ORIGINAL RESEARCH INVESTIGACIÓN ORIGINAL
"Siempre me critican": barriers to reproductive health in Ocotal, Nicaragua
"Siempre me critican": barreras de acceso a la salud reproductiva en Ocotal, Nicaragua
Samantha M. Luffy; Dabney P. Evans; Roger W. Rochat
Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America. Send correspondence to: Dabney P. Evans, Dabney.firstname.lastname@example.org
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.
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 del aborto en Nicaragua.
MÉTODOS: De mayo a junio del 2014, se establecieron tres grupos de discusión 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 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 humanos 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 obstáculos 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.
Worldwide, unintended pregnancy imposes significant burdens on populations, with greater social, physical, and financial costs in resource-poor settings (1). Women of low socioeconomic status with limited access to family planning services are at higher risk for depression, violence, and unemployment due to unintended pregnancy (2, 3). Recent Demographic and Health Survey (DHS) data reveal that the Latin American/Caribbean region has some of the highest levels of unintended pregnancy (1).
In Nicaragua, the latest DHS suggests that 65% of pregnancies among women ages 15-29 are unintended and nearly all women (90.4%) reported having unmet reproductive health care needs (4).
To further exacerbate their lack of reproductive health autonomy, women lack access to legal abortion services to terminate an unintended pregnancy. Since 2006, Nicaraguan law prohibits the termination of a pregnancy, including cases of rape, incest, or danger to the life of the woman (5). The law imposes serious penalties on women who obtain abortions and on medical professionals who perform them (3, 6). Even in the face of such legal consequences, clandestine abortions remain prevalent in Nicaragua; approximately one-third of the country's maternal deaths result from complications from unsafe abortion (7).
In response to the negative effects of this law on women's health, the United Nations Committee on the Elimination of Discrimination against Women (CEDAW) has recommended that the government review the total ban on abortion and remove the punitive measures imposed on women who have abortions (8). CEDAW also expressed concern about the lack of standardized sexual education programs, as well as inadequate family planning services, and high rates of unintended pregnancy throughout Nicaragua (8). Strategic objectives outlined in the Beijing Declaration1 state that access to effective and safe family planning services should be the main method by which unintended pregnancies and unsafe abortions are prevented (9). The total ban on abortion directly contradicts these strategic objectives and violates women's right to comprehensive reproductive health care, including family planning and post-abortion care.
In 2012, the Nicaraguan government implemented Ley 779, a national law to eradicate violence against women (VAW) (10). The law targets persons perpetrating violence against a victim with whom he/she has an interpersonal relationship. It also defines the types of violence prohibited under the law, and sentence lengths for femicide, physical violence, psychological violence, etc. In some cases of intimate partner violence (IPV), unintended pregnancy can result if the woman's right to control her fertility is challenged by pregnancy coercion (11).
Rationale for the research
There is a dearth of research addressing the reproductive health needs of women living outside Managua and León, the two most frequently studied departments in Nicaragua. The total fertility rate (TFR) in Nueva Segovia, the department where Ocotal is located, is 3.0 children per woman-higher than the country's overall TFR (2.7) (1). In addition, 20% of the TFR in Nueva Segovia are unintended pregnancies, a proportion higher than those in Managua and León (18% and 9.5%, respectively) (4). Existing research does not address why unintended pregnancy is more frequent in this part of the country. Exploring women's perceptions of barriers to reproductive health care and their experiences with unintended pregnancy provides crucial context for the available statistics and better prepares health care providers to meet the reproductive health needs of women in Ocotal.
The objectives of this research were to 1) identify perceived barriers to accessing reproductive health care according to the women of Ocotal; 2) describe their understanding of their reproductive rights; and 3) document their opinions on Nicaragua's total ban on abortion.
MATERIALS AND METHODS
Ocotal is the largest city in the northern department of Nueva Segovia, with approximately 47 000 inhabitants. There are 34 neighborhoods (barrios), each with its own identity and community-approved leaders. The barrios are the functional units of the municipality and many public programs operate at this level.
Public facilities offering reproductive health services include one hospital, one health center, and eight health posts. The health center offers primary care services as well as prenatal consultations for newly pregnant women. Health posts offer basic primary care, including family planning services; sexually transmitted infection (STI) testing; and cervical cancer screening. Other sources of reproductive health care include private clinics and pharmacies, which sell condoms and the emergency contraception pill.
