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Emergency contraception as an element in the care of rape victims

Attorney General Offices of the Federal District and the statesof Hidalgo, Tlaxcala, Morelos, Oaxaca, Veracruz, Mexico, Jalisco,and MEXFAM, CEPAHR, SIPAM, Sí Mujer, ADIVAC, AVISE, COVAC, FAVIand COPAS.
Even though in most states in Mexico abortion is excluded as a crime in the case of pregnanciesresulting from rape, the legislation does not specify the norms by which women can obtain alegal abortion, a fact which makes it extremely difficult to choose this alternative. A partialsolution to unwanted pregnancies from rape would be to provide emergency contraception toraped women.
The purpose of this project was to test the feasibility and acceptability of emergencycontraception as an element in the care of rape victims. Psychologists of the Federal District´sAttorney General Office in Mexico were trained to provide information on emergencycontraception to women who reported a rape at four public ministry agencies specialized insexual crimes, and at the Support Therapy Center, where victims are referred for psychologicalcounseling. In addition, eleven medical back-up referral centers were established with theassistance of MEXFAM, CEPAHR and SIPAM, three NGOs that provide services en MexicoCity´s metropolitan area. According to the AGO´s statistics, 82 rape victims were provided thisinformation between July, 1997 and March, 1997, about 10% of all the women aged 13-55 whoreported a vaginal rape during the period. The proportion of reported rapes that ended in apregnancy decreased from 9.8% during the 18 pre-intervention months to 7.4% during the nineintervention months. A total of 22 women attended the referral centers and an additional elevenwomen received information through the telephone.
To scale up the strategy, workshops were provided to representatives from different stateAttorney General Offices and feminist NGOs. By the end of the project, the AGOs of the statesof Hidalgo, Jalisco, Tlaxcala, Morelos, Oaxaca, Veracruz and Mexico, as well as of fiveadditional feminist NGOs (ADIVAC, AVISE, COVAC, COPAS and FAVI) had alsoincorporated emergency contraception as an element in the care of rape victims. In the twomonths after the workshop, these organizations had provided verbal information on emergencycontraception to 248 women, and had handed out the brochure to 411 women. In addition, mostof them had given talks and replicated the workshop.
OPERATIONS RESEARCH ACTIVITIES AND RESULTS Development of IEC and Data Collection Materials Training of the Staff of the Support Therapy Center EMERGENCY CONTRACEPTION AS AN ELEMENT IN THE CARE Title XV of the Federal District=s Penal Code considers as sexual offenses, among Sexual harassment, defined as repeatedly besieging a person of any sex, using ahierarchical position derived from work, academic or domestic relations or any otherimplying subordination.
Sexual abuse, defined as the execution of a sexual act without the consent of a person andwithout the purpose of reaching coitus.
Rape (estupro), defined as coitus with a person older than 12 years of age and youngerthan 18 years of age, obtaining consent by means of deceit.
Rape (violación), defined as coitus with a person of any sex by means of physical ormoral violence, the vaginal or anal introduction of any element other than the penis,coitus with a person under 13 years of age, and coitus with a person without the capacityof understanding the meaning of the act or by any other cause that impedes resisting theact.
When a sexual offense is suffered, the victim must report it to an agency of the FDAGO to set in motion the legal process to detain the aggressor and, in the case of sexual crimes, to referthe victim to specialized care centers. In the Federal District, reports on sexual offenses must bepresented in any of the four Specialized Agencies in Sexual Crimes (SASC) of the FederalDistrict=s Attorney General Office (FDAGO). These specialized agencies are open 24 hours aday, are staffed only by females, and their staff includes physicians and psychologists. Inaddition, the four SASCs refer all women filing reports to the Support Therapy Center (STC)where specialized psychologists provide care to victims until they recover their mental health.
The STC also refers women needing health services to appropriate health care facilities, andprovides legal assistance to those needing it.
