“Siempre Me Critican”: Barriers to Reproductive Health in Ocotal, Nicaragua

Pan American Journal Investigación original / Original research of Public Health

“Siempre me critican”: barriers to reproductive health in Ocotal, Nicaragua

Samantha M. Luffy,1 Dabney P. Evans,1 and Roger W. Rochat1

Suggested citation Luffy SM, Evans DP, Rochat RW. ”Siempre me critican”: barriers to reproductive health in Ocotal, Nicaragua. Rev Panam Salud Publica. 2015;37(4/5):245–50.

abstract Objective. To identify perceived barriers to accessing reproductive health care according to the women of Ocotal, Nicaragua; describe their understanding of their reproductive rights; and document their opinions about Nicaragua’s total ban on abortion. Methods. From May to June 2014, three focus group discussions were held in Spanish with 17 women from two different neighborhoods (barrios) in the city of Ocotal, Nicaragua. A semi-structured discussion guide with open-ended questions was employed to elucidate local perspectives regarding the focus group discussions themes. Results. Serious obstacles including 1) violence against women, 2) machismo, 3) criticism from others, and 4) lack of communication and education limit women’s ability to make their own reproductive health decisions. Women had a pervasive lack of knowledge about reproductive rights and the international human rights documents that define them. In addition, due to religious and cultural ideologies, most women supported the country’s total ban on abortion in most circumstances, with the possible exception of rape. Conclusions. Both men and women in Ocotal should be encouraged to participate in community-level programs designed to reduce the impact of the following obstacles to receiving reproductive health care: 1) violence against women and machismo; 2) insufficient, non-standardized sexual education and information about reproductive rights; and 3) poor communication within families and the community at large. Any future public health campaigns to address women’s reproductive health needs in Ocotal should implement these types of programs, at the neighborhood level, to reduce stigma surrounding sexual health and activity.

Key words Women’s health; reproductive health; abortion, therapeutic; violence against women; communication; Nicaragua.

Worldwide, unintended pregnancy Demographic and Health Survey (DHS) termination of a pregnancy, including imposes significant burdens on popula- data reveal that the Latin American/ cases of rape, incest, or danger to the tions, with greater social, physical, and Caribbean region has some of the high- life of the woman (5). The law imposes financial costs in resource-poor settings est levels of unintended pregnancy (1). serious penalties on women who obtain (1). Women of low socioeconomic status In Nicaragua, the latest DHS suggests abortions and on medical professionals with limited access to family planning that 65% of pregnancies among women who perform them (3, 6). Even in the services are at higher risk for depres- ages 15–29 are unintended and nearly all face of such legal consequences, clandes- sion, violence, and unemployment due women (90.4%) reported having unmet tine abortions remain prevalent in Nica- to unintended pregnancy (2, 3). Recent reproductive health care needs (4). ragua; approximately one-third of the To further exacerbate their lack of country’s maternal deaths result from 1 Hubert Department of Global Health, Rollins reproductive health autonomy, women complications from unsafe abortion (7). School of Public Health, Emory University, lack access to legal abortion services In response to the negative effects of Atlanta, Georgia, United States of America. Send correspondence to: Dabney P. Evans, to terminate an unintended pregnancy. this law on women’s health, the United [email protected] Since 2006, Nicaraguan law prohibits the Nations Committee on the Elimina-

