Argentina - Rural reproductive health (Misiones, Salta, and Santiago del Estero Provinces) (Vol. 1 of 2) : Main report

Report No. 22235-AR Argentina Rural Reproductive Health (Misiones, Salta and Santiago del Estero Provinces) (In Two Volumes) Volume 1: Main Report June 29, 2001 Environmentally and Socially Sustainable Development Latin America and the Caribbean Region Document of the World Dank  CURRENCY EQUIVALENTS Currency Unit = Argentine Peso.(ARS) US$1.0 = ARS$0.99984 (May 31, 2001) GOVERNMENT FISCAL YEAR January I 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 H[V 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 Programna Materno Infantil y de Nutrici6n PQLI Physical Quality of Life Index SAGPyA Secretaria de Agricultura, Ganaderia, Pesca y Alimentaci6n SIEMPRO Sistema de Informaci6n, Monitoreo y Evaluaci6n de Programas 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 ...................................................l1 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 II: (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 Cornejo 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.   EXECUTIVE SUMMARY 1. This report presents the findings of an exploratory study conducted in poor rural areas of three provinces in northern Argentina (Misiones, Salta, and Santiago del Estero). These provinces were selected because they have large concentrations of rural population, particularly small (minifundista) landholdings, high poverty rates, and poor performance on health and basic needs indicators. The study comprised a random (cluster) sample of three hundred households of women in reproductive age with at least one child. Focus groups (13) and in-depth interviews with key informants (health providers, educators, religious and community leaders) were conducted to validate quantitative data and to explore issues such as gender roles, domestic violence, abortion and contraception. The study aimed at contributing to a better understanding of reproductive health issues, quality of life and rural poverty -primarily as it affects women- and providing policy recommendations for addressing reproductive health issues rural poverty alleviation strategies. The study also explored, albeit on a limited basis, men's perceptions and behavior related to reproductive health. Rationale 2. Reproductive health issues have multiple impacts on the quality of life of men and women. From an economic standpoint, a rapid succession of children contributes to increase the household's vulnerability to poverty, limits women participation in the labor market - increasing their dependency while at the same time household work increases disproportionately. In 1999, a World Bank report indicated that the burden of frequent, unwanted, or ill-timed pregnancies can cause emotional and economic hardship to women and their families; and that poor maternal health "drains women of their productive energy, jeopardizes their income-earning capacity, and contributes to their poverty" (World Bank 1999a). The impact of reproductive health issues on poverty and overall quality of life cannot be comprehended without understanding the relations within the household and the income generation strategies of different household members. To reduce reproductive health issues to a pure physical-health dimension would be to ignore the fact that gender roles and productive and reproductive activities (including non-wage labor) are shaped by the relationship between men and women and how this relationship affects women's work, household subsistence strategies, and the control of the biological reproductive process. 3. As the multiple determinants of poverty are considered, it becomes clear that poverty is more than income deprivation. Strategies to alleviate rural poverty are more likely to succeed if designed to address all dimension of social exclusion. Considering reproductive health issues and the cultural norms that dictate gender roles in both the public and private spheres of life is essential for poverty alleviation because it contributes to empowering women, facilitating their decision making, particularly regarding reproductive issues, increasing their income generating capacity and access/control of productive assets. 4. The most recent World Bank Country Assistance Strategy (CAS) for Argentina identifies several key policy issues related to reproductive health. These include: (i) focusing public health care expenditures on those without health insurance; (ii) promoting responsible parenthood and family capacity development given the relationship between large family size and poverty and i  the fact that some 45 percent of Argentine children belong to poor families; and (iii) addressing the needs of the rural poor, including indigenous populations, who have been largely forgotten. This report addresses from a gender perspective the issue of the relationship between poverty and reproductive health issues in rural areas of Argentina. The results presented in this report contributes to advance in the policy dialogue initiated by the Bank's strategy for Argentina in that it examines the relationship between reproductive health and poverty in rural areas and addresses the impact that gender identity and roles have on certain reproductive health issues and behaviors. This report proposes some preliminary recommendations meant to stimulate policy dialogue and decision-making. While the focus is on the rural poor, one can hypothesize that many of the study's findings could be pertinent for the urban poor, increasing the relevance of this work for the country as a whole. Main