During the period January-September, 1995, 2,690 sexual crime reports were presented en the four SASCs. The sexual crime with the highest incidence was rape, with 47.5% of thecases, followed by sexual abuse, with 27.7% of the cases. Of the 1,277 rape reports, 822 werereports for vaginal rape in women between 13 and 55 years of age, and of these, 86 resulted in apregnancy. In addition, there was a loss of follow-up in 288 cases in which pregnancy wasconsidered a possible result. Seventy two percent of rape reports were presented within the first72 hours following the rape.
During January-September, 1995, the Support Therapy Center (STC) cared for 478 rape victims. In addition, its Hotline for Sexual Crime Victims (CETATEL) received 1,449 calls, ofwhich 319 concerned rapes.
The Federal District=s Penal Code considers in articles 329 to 334 the conditions under which induced abortion is punishable. Article 333 excludes as a crime abortion Acaused only bythe neglect of the pregnant women and also in the case that the pregnancy is a result of rape.@ However, the legislation does not specify the norms that a woman in these situations can followin order to obtain a legal abortion, a fact which most of the times leave women without recourse.
In practice, the FDAGO refers for abortions at public hospitals only a fraction of the womenwho report a pregnancy resulting from rape. During January-September 1995, only three womenwere referred for legal abortions. Thus, 83 women were not able to interrupt an unwantedpregnancy resulting from rape, as provided by the law.
The obstacles to legally interrupting a pregnancy resulting from rape are of a practical nature (such as the time needed to comply with legal procedures, the referral to the appropriateinstitution, the scheduling of the surgery) but also of a psychosocial nature, since the weight ofmaking the decision falls on the psychologically harmed victim. Thus, it is not rare that thepregnancy gets to term.
In order to protect the mental and physical health of the woman, and avoid the economic, psychological and social costs of a pregnancy or an abortion resulting from rape, a strategyshould be developed to prevent those pregnancies and abortions.
A partial solution to the problem of unwanted pregnancies resulting from rape would be the use of emergency contraception as an element in the comprehensive care of victims of thiscrime. Emergency contraception is the use of contraceptive methods after an unprotected sexualrelationship. By definition, these methods are Anot abortifacient, they act preventing anunwanted pregnancy"1.
The most common emergency contraception method involves the use of combined oral contraceptives: women who have unprotected sexual relationships may avoid an unwantedpregnancy swallowing as soon as possible, and not after 72 hours of the sexual relation, twocontraceptive pills with 50 mcg ethynil estradiol/250 mcg levonorgestrel followed by twoadditional pills after 12 hours. In the case of low dose pills (30 mcg ethynil estradiol/150 mcglevonorgestrel), four pills must be swallowed in the first 72 hours after the unprotected sexualrelation, followed by four additional pills after 12 hours. There are no known counter indicationsfor these regimes, and they are 98% effective in the prevention of pregnancies. Secondary effectsinclude nausea (in approximately 50% of the cases), irregular uterine bleeding and tenderness of breasts2. Because these side effects are very common, counseling for women should includecorrect use of the emergency contraceptive method; possible side-effects and their management;and family planning methods for preventing pregnancies in the future.
Given that 71.6% of rape victims present the report of the crime at any of the four SASCs in the first three days after the rape, emergency contraception could help prevent over two thirdsof the pregnancies resulting from rapes reported to the FDAGO. Accessibility to the methodwould not be a problem, since combined oral contraceptives are widely available in pharmacies,as well as in social security clinics and health centers. However, emergency contraception isrelatively unknown by service providers, making it necessary to train service providers both inthe clinical management of users, as well as in counseling techniques for rape victims.
The main objective of this project was to test the use of emergency contraception as an element in the care of rape victims in Mexico City. Specific objectives included the following: Test the feasibility, acceptability and effectiveness of providing information onemergency contraception to rape victims that present a report in the four FDAGOagencies specialized in sexual crimes.
Disseminate and scale up the strategy for providing emergency contraception as anelement in the care of rape victims among Attorney General Offices of the different statesof Mexico, as well as among non governmental organization who provide services forabused women.
This operations research was a demonstration project in which no formal experimental Given the restricted access to rape victims and the need for confidentiality of data, the number of rape victims who were advised by the psychologists on emergency contraception, thenumber of medical back-up referral centers and the number of women who attended the referralcenters were used as the main dependent variables to evaluate the strategy to introduceemergency contraception as an element in the care of rape victims. This information wascollected by the staff of the FDAGO and of the referral clinics and physicians.
