Nelson Peñaherrera.
© 2014, 2015-2016 Asociación Civil Factor Tierra. All Rights Reserved.