Rev Panam Salud Publica 37(4/5), 2015 245 Original research Luffy et al. • Barriers to reproductive health in Ocotal, Nicaragua tion of Discrimination against Women provides crucial context for the avail- TABLE 1. Selected demographic data for (CEDAW) has recommended that the able statistics and better prepares health participants in focus groups on barriers to government review the total ban on abor- care providers to meet the reproductive reproductive health (n = 17), Ocotal, Nicaragua, tion and remove the punitive measures health needs of women in Ocotal. May–June 2014 imposed on women who have abor- The objectives of this research were to Characteristic % tions (8). CEDAW also expressed concern 1) identify perceived barriers to access- Marital status about the lack of standardized sexual ing reproductive health care according Single 35 education programs, as well as inade- to the women of Ocotal; 2) describe their In a relationship 65 quate family planning services, and high understanding of their reproductive Religious preference rates of unintended pregnancy through- rights; and 3) document their opinions Catholic 29 Evangelical 53 out Nicaragua (8). Strategic objectives on Nicaragua’s total ban on abortion. Neither 18 outlined in the Beijing Declaration2 state Employment status that access to effective and safe family MATERIALS AND METHODS Unemployed 71 planning services should be the main Employed 29 Education level method by which unintended pregnan- Study site Primary 12 cies and unsafe abortions are prevented Secondary 41 (9). The total ban on abortion directly Ocotal is the largest city in the north- University 47 contradicts these strategic objectives and ern department of Nueva Segovia, with violates women’s right to comprehensive approximately 47 000 inhabitants. There reproductive health care, including fam- are 34 neighborhoods (barrios), each ily planning and post-abortion care. with its own identity and community- Ocotal, 2) their reproductive rights, and In 2012, the Nicaraguan government approved leaders. The barrios are the 3) their opinions about Nicaragua’s to- implemented Ley 779, a national law functional units of the municipality and tal ban on abortion. Participants also to eradicate violence against women many public programs operate at this provided feedback on the nature and (VAW) (10). The law targets persons level. structure of the questions to improve the perpetrating violence against a victim Public facilities offering reproductive cultural appropriateness of the revised with whom he/she has an interpersonal health services include one hospital, one (Spanish) discussion guide. relationship. It also defines the types of health center, and eight health posts. The Three FGDs were performed in Span- violence prohibited under the law, and health center offers primary care services ish for data collection and consisted of sentence lengths for femicide, physical as well as prenatal consultations for groups of up to six women from two violence, psychological violence, etc. In newly pregnant women. Health posts of- barrios: Laura Sofia Olivas and Nuevo some cases of intimate partner violence fer basic primary care, including family Amanecer. A total of 17 participants were (IPV), unintended pregnancy can result if planning services; sexually transmitted recruited with the assistance of com the woman’s right to control her fertility infection (STI) testing; and cervical can- munity leaders and included young is challenged by pregnancy coercion (11). cer screening. Other sources of repro- women 17–27 years old who had been ductive health care include private clin- pregnant at least once and spoke Span- Rationale for the research ics and pharmacies, which sell condoms ish. Demographic information about and the emergency contraception pill. the participants can be found in Table 1. There is a dearth of research address- The revised discussion guide (presented ing the reproductive health needs of Data collection as Supplementary material) was em- women living outside Managua and ployed during these FGDs, but the main León, the two most frequently studied Due to the iterative nature of quali- topics remained the same throughout departments in Nicaragua. The total fer- tative research, data collected during data collection. Probing, follow-up, and tility rate (TFR) in Nueva Segovia, the pilot and initial focus group discussions interpretive questions were used to fur- department where Ocotal is located, is (FGDs) informed later stages of data ther explore topics brought up during 3.0 children per woman—higher than collection. the FGDs. the country’s overall TFR (2.7) (1). In ad- Two pilot FGDs were conducted in dition, 20% of the TFR in Nueva Segovia Spanish to further develop and revise Data management and analysis are unintended pregnancies, a propor- the language used in the original (Eng- tion higher than those in Managua and lish) semi-structured discussion guide All FGDs were audio-recorded, tran- León (18% and 9.5%, respectively) (4). (developed by the authors) according to scribed verbatim, and de-identified. The Existing research does not address why cultural norms. Women 15–30 years old data were analyzed using MAXQDA11 unintended pregnancy is more frequent who had been pregnant at least once and software (VERBI GmbH, Berlin, Ger- in this part of the country. Exploring spoke either Spanish or English were many), which aided in the coding of the women’s perceptions of barriers to re- recruited for participation. The partici- transcripts and the analysis of induc- productive health care and their ex- pants were sampled from a local univer- tive themes. The quotes were translated periences with unintended pregnancy sity and Barrio Teodoro López. Participants using three different online translation were asked open-ended questions about tools and the translations were reviewed 2 http://www.un.org/womenwatch/daw/ 1) what they perceived as obstacles to and combined to best match each partici- beijing/platform/declar.htm receiving reproductive health care in pant’s intended meaning.