To evaluate the second objective, the number of dissemination and institutionalization activities, as well as the impact of these activities were used.
In the following section, further information on variables, data collection instruments and results of the activities are presented.
OPERATIONS RESEARCH ACTIVITIES AND RESULTS Three main activities were carried out to test the use of emergency contraception as an element in the care of rape victims: the development of IEC and evaluation materials, training ofthe psychologists at the Support Therapy Center of the FDAGO, and the establishment of areferral system for medical back-up. In the following three sections of this chapter, each of theseactivities are described. The last section of this chapter presents the results.
Development of IEC and Data Collection Materials IEC materials developed for the project included a brochure on emergency contraception for victims, a leaflet for screening and counseling women, and a package with photocopies withdifferent articles on emergency contraception.
The brochure is presented as Appendix 1. The aim of this brochure is to give all the basic information that a raped women may need to decide if she should use emergency contraceptionand to enable her to follow the treatment if she decides to do so, including form of use,effectiveness, and side effects and their management. A first draft of the brochure was pretestedduring the training sessions of the psychologists of the FDAGO, who were asked to review thedraft brochure and to show it to some patients to see if it was understood. The draft was alsocirculated among different physicians and editors and their comments were incorporated. Themain criticism of the brochure was that no institution signed it. Neither the Attorney GeneralOffice or the General Direction of Reproductive Health wanted to appear as sources of thebrochure, but a few months later MEXFAM agreed to sign it. Other recommendations includedchanging the design, using colors, modify the wording, dropping one brand of pills that did nothave the formulation indicated in the brochure, dropping counter-indications, and including suchinformation as the need to avoid sexual relations or using contraception until the return ofmenses.
The counseling guide for victims consisted of two type-written pages in which step by step suggestions on how to screen women and provide counseling on emergency contraceptionwere listed. The counseling guide is presented as Appendix 2.
Finally, participants were given a package with photocopies of different articles in journals, manuals and leaflets on emergency contraception. It was expected that these materialswould assure participants of the scientific validity of emergency contraception, as well asreferences they could consult in case of doubts.
Regarding the data collection materials, four forms were designed to collect information on the characteristics of women filing reports for rape, and the number who received informationat the public ministry agencies, the Support Therapy Center and the hotline for sexual victims.
Follow-up forms to assess the use of emergency contraception were also designed. However, a follow-up conducted five months after the beginning of the intervention showed that thepsychologists were afraid of using these forms and preferred to keep personal records. A second,simplified version was adopted in December, 1996, but in early 1997 a new director of theSupport Therapy Center was appointed, and one of her first decisions was to change theinformation system that was being used to reflect changes in the service delivery system whichare explained in section 6.4. In this new information system, the Afirst contact@ form includesan item which asks if the woman was given information on emergency contraception (seeAppendix 3). This shows that by that time emergency contraception had for all practical purposesbeen institutionalized at the FDAGO.
Training of the Staff of the Support Therapy Center The objective of the training was to prepare the psychologists of the Support Therapy Center so that they could screen women in need of information on emergency contraception andto give them the appropriate information on form of use and side-effects. This information was tobe provided both at the four specialized public ministry agencies (where victims of rape file theirreports) as well as at the Support Therapy Center, where psychological treatment is provided tothe victims.
The training sessions had a duration of four hours. Four different sessions were conducted in June 17 and June 24, 1996. Besides the psychologists, some legal physicians of the specializedpublic ministry agencies and the telephone operators of CETATEL, the hotline for sexual crimevictims, attended the sessions. Finally, a few staff members from the MOH=s General Directionfor Family Planning and feminist NGOs were invited and attended these sessions. The totalnumber of persons trained was approximately 97, with each session attended by about 15 - 30persons. In addition to the initial training sessions, one session was conducted in February, 1977,to train 33 new staff members who had arrived at the Support Therapy Center as part of the re-organization that took place in the beginning of the year.
