63072 Fertility Decline in Nicaragua 1980–2006 A Case Study The World Bank May 2010 Fertility Decline in Nicaragua, 1980–2006 A case study May 2010 iii contents Acknowledgments v Abbreviations vi Executive summary vii Rationale for country selection 1 Overview of Findings 1 Nicaragua at a Glance 1 What are the causes of Nicaragua’s Falling Fertility? 5 Variation by Residence and Age 5 Determinants of Fertility in Nicaragua 7 Proximate determinants of the decline in Nicaragua’s fertility from 1997–2007 7 Socioeconomic and cultural determinants 12 Programs and Policies that Might Have Contributed to Nicaragua’s Fertility Decline 19 Nicaragua’s health care and family planning efforts since 1979 19 The Nicaraguan government and international donors 22 The role of nongovernmental organizations 22 The role of the private sector 22 Innovations in service provision 22 Lessons from Nicaragua’s Falling Fertility 23 Annex 1. Nicaragua at a Glance 24 References 26 End Notes 28 iv Tables Table 1. Country Selection Criteria and Data 1 Table 2. Nicaragua’s Progress toward Child and Maternal MDGs, 1990–2006 4 Table 3. Highest and Lowest Total Fertility Rates by Department (ENDESAs 1997–2007) 6 Table 4. Highest and Lowest Contraceptive Prevalence Rates by Rural or Urban Residence and Department, 1997–2007 (percent) Department 10 Figures Figure 1. Map of Nicaragua 3 Figure 2. Nicaragua’s Total Fertility Rate Has Fallen by more than Half, 1980–2007 5 Figure 3. Total Fertility Rates in Nicaragua Have Dropped Faster in Rural Areas, 1998–2007 6 Figure 4. Fertility Rates in Nicaragua Differ by Age Range, 1997/98–2006/07 7 Figure 5. Fertility Rates in Nicaragua in Both Rural and Urban Areas Are Highest for Women Ages 15–29, 1997–2007 8 Figure 6. Contraceptive Prevalence Rates Have Risen Dramatically among Nicaraguan Women Ages 15–49 (Married or in Consensual Union), 1981–2007 8 Figure 7. Contraceptive Prevalence Rates among Nicaraguan Women Ages 15–49 (Married or in Consensual Union) Have Risen Faster in Rural than in Urban Areas, 1998–2007 9 Figure 8. Contraceptive Prevalence Rates among Nicaraguan Women Ages 15–49 (Married or in Consensual Union) Have Risen for Most Methods, 1998–2007 9 Figure 9. Contraceptive Prevalence Rate among Nicaraguan Women by Age Range, 1998–2007 10 Figure 10. Declining Rates of Infant Mortality and Under-five Mortality in Nicaragua, 1960–2007 14 Figure 11. Rising Female Education Rates in Nicaragua, 1989–2006 15 Figure 12. Total Fertility Rates in Nicaragua Decline with Women’s Education, 1992–2001 16 Figure 13. Rates of Labor Force Participation in Nicaragua, by Gender, 1980–2006 17 Fertility Decline in Nicaragua, 1980–2006 | A Case Study v Acknowledgments T his report was prepared by Usha Vatsia veloppement), Jose Guzman (United Nations of the Health, Nutrition, and Popula- Population Fund), Karen Hardee (Population tion unit of the Human Development Action International), Daniel Kraushaar (Bill Network (HDNHE) and Sadia Chowdhury and Melinda Gates Foundation), Gilda Sedgh (HDNHE). (Guttmacher Institute), Amy Tsui (Johns Hop- Contributing to the preparation of the re- kins University, Bloomberg School of Public port was, in alphabetical order: Pia Axemo Health), and Wasim Zaman (International (HDNHE), Samuel Mills (HDNHE), Naoko Council on Management of Population Pro- Ohno (SASHN), and Christine L. Peña grammes). The World Bank advisory group (LCSHH). Special thanks are due to Anna comprised: Martha Ainsworth (IEGWB), Peter Gorter, of the Instituto CentroAmericano de la Berman (HDNHE), Eduard Bos (HDNHE), Salud, for sharing her insights and country ex- Rodolfo Bulatao (HDNHE), Hugo Diaz pertise in her technical review and through her Etchevere (HDNVP), Rama Lakshminaray- input. The Centers for Disease Control and Pre- anan (HDNHE), John May (AFTHE), Eliz- vention (CDC) is gratefully acknowledged for abeth Lule (AFTQK), and Thomas Merrick providing the ENDESA 2006/07 reports. The (WBIHS). authors are grateful to the World Bank Library Bruce Ross-Larson, Communications De- Research Services for assisting with the litera- velopment Incorporated, edited the draft report ture search. Mukesh Chawla, Sector Manager and Samuel Mills (HDNHE) reviewed the final (HDNHE), and Julian Schweitzer, Sector Di- draft. The authors would like to thank the gov- rector, (HDNHE) at the World Bank provided ernment of the Netherlands, which provided overall guidance and support. Thanks to Victo- financial support through the World Bank- riano Arias for providing administrative support. Netherlands Partnership Program (BNPP). This case study was part of a larger World Bank Economic and Sector Work entitled Ad- Correspondence Details: dressing the Neglected MDG: World Bank Re- view of Population and High Fertility with an Æ Sadia Chowdhury (HDNHE), World external advisory group comprising: Stan Ber- Bank, Mail Stop G7–701, 1818 H Street nstein (United Nations Population Fund), N.W., Washington, DC 20433, USA, Tel: John Bongaarts (Population Council), John 202-458-1984, email: schowdhury3@ Casterline (Ohio State University), Barbara worldbank.org. Crane (IPAS), Adrienne Germain (Interna- Æ This report is available on the following tional Women’s Health Coalition), Jean Pierre website: http://www.worldbank.org/ Guengant (L’Institut de Recherché Pour le Dé- hnppublications. vi Abbreviations AFTHE Health, Nutrition, and MINSA Nicaraguan Ministry of Health Population unit of the Africa NGO Nongovernmental region Organization AFTQK Africa Operational Quality and PAHO Pan American Health Knowledge Services Organization ENDESA Nicaraguan Demographic PASMO Pan American Social Marketing Health Survey Organization FSLN Sandinista National Liberation RAAN North Atlantic Autonomous Front Region HDNHE Human Development RAAS South Atlantic Autonomous Network, Health, Nutrition, Region and Population unit UNFPA United Nations Fund for IEGWB Independent Evaluation Population Group, World Bank USAID United States Agency for IPPF International Planned International Development Parenthood Federation WBIHS World Bank Institute Health MDG Millennium Development Goal Systems WHO World Health Organization Fertility Decline in Nicaragua, 1980–2006 | A Case Study vii Executive summary N icaragua, a largely urban country (56 and access to primary health care, supported percent of the population lives in urban by funding and constitutional reform. areas), is one of the least populous (5.53 Two other potential contributing factors million) and poorest countries in Central were the steep reduction in infant mortality, America. Following reforms in the 1980s, Ni- which began in the 1970s, and the increasing caragua made remarkable progress in gender availability of family planning services—in- equity in education and the labor force, while cluding an efficient distribution system for the wide availability of primary health care free contraceptives. Donors, international initiated in the 1970’s, including family plan- and national nongovernmental organizations ning services, led to improvements in infant (NGOs), and the private sector were critical and child mortality rates. in providing the family planning services and The total fertility rate fell dramatically be- contraceptive supplies to meet the increased tween 1980 and 2007, dropping 22 percent demand for contraception that ultimately led during the 1980s, 31 percent in the 1990s, to Nicaragua’s dramatic fertility decline. and 17 percent during 2000–07, for a total In Nicaragua, contraceptives are available decline of 55 percent. The total fertility rate is from multiple sources. The Ministry of Health lower for urban women than for rural women, (MINSA), which distributes family planning though the reduction has been greater since supplies through departmental and regional 1998 in rural areas (30 percent) than in urban health offices and facilities, is the main source areas (24 percent). Fertility rates have dropped of free modern family planning methods. The for all age groups, but especially for young private sector and NGOs supply condoms women ages 20–24. Nicaragua’s contraceptive procured internationally and repackaged for prevalence rate rose dramatically as well, from sale at low cost locally. They operate their own 27 percent in 1981 to 72 percent in 2007 clinics and network of agents for distributing among women ages 15–49 (married or con- contraceptives. sensual union). Several lessons emerge from Nicaragua’s Nicaragua’s exceptionally large fertility de- success