Findings Ruralpoor and reproductive health data 5. The lack of national and disaggregated data for rural populations and on key reproductive health indicators at the national and provincial levels is a handicap for appropriate decision- making and policy considerations. Notwithstanding its limitations, the findings of this study contribute a snapshot view of some key issues related to reproductive health and quality of life that are relevant to poverty alleviation efforts in rural areas of Argentina. By and large, Argentina is doing better than other less developed countries, including South American countries, in some basic reproductive health indicators. But there are clear disparities between urban and rural areas in the quality of health indicators such as the percentage of births attended by a health professional. Nation-wide 96% of all births are attended by a health professional, but that number is only 75% in rural areas. Another example is the maternal mortality rate which reaches up to 65 per 100,000 live births in rural areas, compared to 48 for the nation. Women in the northern provinces of Argentina have a general mortality rate approximately 4 times higher than men. Even though these provinces have only 20% of live births, 25% of the total infant mortality and 38% of maternal mortality are concentrated in these provinces (OPS/OMS 1999). 6. The results suggest that poor rural households in the sample are doing better in most cases than poor rural households in other Latin American countries in indicators such as prenatal care, place of delivery and knowledge of AIDS. However, this does not hold true for family planning since the national value in Argentina is only marginally above the mean value for other countries in the Region. This suggests a relative lack of family planning use. It is not surprising, then, that the women in the study have between 1 and 11 children with an average of 3 to 4 children. Furthermore, the reproductive health profile of the nation is worrisome, particularly in rural areas, due to specific economic, social, cultural, and institutional factors. These include the low social status of women; the sexual division of labor and lower pay for women; lack of reproductive health services, including family planning for both men and women; and lack of health insurance coverage, among others. 7. On average, the women studied have completed 6 years of schooling, however, only 20% have gone beyond primary education and less than 4% have completed secondary education. There is a significant difference in the number of children per women by educational attainment. ii  Women with 3 or less years of education have on average 4 children, while women that have completed secondary education have on average only 2 children. Poverty, work, and social networking 8. Reproductive health issues have multiple impacts on women's quality of life. A central dimension in defining women's quality of life is access to and control of income. A key factor affecting the income generating capacity of women is the number of children they have to take care of. To estimate the impact of family size on women's income generating potential, the study developed a statistical model to assess the impact of contraceptive use on wage work. As expected, the results suggest that contraception reduces the probability of a delivery by 11 percentage points. The probability of using modern contraception by the women in the sample is affected by multiple factors, including their educational attainment, the number of children, and other variables such as religious affiliation (Catholic), ethnic identity (Coya), and participation in organizations and social networks (low). 9. This study confirms the extent of poverty in the north of Argentina using food expenditure as a proxy for incomes. The average annual food expenditure for the sample household is US$ 1,454 or US$ 241 per capita.' This low figure reflects the sample used in the study that sought to represent only poor rural households. The results indicate that for most households (86%), per capita food expenditures are within the lowest two quintiles. If the observed food expenditures for the households of the sample were adjusted to reflect the estimated food produced by the unit, the annual per capita food expenditure would increase in average by 33% or up to US $320. Despite this, many of the households in the sample still would fall well below the estimated rural poverty line. 10. Regarding ownership, control and management of assets, only a small percentage of women declared to have some type of asset. Owning their home is the most frequent (29%), by and large through inheritance, followed by small animals and house appliances. With regard to fanns, according to a recent World Bank (1997) study, female headed farms are smaller than the farms run by males (60% of the size), and net income per hectare reaches only 66% of that of males. Of the men, one out of four worked in their farms (26%) as their primary activity, followed by temporary work (24%). One in three men (33%) indicated a salaried job, but salaries are low and farming remains a key household survival strategy. Many of the men (42%) indicated farming as their secondary activity. 