The following topics were included in the training: Introduction and presentation of the project Emergency contraception: treatments and side effects.
Screening rape victims for emergency contraception.
Counseling in emergency contraception for rape victims.
Use of data collection forms to follow up the results of the project A questionnaire was applied at the beginning of the sessions to assess the knowledge and attitudes of attendees toward emergency contraception. A copy of the questionnaire is presentedas Appendix 4. A total of 62 attendees responded the questionnaire, of which 44 werepsychologists, seven social workers, seven physicians and four of other professions. Seventy twopercent said they had heard of emergency contraception, including 75% of the psychologists.
Sixty two percent of the total correctly said emergency contraception consisted in preventing apregnancy in the first few days after unprotected sex. Fifty percent of the total knewcontraceptive pills could be used for emergency contraception purposes. Only two of themthought that emergency contraception worked as a micro abortifacient, with the reminderanswering that it worked by preventing implantation or fecundation. Thirteen percent knewsomebody who had used emergency contraception, most of them psychologists.
In the second part of the questionnaire, a brief explanation of what emergency contraception is was provided and the attitudes towards it was assessed. Eighty nine percent saidthey would completely agree or agree to recommend emergency contraception to women whofiled a report for rape. When asked in which cases should emergency contraception berecommended, 77% said it should be provided to any women in need of it. Fifty six percent saidthe treatment should be made available in centers that attended raped women, hospitals and in allclinics offering family planning, and 26% thought that in addition, it should be offered inpharmacies and schools. Sixty one percent thought information on emergency contraceptionshould be disseminated through the mass media, and 27% thought that only physicians should beinformed through professional journals and meetings.
Even though the results of this questionnaire showed a favorable attitude towards the use of EC as an element in the care of rape victims, during the training sessions several participants,specially physicians, showed large concerns of the implications and potential consequences ofgiving information on emergency contraception in the public ministry agencies. The mainconcern was the potential legal consequences, given that they had not received any written orderrequesting them to provide this treatment. A second source of concern was that the brochure thatwas presented to them was not signed by any institution. A third source of concern forpsychologists was that they felt that, since they were not physicians, they could be accused ofprescribing drugs without a licence. In reality, their main concern was to be accused ofperforming abortions.
As explained in the previous section, during the training, participants were also handed out the brochure on emergency contraception to be give to women, a counseling guide, datacollection forms and a set of photocopies of articles on emergency contraception.
6.3 One of the initial project objectives was to establish referral sites at MOH health centers or hospitals. Given that emergency contraception is not mentioned in the Mexican FamilyPlanning Norms and the uncertainties of its legal status, the General Direction for ReproductiveHealth (DGSR) was hesitant to implement this activity. Although the head of the MOH services of the Federal District was initially supportive of conducting the activity, a request forclarification of the status of EC to the DGSR failed to elicit a response and action was delayed.
For these reasons, MEXFAM and two other small NGOs (SIPAM and CEPARH) were approached to see if they would like to participate as referral sites. They all agreed, and trainingof 35 physicians of 15 clinics and offices was conducted on September 17, 1996. Drs. RaffaelaSchiavon, project consultant, and Josué Garza, director of CEPARH and a very respectedresearcher in biology of reproduction, presented aspects related to the history, medical uses andcurrent research on EC. Other presentations were made by the head of the Support TherapyCenter (on the realities of sexual offenses in Mexico); by Esperanza Reyes, a psychologists whoworks for COVAC, a feminist organization, on psychological aspects of raped women; byDeyanira Herrera, of COVAC, on legal issues and legal assistance for raped women; by GabrielaInfante, of GIRE, on the reproductive rights of raped women; and by Ricardo Vernon, on datacollection and reporting.
Surprisingly enough, many of the same reactions observed in the training of psychologists were observed among participants, not only by some MEXFAM community physicians but alsoby some mid-level managers of the central staff. Nevertheless, the staff of five clinics and sixcommunity physicians were enthusiastic about the opportunity to participate as a referral center.