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Study ethics and informed consent planning method because of what the The [partner] must respect one’s decisions participants described as “ignorance” to plan because there are men who are In its initial review of the study, and fear that their daughter will become machistas [sexists] who do not like it if Emory University’s Institutional Review pregnant. Some participants reported [their partner] plans and prefer [that their partner] is always pregnant, having child Board (IRB) determined that the project that girls in Ocotal are beginning to have after child. was exempt from full review because it sexual relations at younger ages (13–14 years old), which puts them at risk for did not meet the definition of “research” The participants said a new law, Ley an unintended pregnancy. A partici- with human subjects. This determination 779, was “both good and bad” at com- pant named Tania recounted a personal was based on the fact that the study only batting VAW and machismo in Ocotal. example: included 17 participants from two bar- The participants believed that the law rios and therefore the results had limited gives women more power to sue their generalizability. The host organization I have a young girlfriend that has had— you know that now in this time it is com- abuser but that it has also caused more in Nicaragua used Emory’s IRB as a femicide. A participant named Anita ex- proxy. Verbal, informed consent was ob- mon—she has had relations with her boyfriend and I told her as a supportive friend plained the effects of the law as follows: tained from all participants before each that I would accompany her to the [health] FGD and participants were informed center. Then she said “no” because she The opinion of the men now is that they that they could withdraw from partici- is embarrassed—ashamed to be criticized. prefer to kill the woman instead of hitting pation at any time. There was minimal One always tries to raise the self-esteem her because although they will go to jail risk to the participants as their participa- of others because we also have the right to for hitting her, they will also go to jail for tion and the information collected from counsel others who are at risk of an un- killing her, so they say, “It is better if I kill them was kept confidential. wanted pregnancy. When we arrive at the her.” That is the opinion of the men now, center, they criticize us, so then we do not young and old. I say it is awful how lost the get the injection and could get pregnant. men are because those are their thoughts RESULTS now—that is better to kill the woman…. This began because of Ley 779. The law Hormone injections were the most Obstacles to receiving reproductive started it. health care commonly reported form of birth control used in Ocotal, but many participants Participants in all three groups agreed Criticas. Of the many obstacles the admitted that they often did not go to that the law does not protect women women perceived as having a signifi- receive follow-up injections for fear of due to the high prevalence of machismo cant influence on their access to repro- being judged or criticized by their neigh- among the men in Ocotal. ductive health care, criticas (criticism) bors at the health center. from others in the community was the Reproductive rights one most often cited across all groups. Violence against women. The partici- According to the participants, they felt pants in all groups viewed VAW as a When asked to define the term “sex- criticized or judged when they went to formidable obstacle that prevents them ual and reproductive rights” the partici- a health center or health post to receive from accessing reproductive health ser- pants were unable to do so but were able family planning information or STI test- vices. Women gave examples of do- to provide examples. The examples were ing. Given that health facilities are cen- mestic violence between parents and similar across all FGDs and included trally located in their barrios, women their daughter, as well as IPV between the right to decide when to have sexual often encounter people they know. A a woman and her partner. Parental vio- relations and the right to choose how participant named Rosa3 explained the lence commonly occurs when the father many children to have. The groups also situation as follows: thinks the daughter has started hav- mentioned the right to have access to ing sex or discovers that she has been sexual and reproductive health services When a young girl who is 15 or 16 begins secretly dating. A participant named and education, including the ability to to have sexual relations and thinks to Reina explained some fathers’ reaction decide what method of family planning protect herself, sometimes there are many as follows: to use and access to specialty gyneco- people that know her in the health center logic services. and then these people she knows begin to There is domestic abuse after a girl becomes All three groups believed that their judge her harshly. pregnant. What do the parents do when they’re incredibly ignorant? They aren’t sexual and reproductive rights origi- nated from the Nicaraguan government The participants said that this gener- educated and begin to be abusive and say, and national law, including Ley 779. ally affects younger girls, who are more “It would be better for you to leave if you Only one participant said she did not likely to use a family planning method want this man. Get out of the house.” So the family also discriminates against her. know the origin of these rights: “The in secret and/or conceal the fact that government promotes [our sexual rights] they have a boyfriend from their fami- Machismo was also mentioned fre- pretty well, but I honestly do not know lies and other members of the commu- quently in discussions about VAW as a who invented them.” All groups were nity. Parents may not allow their daugh- major cause of femicide, rape, and vio- uncertain about the origin of women’s ters to have boyfriends or use a family lence, as well as a barrier to women us- sexual rights, and none seemed familiar 3 All names have been changed to protect the par- ing a family planning method (“plan”), with international treaties or documents ticipants’ privacy. as a participant named Lupita explained: that define them.