11. Seven out of ten women mention household work as the primary activity, while household-based subsistence farming is listed as the secondary activity by one out of two interviewees. The data show that while household work is the main activity declared by women, their productive role is much broader as most interviewees indicated subsistence farming (62%) wage work (18%) and other micro-entrepreneurial activities (8%) either as their primary or secondary economic activity. Among better off households, women's participation in wage work is lower than it is for women in low-income households. Among women who declared to have wage work (either as primary or secondary activity), 80% are from households classified in the two lowest quintiles of per capita food consumption. The national indigent poverty level is $ 69 per person per month iii  12. As family size increases, women do not drop wage work; rather they work fewer hours. Not having a steady partner or spouse also increases the probability of having wage work. Thus, it appears that poor women with large households are compelled to work on more insecure labor arrangements as they cannot always hold full time employment. This increases the vulnerability of women and the household as these women are more prone to take on seasonal and part-time jobs that pay less, have no job security, and no benefits. On the other hand, women with fewer children (and not as poor) and more educated women tend to work more hours per week. 13. The study suggests that women's level of responsibility towards reproductive responsibilities (non-wage work) may be in conflict with their ability to undertake wage work or for producing commodities or exchange values. In turn, women's participation in the labor market has a significant impact in the amount of money that they possess. However, managing more money does not automatically translate into an increase in women's status. Rather, the economic mobility of women is linked to the income generation capacity of their partners. At the same time, women's identity does not change when they have wage work because it remains driven by the fulfillment of their cultural role as nurturers. 14. In rural poor households where this situation is, by and large, the norm, women's low health status and high caregiving responsibilities often impair their ability to work for wages making their work more fragmented and unstable. This, in turn, increases women's economic and emotional dependency on the male. While on the male's side, the pressure to assure wages can promote feelings of frustration and self-doubt, which can drive him to alcohol abuse, domestic violence or both. 15. There are relatively few social organizations and organized community and support groups in the rural areas of the provinces studied. Participation by men or women in the study is low. This result is consistent with the findings of a recent World Bank (2001) report on social capital in Argentina. Women indicated that they participate in religious activities, but these seem to involve primarily going to religious services. Women that participate in social organizations, with the exception of the church, tend to be more educated and younger. Nevertheless, the number of children is not necessarily associated with more or less participation in social organizations. Gender roles, quality of life, and women 's self-reported identity 16. The situation of women in Argentina has improved significantly over the last decade. However, women continue to suffer disproportionately the effects of poverty, particularly in rural areas. Family size has been identified as the single most important social characteristic contributing to rural poverty. In addition, female-headed farm households are more likely to be poor and mothers and children living alone are more likely to be disadvantaged than those living in extended female-headed households. Furthermore, gender differences are significant in determining opportunities for off-farm earnings (World Bank, 1997). Although nation-wide female-headed households represent about 24%, in the provinces studied only 16% of the households were female-headed. Female-headed farm households are more likely to be poor and gender is significant in determining opportunities for off-farm earnings. This is linked to the opportunities and ability of women to gain entry in farming or other economic groups that in these rural communities are culturally the realm of males. iv  17. The study shows that women define themselves through motherhood. In the poor rural communities studied, becoming a mother is what makes a woman. Pregnancy is viewed as a fundamental event in the woman's life. Maternity is valued because it gives women a place in society, regardless of their age, and is the social reference that allows them to construct their identity. The intrinsic value of the social construction of being a mother cannot be overstated. Yet, there are situations when repeated, often unwanted, pregnancies result in ill physical and mental health for the mother and the offspring. This situation, coupled with poor living conditions and low socio-economic status that are detrimental to the woman's ability to live a productive and healthy life and take care of her family, means that a whole generation of men and women are not able to reach their full potential. Consequently, the capacity of these families to break the vicious cycle of poverty is seriously undermined. 