To facilitate the referrals, the addresses of these clinics and physicians were printed in a slip that was attached to the brochures for women (see Appendix 5). In this way, the womenreceived both the information needed to use emergency contraception on their own, as well as alist of physicians spread around Mexico City´s metropolitan area which they could visit to clarifyany doubts.
Information giving activities started in July, 1996. As explained, the psychologists were supposed to provide information in the first contact the women had either at the public ministryagencies or at the Support Therapy Center. However, in the second month of activities it becameclear that very few of the psychologist working at the public ministry agencies were giving theinformation to women. Their reluctance to do so stemmed from not having direct written ordersfrom the appropriate authorities and their fear of consequences. Other factors included the lack ofa sponsoring institution of the brochure and the fear of prescribing drugs. Nevertheless, at thisstage, nine women had received information at the Support Therapy Center, all of them had seentheir menses return, and all of them were reportedly very grateful for the information given. Allwomen were single, six were 17 or less years of age, all were students or unemployed, and allhad at least some junior high schooling.
In September, the final version of the brochure sponsored by MEXFAM was printed and distributed, and the medical back-up referral sites were established. In October, 1996, a follow upvisit was made to twelve psychologists who worked in three different shifts at the public ministryagencies. During the interviews, it was found that only four said they had given the information to women, and two more said that they had not given the information but referred the women tothe Support Therapy Center. These last two said they would start giving the information giventhe new brochure and the existence of referral sites, and one which had not participated said shewould start providing the information. All of them considered it a great advance theestablishment of the referral centers and the changes in the brochure. Five said that greatersupport from the Support Therapy Center was needed (i.e., written instructions to provide EC). Itwas also observed that the psychologists were not filling out the data collection forms, but werekeeping private records of the women they advised about emergency contraception. In all, thesewomen said they had given the information to 25 women, but only one had kept records. Of her15 clients, 12 had reported the return of menses and 3 had not reported back their status. Thus,apparently 34 women had been given the EC treatment, of which 20 had been followed up. Nopregnancies had resulted in these cases. Follow-up visits showed an increased rate ofparticipation of the psychologists after the referral centers were established.
Table 1 shows that according to FDAGO service statistics, a total of 82 women were given information on emergency contraception between July, 1996 and March, 1997. In the firsttrimester of 1997, there was a decreased number of rapes reported at the Support Therapy Center.
At this time, psychologists working at the public ministry agencies were redeployed to theSupport Therapy Center and started going to the public ministry RAPES, PREGNANCIES, REQUESTS FOR ABORTION, LEGAL ABORTIONS ANDWOMEN ADVISED ON EMERGENCY CONTRACEPTION ACCORDING TO THE SUPPORT THERAPY CENTER=S SERVICE STATISTICS agencies only when informed of the presence of a woman filing a report for sexual abuse or forrape. This apparently made themless effective in providing services. However, as in the previous period, about 10% of the womenwho reported a rape received information on emergency contraception. Even though this seemsto be a small percentage of the cases, it should be considered that the contraceptive prevalencerate in Mexico City is of about 71% of married women of fertile age, that the age range reportedby the service statistics is 13 to 55 years of age, and that about 27% of women file their reportsfor rape more than three days after the rape, so perhaps a high proportion of women who couldactually benefit from the information received it. Unfortunately, no information regarding thenumber of potential beneficiaries is available to assess the coverage of women in actual need.
Table 1 also shows an apparent decline in the proportion of rapes resulting in pregnancies, from about 9.8% of all rapes reported during January 1995-June 1996, to 7.4%during July 1996-March 1997. The effects of providing information on emergency contraception on the number of abortion requests cannot be assessed given the unavailability of thisinformation for the pre-intervention period.
Regarding the medical back-up referral centers, until May, 1997, seven of the 11 reference clinics and physicians had provided services to 22 women and had providedinformation through the telephone to 11 women. Only eight women had returned for follow up,and no pregnancies had resulted. The remaining four reference centers had not received womenor telephone calls of women requesting emergency contraception services.
As part of this project, a large effort was made to disseminate the information on emergency contraception and to scale-up the introduction of emergency contraception as anelement in the care of rape victims.
