The current sexual and reproductive health landscape in Mexico is one of both progress and challenges. It is one of divisions between rich and poor, between urban and rural populations, and between younger and older generations.

Mexico is the second largest economy in Latin America; however, aggregate figures distort the reality of a large cohort of the population that continues to live in striking poverty. About 52 percent of Mexico’s total income is held by the wealthiest 20 percent in the country, and more than 3 percent live on less than $2 a day. Despite this reality, donor countries are graduating countries such as Mexico from foreign aid, failing to acknowledge the sharp inequalities and the still weak health systems.

At the same time, Mexico is at an advanced stage in its demographic transition. With a very young population — 18 percent are between the ages 15 to 24 and the median age of total population is 27 — the county is experiencing an increasing strain on education, health, and social welfare systems. Challenges are also emerging to improve the sexual and reproductive health of this population group. Young people are becoming sexually active at increasingly younger ages (mean of 15.9 years), but 75 percent of them do not use contraceptives at their first sexual experience. HIV/AIDS is among the top ten causes of mortality for men and women ages 25 to 34.

The marital, sexual, and reproductive behavior of young women varies greatly depending on where they live. In 2006, 29 percent of women ages 20 to 24 in rural areas reported having been married before age 18, compared with 17 percent in urban areas. Fewer urban than rural women had had a birth before age 18 (14 percent vs. 22 percent). Meanwhile, the proportion of married women who have an unmet need for contraception— that is, who are able to become pregnant, but are not using any contraceptive method, even though they do not want to have a child soon or at all—increased among this age-group, from 23 percent to 31 percent. The situation is more critical among sexually active, unmarried young women ages 15 to 24: Only 35 percent were using a contraceptive method in 2006.

In Mexico, as in many countries throughout the region, the health and well-bring of women and youth are subject to vast geographic disparities. Those living in the relatively less developed, less urbanized, and poorer southern states have more limited access to sexual and reproductive health services and information than those living in the more developed, more urbanized areas, such as Mexico City.

As the fifth largest state of Mexico, Oaxaca is characterized by extreme geographic fragmentation. Located where the Eastern Sierra Madre and the Southern Sierra Madre come together, Oaxaca shares a common border with the states of Veracruz and Puebla (on the north), Chiapas (on the east), and Guerrero (on the west). Oaxaca’s rugged topography has played a significant role in giving rise to its amazing cultural diversity. Because individual towns and tribal groups lived in isolation from each other for long periods of time, there are sixteen groups that maintained individual languages, customs, and ancestral traditions well into the colonial era, and – to some extent – to the present day. According to many, Oaxaca is – by and large – the most ethnically complex of Mexico’s thirty-one states, and it is believed that, even today, at least half of the population of Oaxaca still speaks an indigenous dialect.

According to Conapo (Mexico’s National Population Council), Oaxaca is the third most economically marginalized state in Mexico. The state has 3.3 percent of the population, but produces only 1.5 percent of the GNP. Eighty percent of the state’s municipalities do not meet federal minimums for housing and education. While the majority of Oaxaca’s population lives in rural areas, most development projects are planned for the capital and surrounding area. About 31 percent of the population is employed in agriculture, about 50% in commerce and services, and 22 percent in industry.

While maternal mortality has decreased steadily in Mexico since the 1950s, the national numbers mask glaring inequalities, which continue to divide Mexico along lines of class, ethnicity, and geography. In Oaxaca, where 53 percent of the population lives in rural areas, indigenous women and rural communities face acute health challenges on many fronts because of abject poverty, poor education, and a dire shortage of medical staff.

In 2008, there were 57 maternal deaths per 100,000 live births in Mexico, a ratio that is five times that found in industrialized countries. Moreover, the maternal mortality ratio in the least developed region of the country (comprised of the states of Guerrero, Oaxaca, and Chiapas) is 97 maternal deaths per 100,000 live births—almost double the national average. Such regional disparities are partly due to the uneven distribution of health care resources and providers, which favors urban areas.

Despite a changing environment, local NGO Mexfam continues to provide high quality sexual and reproductive health services throughout the country. Its three-tiered approach to sexual and reproductive health — services, education and community — gives them the critical capacity to reach those most in need.

Throughout Mexico, Mexfam employs approximately 1,000 health promoters. These promoters educate community members about sexual ad reproductive health and provide a much-needed link to Mexfam’s clinical services — as well as condoms and contraception— in rural and underserved areas. As part of this work, Mexfam’s health promoters host JOCCAs — two-day local events that bring the community together for discussions and learning about sex.

In San Catarina Minas, I had the opportunity to see one of Mexfam’s JOCCAs in action. In the middle of this small town an hour south of the city of Oaxaca, the school gymnasium was packed with hundreds of community members, young and old. After opening the session with a traditional Oaxacan dance, Mexfam went to work. They divided up the participants into groups according to age and Mexfam health promoters and staff led discussions with each group about sexuality and health. At the end of the JOCCA, each group presented a skit or poster it had created on the topic of their choice to the larger group.

Walking through the gymnasium and listening to snippets of the group discussions afforded a rare insight about the evolving nature of sexuality: while we often discuss sexuality education in the context of youth development, too often we forget the fact that the need for accurate and complete information is one that remains with us throughout our lives. Among the 12-year-olds, I heard questions about masturbation and dating, while a group of middle-aged women shared strategies on how to initiate the topic of condom use with their husbands.

The JOCCAs have been so effective at disseminating accurate information and facilitating access to sexual health services that the Ministry of Health in Oaxaca has begun to replicate Mexfam’s JOCCA model in other communities throughout the state. As a result, the state of Oaxaca has seen a 25 percent decrease in teen pregnancy over the last five years.

Perhaps most importantly, the JOCCAs have been invaluable at creating a climate where sexual and reproductive health and rights can be discussed openly across gender and age lines. One Mexfam health educator said it best:

“When it’s time for your child to start brushing their teeth, you don’t immediately send them to the dentist; you give them the tools and information they need to learn to take care of themselves. Learning about sexuality and how to protect yourself needs to become a part of what you learn at home, a natural part of your community.”

Ultimately, she told me, she would like to see topics like correct condom use as prevalent in household discussions as the importance of brushing your teeth or washing your hands.

Mexfam’s high-quality sexual and reproductive health services provides rural and marginalized populations lifesaving health care to which they would not otherwise have access. Although obstacles remain, Mexfam is a leading advocate meeting the vital needs of the most vulnerable Mexicans.