at reducing fertility. The government cline between 1980 and 2007 appears to have was committed to gender equity and female been due mainly to the Sandinista govern- empowerment through educating girls and ment’s sweeping changes to policies and public women and recruiting women into the labor programs during the early years of the period. force. Family planning services were provided The government promoted increased educa- within a well functioning primary health care tion, equal rights for women, participation of system, including an extensive, efficient con- women in the workforce, public education, traceptive distribution network that works viii with international donors, and international holders, which may initially mean avoiding and national NGOs to offer women a good unnecessary confrontation and publicity of mix of options. Demand must be created services for addressing the concerns of more through a timely public education campaign. conservative stakeholders. Success requires civic engagement with stake- Fertility Decline in Nicaragua, 1980–2006 | A Case Study 1 Rationale for country selection N icaragua was chosen as one of the five The organization of family planning ser- fertility case studies (the other four vices, including the efficient distribution countries are Algeria, Botswana, Iran, system for free contraceptives, appear to have and Pakistan) because it has had one of the been significant factors in increasing women’s most significant total fertility rate declines contraceptive usage, and ultimately in the de- globally and regionally over the last 30 years cline in Nicaragua’s total fertility rate. Coordi- based on the following criteria (table 1). nation with donors, international and national NGOs, and the private sector were critical in Overview of Findings providing family planning services and con- The most significant factors in Nicaragua’s fer- traceptive supplies to meet increased demand tility decline between 1980 and 2007 appear that ultimately led to Nicaragua’s dramatic fer- to have been the Sandinista government’s vi- tility decline. sion along with the sweeping changes to poli- cies and public programs in their early years Nicaragua at a Glance in power that promoted increased educa- Nicaragua, colonized by the Spanish in 1522, tion, equal rights for women, participation won its independence in 1838. The Nica- of women in the work force, and public edu- raguan people have suffered a series of dev- cation and access to primary health care, in- astating disasters in their recent history, cluding funding and constitutional reform for including natural disasters and years of po- their programs. The steep reduction in infant litical conflict. In 1937 General Somoza ini- mortality rate that started in the 1970s may tiated a 44-year family dictatorship that also have contributed. ended in 1979 with a revolution led by the Table 1 | country selection criteria and Data selection criterion Data for Nicaragua Total fertility rate greater than 6.0 in 1980 Total fertility rate of 6.05 in 1980 Substantial fertility reduction between 1980 and 2006 Total fertility rate declined 54 percent during this period, from 6.05 to 2.7 Population greater than 1 million Population of 5.53 million in 2006 Potentially relevant literature, published between Initial search identified 67 articles 1994–2008, according to a preliminary search Regional representation Experienced the greatest absolute total fertility rate reduction in the Latin America and Caribbean region Source: Authors’ analysis of data described in the text. 2 Sandinista National Liberation Front (FSLN). and Xiu—though most are now mixed with After winning national elections in 1984, the Mestizos and speak Spanish. The indigenous FSLN governed Nicaragua until 1990, when and Afro-descendant communities in the At- the center-right National Opposition Union lantic region consist of Miskitos, Mayagnas, (headed by Violeta Chamorro) was voted Garifunas, Ramas, Sumus, and Creoles who into office.1 In the 1990s Nicaragua became a still speak their native languages and main- market economy when it dropped trade bar- tain their cultural practices. Together, Nica- riers and modernized its government. Progress ragua’s indigenous groups make up close to stalled with a change in leadership in 1996, 10 percent of the population.5 (For a detailed when Arnoldo Alemán came to power. He was country map, see figure 1. To review Nicara- later charged with money laundering and em- gua’s development indicators, see the annex 1.) bezzlement during his term in office.2 Today, Although Nicaragua has embraced the Nicaragua is led by former Sandinista presi- Millennium Development Goals (MDGs) in dent Daniel Ortega who was re-elected presi- its National Development Plans, assessments dent in 2006 with 38 percent of the vote, and of the status of most of the MDGs, particu- took office in January 2007. larly those related to maternal and child health With a per capita gross national income are not being met, including meeting interim (GNI) of $980 per capita and 5.53 million targets.6 people in 2006, Nicaragua is one of the least While the country has made progress on populous countries in Central America. More MDG 4 in reducing child and infant mor- than 56 percent of Nicaraguans live in urban tality, neonatal mortality (the probability of areas.3 The people are unevenly distributed dying within the first 28 days of life) is now across three geographic regions: more than higher than post neonatal mortality (the prob- half live in the Pacific region, about a third in ability of dying between the 28th day of life the central region, and about 13 percent in and the first birthday). The country is lag- the Atlantic region.4 ging on its targets for reducing malnutrition The country is divided into 15 depart- for children under five (MDG 1), though it ments and two autonomous regions, and is appears to have performed better than other comprised of 153 mostly rural or semi-urban countries in the region facing acute develop- municipalities. Most of the population is ment challenges (El Salvador, Guatemala, and Christian and Spanish-speaking, though the Honduras) in reducing maternal mortality country is multiethnic and pluricultural, with rates (MDG 5) 7. However, vast discrepan- Mestizos a majority of the population. The cies were noted in the maternal mortality data indigenous people native to the Pacific and (table 2)8, which make progress for this MDG central regions and to northern Nicaragua in- ambiguous.9 clude the Cacaoperas, Chorotegas, Nahuas, Fertility Decline in Nicaragua, 1980–2006 | A Case Study 3 Figure 1 | Map of Nicaragua IBRD 33456 Source: The World Bank, Map Design Unit, 2010. 4 Table 2 | Nicaragua’s progress Toward child and Maternal MDGs, 1990–2006 1990 or the earliest available Latest available MDG # Indicator data data 1 Malnutrition prevalence, weight for age (percent of 11.9 (1993) 9.6 (2001) children under five) 4 Mortality rate, under age five (per 1,000 live births) 68 (1990) 36 (2006) Mortality rate, infant (per 1,000 live births) 52 (1990) 29 (2006) Percentage of children 12–23 months immunized 82 (1990) 99 (2006) against measles 5 Maternal mortality ratio (modeled estimate per 100,000 170 (2005) Unavailable live births) Maternal mortality ratio (national estimate per 100,000 91.1 (1992) 125 (2002) live births) 87.3 (2004) Percentage of births attended by skilled health staff 61 (1993) 66.9 (2001) Source: For earliest available data, United Nations 2009; for 1992 national estimate of maternal mortality ration, PAHO 2007; for 2002 estimate of maternal mortality ratio, World Bank 2007; and for 2004 estimate of maternal mortality ratio, PAHO 2007. Fertility Decline in Nicaragua, 1980–2006 | A Case Study 5 What Are the causes of Nicaragua’s Falling Fertility? T he total fertility rate for Nicaraguan was 2.2 percent in urban areas compared to 3.5 women declined steadily during the 1960s percent in rural areas.12 and 1970s, from a high of 7.25 (1960) to 6.05 (1980)—a 17 percent reduction over 20 Variation by Residence and Age years.10 Since then, fertility rates have declined Fertility has varied greatly by urban-rural lo- even more dramatically: 22 percent during the cale, region, and age. 1980s, 31 percent in the 1990s, and 17 per- Total fertility rates have been lower in cent from 2000 to 2007, for a total decline of urban areas than in rural areas. During 55 percent over 27 years (figure 2).11 Fertility 1998–2007, the total fertility rate dropped 24 has varied greatly depending on the area of the percent in urban areas compared to the more country in which a Nicaraguan woman lives. significant drop of 30 percent in rural areas Total fertility rate for urban women has been (figure 3).13 lower than for rural women. The most recent Table 3 provides more information re- total fertility rate (2007) was 2.7, although it garding Nicaragua’s regional variation in total Figure 2 | Nicaragua’s Total Fertility Rate Has Fallen by more than Half, 1980–2007 7 6 No. of children per woman 5 4 3 2 1 0 1980 1982 1985 1987 1990 1992 1995 1997 2000 2001 2002 2005 2006 2007 Nicaragua 6.05 5.85 5.34 5.00 4.70 4.50 3.96 3.60 3.24 3.20 3.00 2.85 2.80 2.70 Source: The World Bank, WDI, 2009; Measure DHS. 2003. “Fertility and Mortality Decline in Nicaragua; Contraceptive Use Increases.” DHS+ Dimensions 5 (1): 4. 