Although not in the scope of work of this project, dissemination activities were carried out on the basis of opportunities that were detected. These included the following: E-mail: twenty-five organizations listed in one server as feminist and health/socialdevelopment organizations were sent a letter entitled AYou can help us preventpregnancies from rape@ (See Appendix 6). The letter offered training and materials tothose organizations who attended rape victims and gave information on emergencycontraception. Six organizations responded to the offer and were sent materials. Oneorganization posted the letter and the project brochure on their electronic conference andanother published the letter in the January, 1997, issue of Fem magazine, a feministmagazine in Mexico. The largest news group in Mexico on reproductive health,Genero.Venus, also requested the brochure to post it after they read this letter.
Letters to editors: in October, 1996, two national newspapers published news items inwhich it was said that the church approved the use of the pill in certain cases, such assexual violence. This opportunity was used to send one letter to each of the editors inwhich information on emergency contraception was provided and in which personswilling to help prevent pregnancies from rape were invited to participate in our project.
Two persons responded to the invitation, including the manager of a telephone hot line inthe city of Cuernavaca who wanted to include the information on emergencycontraception. The articles and letters to the editors are presented as Appendix 7.
Publication of the emergency contraception brochure in Alternativas: the November,1996, issue of Alternativas, the INOPAL III newsletter with a circulation of 2,000 copiesin Latin America, invited family planning organizations to establish a program to provideemergency contraception to rape victims. In addition, it published a brochure for rape victims that could be readily photocopied (see Appendix 8). Although Alternativasoffered to customize the brochure to the needs of those interested in establishing theseservices, no responses were obtained.
Mailing to justice, family planning and feminist organizations: in June, 1997, packageswith a letter inviting them to establish emergency contraception services for rape victimsand a set of materials on emergency contraception were mailed to 185 justice, familyplanning and feminist organizations in Latin America and the Caribbean, includingAttorney General Offices of the different states in Mexico, the IPPF affiliates, and a largevariety of feminist organizations. The package included 25 project brochures, the Outlookissue on emergency contraception, two MEXFAM and GAP issues on emergencycontraception, the IPPF Medical Bulletin on emergency contraception and the chapter onemergency contraception in Contraceptive Technology. At the time this report wasprepared, one month after the mailing, three responses had been received, twoacknowledging the mailing, and one from a researcher at the Colegio de Mexico, who hadphotocopied the materials and included the topic for discussion in a working group ondomestic violence and health.
Presentation in conferences and meetings: the characteristics and preliminary results ofthe project have been or will be presented at the international meetings on emergencycontraception conducted at the Population Council in New York on October, 1996 and1997; the National Public Health Congress held in Cuernavaca, Mexico, in March, 1997;the annual meeting of the Social Workers in Jalisco and at ITAM´s Violence and WomanWeek, in September,1997: and the annual meeting of the Colegio de Psicólogos, inOctober, 1997.
Scaling-up activities included mostly workshops for justice and feminist organizations, Workshops for justice organizations: three workshops for the staff of the AttorneyGeneral Offices, MOH staff and NGOs were conducted in the states of Coahuila andHidalgo. In Coahuila, in the cities of Saltillo and Torreón, the workshops were attendedby public ministry agents, MOH staff and staff of Sí Mujer, a feminist organization thatprovides health services. Representatives from the AGO of the nearby states of NuevoLeon and Durango were invited to these workshops. Although only four rape victims hadbeen referred by June, 1997 (and only one of them was in the first three days), MOHparticipants in Torreón reported having given five talks on emergency contraception to anapproximate audience of 600 physicians, social workers and staff of the public ministryagencies in the city. In Hidalgo, a workshop was conducted in February, 1997, for staff ofthe state´s AGO, MOH and the University of Hidalgo. The strategy was institutionalized.
By May, 1997, 10 women had received emergency contraception and no pregnancies hadresulted from the rapes.
Workshops for feminist organizations: these have included 1) a workshop for the staff ofFAVI, an NGO in Mexico City that provides services for victims of violence; 2) aworkshop for representatives of 10 feminist organizations coordinated by GIRE. Gireincorporated the topic of emergency contraception on two workshops on abortion (fundedby the McArthur Foundation) for MOH and social security staff in the states of Veracruzand Chihuahua.