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Prohibition of abortion her belly, her womb, and she has to have decrease the prevalence of unintended it, accept it. pregnancy. If young girls could talk Total ban on abortion. All participants with their parents openly, they would were familiar with the country’s law that Religion influences women’s opin- not have to family plan or date in secret, bans therapeutic abortion in all circum- ions about abortion. Some participants which would decrease their risk of get- stances. Their reaction to this law, as viewed abortion as a sin, so were there- ting pregnant. According to the partici- explained by a participant named Vilma, fore in favor of the law. It was widely pant named Tania, “it is nice to have a was similar to women’s opinions about agreed that giving the child up for adop- relationship and a conversation with Ley 779: tion or giving the child as a “gift” to [one’s] family.” someone else who had the resources to In addition, the participants believe It is good and bad … . Sometimes … take care of it are “more favorable than that open communication with their women … make the decision to abort for abortion.” partners would mitigate the influence of some problem they have … they may have The participants also reported that machismo in their relationship because a very small uterus or sometimes the child abortion is uncommon in Ocotal. Some the man would begin to view the woman does not develop where it should be. But group members mentioned extreme as an equal and see her as capable of then there are some women ... who abort cases of young girls who had attempted making her own decisions about pursu- because they are very young. But I say you or successfully completed an abortion, ing education or a career. should not abort because one must fight for but they said the “majority” of women her children because our parents fought for have the baby regardless of the circum- us and so one must fight for her children.... DISCUSSION stances surrounding the pregnancy. So I agree with the law and at the same time, I don’t, you know? This qualitative evaluation has dem- Communication onstrated that in Ocotal, Nicaragua, seri- It was common for women to dis- ous obstacles, such as VAW, machismo, Lack of communication. Across all approve of an abortion in most cases, criticism, and lack of communication groups, women said that a lack of com- including an unintended pregnancy or and education limit women’s ability to munication between a woman and her if the mother is very young. Across all make their own reproductive health de- parents or her partner contributes to three FGDs, however, the participants cisions. There is a lack of knowledge instances of VAW and decreases wom- agreed that in the case of rape, an abor- about reproductive rights as well as en’s freedom to make their own deci- tion could be seen as acceptable. The the international documents that define sions about their reproductive health participant named Tania explained this them. In addition, because of religious and future. Participants reported that as follows: and cultural ideologies, the majority of they could not communicate with their women support the country’s total ban parents or partners for fear of discrimi- on abortion in most circumstances, with I say in the example of rape—imagine a nation, violence, and embarrassment. rape, an unwanted child from a rape: to the possible exception of rape. The participant named Reina explained this I say ... I don’t know, to be honest; Though Ley 779 was intended to re- maybe God changes the woman’s mind, but how machismo influenced her partner’s duce VAW in Nicaragua, women in Oco- it hurts to have a child that is unwanted reaction to her future goals: tal believe that it has caused more vio- because it is from a rape. lence, particularly femicide, throughout Sometimes he understands me and some- the country. They also said that having a times he does not. Because when I say Though many participants wavered partner who is a machista severely limits that I want to work, he does not like women’s autonomy and ability to make on the fairness of the law in the case of those decisions. If I tell him that I want to rape, some participants used religious or study, because I want to [pursue] a profes- personal decisions regarding their repro- cultural sentiments to justify continuing sion … he says, “No, I do not like that deci- ductive health, work, and education. The a pregnancy, regardless of whether it sion.”… Sometimes I do not understand findings about the influence of VAW and resulted from a rape. his mentality. machismo are similar to those found by other studies in Nicaragua showing that “El niño no tiene culpa.” At least one Many participants said that due to ma- gender inequalities are associated with participant in each group said “el niño chismo, their father or partner wanted women’s poor physical, mental, and re- no tiene culpa” [“the child is not at fault”] to limit their ability to make personal productive health (12–14). These studies when explaining why they believe abor- choices related to family planning, edu- have also found that it is important to tion is wrong. The rest of the group of- cation, and work. include men in programs to improve ten nodded or murmured in agreement women’s access to sexual and reproduc- when this phrase was mentioned. When Improved communication. Each group tive health services in Nicaragua. The discussing rape, a participant named said that improved communication be- results from this study highlighting the Mary said the following: tween women and their parents and importance of improved communication partners would have a positive impact with fathers and partners confirm that ... The child is not to blame for what the on women’s lives in Ocotal. According women in Ocotal also believe that men father, the man, did to the woman. In this to the participants, being able to talk need to be involved in decisions regard- situation one has to start thinking that the with parents and partners without fear ing sexual and reproductive health. child is not at fault, and she must have it of negative consequences would greatly As shown in this study, women’s lack because, either way, the child comes from increase trust in the relationship and of knowledge regarding their reproduc-