6 | Figure 3 Total Fertility Rates in rate) in the Central region, both of which saw Nicaragua Have Dropped a 43 percent decline in total fertility rates, and Faster in Rural Areas, the lowest reduction in the departments of 1998–2007 Managua (low total fertility rate) in the Pa- 6 cific region with a total fertility rate decline of 21 percent, and RAAN in the Atlantic region No. of children per woman 5 (high total fertility rate), which had a decline 4 of 24 percent. Fertility has declined for all age ranges 3 since 1998, the most dramatic of which 2 can be seen in the figure 4 amongst young women ages 20–24. An important decrease 1 in births per 1,000 women aged 15–19 has 0 been observed: 130 in 1998, 119 in 2001 1998 2001 2007 and 106 in 2006, but the decrease is much Rural areas Urban areas less than the one observed in the other age Source: Republic of Nicaragua, 2008; Measure DHS. STAT- groups as shown in figure 4 (ENDESA compiler, www.statcompiler.com. April 2009. 1997–98, 2001, 2006–07). Because of a greater decrease in the older age groups, fertility rates. The highest total fertility rates the contribution of adolescents to the birth are in the Central and Atlantic region and the rates has increased and is now about 20 per- lowest in the Pacific region. Over the last de- cent. The number of births per 1,000 ado- cade, the greatest reductions have occurred in lescents in rural areas is much higher at 139 the departments of Rio San Juan (high total compared to 83 in urban areas (ENDESA fertility rate) and Chontales (low total fertility 2006–07). Table 3 | Highest and Lowest Total Fertility Rates by Department (ENDEsAs 1997–2007) Total Fertility Rate Department 1997/98 2001 2006/07 Highest RAAN 5.9 5.2 4.5 Jinotega 6.2 5.3 4.2 Rio san Juan 5.4 4.1 3.1 RAAs 4.3 4.4 3.0 Lowest Managua 2.8 2..5 2.2 Leon 3.2 2.5 2.1 carazo 3.4 2.8 2.1 chontales 3.5 3.0 2.0 Source: Republic of Nicaragua, September 2008; Measure DHS. STATcompiler, www.statcompiler.comMacro International, Inc., www.measuredhs.com, April 2009. Fertility Decline in Nicaragua, 1980–2006 | A Case Study 7 Figure 4 | Fertility Rates in Nicaragua Differ by Age Range, 1997/98–2006/07 250 Births per 1,000 women 200 150 100 50 0 15–19 20–24 25–29 30–34 35–39 40–44 45–49 2006–07 2001 1998 Source: Republic of Nicaragua 2008; Measure DHS. STATcompiler, www.statcompiler.comMacro International, Inc., www.measuredhs.com, April 2009. Determinants of Fertility in vador, Guatemala, and Honduras (first inter- Nicaragua course at 17.9, first union at 18.3, first birth This section looks at common proximate, so- at 19.6).14 Fertility rates in both rural and cioeconomic, and cultural determinants of urban areas are highest for women ages 15–29 fertility that might have led to the dramatic (figure 5). There is no comparable data avail- decline in Nicaragua’s fertility since 1980. The able for Nicaraguan men. roles of particular programs, policies, types First sex for Nicaraguan women tends to and sources of support, and innovations in precede marriage and is followed by first birth service, just touched on here, are examined in shortly thereafter.15 These findings suggest that more detail in the next section. marriage and sexual union have not influenced fertility rate declines in Nicaragua. proximate determinants of the decline in Nicaragua’s fertility from Contraceptive use (mix of methods) 1997–2007 Since 1998 almost all Nicaraguan women Possible proximate determinants of fertility in- (97–99 percent) have reported being aware clude marriage and sexual union, contracep- of at least one method of contraception.16 tive use and methods, induced abortion, and Nicaragua’s contraceptive prevalence rate in duration of breast feeding. women ages 15–49 (married or consensual union) has increased significantly over the Marriage and sexual union last three decades—from 27 percent in 1981 Fertility is affected by the ages at which to 72 percent in 2007.17 The most dramatic women and men become sexually active, increases occurred between 1981 and 1998, marry, and have children. Nicaraguan women when the contraceptive prevalence rate rose initiate all three activities somewhat earlier by 33 percentage points. The 12 percentage than their counterparts in the region in El Sal- point increase between 1998 and 2007 indi- 8 Figure 5 | Fertility Rates in Nicaragua in both Rural and urban Areas Are Highest For Women Ages 15–29, 1997–2007 300 250 Births per 1,000 women 200 150 100 50 0 Urban Rural Total Urban Rural Total Urban Rural Total 2006–07 2001 1997–98 15–19 20–24 25–29 30–34 35–39 40–44 45–49 Source: Republic of Nicaragua 2008; Measure DHS. STATcompiler, www.statcompiler.comMacro International, Inc., www.measuredhs.com, April 2009. | cates a continuing trend of increasing contra- Figure 6 contraceptive prevalence ceptive use (figure 6).18 Rates Have Risen Dramatically Between 1998 and 2007, contraceptive among Nicaraguan Women prevalence rates increased more dramatically Ages 15–49 (Married or in in rural areas (19 percentage points, from 51 consensual union), 1981–2007 percent to 70 percent) than in urban areas (9 80 percentage points, from 66 percent to 75 per- 70 cent; figure 7). Use of modern methods has also in- 50 creased—from 57 percent in 1998 to 68 per- 50 cent in 2007 (figure 8). Percent 40 Over the past decade, female steriliza- tion has been the most widely used contracep- 30 tive method, increasing 5 percentage points 20 between 1998 (20 percent) and 2007 (25 10 percent). Over the same period, hormone in- jections rapidly became the second most widely 0 1981 1998 1993 2001 2007 used method—rising 17 percentage points Year from 1998 (6 percent) to 2007 (23 percent). Condom use also increased, though just by Source: World Bank, 2009b. Fertility Decline in Nicaragua, 1980–2006 | A Case Study 9 | Figure 7 contraceptive prevalence 3 percentage points. The use of traditional Rates among Nicaraguan methods did not change significantly (from 3.3 Women Ages 15–49 (Married percent in 1998 to 3.0 percent in 2007).19 At or in consensual union) Have the same time, oral contraceptive use declined Risen Faster in Rural than in 6 percentage points (from 19 percent in 1998 urban Areas, 1998–2007 to 13 percent in 2007), while intrauterine de- 80 vice (IUD) usage declined more dramatically, 70 by 9 percentage points (from 12.5 percent in 1998 to 3 percent in 2007). 50 Of Nicaragua’s 15 departments, Río 50 San Juan, Chontales, and Managua have the Percent 40 highest contraceptive prevalence rates while Ji- 10 notega and RAAN have the lowest in the most recent ENDESA 2006/07 (table 4). Over the 10 last 10 years, RAAN, in the Atlantic region, 10 contraceptive use (58 percent) jumped signifi- 0 cantly, followed by Río San Juan (55 percent) 1998 2001 2007 and Jinotega (47 percent), in the Central re- Year gion. Female sterilization is the most prevalent Urban Rural method in Pacific region departments, while Source: Republic of Nicaragua 2008; Measure DHS. STAT- hormone injections are most commonly used compiler, www.statcompiler.comMacro International, Inc., in the Central and Atlantic regions.20 www.measuredhs.com, April 2009. Figure 8 | contraceptiveconsensual Rates amongRisen for Most Methods, 1998–2007 (Married or in prevalence union) Have Nicaraguan Women Ages 15–49 30 25 20 15 Percent 10 5 0 Female sterilization Pill IUD Condom Traditional Hormone injections Contraceptive method used 2006–07 2001 1997–98 Source: Republic of Nicaragua 2008; Measure DHS. STATcompiler, www.statcompiler.comMacro International, Inc., www.measuredhs.com, April 2009. 