Slowing the “Reproductive Treadmill” in Rural Venezuela: The Turimiquire Foundation Story

In the 1970s, I was part of a small group of North Americans, all recent college graduates, who relocated to the northeastern state of Sucre in Venezuela to pursue tropical fruit farming. The remote valley where we have lived and worked since then is typical of the impoverished hinterlands along the South American Caribbean coast. Far removed from public sanitation, medical care, and social services, our campesino (country) neighbors — while living in what many of us might consider a tropical paradise — were and are, by standard economic indicators, extremely poor, generating barely enough income to feed and clothe their large families. When we first arrived in our community, illiteracy was the norm. Girls often had their first child at fourteen or even younger, giving birth to a new baby every other year, so that it was not uncommon for a thirty-year-old woman to have seven or eight kids, with another on the way. Many women went for years from one pregnancy to the next without experiencing menstrual periods. Maternal and infant mortality and morbidity were prevalent facts of life.

In the early years, our crew did what we could to help local families get reproductive health care and family planning through our friendships with doctors and other professionals in the nearby city of Cumaná. The death of a campesina neighbor in childbirth in 1994 became our wake-up call to do more. Brunilde died from postpartum hemorrhaging after giving birth to her seventh child, at the age of thirty-one, in a small mud hut located a two-hour walk from the nearest road. She died while being carried down rocky foot trails and across mountain rivers in a blood-drenched hammock, in a desperate attempt to get her to the road and then to the local hospital in time to save her life. Her newborn died shortly thereafter. Brunilde’s death became a major impetus to create the Turimiquire Foundation, a non-profit organization registered in the United States in 1996 to seek tax-deductible funding in order to offer family planning and education to rural communities in Venezuela and prevent such tragedies in the future.

Dr. Maria Eugenia distributing family planning materials to rural health care providers

In the time that we have lived and worked in Venezuela, the number of inhabitants has grown from about 12 million in the 1970s to well over 30 million in 2018. Very few of the country’s public services have been able to keep up with this population growth. The public health system has been overwhelmed by the large and growing demographic that is — or soon will be — of reproductive age, and family planning services are limited in scope and rarely available. Electricity and water are frequently rationed, and to accommodate all the youngsters coming of school age, public schools now work on a double shift schedule, offering primary classes in the morning and secondary classes in the afternoon. Sadly, although Venezuela has great natural beauty and abundant natural resources, ranging from coastlines to mountains to jungles, the once-pristine environment has been degraded by unregulated human intervention. Primitive slash-and-burn agriculture and small-scale subsistence surface mining have led to deforestation, erosion, and contamination of topsoil and surface water, as well as decimation of the country’s remarkable biodiversity.

Turimiquire is based in the city of Cumaná, the capital of both our municipality and the state of Sucre. We focus primarily on family planning and secondarily on rural education and development, responding to the stated priorities of the communities we serve. From the beginning, working closely with the State Ministry of Maternal-Infant Health, supplementing its existing infrastructure, good policies, and willing staff with our personnel, logistics, and contraceptive supplies as needed, we were able to have a palpable impact in our largely rural county. Over time, responding to word-of-mouth demand, we extended our outreach to two additional rural counties. Through June 2018, on a shoestring budget, the Turimiquire Foundation had served over 45,000 low-income mainly rural women with more than 170,000 cycles of hormonal contraceptives, 8,000 IUDs, and 6,400 surgical sterilizations, and had conducted more than 3,000 reproductive health workshops for over 55,000 teens. We have cumulatively offered over 100,000 “couple years of protection,” the metric by which USAID measures family planning achievement, to the low-income populations that we serve.

Dr. Maria Eugenia distributing family planning materials to rural health care providers

Our experience strongly validates family planning as a powerful catalyst for prosperous families, thriving communities, and healthy ecosystems. We have directly witnessed how, as family size shrinks and maternal and infant morbidity and mortality decrease, each family’s modest resources go further, children grow up healthier, and families can afford to send their (fewer) children to school. Youth, especially girls, thrive with the educational opportunities that their parents never had, and isolated rural communities are invigorated. In the rural areas where population growth has slowed because of our family planning services, we have observed a reduction in slash-and-burn agriculture, leading to less erosion, reforestation, replenished watersheds, and returning wildlife.

But we have reached only a small percentage of the population in the vast rural hinterland that surrounds us. In many of these areas, the reproductive treadmill continues unabated as it has for the past centuries, bearing its quota of pain and tragedy. The enormous unmet need for family planning beckons to us from all sides, just beyond our current realm of influence. Scaling up to meet this demand is our ongoing dream.

The teenage pregnancy rate in Venezuela continues to be one of the highest in Latin America, and the world. Sixteen-year-old Maria came from the countryside to study and work in the capital city of Cumaná, the local magnet for rural immigrants. A sweet, vivacious girl, she grew up in a large family in a remote mountainous area. Maria and one of her brothers are the only literate members of their family. Her innocence was short-lived after she arrived in the city, however, and when she unintentionally became pregnant, she was mortified. She used her very thin physique to hide her pregnancy until almost the seventh month, though many of the experienced women in her milieu suspected the truth of her situation. Maria did not seek an (illegal) abortion, anathema to her rural culture, but she did everything she could to discourage the pregnancy from progressing. She stopped eating to flatten her abdomen, took folkloric “remedies,” exercised inappropriately, and followed whatever bizarre suggestions her peers and others gave her. When her family finally saved money for and insisted on an ultrasound, it showed not one fetus, but two. Even then, she continued in denial, refusing to eat or otherwise cooperate with a healthy pregnancy, until finally she had an extremely difficult, life-threatening, and frightening birth with poor medical support. One of her babies died immediately, and the other baby died shortly thereafter. After six months of painful recovery and feelings of shame, during which the father of the twins was nowhere to be found, Maria resumed her previous student and workaday life, sadly and decidedly wiser.