End of Project Conference: the last activity conducted by the project was a workshopattended by 65 representatives from eight state AGOs and 10 feminist organizations fromseven states near Mexico City. Presenters at the workshop included Rafaella Schiavon,project consultant, and representatives from organizations that had participated in projectactivities, such as the AGOs of the Federal District and Hidalgo, MEXFAM, FAVI, GIREand CEPARH. Participants were given a package of printed materials on emergencycontraception, and a set of slides to replicate the most important presentations in theirorganizations and cities. The workshop was held in May, 1997. To evaluate theworkshop, a questionnaire was mailed to all participants (see Appendix 9). Thirtyparticipants from 18 different organizations had responded the questionnaire five weeksafter the mailing (mail delivery takes two weeks in Mexico, so respondents had had thequestionnaire only for a week). Seven of the organizations were state AGO; seven werefeminist organizations, and four were educational or reproductive health organizations. Tables 2 and 3 present the main results of this questionnaire.
NUMBER OF PARTICIPANTS WHO HAVE CONDUCTED DIFFERENT EMERGENCYCONTRACEPTION ACTIVITIES AND NUMBER BENEFICIARIES OF THIS ACTIVITIES BY TYPE OF ORGANIZATION OF THE or other staff to provideinformation to women in need victims or women who have hadunprotected sex the implementation of ECactivities in the organization.
Notes: N= Number of respondents; B= Number of beneficiaries of theactivities (persons informed or trained, women given information, etc) NA-not available; rd=radio; /1: only one respondent provided information onnumber of beneficiaries.
In some cases, several participants from one organization responded the questionnaire. If two or more questionnaires provided the same data, only the data from one questionnaire wasused. If different data was presented, then it was assumed that the respondent had includedinformation of her or his own activities and was added. As it can be observed in Table 2, a large proportion of participants had conducted different activities in the weeks following theworkshop, including making available the information to others in their own organizations, giventalks in other organizations, conducted meetings to explore how to institutionalize the use ofemergency contraception and given information on emergency contraception to women whoneeded it.
An analysis of the questionnaires from an institutional point of view showed that of the sixAGOs who participated, six were giving verbal information and brochures to rape victims, andone more was giving only verbal information. Of the six NGOs who participated in theworkshop, four had already given verbal information and brochures to women in need. Finally, ofthe four participants from other type of organizations (MOH in Veracruz, the IPAS representativein Mexico, and two fellows of the Latin American Women=s Health Network from Brazil andChile, three claimed to have given verbal information to women and two to have handed outbrochures.
Except for three participants who said they had had problems, all the respondents said the activities they had conducted had been well received. In all three cases, the association that someusers made with abortion was mentioned. When asked what they had liked most of theworkshop, the participants mentioned mainly the organization and treatment of the participants,the presentations of Drs Schiavon and Garza, the novelty of the topic and the materials that werehanded out. Least liked things were a few presentations, the tendency of some participant toconsider emergency contraception as an abortifacient and their apparent reluctance to use it, andthe fact that the workshop was held in one single day and it was too long.
Finally, in the questionnaire, participants were asked if they had any activities scheduled in the near future, with defined dates, place and participants. As it can be seen, at least one half ofthe participants had scheduled talks, replication of workshops, training of personnel, mass mediamessages, and providing information on emergency contraception to women in need.