10 Table 4 | Highest andand Department, 1997–2007 (percent) Department or urban Residence Lowest contraceptive prevalence Rates by Rural North Atlantic Río san Autonomous Year Total urban Rural Juan chontales Managua Jinotega Region (RAAN) 2006/07 72 75 69 79 77 76 63 57 2001 69 73 62 70 72 73 55 46 1997/98 60 66 51 51 66 67 43 36 Source: Republic of Nicaragua 2008; Measure DHS 2001. The total unmet need for contraception percent) and 35–39 (79 percent), up from 60 in 2007 was estimated at 11 percent among percent in 1998 (figure 9). The lowest con- women in marital or consensual union,21 traceptive prevalence rates in the same period down from 15 percent in 1997 and 2001.22 are for women ages 15–19 (61 percent) and Unmet need was much higher in RAAN (29 45–49 (62 percent), up from 11 percent and percent), Jinotega (21 percent), Matagalpa (18 40 percent respectively in 1998. About 75 percent), Madriz (16 percent), RAAS (16 per- percent of women ages 20–44 reported using cent), and Nueva Segovia (15 percent) than in contraception in 2007–22 percentage points Boaco (12 percent), Chinandega (12 percent), greater than for the same age range in 1998. Chontales (11 percent), Carazo (9 percent), Contraceptive use has generally increased and Leon (9 percent).23 along with socioeconomic and educational In 2007, the highest rates of contracep- levels in Nicaragua. In 2007, the contraceptive tive use were among women ages 30–34 (78 prevalence rate of the lowest wealth quintile Figure 9 | contraceptive prevalence Rate among Nicaraguan Women by Age Range, 1998–2007 90 80 Percent use of any method 70 60 50 40 30 20 10 0 15–19 20–24 25–29 30–34 35–39 40–44 45–49 Age ranges 2006–07 2001 1997–98 Source: Republic of Nicaragua 2008; Measure DHS 2001. Fertility Decline in Nicaragua, 1980–2006 | A Case Study 11 and those with no schooling were 65 to 66 per- Ortega, who voted in favor of the new legis- cent compared to the highest wealth quintile lation, won the election. Under the new law, and those with secondary schooling or higher doctors face up to six years in prison for per- whose contraceptive usage was 79 percent and forming an abortion, while women who abort 76 percent respectively. Almost a decade ear- face up to four years imprisonment.25 For lier in 1998, the contraceptive prevalence rate these reasons, national statistics are not col- for the lowest quintile was 42 percent and for lected on induced abortion in Nicaragua. The those with no schooling was 46 percent, while discussion here relies on several studies that it was 69 percent for the highest quintile and may offer some insight into the complexities those with secondary or higher education.24 of putting Nicaragua’s abortion laws into prac- So, contraceptive use has a strong associa- tice, though the studies cannot be seen as rep- tion with fertility reduction over the period resentative or reliable. 1980–2007. An exception is adolescents ages 15–19, who had the greatest rise in contracep- Æ A 2004 study cites a dramatic drop in tive prevalence but not the largest fertility rate therapeutic abortion requests after 1989 reduction. This is likely because most adoles- in the national maternity hospital, Bertha cents in this age group start contraceptive use Calderón Roque. Recorded requests only after giving birth. dropped from 368 in 1989 (236 ap- proved) to 54 in 1991–92 (16 approved). Induced abortion Between 1999 and 2003 there were only Abortion has been illegal in Nicaragua for two recorded requests and only one was more than 100 years except to protect the approved. Nicaragua’s Ministry of Health mother’s health, when rape or incest has oc- recorded six legal abortions nationwide in curred, and when severe fetal malformation 2001 and again in 2002.26 is detected. Over the last decade, the law has Æ A 2006 study found that abortions per- been heavily debated between church leaders formed on adolescents made up a quarter demanding antiabortion laws and pro-choice of all abortions reported to the Ministry activists trying to convince the mostly Cath- of Health’s Department of Statistics in olic population that therapeutic abortion is a 2003.27 human right that did not contradict church Æ A 2002 study reported that the health teachings. In October 2006, the legislature re- ministry identified abortion as one of three moved an article in the country’s penal code major reasons for women’s hospitalization, permitting therapeutic abortion. The new leg- and a 1998 study estimated that 14,706 islation was fast-tracked, passed unanimously hospitalizations of women annually were on the eve of the last presidential election, due to abortion-related complications. and signed into law in the presence of Cath- Hospital records at Bertha Calderón Roque olic and Evangelical church leaders who had indicate that no abortions were granted campaigned for the change. The only candi- there from 1997 through 2001.28 date who favored keeping therapeutic abortion Æ A 1998 study of five Nicaraguan hospi- received only 6 percent of the vote. Daniel tals identified 150 women admitted due 12 to abortion or miscarriage, 32 percent viding a period of time when she is not sus- of them younger than 19. The director ceptible to another pregnancy. The most of Bertha Calderón Roque reported that recent ENDESA 2006/07 indicates that botched abortions were filling half of the most Nicaraguan infants (99.7 percent) are hospital’s obstetrics beds and absorbing breastfed in the first month of life, although much of its budget. The same report cited only 46.2 percent are exclusively breastfed. By a University of Leon study that found that 2–3 months only 27.8 percent of infants are 80,000 high-risk abortions were being exclusively breastfed, and by 6–7 months only performed each year.29 4.4 percent are.33 Æ A 1981 study, shortly after the Sandinista Between 1987 and 2003, the mean du- revolution found that abortions, although ration of breastfeeding in Nicaragua and illegal, were not uncommon. They were Honduras were the lowest in the region at often initiated at home, and completed in 17.6 months, compared with a high of 20.5 hospitals. In the first half of 1981, 1271 months for Guatemala.34 The duration of ex- “incomplete” abortions were treated at clusive breastfeeding ranged from 1.4 months Vélez Páez Hospital, during which pe- to 3.5 months in the region (El Salvador, Gua- riod the hospital recorded 10,217 births temala, Honduras, and Nicaragua); with a and 153 neonatal deaths. The first hos- rapid trend downward by the time a child is pital-initiated therapeutic abortion in the 4–5 months. Only 12 percent of children in country was said to have been performed Nicaragua were exclusively breastfed at 4–5 in the same hospital in late 1981.30 months. The lowest first-year continuation Æ One study stated that during the Sand- rates ages 12–15 months were in Nicaragua inista administration, concerns about the at 63.8 percent, compared with the highest at complications of unsafe abortion led to a 81.1 percent for Guatemala. more flexible policy of therapeutic abor- These findings suggest that breastfeeding tion, making abortion somewhat more ac- practices are far from ideal in Nicaragua as cessible and safer.31 Another study found elsewhere in the region, and for which reason the 1974 penal code that made abortion lactational infecundability is not considered illegal not being enforced by the Sand- significant in the fertility decline in Nicaragua. inista government.32 socioeconomic and cultural These studies show no evidence of a cor- determinants relation between induced abortion and de- clining fertility in Nicaragua. Economic and political conditions During the 1950s and 1960s, Nicaragua had Duration of breastfeeding (postpartum one of the region’s fastest growing econo- infecundability) mies35, although its people lived under a dic- Breastfeeding practices affect not only the tatorship (Somoza). In 1979, the dictatorship health of the child, but also that of the mother was overthrown by a revolutionary govern- by delaying the start of ovulation thereby pro- ment, the FSLN led by Daniel Ortega, which Fertility Decline in Nicaragua, 1980–2006 | A Case Study 13 initiated a wide range of economic and social the social policies. This government is also reforms in the early 1980s. The FSLN govern- interested in improving the country’s eco- ment became financially unsustainable in the nomic performance while reducing poverty later part of that decade due to the costs of a and sharing economic