Due to the iterative nature of qualitative research, data collected during pilot and initial focus group discussions (FGDs) informed later stages of data collection.
Two pilot FGDs were conducted in Spanish to further develop and revise the language used in the original (English) semi-structured discussion guide (developed by the authors) according to cultural norms. Women 15-30 years old who had been pregnant at least once and spoke either Spanish or English were recruited for participation. The participants were sampled from a local university and Barrio Teodoro López. Participants were asked open-ended questions about 1) what they perceived as obstacles to receiving reproductive health care in Ocotal, 2) their reproductive rights, and 3) their opinions about Nicaragua's total ban on abortion. Participants also provided feedback on the nature and structure of the questions to improve the cultural appropriateness of the revised (Spanish) discussion guide.
Three FGDs were performed in Spanish for data collection and consisted of groups of up to six women from two barrios: Laura Sofia Olivas and Nuevo Amanecer. A total of 17 participants were recruited with the assistance of community leaders and included young women 17-27 years old who had been pregnant at least once and spoke Spanish. Demographic information about the participants can be found in Table 1. The revised discussion guide (presented as Supplementary material) was employed during these FGDs, but the main topics remained the same throughout data collection. Probing, follow-up, and interpretive questions were used to further explore topics brought up during the FGDs.
Data management and analysis
All FGDs were audio-recorded, transcribed verbatim, and de-identified. The data were analyzed using MAXQDA11 software (VERBI GmbH, Berlin, Germany), which aided in the coding of the transcripts and the analysis of inductive themes. The quotes were translated using three different online translation tools and the translations were reviewed and combined to best match each participant's intended meaning.
Study ethics and informed consent
In its initial review of the study, Emory University's Institutional Review Board (IRB) determined that the project was exempt from full review because it did not meet the definition of "research" with human subjects. This determination was based on the fact that the study only included 17 participants from two barrios and therefore the results had limited generalizability. The host organization in Nicaragua used Emory's IRB as a proxy. Verbal, informed consent was obtained from all participants before each FGD and participants were informed that they could withdraw from participation at any time. There was minimal risk to the participants as their participation and the information collected from them was kept confidential.
Obstacles to receiving reproductive health care
Criticas. Of the many obstacles the women perceived as having a significant influence on their access to reproductive health care, criticas (criticism) from others in the community was the one most often cited across all groups. According to the participants, they felt criticized or judged when they went to a health center or health post to receive family planning information or STI testing. Given that health facilities are centrally located in their barrios, women often encounter people they know. A participant named Rosa2 explained the situation as follows:
When a young girl who is 15 or 16 begins to have sexual relations and thinks to protect herself, sometimes there are many people that know her in the health center and then these people she knows begin to judge her harshly.
The participants said that this generally affects younger girls, who are more likely to use a family planning method in secret and/or conceal the fact that they have a boyfriend from their families and other members of the community. Parents may not allow their daughters to have boyfriends or use a family planning method because of what the participants described as "ignorance" and fear that their daughter will become pregnant. Some participants reported that girls in Ocotal are beginning to have sexual relations at younger ages (13-14 years old), which puts them at risk for an unintended pregnancy. A participant named Tania recounted a personal example:
I have a young girlfriend that has had-you know that now in this time it is common-she has had relations with her boyfriend and I told her as a supportive friend that I would accompany her to the [health] center. Then she said "no" because she is embarrassed-ashamed to be criticized. One always tries to raise the self-esteem of others because we also have the right to counsel others who are at risk of an unwanted pregnancy. When we arrive at the center, they criticize us, so then we do not get the injection and could get pregnant.
Hormone injections were the most commonly reported form of birth control used in Ocotal, but many participants admitted that they often did not go to receive follow-up injections for fear of being judged or criticized by their neighbors at the health center.
Violence against women. The participants in all groups viewed VAW as a formidable obstacle that prevents them from accessing reproductive health services. Women gave examples of domestic violence between parents and their daughter, as well as IPV between a woman and her partner. Parental violence commonly occurs when the father thinks the daughter has started having sex or discovers that she has been secretly dating. A participant named Reina explained some fathers' reaction as follows:
There is domestic abuse after a girl becomes pregnant. What do the parents do when they're incredibly ignorant? They aren't educated and begin to be abusive and say, "It would be better for you to leave if you want this man. Get out of the house." So the family also discriminates against her.