Sociologist Amarylis Jimenez leading a rural reproductive health workshop

In another of so many similar stories, nineteen-year-old Gabriela was not so fortunate. She died in childbirth at the local hospital, following a difficult pregnancy that she resisted and denied as long as she could. Gabriela’s child just barely survived delivery and is being raised by her immediate family.

We also see cases of (sometimes fatal) illegal abortion complications, newborn abandonment, and even infanticide, but they are less common. What I have most painfully witnessed in my years of working in the field is the tragic human price paid by families when they do not have ready access to reproductive health education and family planning: The sad nobility of mature women forced to bear yet another pregnancy under impossible circumstances. The wrenching trauma of parents whose teenage daughter becomes pregnant and puts herself at risk to terminate the pregnancy, or drops out of school to care for the newborn under the same impossible circumstances. The frustrated love lives of couples who fear an unintended pregnancy. The intimate partner violence that occurs when parents can’t appropriately channel the stress of their reproductive situation. The children who face limited life prospects as scant resources must be spread thin.

And if life wasn’t already difficult enough for poor Venezuelans, everything has become much harder in the current economic crisis. The steep deterioration of the economy and associated social and political strife have led to the collapse of public family planning services and a severe scarcity of contraceptives at the national level. Families are more desperate than ever to control their fertility in a time when raising a child is formidably difficult.

Above, left: Sociologist Juan Carlos leading a rural reproductive health workshop

The Turimiquire Foundation has responded to the decline of public health services by strengthening and expanding its partnerships with the willing-and-able private health care sector. Working together through social marketing, we have been able to maintain and even increase our services in the face of the growing unmet need for family planning. Our biggest challenges are the extreme shortages and hyperinflationary costs of short-term contraceptives — condoms, birth control pills, injectables, and emergency contraceptive pills. Our existing inventory will not last through the end of this year, and there’s little hope of stock replenishment in sight.

Long Acting Reversible Contraception (LARC) offers an important alternative, and thanks to a grant from the Erik and Edith Bergstrom Foundation (which also supports Population Connection), we will be able to sustain our current delivery of IUDs, add implants as a hormonal alternative, and continue apace with surgical sterilizations into the coming year.

Since the late 1990s, we have provided remote rural populations with short-term contraception via the nurses who maintain the rural dispensaries throughout the state. But placing IUDs and implants requires doctors and medical infrastructure — not generally available in remote rural areas. To address this challenge, we are partnering with rural townships that can provide public buses to bring groups of eligible women to the clinics where we provide our LARC services and take them home afterwards, often an all-day enterprise.

Surgical sterilization (tubal ligation) is Venezuela’s most popular form of birth control. Traditionally, women have had the number of children they desired, often without physician-recommended spacing, and then sought sterilization. Over the past twenty years, the Turimiquire Foundation may well have become the most affordable provider of safe surgical sterilizations in Venezuela. Women come to us from all over the eastern half of the country, including from the capital city of Caracas, some 200 miles to the west. The average age of our patients is about thirty years old, and the average number of children they have is four. These measures are shifting to a younger average age with a smaller number of children, as we have already reached many of the older women in our purview and younger women are deciding earlier to have fewer children.

Over the years, Turimiquire has seen mothers and daughters come to the clinic together to be sterilized on the same day — a family event. Gleibys, forty years old with three children, and her daughter Girardine, twenty years old with two children, came together from their rural community to have their surgical sterilizations on the same day. Gleibys did not have her eldest daughter until she was twenty years old, but Girardine already had two children by that age.

In another example, Francis, forty years old with two children, and her daughter Francis Riva, twenty-five years old with three children, came into the clinic from a small coastal fishing village to have their sterilizations together. Francis gave birth to Francis Riva when she was fifteen (not uncommon in remote rural areas), used an IUD for many years, and recently had another baby. In order to avoid any future pregnancies, which at her age would be high-risk, she chose to be sterilized. Francis Riva already had three children and considered her family complete. Her children are the older niece and nephews of her mother’s baby boy. (In rural areas where childbearing typically begins in adolescence and ends in middle age, it is not unusual for nephews and nieces to be older than their aunts and uncles.)

Dr. Silvia Quijada, Turimiquire Foundation surgery coordinator, holds a Population Connection envelope being used to deliver paperwork to a surgery team. Steven Bloomstein, right, says that Population Connection envelopes also come in handy for distributing condoms, especially to adolescents concerned with privacy.

At the Turimiquire Foundation, we have seen reproductive health in our target populations tangibly improve in the two decades since our founding. We have developed and demonstrated proven strategies to deliver our services, and our small local initiative has grown to become the only recognized reproductive health non-profit serving three rural counties in our state of Sucre. We are proud of the positive impact that the Foundation has had in so many rural communities and urban barrios (neighborhoods).

When we started, our mission was to keep women like Brunilde from dying from preventable causes through access to family planning. Over the years, having seen for ourselves the multitude of benefits that family planning brings, we have learned that meeting reproductive health care needs is not only a cornerstone of family and community well-being, but the key to prosperity in poor rural environments. Our vision has expanded, and we are truly grateful to all our institutional and individual donors for giving us the opportunity to continue this critical effort throughout and beyond these tumultuous times.

The Turimiquire Foundation was formed in 1996 to help the poor rural communities in northeastern Venezuela. Turimiquire, pronounced Too-ree-mee-kee-ray, means “Seat of the Gods” in the indigenous Carib language, and refers to the mountain range that dominates this tropical coastal area. To learn more, please visit turimiquire.org.

 

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