achievements more lengthy civil war36 and a devastating hurricane widely.41 that left 180,000 homeless37. By the 1990s, The political, economic, and social the country was transformed to one of the re- changes, i.e., improved access to information, gion’s most economically unstable, slowest in sexual and reproductive health, higher female growth, indebted, and corrupt.38 educational levels and participation of women In the early 1990s, a new conserva- in the workforce brought about by Sandinistas tive government coalition headed by Vio- seem to have had a strong influence on the leta Chamorro initiated measures to stabilize health, social, and economic conditions which the economy.39 Nicaragua became a market did have an influence on fertility reduction economy when it dropped trade barriers, re- even after 1990. duced the size of its public sector while mod- ernizing its government. A greater proportion Child infant mortality and fertility desires of its public spending was allocated to assist Declining infant mortality rates can lead to poor people. But progress stalled after 1996 lower desired fertility and thus to lower fertility with the change in leadership (led by Ar- rates. During 1980–2006, Nicaragua’s infant noldo Alemán—later charged with money mortality rate fell dramatically, from 82 to 29 laundering, and embezzlement during his per 1,000 live births, and its under-five mor- term)40—and the devastation following an- tality rate fell from 113 to 36 per 1,000, a 68 other hurricane when the government’s focus percent decline. However, the rapid reductions was drawn to meeting the short-term needs of in both infant and child mortality rates had its people. begun earlier in the 1970s (figure 10). These Nicaragua’s economic performance im- downward trends in infant and child mortality proved following the election of Enrique have slowed since the last surveys in 2006–07. Bolaños in 2002, who brought a focus on ad- One study found improved access to dressing corruption and establishing fiscal dis- health services to be the most important factor cipline. The economy has grown moderately in reducing child mortality. This was due to since then, at an average annual rate of 3.2 the increasing numbers of health care profes- percent, and related indicators are showing sionals, particularly nurses that become avail- signs of improving. Poverty levels, however, able in the 1970s to staff the primary health have not improved much, although extreme facilities built in the 1960s. The study further poverty has declined since the early 1990s. found that progress made in public health in The current government led by Daniel Ortega Nicaragua since the 1979 revolution appears that assumed power in January 2007 has in- to have maintained the decline in child mor- dicated an interest in maintaining continuity, tality seen in the 1970s.42 recognizing the need to review policies im- One retrospective study of the association pacting the poorest population, particularly between women’s education and the infant 14 Figure 10 | Declining Rates of Infant Mortality and under-Five Mortality in Nicaragua, 1960–2007 250 Deaths per 1,000 live births 200 150 100 50 0 1960 1970 1980 1985 1990 1995 2000 2005 2006 2007 Mortality rate, under-5 (per 1,000) Mortality rate, infant (per 1,000 live births) Source: The World Bank, 2009a. mortality rate in Nicaragua over 1964–93 did rates were higher in rural compared to urban not find the mother’s education to be a major areas and tended to be due to reductions in contributing factor. Like other studies, it at- postneonatal mortality. All countries showed tributed the decline in infant mortality rate to a systematic decline in the decade prior to the the improved quality and access to health care study. Contrary to the retrospective study, this for the poorest segments of Nicaraguan so- analysis generally found infant mortality rate ciety, resulting in greater equity in chances of decreases as the mothers education increases child survival by the end of the 1980s.43 and most pronounced for postneonatal mor- A regional comparison study of health tality in the case of Nicaragua, Honduras, and surveys for El Salvador, Guatemala, Hon- Guatemala, and less so for neonatal mortality duras, and Nicaragua between 1997and 2003 for Nicaragua, El Salvador, and Honduras. found the largest differences in Guatemala and The regional comparison study found Ni- somewhat in Nicaragua with the infant mor- caragua to have the highest percentage of un- tality rates lower in the Pacific compared to wanted pregnancies (27 percent), followed by the Caribbean coasts (see figure 1).44 Infant Honduras (26 percent) and El Salvador (24 mortality tended to be lowest in metropolitan percent).45 Desired total fertility rates for rural capital cities in each of these countries, with El Salvador and Nicaragua were remarkably higher neonatal mortality (the probability of low (2.8 and 3.0)—and below replacement dying in the first 28 days of life) than postneo- level in urban areas (1.8) in both countries. natal mortality (the probability of dying be- The most recent ENDESA 2006/07 found tween the 28th day of life and first birthday). the unwanted total fertility rate for rural Ni- This is not unexpected as infant mortality de- caragua to be 1.3 times greater than urban clines, neonatal mortality typically rises. With areas—0.5 births for rural compared with 0.4 the exception of El Salvador, child mortality for urban women.46 The unwanted total fer- Fertility Decline in Nicaragua, 1980–2006 | A Case Study 15 tility rate for Nicaraguan women without in the last decade (1996–2006) from 38 to 47 formal education was 2.6 times higher than percent (2006).47 the rate for those with a university education. The most recent ENDESA 2006/07 These studies suggest that the steep de- found slightly more than half of Nicaraguan cline in infant mortality starting in the 1970s women had completed at least some sec- may have influenced the dramatic reduction ondary education or taken university-level in Nicaragua’s total fertility rate in the 1980s. courses; the proportion with some university education, 7 percent in 1998, had increased to Female education 14 percent by 2007. In contrast, the propor- Greater levels of uninterrupted educational at- tion of Nicaraguan women ages 15–49 with tainment for girls are believed to lead them to less than four years of instruction fell signifi- greater aspirations, career goals, and plan their cantly, from 30 percent in 1998 to 24 percent own future where they are more likely to use in 2007. Only 12 percent of those surveyed in contraception. 2007 had no education.48 Education rates for Nicaraguan females A comparative study of El Salvador, Gua- have increased significantly during this study temala, Honduras, and Nicaragua found im- period. As shown in figure 11, primary school provements in all four countries between 1987 rates for females increased by 31 percent from and 2003—though it also found sizable dif- 59 to 77 percent in the last 17 years (1989 ferences. 49 When comparing the most recent and 2006); this rate increased by 39 per- surveys, El Salvador and Nicaragua, about half cent from 55 to 77 percent in the last decade of women of reproductive age had some sec- (1996–2006). Secondary school enrolment ondary education, compared with less than rates (net) for females increased by 24 percent a third in Honduras. A quarter of women in Figure 11 | Rising Female Education Rates in Nicaragua, 1989–2006 90 80 70 60 Percent 50 40 30 20 10 0 1989 1994 1995 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006 Primary completion rate, female (% of relevant group) School enrollment, secondary, female (% net) Source: The World Bank, 2009b. (Secondary school data prior to 2000 N.A.) 16 Guatemala report no formal education at all. the period.51 It also found that a decline in Differences in education attainment in rural the crude fertility rate was associated with a and urban areas were also found. Considerably marked increase in female education. Of note more women in urban areas had some sec- was the proportion of adolescents that com- ondary education: 62 percent in Nicaragua in pleted primary school, which doubled be- rural areas], compared to 48 percent in Gua- tween the 1960s to the start of the 1990s temala, the lowest rate. In contrast, the rural (from 20 to 51 percent). In 1989–93, the total rate of secondary education in both countries fertility rate was 4.3 for women with no edu- was between 17 and 18 percent. cation, 2.7 for women with primary educa- The same study found lower fertility rates tion, and 2.2 for women with secondary or among more educated women. The total fer- higher education. The study concluded that tility rate differential between the highest and women’s education explained most of Nicara- lowest levels of education ranges from 2.8 to gua’s fertility decline over the three decades. 