Machismo was also mentioned frequently in discussions about VAW as a major cause of femicide, rape, and violence, as well as a barrier to women using a family planning method ("plan"), as a participant named Lupita explained:
The [partner] must respect one's decisions to plan because there are men who are machistas [sexists] who do not like it if [their partner] plans and prefer [that their partner] is always pregnant, having child after child.
The participants said a new law, Ley 779, was "both good and bad" at combatting VAW and machismo in Ocotal. The participants believed that the law gives women more power to sue their abuser but that it has also caused more femicide. A participant named Anita explained the effects of the law as follows:
The opinion of the men now is that they prefer to kill the woman instead of hitting her because although they will go to jail for hitting her, they will also go to jail for killing her, so they say, "It is better if I kill her." That is the opinion of the men now, young and old. I say it is awful how lost the men are because those are their thoughts now-that is better to kill the woman.... This began because of Ley 779. The law started it.
Participants in all three groups agreed that the law does not protect women due to the high prevalence of machismo among the men in Ocotal.
When asked to define the term "sexual and reproductive rights" the participants were unable to do so but were able to provide examples. The examples were similar across all FGDs and included the right to decide when to have sexual relations and the right to choose how many children to have. The groups also mentioned the right to have access to sexual and reproductive health services and education, including the ability to decide what method of family planning to use and access to specialty gynecologic services.
All three groups believed that their sexual and reproductive rights originated from the Nicaraguan government and national law, including Ley 779. Only one participant said she did not know the origin of these rights: "The government promotes [our sexual rights] pretty well, but I honestly do not know who invented them." All groups were uncertain about the origin of women's sexual rights, and none seemed familiar with international treaties or documents that define them.
Prohibition of abortion
Total ban on abortion. All participants were familiar with the country's law that bans therapeutic abortion in all circumstances. Their reaction to this law, as explained by a participant named Vilma, was similar to women's opinions about Ley 779:
It is good and bad ... . Sometimes ... women ... make the decision to abort for some problem they have ... they may have a very small uterus or sometimes the child does not develop where it should be. But then there are some women ... who abort because they are very young. But I say you should not abort because one must fight for her children because our parents fought for us and so one must fight for her children.... So I agree with the law and at the same time, I don't, you know?
It was common for women to disapprove of an abortion in most cases, including an unintended pregnancy or if the mother is very young. Across all three FGDs, however, the participants agreed that in the case of rape, an abortion could be seen as acceptable. The participant named Tania explained this as follows:
I say in the example of rape-imagine a rape, an unwanted child from a rape: to this I say ... I don't know, to be honest; maybe God changes the woman's mind, but it hurts to have a child that is unwanted because it is from a rape.
Though many participants wavered on the fairness of the law in the case of rape, some participants used religious or cultural sentiments to justify continuing a pregnancy, regardless of whether it resulted from a rape.
"El niño no tiene culpa." At least one participant in each group said "el niño no tiene culpa" ["the child is not at fault"] when explaining why they believe abortion is wrong. The rest of the group often nodded or murmured in agreement when this phrase was mentioned. When discussing rape, a participant named Mary said the following:
... The child is not to blame for what the father, the man, did to the woman. In this situation one has to start thinking that the child is not at fault, and she must have it because, either way, the child comes from her belly, her womb, and she has to have it, accept it.
Religion influences women's opinions about abortion. Some participants viewed abortion as a sin, so were therefore in favor of the law. It was widely agreed that giving the child up for adoption or giving the child as a "gift" to someone else who had the resources to take care of it are "more favorable than abortion."
The participants also reported that abortion is uncommon in Ocotal. Some group members mentioned extreme cases of young girls who had attempted or successfully completed an abortion, but they said the "majority" of women have the baby regardless of the circumstances surrounding the pregnancy.