18. The gender identity reported by the women of the study has a direct impact on key reproductive health issues. First, female children are raised to be mothers. This implies that controlling the biological reproductive process is important in as much as it ensures the fulfillment of the expected cultural role. As a result of the above, women start their reproductive lives very early because that is the main avenue for asserting their position in society. Thus, the reproductive behavior is not only an outcome of gender identity but of gender relations as well. The control of the reproductive process and of women's sexuality becomes privatized-that is, inherently a matter within the household that responds to broad societal norms in which the woman has little to say Women's reproductive functions are seen as a subset of the household and, thus, subject to the control of men. This reproductive behavior results in: (i) low or no use of family planning methods which leads to larger families and increased health risks; and (ii) a diminished capacity of women to control assets and generate income. 19. At the same time, women do not see sexual relations as a dimension of self-fulfillment, even though a large percentage (73%) indicated that it is important to enjoy sexual relations. For these women the concept of sexuality is limited to procreation and menstruation. The women surveyed stated that sexuality is important for both men and women, though more so for men because they are assumed to have a highly sexual nature. Sexual education, then, was seen to be especially important for young men. Women's perception is that men experience unlimited sexual desire, which they must satisfy whenever the man demands it of them. Women, in general, do not conceptualize sexual relations as a choice, but as a consequence of couplehood in which rejection of male's sexual advances is not possible and if attempted can result in forced relations or violence. Policy framework and availability of reproductive health information and services 20. In virtually every nation, the government is a key player in reproductive health and human rights by regulating and implementing policies and allocating resources. The absence of a clear endorsement for and implementation of reproductive health programs by the government is more poignantly felt by poor populations who have limited access to information, services and supplies, adolescents and youth, and those who are abused or at high risk for STDs. Yet, ironically, these are the groups who most need and can benefit the most from comprehensive reproductive health information and services. This situation exacerbates the lack of equity between rural and poor populations and between those who can and those who cannot pay for private health services. v  21. The situation in Argentina is contradictory. It is a country that, in so many socio- economic indicators, shows a fair degree of social progress and where gender equality is taken for granted by many. Yet, Argentina is less progressive when it comes to population and reproductive health issues and lags behind its Latin American peers in addressing these concerns. Past efforts to pass national legislation on reproductive health have failed. Argentina was one of only six countries that voiced opposition to the programme adopted at the International Conference on Population and Development in Cairo in 1994. Dominant religious institutions encourage this population policy and help perpetuate inequities within the country given that only those who can not pay suffer the existing political and legal restrictions t towards reproductive health services. One consequence of this active "non-engagement" in reproductive health is the substantial lack of awareness among men and women, and often health providers, of what reproductive health encompasses (as opposed to maternal-related services), why preventive cancer or STDs screening is important for both men and women, or how family planning method use can decrease illegal abortion.. 22. Historically, Argentina had developed health policies and programs aimed at promoting family expansion and restricting access to family planning under publicly funded health care programs with a direct adverse consequence mainly on the poor who do not have private health care.. Argentina is now making slow but steady progress in establishing national public policies, laws, and programs on reproductive health and has advanced on the provision of routine maternal and child health care in poor urban areas, under programs such as PROMIN, partly financed by the World Bank. Recently Argentina established national public policies and programs on reproductive health to facilitate the individual's right to decide the timing and number of his or her children. However, there is still no national legislation regulating the provision and distribution of contraceptives, and other reproductive health services, except for sterilization and abortion, which are prohibited by law. 23. Progress has also been made at the provincial and local levels in legislation and program development. As part of reforms (1989-1994), the Federal Govenmment transferred the provision of health, education, and assistance programs to the provinces. Several provinces including Rio Negro, La Pampa, Chaco, C6rdoba, Mendoza, and Neuquen have established reproductive health programs, though each varies in their level of implementation. Of the three provinces included in the current study, only Misiones has developed a policy on reproductive health. In February 1998, the Government of Misiones issued Provincial Decree 92, outlining the Provincial Program for Integral Family Planning. The objectives include: (i) to promote social and political change in raising a national consciousness on family planning; (ii) to institute equal access to reproductive health services; (iii) to ensure access to information and free decision-making on issues of birth control and STD/AIDS prevention; and (iv) to develop a plan of action for understanding population characteristics of the most vulnerable groups in order to design effective programs