248 Rev Panam Salud Publica 37(4/5), 2015 Luffy et al. • Barriers to reproductive health in Ocotal, Nicaragua Original research tive rights reflects limited access to in- study area was limited to the munici- barrio. Community-level programs with formation and education on the subject, pality of Ocotal, so the findings cannot both men and women should address which coincides with the nonexistence of be generalized to other populations. the negative impacts of machismo and standardized and comprehensive sexual These findings could, however, reflect VAW on the health of the population as education curricula in schools (3). Fur- the sentiments of women from similar a whole, in addition to women’s health. thermore, the concept of fetal rights held communities in Nicaragua and Central Workshops to focus on communication by the Catholic and Evangelical church America. Second, FGDs were not con- strategies within families and within dominates the national discourse sur- ducted in all barrios, so the experiences the community should aim to increase rounding abortion. This religious idea of women living in the barrios that were acceptability and reduce the amount of has developed into the widespread cul- not studied could differ from those ex- criticism that women receive when seek- tural belief that a fetus is a child that has pressed by the study population. Third, ing family planning and sexual health the right to live, regardless of the circum- community leaders used the predefined care. Finally, educational campaigns stances surrounding its conception (15). inclusion criteria to recruit participants, should include information about repro- Findings from this study confirm that but their application of these criteria ductive rights in addition to comprehen- the majority of women agree with this was not verified. Finally, the principal sive sexual education, which would help sentiment, regardless of their religious investigator (PI) (SML) is a non-native to decrease stigma surrounding sexual affiliation or lack thereof. but fluent Spanish speaker and con- health and behavior in Ocotal. The complexity and variety of opin- ducted all FGDs in Spanish. Some lan- ions surrounding abortion is highlighted guage barriers existed that could have Acknowledgments. The authors thank by the fact that very few participants affected the quality of the data, but the the research team; the collaborators of self-identified as completely for or PI asked clarifying questions through- Proyecto Paz y Amistad, an indepen- against abortion. Instead, the majority out the FGDs to address these potential dent, nongovernmental organization in of participants fell somewhere in the issues. Ocotal (Nicaragua); and the commu- middle of the spectrum and favored nity leaders and study population of the legalization of abortion in select cir- Conclusions Ocotal. cumstances, such as rape. This is consis- tent with opinion research on abortion Women in Ocotal perceive VAW, ma- Funding. Financial support was re- in Latin American countries with strict chismo, criticism, and lack of communi- ceived from Emory University’s Global abortion bans (16). cation and education as major obstacles Field Experience (GFE) Fund and Global that limit women’s autonomy. There- Elimination of Maternal Mortality from Limitations fore, future public health campaigns to Abortion (GEMMA) Fund (Atlanta, address women’s reproductive health Georgia, United States). The findings of this study were sub- needs should include programs to ad- ject to several limitations. First, the dress these obstacles within each distinct Conflicts of Interest. None.

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resumen Objetivo. Determinar cómo perciben las mujeres de Ocotal, Nicaragua, las barreras de acceso a la atención de salud reproductiva; describir sus conocimientos acerca de los derechos reproductivos; y consignar sus opiniones acerca de la prohibición total “Siempre me critican”: del aborto en Nicaragua. barreras de acceso a la Métodos. De mayo a junio del 2014, se establecieron tres grupos de discusión en salud reproductiva en español en los que participaron 17 mujeres de dos barrios diferentes de la ciudad de Ocotal. Se utilizó una guía de discusión semiestructurada que constaba de preguntas Ocotal, Nicaragua de respuesta libre para dilucidar las perspectivas locales con respecto a los temas del grupo de discusión. Resultados. Los obstáculos graves, incluidos 1) la violencia contra la mujer, 2) el machismo, 3) las críticas por parte de otros, y 4) la falta de comunicación y formación, limitan la capacidad de las mujeres para tomar sus propias decisiones de salud reproductiva. Las mujeres mostraron una carencia generalizada de conocimientos acerca de sus derechos reproductivos y los documentos internacionales de derechos huma- nos que los definen. Además, como consecuencia de sus ideas religiosas y culturales, la mayor parte de las mujeres apoyaron la prohibición total del aborto en el país en la mayor parte de las circunstancias, con la posible excepción de la violación. Conclusiones. Se debe alentar a los hombres y mujeres de Ocotal a participar en los programas comunitarios diseñados para reducir la repercusión de los siguientes obs- táculos para obtener atención de salud reproductiva: 1) la violencia contra la mujer y el machismo; 2) la educación sexual no estandarizada y la información acerca de sus derechos reproductivos insuficientes; y 3) la comunicación deficiente dentro de las familias y en la comunidad en general. Con objeto de reducir el estigma en torno a la salud y la actividad sexuales, las futuras campañas de salud pública orientadas a tratar las necesidades de salud reproductiva de las mujeres de Ocotal deben llevar a cabo en los barrios estos tipos de programas.

Palabras clave Salud de la mujer; salud reproductiva; aborto terapéutico; violencia contra la mujer; comunicación; Nicaragua.

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