Lack of communication. Across all groups, women said that a lack of communication between a woman and her parents or her partner contributes to instances of VAW and decreases women's freedom to make their own decisions about their reproductive health and future. Participants reported that they could not communicate with their parents or partners for fear of discrimination, violence, and embarrassment. The participant named Reina explained how machismo influenced her partner's reaction to her future goals:
Sometimes he understands me and sometimes he does not. Because when I say that I want to work, he does not like those decisions. If I tell him that I want to study, because I want to [pursue] a profession ... he says, "No, I do not like that decision."... Sometimes I do not understand his mentality.
Many participants said that due to machismo, their father or partner wanted to limit their ability to make personal choices related to family planning, education, and work.
Improved communication. Each group said that improved communication between women and their parents and partners would have a positive impact on women's lives in Ocotal. According to the participants, being able to talk with parents and partners without fear of negative consequences would greatly increase trust in the relationship and decrease the prevalence of unintended pregnancy. If young girls could talk with their parents openly, they would not have to family plan or date in secret, which would decrease their risk of getting pregnant. According to the participant named Tania, "it is nice to have a relationship and a conversation with [one's] family."
In addition, the participants believe that open communication with their partners would mitigate the influence of machismo in their relationship because the man would begin to view the woman as an equal and see her as capable of making her own decisions about pursuing education or a career.
This qualitative evaluation has demonstrated that in Ocotal, Nicaragua, serious obstacles, such as VAW, machismo, criticism, and lack of communication and education limit women's ability to make their own reproductive health decisions. There is a lack of knowledge about reproductive rights as well as the international documents that define them. In addition, because of religious and cultural ideologies, the majority of women support the country's total ban on abortion in most circumstances, with the possible exception of rape.
Though Ley 779 was intended to reduce VAW in Nicaragua, women in Ocotal believe that it has caused more violence, particularly femicide, throughout the country. They also said that having a partner who is a machista severely limits women's autonomy and ability to make personal decisions regarding their reproductive health, work, and education. The findings about the influence of VAW and machismo are similar to those found by other studies in Nicaragua showing that gender inequalities are associated with women's poor physical, mental, and reproductive health (12-14). These studies have also found that it is important to include men in programs to improve women's access to sexual and reproductive health services in Nicaragua. The results from this study highlighting the importance of improved communication with fathers and partners confirm that women in Ocotal also believe that men need to be involved in decisions regarding sexual and reproductive health.
As shown in this study, women's lack of knowledge regarding their reproductive rights reflects limited access to information and education on the subject, which coincides with the nonexistence of standardized and comprehensive sexual education curricula in schools (3). Furthermore, the concept of fetal rights held by the Catholic and Evangelical church dominates the national discourse surrounding abortion. This religious idea has developed into the widespread cultural belief that a fetus is a child that has the right to live, regardless of the circumstances surrounding its conception (15). Findings from this study confirm that the majority of women agree with this sentiment, regardless of their religious affiliation or lack thereof.
The complexity and variety of opinions surrounding abortion is highlighted by the fact that very few participants self-identified as completely for or against abortion. Instead, the majority of participants fell somewhere in the middle of the spectrum and favored the legalization of abortion in select circumstances, such as rape. This is consistent with opinion research on abortion in Latin American countries with strict abortion bans (16).
The findings of this study were subject to several limitations. First, the study area was limited to the municipality of Ocotal, so the findings cannot be generalized to other populations. These findings could, however, reflect the sentiments of women from similar communities in Nicaragua and Central America. Second, FGDs were not conducted in all barrios, so the experiences of women living in the barrios that were not studied could differ from those expressed by the study population. Third, community leaders used the predefined inclusion criteria to recruit participants, but their application of these criteria was not verified. Finally, the principal investigator (PI) (SML) is a non-native but fluent Spanish speaker and conducted all FGDs in Spanish. Some language barriers existed that could have affected the quality of the data, but the PI asked clarifying questions throughout the FGDs to address these potential issues.
Women in Ocotal perceive VAW, machismo, criticism, and lack of communication and education as major obstacles that limit women's autonomy. Therefore, future public health campaigns to address women's reproductive health needs should include programs to address these obstacles within each distinct barrio. Community-level programs with both men and women should address the negative impacts of machismo and VAW on the health of the population as a whole, in addition to women's health. Workshops to focus on communication strategies within families and within the community should aim to increase acceptability and reduce the amount of criticism that women receive when seeking family planning and sexual health care. Finally, educational campaigns should include information about reproductive rights in addition to comprehensive sexual education, which would help to decrease stigma surrounding sexual health and behavior in Ocotal.