4.3 births, with a differential of 3.5 births in In sum, female education appears to have Nicaragua compared to Guatemala that had been a major determinant of fertility reduc- a difference of 4.3 births. Women with some tion in Nicaragua—probably more important secondary education generally had total fer- than any other. tility rates below 3.0 (figure 12). 50 A retrospective community-based study Women’s empowerment (autonomy) and of fertility in Nicaragua over a thirty-year pe- labor force participation riod between 1964 and 1993 found no change During the 1970s, social inequity was high in the correlation between women’s educa- in Nicaragua.52 More than half the popula- tion and the fertility gradient and throughout tion earned just 16 percent of the national Figure 12 | 1992–2001 Rates in Nicaragua Decline with Women’s Education, Total Fertility 8 7 No. of children per woman 6 5 4 3 2 1 0 Total None 1–3 years 4–6 years Secondary Superior 1992–93 1998 2001 Source: Monteith and others 2005. Fertility Decline in Nicaragua, 1980–2006 | A Case Study 17 income, while 41 percent lacked the means Religion and religious leadership to meet their basic nutrition needs. Illiteracy Nicaragua is a predominantly Catholic was 52 percent, and infant mortality was 121 country where religious institutions play an per 1,000 live births. Following their rise to important role. The Sandinista government power in 1979, the Sandinista government did not want to alienate its Catholic sup- took measures to increase women’s access to porters—or to incite its opponents within the education and jobs, with explicit language in Catholic hierarchy—by openly promoting the new Constitution granting women equal contraceptives. As a result, while public health rights. campaigns on television and billboards pro- Women’s participation in the formal moted breastfeeding and immunizations, labor market in Nicaragua steadily rose be- few promoted sex education or birth control. tween 1980 and 2006 (figure 13), although Later, the Catholic Church and clergy grew it dipped slightly in the mid-1990s as it did more overtly political, playing a central role for men in the labor force.53 Women ages in the 2006 removal from the penal code of 30–44 have consistently made up the largest the provision allowing therapeutic abortions. share of the female workforce in Nicaragua Motherhood is celebrated in Nicaragua on the (50 percent of women with jobs in 1980, 45 holiday of Mary’s conception (in Nicaragua percent in 1996, and 62 percent in 2006). In Mary is honored almost as much as her son, 2006, more than half of women ages 25–54 Jesus) and on Mother’s Day, when childless had jobs. women are honored as “potential mothers.”54 Based on this data and literature reviewed, Traditional Catholic morality promotes the women’s participation in the labor force is idea of maternity being a woman’s supreme likely to have significantly played an impor- calling as demonstrated by Virgin Mary, who tant role in Nicaragua’s fertility decline. assumes her maternal destiny silently.55 Figure 13 | Rates of Labor Force participation in Nicaragua, by Gender, 1980–2006 60 50 40 Percent 30 20 10 0 1980 1985 1989 1991 1995 1996 1998 1999 2000 2001 2006 Men Women Total Source: International Labor Organization, LABORSTA http://laborsta.ilo.org/data_topic_E.html. 18 Although the country’s conservative reli- her lifetime.58 Generally, women in urban areas gious institutions have become more politi- and the Pacific region were more likely than cally active in advocating against abortion, women in the North-Central region to suffer their efforts appear not to have deterred Ni- domestic violence, although women in the At- caraguan women from accessing contracep- lantic region experienced only slightly less tion and family planning services where its physical violence than did women in the Pacific influence might have been expected. Religion region. Domestic violence declines as education therefore appears not to have had a significant rises. However, no clear relationship is seen be- impact in Nicaragua’s fertility reduction be- tween domestic violence and wealth. 59 tween 1980 and 2007. Domestic violence could have many im- plications for Nicaraguan women’s repro- The impact of the role of men and ductive health and access to contraceptive spousal communication options—besides directly harming the fetus. Traditional views of masculinity and femininity However, no direct correlation with fertility are still common in Nicaraguan society.56 Nica- reduction can be made from this review. raguan machismo promotes the view that men who have lots of children with different women Civil society involvement are powerful; in fact, getting a woman preg- Since the early Sandinista years, women’s or- nant is seen as the highest expression of ma- ganizations have advocated improving wom- chismo. Many women get pregnant hoping to en’s reproductive health rights in Nicaragua. keep a man or create love. And many women Grassroots women’s groups, in particular, have are influenced by the Christian image of Mary, promoted childcare and birth control.60 mother of Jesus, sacrificing silently and reveling During the Sandinista period, women’s in her maternal role. Such concepts of mascu- roles were still traditionally defined. Women linity and femininity could affect how men and were expected to do all the household work, women communicate about fertility desires, and activities outside the home were viewed even though no specific evidence in the litera- as unacceptable for many Nicaraguan women. ture reviewed points to this cultural feature as a However, grassroots women’s organizations determinant of fertility in Nicaragua. emerged within other mass organizations such In 1996, Chamorro’s presidential cam- as blue collar, professional, small farmer, and paign openly recognized domestic violence as a cooperative unions.61 At the same time, femi- public health problem in Nicaragua.57 In 2007, nist lawyers and health workers began openly nearly 48 percent of women who had ever been discussing reproductive rights, rape, and do- married were found to have suffered verbal or mestic violence openly in forums, debates, and psychological abuse (up from 29 percent in the media. Female doctors began to publish ENDESA 2001), 27 percent to have suffered maternal mortality statistics from the national physical violence, and 13 percent to have suf- maternity hospital, showing the harmful ef- fered sexual violence. Overall, almost one in fects of abortion laws and self-induced abor- three Nicaraguan women (29 percent) had tions. It was mostly middle-class women who been subjected to physical or sexual violence in demanded legalization or decriminalization of Fertility Decline in Nicaragua, 1980–2006 | A Case Study 19 abortion without guaranteeing abortion rights The new government’s broad social and eco- so as not to offend abortion opponents. The nomic reforms included an expansion of pri- Luisa Amanda Espinoza Association of Nica- mary health care services as well as an effort raguan Women, despite its conventional ori- to improve the situation of women (discussed gins as an association of women as mothers, previously under socioeconomic and cultural began to call for the need to reduce maternal determinants).64 mortality from self-induced abortions, increase contraceptive availability, and sex education. Nicaragua’s health care and family In the 1989 elections, some women’s planning efforts since 1979 groups called for actions to end maternal Health care under the Samoza regime was mortality and make birth control more much worse than its Central American neigh- affordable—though most did not publicly de- bors. However, in response to the political mand legalizing abortion. After the Sandinistas’ turmoil of the 1970s, the Somoza regime in- defeat, women’s organizations became vocal troduced new health sector measures that ini- about the shortcomings of Sandinista policies tiated the sharp decline in Nicaragua’s child and practices and the machismo and sexist at- mortality rate.65 titudes of many party leaders.62 These organi- International observers documented Ni- zations also worked to protect the gains made caragua’s healthcare in 1981 that provides a during the Sandinista years by participating unique window to view the developments in in strikes against the Chamorro government, Nicaragua 30 years ago. 66 Soon after the San- which tried to reverse the social and economic dinista revolution in 1981, the study found reforms benefiting workers and the poor. Be- that about 70 percent of Nicaragua’s popula- fore the 2006 law repealing the right to thera- tion had regular contact with medical prac- peutic abortion and criminalizing doctors and titioners or facilities— a vast improvement women involved in abortions, women’s orga- over the 28 percent in 1979.67 During the nizations tried to convince Nicaragua’s mostly emergency period after the revolution, sev- Catholic population that abortion to save the eral new hospitals were opened. Foreign life of a woman supported human rights and doctors were recruited, and many interna- did not contradict Catholic teaching.63 tional groups provided substantial aid. As In sum, Nicaraguan civil society organiza- people were informed of their entitlement to tions have been influential in increasing sup- public healthcare, people flooded hospitals, port for women’s reproductive health over the urban health care centers, and newly opened last three decades. health “outposts” in small towns. Heath fa- cilities were staffed with nurses, and doctors programs and policies That Might visited weekly. Medical and nursing stu- Have contributed to Nicaragua’s dents accompanied agricultural workers to Fertility Decline the fields to harvest cotton, coffee, and other The Somoza dictatorship that had been in cash crops. Emergency training and medical place since 1937 was replaced by the revo- kits were provided to remote haciendas. Psy- lutionary Sandinista government in 1979. chiatric and dental care outreach served re- 20 mote areas. Thus, by 1981, the concept of a medicine subsidies and dramatically cut public unified health system was established, and sector spending.70 a structure for regionalizing health care was outlined. Nicaragua’s National Population Policy Public health education and family plan- In 1996, the Nicaraguan government ap- ning under the Sandinistas. The changes made proved its first population policy. Calling for by the Sandinista government after 1979 in- heath improvements as a cornerstone of na- cluded an effort to educate all Nicaraguans. tional development, the National Population In 1980, the government launched a basic Policy assigned high priority to reducing the literacy campaign, which reduced illiteracy birth rate and providing preventive services from 52 percent to 12. This literacy campaign to reduce maternal and child mortality.71 The was also used for health education; 100,000 policy was part of a national development young people were recruited to go to rural strategy that stressed integrating population areas to teach people how to read and write, objectives with socioeconomic development. live amongst the people, and teach elementary The National Population Policy has been health principles. One in 10 literacy workers important in promoting reproductive health received a week of health training and were re- and service delivery. Its legal framework recog- sponsible for distributing antimalarial drugs to nizes the right of couples to freely decide the other literacy workers.68 number and spacing of their children, and it Family planning was challenging because outlines the state’s responsibility to create social most Nicaraguans are Catholic; even under conditions and institutions that help people ex- the Sandinistas, four government ministers ercise their reproductive rights. Objectives in- were priests. Most contraceptive services were clude reducing pregnancy among unmarried provided by an International Planned Par- adolescent girls and developing in men and enthood affiliate under contract to the health women a sense of mutual respect, exercising ministry. Birth control information was to be sexuality with faithfulness and responsibility. disseminated following the model of other Youth and adults are to receive integrated sex health education campaigns. Abortions were education to empower them with accurate in- illegal, but not found to be uncommon (see formation to exercise their rights so they can previous section under proximate determi- prevent unplanned pregnancies and avoid con- nants for more on abortion).69 tracting sexually transmitted diseases.72 From 1979 to 1983, health and education Action plan for the National Population received a major share of Nicaragua’s national Policy in 2001–05. After 1996, the Alemán budget. Health care was reoriented from sec- government established the National Popula- ondary to primary care and health education. tion Commission, whose technical committee But during the second half of the 1980s, war was tasked with developing a 2001–05 action and economic crisis made former levels of so- plan to implement the National Population cial services and food subsidies unsustainable. Policy. The plan was presented in July 2001 The new, conservative government coalition with three subprograms: Education in Popu- that took charge in 1990 eliminated food and lation and Sexuality, Sexual and Reproduc- Fertility Decline in Nicaragua, 1980–2006 | A Case Study 21 tive Health, and Population Distribution. The cial Marketing Organization (PASMO), is plan was never implemented, however, be- the major supplier of quality low cost con- cause funding was lacking.73 doms.80 The National Health Plan for 2004–15. Contraceptive goods are donated and The Nicaraguan government is now going procured by the United States Agency for In- through a reform process, including the health ternational Development (USAID; 66 per- sector, and intensifying efforts to decentralize. cent) and the United Nations Population Progress has been made in formulating na- Fund (UNFPA; 34 percent) and are distrib- tional health policies under the National uted by the MINSA. In 2004, USAID con- Health Plan.74 Aiming to ensure equitable tributed $773,000 in goods and UNFPA access to basic health services designed to in- $395,000. By agreement with MINSA, these crease life expectancy and quality of life, the donations were expected to stop soon (from plan calls for reducing unmet need for family USAID by 2008 or 2009; from UNFPA by planning and for using unmet need as a per- a date to be determined). There are some na- formance indicator.75 tional laboratories that repackage imported The Women’s Integrated Health Program. In contraceptive commodities for resale locally 2004 the Women’s Integrated Health Program which are supplied from companies based in produced a new National Sexual Reproductive Europe, the US, Canada, Mexico, Argentina, Health Program document to guide reproduc- Columbia, and Brazil and include Schering, tive health services as part of the health sector Wyeth, Pfizer, among others. Contracep- reform.76 tives are provided by these companies to their Nicaragua’s contraceptive supply and dis- local representatives, UNFPA, USAID, pri- tribution system. The Nicaragua Ministry of vate pharmacies, and PASMO and PROFA- Health (MINSA) is the main source of free MILIA.81 modern family planning methods, accounting PROFAMILIA distributes family plan- for 67 percent of the total in 2007.77 It dis- ning methods through its own clinics and net- tributes family planning supplies through de- work of agents, and procures mostly from the partmental and autonomous regional health International Planned Parenthood Federation offices and facilities (called local systems of in- (IPPF). It is also a co-distributor of condoms tegrated health attention, or SILAIS). The Ni- for PASMO. caraguan army and national police force also PASMO acquires its contraceptive participate in providing health services, in- methods directly from international vendors cluding family planning.78 and distributes them through a network of pri- In 2007, the private sector and NGOs vate pharmacies, service stations, and stores. served 32 percent of Nicaraguan family plan- Marie Stopes International and local ning clients.79 The private pharmacies and NGOs—for example, IXCHEN—also receive clinics of the International Planned Parent- donated contraceptive goods from UNFPA, hood Federation affiliate, PROFAMILIA, distributing them to low-income populations represent two major private sector pro- through health agents. The NGOs also buy viders. Another NGO, the Pan American So- contraceptives from PROFAMILIA. In the pri- 22 vate sector, most contraceptives come from trasound, and other diagnostic services as well local representatives of international companies, as temporary contraceptive methods.83 PRO- although condoms also come from PASMO. FAMILIA and PASMO are the main NGOs The contraceptives are distributed through non- involved in family planning in Nicaragua. traditional outlets and to at-risk populations. They procure their supplies through a pro- The Nicaraguan Social Security Institute, which curement agent, such as IPPF, and distribute covers 10 percent of primary health care needs them through their own respective networks (mostly in urban areas), contracts with private of health, service delivery points, and pharma- medical centers to procure contraceptive sup- cies.84 NGOs provide a smaller proportion of plies from the commercial market. family planning services compared to the gov- ernment, though their contribution is signifi- The Nicaraguan government and cant in certain types of services.85 international donors The government has been the primary pro- The role of the private sector vider of contraceptive and family planning Private pharmacies in Nicaragua procure supplies and services in Nicaragua. For the last goods from international suppliers and dis- 30 years, USAID and UNFPA have provided tribute them to the general public. They are contraceptive supplies to the government, the most common provider of condoms and which has distributed them at no cost to the the second most important source of oral con- general public. Donors now plan to phase out traceptives.86 contraceptive supplies, and the government will take over contraceptive procurement. 82 Innovations in service provision Casas maternas, or women’s homes, are low- The role of nongovernmental cost assisted-living arrangements located next organizations to hospitals and used for lodging pregnant In 1970, the Nicaraguan Association for women from remote villages just before and Family Welfare, now PROFAMILIA, was the after delivery. Communities support the fa- first organization to introduce family planning cilities financially and manage the homes. to the country. An NGO associated with the Preliminary data suggest that the women’s International Planned Parenthood Federation, homes been effective in reducing maternal it began in 1970 by collecting and analyzing mortality by promoting access to institutional demographic data and providing family plan- delivery. The homes also provide family plan- ning services. Later, shifting its focus to family ning, child nutrition counseling, and other planning and health service provision (and education to empower women. MINSA plans changing its name to PROFAMILIA). It ini- to expand the network, and have been rec- tially provided contraceptives and, since 1998, ommended as a model for other countries in diversified to include Pap smears, x-rays, ul- the region.87 Fertility Decline in Nicaragua, 1980–2006 | A Case Study 23 Lessons from Nicaragua’s Falling Fertility s everal lessons emerge from Nicaragua’s cient contraceptive distribution network success at reducing its total fertility rate: that works with international donors, and international national NGOs to offer Æ The government was committed to gender women a good mix of options. In addi- equity and female empowerment through tion, demand must be created through a educating girls and women and recruiting timely public education campaign. women into the labor force, including Æ Success requires appropriate civic engage- funding for programs and constitutional ment with different stakeholders, which reforms. may initially mean avoiding unnecessary Æ Family planning services was provided confrontation and publicity of services for within a well functioning primary health addressing concerns of the more conserva- care system, including an extensive, effi- tive stakeholders. 24 Annex 1. Nicaragua at a Glance Earliest available Latest available data, data, 1980–2006 1980–2006 Indicator Value Year Value Year Economy GNI per capita, purchasing power parity (current 1,230 1980 2,380 2006 international US$) GNI per capita (current US$) 600 1980 980 2007 Poverty gap at national poverty line (percent) 17 2001 17 2001 Demography Population, total (million) 3.3 1980 5.5 2006 Population growth (annual percentage change) 2.9 1980 1.3 2006 Population ages 0–14 (percent of total) 47.5 1980 37.2 2006 Urban population (percent of total) 49.9 1980 56.18 2006 Fertility rate, total (births per woman) 6.05 1980 2.80 2006 Adolescent fertility rate (births per 1,000 women ages 132.6 1997 114.03 2006 15–19) Life expectancy at birth, female (years) 61.6 1980 75.6 2006 Under-five mortality rate (per 1,000) 113 1980 35.6 2006 Infant mortality rate (per 1,000 live births) 82 1980 29.2 2006 Maternal mortality ratio (modeled estimate, per 170 2005 170 2005 100,000 live births) Health Total health expenditure (percent of GDP) 7.6 2001 8.3 2005 Public health expenditure (percent of GDP) 3.7 2001 4.1 2005 Health expenditure per capita (current US$) 60 2001 75 2005 Immunization, measles (percent of children ages 15 1980 99 2007 12–23 months) Malnutrition prevalence (weight for age, percent of 10 1993 8 2001 children under five) Prevalence of HIV (percent of population ages 0.2 2001 0.2 2007 15–49) Contraceptive prevalence (percent of women ages 27 1981 68.6 2001 15–49) (continued on next page) Fertility Decline in Nicaragua, 1980–2006 | A Case Study 25 (continued) Earliest available Latest available data, data, 1980–2006 1980–2006 Indicator Value Year Value Year Births attended by skilled health staff (percent of 64.6 1998 66.9 2001 total) Nurses and midwives (per 1,000 people) 1.07 2003 1.07 2003 Physicians (per 1,000 people) 0.42 1980 0.37 2003 Education Literacy rate, adult female (percent of females ages 15 76.6 2001 76.6 2001 and older) Secondary school enrollment, female (percent net) 37.6 2000 46.6 2006 Primary school enrollment, female (percent net) 70.84 1991 89.90 2006 Primary completion rate, female (percent of relevant 58.5 1989 76.7 2006 age group) Source: The World Bank, 2009b. 26 References Adkins-Blanch, S. 1996. “Spotlight: Nica- Halperin, D.C., and R. 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Reproductive, maternal, and child health 4 Republic of Nicaragua 2008. 2008. Prelim- in Central America: trends and challenges inary Report: Nicaraguan Demographic and facing women and children. El Salvador, Health Survey 2006/07, National Institute Guatemala, Honduras, Nicaragua, CDC for Development Information (INIDE) (Division of Reproductive Health) & and Ministry of Health (MINSA), Cen- USAID, August 2005. ters for Disease Control and Prevention 15 Republic of Nicaragua 2008. (CDC)/ENDESA Project, Managua, Ni- 16 Republic of Nicaragua 2008; MEASURE caragua. DHS STATcompiler.” Retrieved April and 5 PAHO, Health In The Americas: Nica- June 2009. ragua, Volume Ii–Countries, 2007. 17 World Bank 2009 b. 6 PAHO 2007. 18 Republic of Nicaragua 2008. 7 World Bank, March 8, 2007b Key Issues 19 Republic of Nicaragua 2008; Measure in Central America Health Reforms: Diag- DHS 2009. nosis and Strategic Implications: Volume 20 Republic of Nicaragua 2008. 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Prada, and J. Drescher. 2006. 38 World Bank 2009 a. “Early Childbearing in Nicaragua: A Con- 39 Pena and others 1999. tinuing Challenge.” Issues Brief. Alan 40 BBC News, 2008. Guttmacher Institute, Washington, D.C. 41 World Bank 2009 a. 28 McNaughton, H.L., M.M. Blandon, and 42 Sandiford, P., P. Morales, A. Garter, E. L. Altamirano. 2002. “Should Therapeutic Coyle, and G. Davey Smith. 1991. “Why Abortion Be Legal in Nicaragua: The Re- Do Child Mortality Rates Fall? An Analysis sponse of Nicaraguan Obstetrician-Gynae- of the Nicaraguan Experience.” American cologists.” Reproductive Health Matters10 Journal of Public Health 81 (1): 30–37. (19): 111–19. 43 Pena and others 1999. 29 Pizarro, A. 2004. “Women’s Health in Ni- 44 Monteith and others 2005. caragua: The Need for a Secular State.” 45 Monteith and others 2005. Americas Program. Interhemispheric Re- 46 Republic of Nicaragua 2008. source Center, Silver City, N.M. 47 World Bank. 2009 b. Net secondary school 30 Halperin, D.C., and R. 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