Argentina - Rural reproductive health (Misiones, Salta, and Santiago del Estero Provinces) (Vol. 2 of 2) : Annexes

Report No. 22235-AR Argentina Rural Reproductive Health (Misiones, Salta and Santiago del Estero Provinces) (In Two Volumes) Volume 11: Annexes June 29, 2001 Environmentally and Socially Sustainable Development Latin America and the Caribbean Region Document of the World Bank  CURRENCY EQUIVALENTS Currency Unit = Argentine Peso.(ARS) US$1.0 = ARS$0.99984 (May 31, 2001) GOVERNMENT FISCAL YEAR January 1 to December 31 WEIGHTS MEASURES Metric System MAIN ABBREVIATIONS AND ACRONYMS AIDS Acquired immune deficiency syndrome APS Areas de Programas de Salud CEDES Centro de Estudios del Estado y la Sociedad CEPA Comite Ejecutivo Para el Estudio de la Pobreza CGAP Consultative Group to Assist the Poorest CRLP The Center for Reproductive Law and Policy GNP Gross National Product GDP Gross Domestic Product CNM Consejo Nacional de la Mujer GWCIH GW Center for International Health HDI Human Development Index IRV Human immunodeficiency virus ICPD International Conference on Population and Development INDEC Instituto Nacional de Estadistica y Censos NBI Basic Needs Index NGO Non governmental Organization PAHO Pan American Health Organization PFA Platform for Action of the Fourth World Conference on Women PROMIN Programa Materno Infantil y de Nutrici6n PQLI Physical Quality of Life Index SAGPyA Secretaria de Agricultura, Ganaderia, Pesca y Alimentacion SIEMPRO Sistema de Informaci6n, Monitoreo y Evaluaci6n de Progranas Sociales SPSS Statistical Package for the Social Sciences STD Sexually transmitted diseases TFD Total Fertility Rate UBN Unsatisfied basic needs UNDP United Nations Development Program UNICEF United Nations Children's Fund WHO World Health Organization Vice President David de Ferranti Country Director Myrna Alexander Sector Director John Redwood Task Manager Estanislao Gacitua-Mario  ARGENTINA RURAL REPRODUCTIVE HEALTH (Misiones, Salta and Santiago del Estero Provinces) TABLE OF CONTENTS Volume I: Main Report EXECUTIVE SUMMARY ...........................I CHAPTER 1 INTRODUCTION .....................................................................................................1 CHAPTER 2 REPRODUCTIVE HEALTH AND POVERTY ...................................................6 CHAPTER 3 POLICY, PROGRAMS AND SERVICES .................................................. 17 CHAPTER 4 POVERTY, GENDER AND REPRODUCTIVE HEALTH ................................. 26 CHAPTER 5 CONCLUSIONS AND POLICY ISSUES ............................................................ 67 REFERENCES Volume 1I: (Annexes) Annex 1 Study Methodology Annex 2 Reproductive Health Legislation in Argentina Annex 3 Focus Group Reports (Spanish) Annex 4 Informant Interviews (Spanish) Annex 5 Annotated Bibliography This report was prepared by a team led by Estanislao Gacitua Mari6 (LCSEO) and consisting of Steven Schonberger (LCSER), Quentin Wodon (LCSPE) and Corinee Siaens (LCSPE); Rosalia Rodriguez-Garcia, Xavier Solorzano, Santiago Cornejo, Marita Schlesser and Sara Semal of The George Washington University Center for International Health (GWCIH); Natividad Nassif, Ruben Dario BrandAn and Silvana Passeri of the Universidad Nacional de Santiago del Estero (Santiago, del Estero, Argentina); Lidia Schiavoni and Eda Comejo of the Universidad Nacional de Misiones (Posadas, Argentina); Maria Angela Aguilar and M6nica Vandam of the Universidad Nacional de Salta (Salta, Argentina). Sandra Cesilini and Norma Sanchis from the Buenos Aires Resident Mission provided outstanding support in the field. Valuable peer review comments were provided by Anabela Abreu, Maria C. Correira, Ariel Fiszbein, Ruth Levine, Thomas Merrick, Maria Valeria Pena, and Laura Tlaiye from the World Bank; Muhiuddin Haider from the Department of International Public Health, School of Public Health and Health Services, the George Washington University; and Robert Bernstein from the GW Department of International Public Health and the US Department of Health and Human Services.   ARGENTINA RURAL REPRODUCTIVE HEALTH ANNEX 1 METHODOLOGY   Introduction 1. This study analyzes the interaction between reproductive health issues, socioeconomic factors and gender identity among poor rural women in three provinces in Northern Argentina (Misiones, Salta, and Santiago del Estero). The study uses a social exclusion framework to look at the relationship between reproductive health issues and poverty. A central dimension in defining the women's quality of life is access and control of assets and income, and control of the reproductive process and of women's sexuality are essential to define women's position in society and their capacity to control assets and generate income. The social exclusion framework is a multidimensional model that seeks to identify and explain the processes contributing to the generation of poverty and social inequality. As such, it focuses on the accumulation of risk factors (economic, social, cultural, institutional), making possible to deal with multiple dimensions and variables that other analytical tools do not contemplate. 2. From a methodological perspective, the social exclusion framework combines multiple quantitative and qualitative research tools. The value of using mixed research techniques has long been recognized and World Bank studies are increasingly using this approach in analytical and operational work on poverty (Bamberger 2000; Coudouel and Hentschel 2001; Gacitua and Sojo 2000). Besides the analytical advantage, the social exclusion perspective helps the policy maker to identify specific policy nodes, articulate and prioritize different policy interventions. Specifically, in this case, the social exclusion approach allows to: (i) concentrate attention on a process -that of reproductive health decision making- and the impact this has on impoverishment and overall women's quality of life; (ii) identify forewarning signs, or the level of intensity of certain risks that tend to accumulate and to make more difficult for poor rural women to overcome and; (iii) decision-makers to assess policy interventions and to set priorities by identifying the factors more relevant for improving the reproductive health status of rural women. Study Design 3. This is a prospective, cross-sectional study that applies qualitative and quantitative research methods. The study was designed to gather primary (and secondary) data on key reproductive health indicators among poor rural women and to understand the relationships between knowledge, beliefs, and attitudes about reproductive health and socioeconomic conditions of the women. Particularly, the study looked into reproductive health behavior, attitudes related to family planning, illness, medical services, community participation, women's perceptions of everyday realities and the value they assign to their roles (gender identity) and, the relationship between these factors, reproductive health status and access to means of production. The study seeks to understand how the reproductive health status favors or limits women's productivity, their income generation potential and social inclusion. 4. The study comprised a random (cluster) sample of three hundred household (1,973 individuals, 52 percent women, 48 percent men)with poor rural women with at least one child, focus groups (13) with women and men, and in-depth interviews (18) with key 1  informants. The study results cannot be generalized to all rural populations in Argentina. However, key socio-economic findings are consistent with other studies on rural populations in Argentina and, thus provide a basis for understanding the relationships between reproductive health issues and women's socioeconomic conditions in rural areas. 5. The study was conducted by an interdisciplinary team led by specialists from The World Bank and consultants from The George Washington University Center for International Health (GWCIH) and three Argentine, provincial universities: (i) Universidad Nacional de Santiago del Estero (Santiago, del Estero, Argentina); (ii) Universidad Nacional de Misiones (Posadas, Argentina) and; (iii) Universidad Nacional de Salta (Salta, Argentina). Field work was carried out by the local consultants under the coordination of the Universidad Nacional de Santiago del Estero. Site Selection and Subjects 6. Based on existing information regarding the distribution and severity of rural poverty in Argentina, the provinces of Misiones, Salta, and Santiago del Estero were selected based on their high rural poverty rates and large concentration of small farmers. The study has two different units of analysis: (i) the household and; (ii) women in reproductive age with at least one childe within the household. Sampling 7. In each province a multi-stage cluster sampling strategy was used to select the households (100 in each province; n = 300) from departments that have at least 50% of households with unsatisfied basic needs (NBI). In each department clusters of rural households were selected and in each cluster households to be included in the survey were selected randomly following a transect starting from the household located on the most Northeast point of the cluster. The sample is representative of rural households in poor districts (more than 50% households with at least one NBI) at the provincial level. The interviewees were females of reproductive age that have had at least one child. In the event that the male partner of an interviewee was present at the time of the survey, a separate set of questions was posed directly to him1. Data Collection 8. A review of secondary data and relevant literature (see Volume III) was completed during the design stage of the study. The desk review informed the design of the quantitative and qualitative data collection instruments and tools. Survey 9. The quantitative survey was designed jointly by Bank staff, international consultants (GWCIH) and local consultants (Universidad de Santiago del Estero). The 1 It is worth noting that no attempt was made to elicit data from men if they were not present in the household at the time of the woman's interview. The number of completed questionnaires from men (n= 165) varied by province, and the results were used by researchers to get a broad understanding of men's perspective on this topic. 2  questionnaire was pre-tested in Santiago del Estero to a sample of 30 households in June 2000. During testing, the interviewers were asked to evaluate whether: (i) the questions were rightly formulated (language and style); (ii) the level of comprehension of each question (validity); (iii) different respondents could answer selected questions consistently (reliability) and (iv) the degree of sensibility for the respondents of the questions. Data collection took place simultaneously in the three provinces between July and August 2000. The questionnaire was administered by local trained interviewers (female and male graduate students from the three to local universities) under the guidance of field coordinators. 10. The questionnaire covered basic demographic and socio-economic information for the household, including educational attainment, literacy, age, religious beliefs, ethnic origin, migration, participation in community organizations, economic activities and income flows for each household member, household assets, household expenditures, access to services, health status and reproductive health issues. Reproductive health variables included fertility; prenatal, delivery and postnatal care; complications of delivery; abortion; maternal mortality; sexual and domestic violence; sexually transmitted diseases; sex education; and sexual behavior. Most questions were closed and pre-coded to facilitate the administration of the survey. However, several open-ended questions were included, which were designed to capture interviewees' opinions and perceptions related to women's roles, quality of services, and reproductive behavior. Qualitative Tools 11. Qualitative data was gathered through focus groups and in-depth interviews with key informants. A total of 13 focus groups were organized (6 only women, 4 only men and 3 men and women together). Female participants were all females of reproductive age with and without children. Male participants included both partners of the women and single males with and without children. Focus groups sought to identify perceptions about reproductive health including definitional issues, control over reproductive health, decision making processes, access and management of assets, access to services, and economic and social activities. A detailed guide was designed as a protocol for conducting and recording focus group sessions in order to ensure consistency in the different provinces (see annex 3). 12. In addition to the focus groups, 18 in depth-depth interviews (7 in Misiones; 4 in Salta and 7 in Santiago del Estero), with key informants were conducted to obtain context information, check consistency of the findings and register the views of key stakeholders regarding reproductive health issues. Informants included staff from government programs (extension agents) working on rural development; staff from government reproductive health services; rural women leaders; policy makers; school teachers, and religious leaders from different denominations at the community level. 13. Also, two consultation workshops with national level government officials, civil society representatives and academics working on reproductive health issues were organized in Buenos Aires. In these workshops the study design and, later on, the preliminary results were presented and discussed with the participants to ensure the views of local experts and policy makers were properly considered in the analysis. 3  Data Management and Analysis 14. Each provincial team was responsible for data entry and the preparation of a database with the survey results (n = 100 x 3). In each province, local researchers reviewed and cleaned the data, checking for inconsistencies and errors. Consolidation of the database and initial processing for all of the three provinces was conducted in Santiago del Estero, where data were coded and entered into a SPSS database. Later on, the World Bank team and the GWCIH consultants conducted a quality-level appraisal of the database, tested the consistency of the database, processed the data for analysis, analyzed the data, and articulated the findings. Similarly, the review, processing, and analysis of the focus groups and in-depth interviews was conducted in the field. Gender Identity 15. In an attempt to comprehend how the women in the sample viewed their own identity, this study asked multiple questions to elicit women's perception on issues related to their productive/reproductive and public/private lives. The answers to these questions were latter on classified and a score assigned to each answer based on the place they occupied two axes: (i) productive-reproductive and; (ii) public-private. A modified Delphi technique2 was used to code and assign scores to the women's responses to the open-ended questions about self-identity and gender roles. The scores were summarized in an index for each women in each dimension and plotted. Models to Estimate Impacts 16. To estimate the impact of family size on the women's income generating potential, a model to assess the impact of contraception on wage work was developed. Using a two step procedure - first, the determinants of contraception and delivery were analyzed using a bivariate probit model. The second step consisted in estimating the loss in earnings per capita due to delivery. Using bivariate probit models generates efficiency gains in the estimation because the correlation between the error terms of the contraception and delivery regressions is taken into account. It also enables computing the probability of having a delivery conditional on using contraception or not. Denoting by D* and C* the latent and unobserved continuous delivery and contraception variables, by D and C their categorical observed counterparts, and by X the vector of independent exogenous variables, the bivariate profit model can be expressed as: D* ,X +eD D =1 ifD * > O, D = O otherwise C *=c CX +E C =I if C *> O, C = 0 otherwise El eD I = El ec I =