Acknowledgments. The authors thank the research team; the collaborators of Proyecto Paz y Amistad, an independent, nongovernmental organization in Ocotal (Nicaragua); and the community leaders and study population of Ocotal.
Funding. Financial support was received from Emory University's Global Field Experience (GFE) Fund and Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund (Atlanta, Georgia, United States).
Conflicts of Interest. None.
1. Gipson JD, Koenig MA, Hindin MJ. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Stud Family Plann. 2008;39(1):18-38.
2. Berglund S, Liljestrand J, Marín FM, Salgado N, Zelaya E. The background of adolescent pregnancies in Nicaragua: a qualitative approach. Soc Sci Med. 1997;44(1):1-12.
3. Walsh J, Mollmann M, Heimburger A. Abortion and human rights: examples from Latin America. IDS Bull. 2008;39(3):28-39.
4. Instituto Nacional de Información de Desarrollo, Ministry of Health (NI). Nicaraguan Demographic and Health Survey 2006/07: final report. Managua: INIDE; 2008. Available from: http://www.inide.gob.ni/bibliovirtual/Publicacion09/EndesaV.ingles.pdf
5. Reuterswärd C, Zetterberg P, Thapar- Björkert, Molyneux M. Abortion law reforms in Colombia and Nicaragua: issue networks and opportunity contexts. Dev Change. 2011;42(3):805-31.
6. Kulczycki A. Abortion in Latin America: changes in practice, growing conflict, and recent policy developments. Stud Fam Plann. 2011;42(3):199-220.
7. Wessels, L. Reproductive rights in Nicaragua: from the Sandanistas to the government of Violeta Chamorro. Fem Stud. 1991;17(3):537-49.
8. United Nations Office of the High Commissioner for Human Rights. Committee on the Elimination of Discrimination against Women. Geneva: UN OHCHR; 2007. Available from: http://tbinternet.ohchr.org/_layouts/treatybodyexternal/Download.aspx?symbolno=CEDAW%2fC%2fNIC%2fCO%2f6&Lang=en
9. United Nations Fourth World Conference on Women. Beijing Declaration and Platform for Action. Beijing: UN; 1995. Available from: http://www.un.org/en/events/pastevents/pdfs/Beijing_Declaration_and_Platform_for_Action.pdf
10. National Assembly (NI). Ley No. 779, Ley Integral Contra la Violencia hacia las Mujeres y de Reformas a la Ley No. 641, "Código Penal." Diario Official. Managua: National Assembly; 2012. Available from: http://www.poderjudicial.gob.ni/pjupload/leyes/Ley_No_779_Ley_Integral_Contra_la_Violencia_hacia_la_Mujer.pdf
11. Salazar M, Valladares E, Högberg U. Questions about intimate partner violence should be part of contraceptive counselling: findings from a community-based longitudinal study in Nicaragua. J Fam Plan Reprod Health Care. 2012;38(4):221-8.
12. Sternberg P. Challenging machismo: promoting sexual and reproductive health with Nicaraguan men. Gend Dev. 2000;8(1):89-99.
13. Sternberg P, White A, Hubley JH. Damned if they do, damned if they don't. Tensions in Nicaraguan masculinities as barriers to sexual and reproductive health promotion. Men Masc. 2008;10(5):538-56.
14. Torres VM, Goicolea I, Edin K, Ohman A. 'Expanding your mind': the process of constructing gender-equitable masculinities in young Nicaraguan men participating in reproductive health or gender training programs. Glob Health Action. 2012;5. Epub 2012 Aug 2.
15. Morgan LM, Roberts EF. Reproductive governance in Latin America. Anthropol Med. 2012;19(2):241-54.
16. Richardson E, Birn AE. Sexual and reproductive health and rights in Latin America: an analysis of trends, commitments and achievements. Reprod Health Matters. 2011;19(38):183-96.
Manuscript received on 16 August 2014
Revised version accepted for publication on 23 January 2015
2 All names have been changed to protect the participants' privacy
The supplementary material is available in pdf: [Supplementary material]