NUMBER OF PARTICIPANTS WHO HAVE PROGRAMMED EMERGENCYCONTRACEPTION ACTIVITIES BY TYPE OF ORGANIZATION other staff to provide informationto women in need This project sought to test the acceptability of emergency contraception as an element in the care of rape victims and to extend its use in this context. At the beginning, we faced greatreluctance from all organizations to implement the project. At the Federal District´s AttorneyGeneral Office, it took more than six months of conversations and a substitution of the GeneralDirector for the Assistance of Victims to be able to begin project activities. Conversations toopen MOH referral centers for rape victims failed despite our persistence. Once the projectbegun, the psychologists were reluctant to provide the information to women and theirsupervisors were reluctant to order them in written form to conduct the activities. This reluctancestemmed from the fact that the treatment is taken after the sexual relation and, thus, isimmediately associated with abortion, which is illegal in Mexico. Even when it might beunderstood that emergency contraception is not abortion, the perception that using it can lead tolegal problems remains. Nonetheless, once a few brave psychologists started providing theinformation to women and their gratefulness and the absence of negative incidents was observed,emergency contraception became a routine element in the care of victims. During the course of this project, 82 women were provided the information and perhaps about eight unwantedpregnancies were prevented.
During this project, a very large effort to scale up the strategy was made. As mentioned before, conversations with the MOH to establish referral centers lead nowhere. The value ofNGOs was again proven when MEXFAM decided to provide its support in establishing referralcenters and sponsoring the brochure. CEPARH and SIPAM were also eager to join the project.
Workshops to train the staff of different organizations showed us that, as always, a key element in the introduction of emergency contraception is the support from top management. Inthe states of Coahuila and Hidalgo, a large number of staff members of the AGOs, the MOH andNGOs were trained. However, whereas in Hidalgo the General Director for the Assistance ofVictims took an enthusiastic lead in the implementation of the strategy in all public ministryagencies in her state, in Coahuila no such leadership became apparent and little progress in theimplementation of activities was observed after the workshop.
The end-of-project workshop showed that gathering a large number of organizations that provide services to raped women was a good strategy, specially because by that time we couldalready count on the participation of several organizations that could share their experience. As aconsequence, the workshop seems to have had a very strong impact on the introduction ofemergency contraception as an element in the care of rape victims. Two months after the end-of-project workshop, the AGOs of the Federal District and the states of Hidalgo, Tlaxcala, Morelos,Oaxaca, Veracruz and Mexico, as well as eight NGOs (MEXFAM, CEPAHR, SIPAM,ADIVAC, AVISE, FAVI, COVAC, COPAS and Sí Mujer) were providing emergencycontraception services to victims of abuse. Project statistics of organizations who received directtraining shows that 93 women had been provided emergency contraception, whereas data fromthe end-of-project workshop follow-up questionnaire show that 248 women had been verbalinformation and 411 were given the brochure. However, several organizations had not yetreturned the evaluation questionnaire and it is likely that these numbers sub-estimate both thenumber of organizations providing EC information and the number of beneficiaries from theseactivities.
Finally, this project showed that regardless of whether information on emergency contraception is provided to women or not, often those who come in contact with thisinformation are sufficiently interested in it to further disseminate it. This was a constantoccurrence in this project, both from organizations as well as from individuals participating inthe workshops.
Support Therapy Center AFirst Contact@ Form End-of-project Follow-up Evaluation Questionnaire 1. Consensus statement on emergency contraception. Contraception 52, pp 211-213, October1995.
2. IPPF Medical Bulletin. IMAP Statement on emergency contraception. Volume 28, No. 6,December 1994. 2. Consensus statement on emergency contraception. Contraception 52, pp 211-213, October 1995.
2. IPPF Medical Bulletin. IMAP Statement on emergency contraception. Volume 28, No. 6,December 1994.


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Curriculum Vitae Neil A Martinson Postal Address 27 Illovo Rd Emmarentia 2195 SOUTH AFRICA Tel: +27823316756 Email: Educational Qualifications University of the Witwatersrand, Johannesburg, School of Public Health, Johns Hopkins University, Board certification as a Family Physician Employment History June 2002-present Deputy Director Perinatal HIV Resear

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U ϭ 4.0, P ϭ 0.028), when birds are onlymoving away from the shelf area during thefirst day of foraging. The difference wasonly due to the higher sinuosity of tracksduringHenri Weimerskirch,1,2* Francesco Bonadonna,1(0.294 Ϯ 0.084), where birds are known toFre´de´ric Bailleul,1 Ge´raldine Mabille,1 Giacomo Dell’Omo,3catch most prey ( 9 ), compared with whenbirds were over the

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