to meet their needs (Consejo Nacional de la Mujer, 2000). There are no fully implemented programs or formal evaluations of these activities as yet. Reproductive health 24. Awareness of reproductive health is very low. For both men and women, the notion of reproductive health is limited to "something pertaining to a woman's health in her fertile years" and related to the notion of health in general. It includes services related to maternity and vi  sometimes methods to prevent pregnancies, but excludes any notion of prevention. This is likely to be found among the urban population as well. In this context it is not surprising that reproductive health is seen as the exclusive responsibility of women because it is related to motherhood. The concept of family planning for the study population involves two main dimensions: (i) the knowledge and mechanisms to become pregnant; and (ii) the possibility of preventing pregnancies. In general, both men and women saw the practice of controlling the number of births as positive but particularly among women who indicated that family planning could help them avoid unwanted pregnancies. On the supply side, key service providers indicated that they did not often have the supplies, the infrastructure and/or the know-how to provide comprehensive reproductive health services including for cancer and STDs screening or family planning. 25. Knowledge of the existence of child spacing methods is adequate but use is low. With respect to knowledge regarding methods to prevent pregnancies, three out of four women (less frequent among women with less education) have knowledge of different methods. Regarding family planning use, 51% of women declared to use some type of contraceptive method. However, only 25% of the women use modem family planning methods. There is a significantly higher proportion of women in Misiones (63%) that uses family planning, compared with 58% in Salta and 38% in Santiago del Estero. This could be explained by the fact that Misiones, as mentioned, has a provincial program that addressed some reproductive health related issues. 26. Family planning use is more frequent among women that participate in social organizations (5 5%), and among women in the 31 to 36 years old range. Women who have seven or more years of schooling (average in the sample = 6.3 years) have a higher probability of using modem contraception and a lesser probability of delivery. The use of contraception reduces the probability of a delivery by 11 percentage points. Other studies have demonstrated the relationship between education and poverty indicating that among better off households, the probability of having children decreases. This is consistent with the general conclusion of past studies that poor people tend to have more children. However, in the sample for this study, economic status (measured as food expenditures) does not affect the probability of using contraception. In this study there is a higher probability of delivery over the last three years among those women who have access to health insurance but, as expected, health insurance has no impact on the use of contraception because family planning is not covered and the overall coverage rate for rural areas is low. 27. Abortion and adolescent/youth pregnancy rates are high. Women in the study tend to have early pregnancies. Pregnancy, whether wanted or not, occurs as early as 12 years old, exposing women to psychophysical risk, social insecurity and vulnerability. While the average age for the first pregnancy is 18 years old, 16% of the sample have their first pregnancy under 15 years old, and 54% under 19 years old. 28. One of four (24%) women interviewed has had either a natural or induced abortion at least once in their lives. The women attributed the occurrence of abortion to multiple causes. While less than 3% of women openly admitted that they did not want the pregnancy (since abortion is illegal there is a substantial under-reporting), a significant number of causes offered by women such as excess of physical activity (7%), use of contraceptives (4%), trauma (27%), vii  and uterine bleeding (14%) may have an inferred association with induced abortion. Up to 60% of the causes for losing a pregnancy as reported by women may have been the result of an induced abortion. About 16% of women in the sample could have had induced abortions. Yet, there is no substantive information as to how physical or emotional complications of unsafe abortion are managed. The limited participation in social networks among the women of the study that was mentioned previously would indicate that there is not a support system at the community level to help women with counseling about family planning and ways of preventing abortion or with the aftermath of such event. 29. Prenatal care is limited and postnatal care is almost non-existent. More than 90% of women indicated that they received at least one prenatal check-up in public hospitals or health posts during their last pregnancy. However, usually the prenatal control took place during the last trimester of the pregnancy and particularly within two weeks before giving birth, when delivery symptoms began to appear or when they had some health problem or difficulty in carrying out their daily tasks. While in three out of four cases the control was done by a qualified provider such as a physician, the exam only involved checking the woman's weight and other basic measurements to estimate fetal development but no blood tests or any lab exams. 