About Nicaragua

Traditional Approaches to Women’s Health

The most significant component of women’s health in Nicaragua is that of the midwife–generally referred to as a partera or more specifically as an apa in the Rama indigenous community. About 50% of women have home delivery assisted by traditional birth attendants, as this is almost always more affordable than delivering at a clinic. These midwives provide care to expecting mothers, those in childbirth, and also to infants; most are completely non-interventionist in their approaches, using some medicinal plants to ease labor pain, treat for female reproductive disorders and as a form of contraception. During pregnancy, parteras are authorized to register births, cut cords,  provide guidance to expectant mothers on issues ranging from social activities to hygiene and diet. For example, certain foods are forbidden because they are considered “hot” (referring to the classification of the food, not the temperature), as it is believed that consuming them  would induce an early delivery or cause the fetus to abort.

Santa Elena Figueroa Martínez is one of the Miskito community midwives of the RAAN. Here, she is giving HIV counseling to pregnant women in her community (UNICEF).

Santa Elena Figueroa Martínez is one of the Miskito community midwives of the RAAN. Here, she is giving HIV counseling to pregnant women in her community (UNICEF).

Moreover, the use of certain plants is encouraged both pre- and postpartum because the plants are beneficial to both mother and fetus. For example, pre- and post-parturition fortifiers or “blood tonics” (prepared as decoctions) are made by midwives from the wood of monkey ladder, the bark of naked man , the bark of laulau , chainey root , the leaves and roots of broom weed, the leaves of baasley, the leaves of sorosi, and the leaves and roots of piss-a-bed. Other similar decoctions are produced to induce labor, reduce pain during childbirth, and regulate menstrual flow and fertility.

Sorosi

Sorosi

Such traditional methods pose their own advantages and disadvantages. Considering the conditions under which the Rama live (isolation, poor sanitation, little protection from malaria or parasites), their overall health is good. Moreover, many natural remedies have scientific support; for instance, “blood tonics” contain relatively high concentrations of iron (50–1300 ppm), supplementing the iron requirement during both pregnancy and lactation. However, maternal mortality represents almost 4% of all the causes of death in Nicaragua (Ministerio de Salud de Nicaragua (MINSA), 2005); a contributing factor to this statistic is the fact that most of the parteras are illiterate or have not completed primary education, and have another main occupation in addition to their work as partera. In addition 72% of parteras received some training in the past, but only 66% received training after 2002.

midwife

As an alternative to homebirths, the Ministry of Health has implemented casas maternas, or maternity waiting homes aimed at decreasing maternal and perinatal mortality. Such casas maternas are low-cost lodging services co-managed by civil society organizations (such as NGOs), whose purpose is to house pregnant women from remote rural zones, thereby facilitating access to professional obstetrical services. Here, women receive daily medical visits from health center doctors and instruction on sexual and reproductive health, including family planning and child care.

The first Casa Materna in Carazo, Nicaragua

The first Casa Materna in Carazo, Nicaragua

There are several barriers that impede access to institutional healthcare in Nicaragua; a significant factor can be attributed to a culture of machismo and associated societal expectations on women. For instance, although Nicaraguan society often encourages young men to have premarital sex, it disapproves of young women doing so.Thus, many young unmarried women do not seek contraceptive and reproductive health services because they fear, or feel ashamed of disclosing their sexual activity. Moreover, men in these communities often dismiss or overlook the value of an institutional birth for a safe delivery, and question the healthcare procedures of biomedical professionals and restrict women from leaving their home for long periods of time (as women are expected to care for small children and household chores). In addition, there a value that is persistently attached to women who are considered good “child deliverers” and who do not need to resort to “help” beyond traditional sources (partera or family); therefore, there is a societal and familial pressure placed on women to prove their “effectiveness” as a child bearer. Lastly, neither the husbands nor the women themselves are very comfortable with the fact that most institutional delivery care is provided by male doctors; this is especially true for women who belong to ethnic groups, such as the Miskito women.

In addition, financial barriers (as discussed earlier) span most healthcare resources; for instance emergency contraceptive pills are not offered by Nicaragua’s public health care services; they are available only in the private healthcare sector. Private pharmacies are the main providers of emergency contraceptive pills, which sell for US $2-3– a price that is not affordable for many Nicaraguans.

Lastly, access to maternal healthcare resources is hindered by a sense of ignorance among healthcare personnel, due to lack of knowledge and negative attitudes among healthcare staff–such as the idea that contraception may promote promiscuity.

In summary, obstacles to receiving reproductive healthcare include  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.