30. Nine out of ten women had an institutional delivery for their last pregnancy, and over the last 15 years the percentage of deliveries occurring in the home without professional care or with a midwife has dropped almost in half. 31. In sharp contrast to the prenatal control figures, one half of women interviewed did not received postnatal care after delivery, while one quarter (27%) of women received one check-up. Only 23% of women attended more than one postnatal care visit. This is important because, in the majority of reproductive health and safe motherhood programs, it is during the post-partum period that providers counsel couples or women about child spacing methods, in addition to breastfeeding, and monitor women's health status especially infection, hemorrhage and anemia. 32. Preventive behavior is very rare. A conscious attitude or intention towards preventive behaviors does not exist among the women or men in the study. Seven out of ten women (68%) declared not having had a preventive health consultation in the last two years. Women do not see the need for periodic check-ups if they do not have a health problem impairing them. In addition to the women's perception of the need for a check-up, there are other factors that affect this lack of preventive behavior: (i) even when women are aware of the potential harm of an illness and the need for preventive controls, the opportunity cost in terms of their daily tasks is too high; (ii) culturally, women are ashamed of having their genitals examined and their husbands/partners do not like it either; (iii) the lack of privacy that is prevalent in so many health facilities and the provider-client relationship that is often not enabling does not help; (iv) access, including lack of transportation, lack of funds to pay for transportation, and the schedule of the providers represent an additional burden for this population; (v) economically, going to a health facility may present real out of pocket expenses because the majority of this population is not insured and even when they are, they need to cover the co-payment; and finally (vi) even when women do go to a health facility for a check-up, the services they need are not always available. Contraceptives are not free and purchasing oral contraceptives in the pharmacy, for instance, represents an important economic commitment that many are not able to make on a continuous basis. viii  Conclusions and Policy Implications 33. The principal findings of this study can be summarized as follows: * There is a lack of appropriate, accurate and reliable data for decision-making especially disaggregated at sub-national levels and between urban and rural populations. Statistics on reproductive health indicators are scant and dispersed. There are significant information gaps because the information is out-dated, based primarily on hospital mortality statistics, and the system is managed at the provincial level with no standards across provinces. * Family size has a direct impact on women's income generating capacity and quality of life as women must fulfill their social roles as caretakers and income earners to ensure the family wellbeing and livelihood. The tension between the demands of the productive and reproductive roles decreases women's productivity and psycho-social wellbeing. These cultural norms of conduct shape how rural poor women organize their lives and participate in society. Family and social institutions contribute to a situation in which women usually have little or no bargaining power and balancing their reproductive and productive roles is not in their control. Wage earning opportunities are low and income generation activities are very limited, further inhibiting the development of human capacity. * There is no clear population/reproductive health policy in the country. Current efforts on responsible parenthood are moving in the right direction but slowly. Without political will at the national and provincial levels to promote and implement comprehensive reproductive health programs, the welfare and productivity of rural poor populations, particularly women, will remain precarious. This applies equally to the urban poor. * Awareness of reproductive health by both men and women and access to services is minimal, and use of family planning methods is low. The adolescent and youth pregnancy rate and the abortion rate are high and there is scant data on the impact of the existing polices on these high-risk fertility behaviors or related issues of alcoholism or domestic violence. There are no preventive programs in the health system to address these issues. Perinatal care is poor and there is no evidence that post-abortion care and guidance are available. * There is no evidence of preventive behavior. Men and women seek health services, by and large, only when a condition causes them impairment to carry on regular duties or because of a pregnancy related issue. When services are available, lack of health insurance, lack of transportation and lack of expendable income are key factors in the underutilization of health services and contraceptives. Moreover, men tend to consider prevention to be the role of women, and not something for which they should share responsibility. 34. These conclusions point to the need for increasing policy dialogue regarding new program interventions that would address and focus on the social and health conditions prevailing in the groups that are of greatest concern from a poverty alleviation and equity perspective. They also point to the need to integrate men explicitly into the discussion of reproductive health and prevention. ix  35. The conclusions also point to several possible policy and programmatic actions: