93093 Knowledge Brief Health, Nutrition and Population Global Practice ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS IN NICARAGUA: AN ANALYSIS USING A SEXUAL AND REPRODUCTIVE HEALTH FRAMEWORK AND HUMAN RIGHTS Amparo Gordillo-Tobar, Geraldine Beneitez, Juana Ortega, William Waters and Emig Bravo November 2014 KEY MESSAGES: hmed Al-Sabir, Bushra Binte Alam,  Adolescents El-Saharty and Sameh perceive gender inequality in terms of decision-making and access to family planning methods.  Most adolescents have little knowledge about the laws and their rights.  The Constitution recognizes and upholds the dignity of the person and establishes unconditional equality of all Nicaraguans, however laws and policies are not being enforced.  Although the SRH curriculum has been developed properly, teacher training, resources and classroom planning are impractical. Introduction , four geographic regions; and integrated the results of the study into a national multi-sectoral strategy on adolescents sexual and reproductive health and rights In an effort to integrate operational and analytical work on (SRHR). The strategy will inform the Bank’s operational adolescents and youth sexual and reproductive health plans and agreements for the next five years. (SRH) and Human Rights in Nicaragua, the World Bank, in coordination with the Nicaraguan Ministry of Health, the Results of the Study Pan American Health Organization (PAHO), and the LEGAL FRAMEWORK United Nations Population Fund (UNFPA) conducted the study titled: “Sexual and Reproductive Health Among The Nicaraguan Constitution recognizes and upholds the Youth in Latin America: Adding a Human Rights dignity of each person and establishes unconditional Perspective.” The study was conducted within the equality of all Nicaraguans in the enjoyment of their umbrella of the ongoing Family Community Health World political and social rights and the fulfillment of their duties Bank project. and responsibilities. It affirms absolute equality between To gain a better understanding of the SRH and Human men and women and recognizes the Convention on the Rights in the country, the study, funded by the Nordic Rights of the Child. There are specific laws that protect Development Trust Fund (NTF), reviewed the national the rights of men, women and children. However, these legal framework and the school curricula; consulted focus laws and policies are not enforced. Some examples (J. groups for adolescents from representative samples in Ortega, 2012) Page 1 HNPGP Knowledge Brief  (CONAPINA). The Council is responsible for formulating, coordinating, and implementing national Background in Adolescent Health in Nicaragua care and comprehensive protection policies for children and adolescents. The State also guarantees Nicaragua is the poorest country in Central America with a gross children and adolescents a standard of adequate national income (GNI) per capita of US$1,650 in 2012. More living and protection, so that they can grow up in an than half (51 percent) of adolescents 15-19 years of age in environment that ensures healthy growth and Nicaragua live in poverty, over a third of which live in extreme development. poverty (35 percent). For adolescents 12-14 years of age, the results are much worse. Although the adolescent fertility rate  To address privacy and family rights, Nicaragua has decreased from 124.7 births (per 1,000 women 15-19 years recognizes that both parents are equally responsible of age) in 2000 to 105.6 births (per 1,000 women 15-19 years of for, and have obligations to their children as age) in 2010, it is still high, especially when compared to total established in the Parental Responsibility Act. pregnancies in all relevant age groups. According to the Ministry of Health, adolescents represent 31 percent of total births  To ensure sexual education, Nicaragua has passed registered in 2010 and 27 percent in 2011; out of 100 adolescent several national laws that clearly state the girls who are pregnant or already mothers, 65 are uneducated population’s right to comprehensive sexual education and 34 live in the poorest quintile. and the state’s obligation to provide such education. The government, however, has not complied with this Suicide among adolescents, 10-19 years of age, represents 12 law due to political and religious reasons. percent of the total suicide mortality in Nicaragua (Policia Nacional de Nicaragua (PNN), 2011). In 2011, 5.8 percent of Although Nicaragua has various laws that protect the cases of violence involved adolescents, while 32.6 percent of rights of men, women, children, and adolescents, it does women who were raped or abused were less than 13 years of not necessarily mean that these laws and policies are age (PNN, 2011). In fact, over 90 percent of gender-based being enforced. In effect, the study found the following: violence occurs among adolescents and youth. In 2011, 84 percent of reported cases of violence were victims of sexual  The country has laws related to sexual and violence, of which 19 percent were adolescents less than 18 reproductive health; however most of them do not years of age. specify or target adolescents. Source: Estrategia Nacional de Salud Sexual y Reproductiva (MINSA,2008), Reporte anual de estadísticas (Policía Nacional de  The Code on Childhood and Adolescence lacks Nicaragua., 2011) and ENSDIA, Estrategia de Salud y Desarrollo institutional, human, technical, and financial resources Integral para Adolescentes, (MINSA, 2014) necessary to achieve its full implementation;  The implementation of the normative framework is  To ensure equality and non-discrimination between almost non-existent due to lack of an institutional women and men, the Gender Policy was established structure to support its implementation and strong in 2007. The government also passed the Equal cultural factors. Rights and Opportunities law; the 789 Law was passed in 2012 as an amendment to the  Nicaragua has subscribed to most of the international Municipalities Act to establish gender equality in instruments related to human rights, which are elections for mayors and vice mayors. reflected in the National Constitution. However there is only partial compliance with those instruments.  To protect women and children against sexual  There is a lengthy judicial, medical and administrative violence, Nicaragua passed a comprehensive law in process to respond to the victims of family violence. 2012 against gender-based violence while reforming the penal code. Furthermore, women and children receive support from the Nicaraguan Institute of  Progress has been made with laws supporting the Women and the National Commission on Violence rights of those living with HIV, however, bottlenecks in Against Women, Children, and Adolescents. the implementation of these laws still exist.  To protect children and adolescents, Nicaragua ADOLESCENT PERPECTIVES guarantees children’s rights through its Code on Childhood and Adolescence as well as through the Focus groups were conducted in four regions of National Council on Comprehensive Care and Nicaragua (Beneitez et al, 2012b) at schools and Protection for Children and Adolescents maternal homes. A total of 188 adolescents (116 females Page 2 HNPGP Knowledge Brief  When you have sex it’s necessary to use and 72 males) between 10 and 19 years of age were interviewed on the following subjects: i) the perception of contraception in order to protect us from diseases or themselves and as members of society; ii) relationships pregnancy. (W1) and sexual identity; iii) family perceptions; iv) knowledge about sex, sexuality, and reproduction; and v) knowledge, As for access to SRH information, participants identified perceptions, and recommendations for the Nicaraguan educational talks as the most effective method, which MOH. took place in schools and health centers. When asked about gender inequality, adolescents In addition, the interviews identified two important points: reported that it existed, especially in terms of decision- in all of the groups interviewed, most adolescents had making and access to family planning methods. little knowledge with regards to the laws and their rights ; Adolescents reported that women had less power than and the conditions of the maternal waiting homes were men. They also stated that although women understood poor in terms of physical space and an unproductive use and experienced inequality, they were sometimes not of time for adolescents. willing to take measures to prevent it from happening. For men anything and everything comes easily. Men SCHOOL CURRICULA go to a pharmacy and can easily buy condoms. If a woman asks for contraception, people start talking In an effort to reach and educate new generation and about you. (W1) prevent early pregnancy, the Ministry of Education (MOE) has designed a new educational curriculum with Sometimes it is easier for a man to obtain crosscutting themes with the goal of implementing contraception, although it depends on the situation educational policies that enable comprehensive childhood (M2) and adolescent education. The themes focus on Human Rights, Gender, Sexuality and Reproductive Education Adolescents at maternal waiting homes identified (including HIV), Health Education, Environmental dramatic changes to their lives since becoming pregnant, Education, Education for Peace and Reconciliation, and noting that they had dropped out of school and Family Education using information communication experienced a shift in their social status. technologies (ICT) (ENSDIA, 2013). The MOE also has The interviewers identified gender differences between developed a variety of teaching tools such as a Sexuality female and male participants, contextualized as gender Education: Basic Reference Guide for Teachers (2010); roles in Nicaraguan society. Although many of these HIV Education (Anthology for secondary teachers: young people were aware of equity and the shift towards Coexistence and Civics 7th - 9th grade), in collaboration equity, there was still a complex interaction between with UNICEF; a Reference Guide on HIV and sexually males and females and this shift was perceived as slow, transmitted infections, an anthology for secondary school contradictory, and/or confusing to many. For example, teachers: Citizenship and Coexistence 10th - 11th grade; when discussing the responsibility for sexual relations, and the Pro-Values program in collaboration with many adolescents noted that young women were more international and national agencies. vulnerable to unplanned pregnancies The curricula review focused on SRH education, targeting In terms of SRH knowledge, most adolescents had an two subjects: Science (Ciencias Naturales) and Civics adequate level of knowledge about contraception, STIs, (Convivencia y Civismo) from grade 5 to grade 11. Some and the complexities of relationships as they entered of the findings revealed that the MOE aims to develop a young adulthood. There were gaps in knowledge on curriculum that covers the necessary SRH skills for certain issues, and they had difficulty applying this children and adolescents; how SRH is distributed in both knowledge to their daily lives. Further, the research subjects from grades 5 to 9, and only in Civics in grades indicated that adolescents from maternal waiting homes 10 and 11; and how some SRH concepts were found in had a lower level of knowledge and understanding of civics and science in lower grades (Beneitez, 2012a). these matters (as illustrated in the blue text below). Me? I care about using protection, and I decide with Although the SRH curriculum has been developed whom I have a relationship. Who doesn’t? (M 2) properly, teacher training, resources and classroom planning were found to be impractical. I cared for a month, and then stopped taking it. When I stopped, I wasn’t pregnant but then suddenly was. (MH 1) Page 3 HNPGP Knowledge Brief  Recommendations by sector records, the Institute of Legal Medicine and the Ministry of Health, to include data on adolescent Education pregnancy;  Coordinate efforts with non-governmental  Review the needs and challenges that teacher’s face organizations that develop and implement SRH when teaching these themes; programs and activities, emphasizing adolescents at  Develop and design friendly materials to guide risk; ensure joint coordination with local and national teachers and to better approach students; public health units to achieve sustained healthy living  Develop training courses for teachers to improve their practices among adolescents. skills on teaching the subject. REFERENCES Health Amparo Gordillo-Tobar, Geraldine Beneitez, Juana  Lead inter-sectoral work towards prevention of Ortega,William Waters, and Emig Bravo. 2013. Adolescent adolescent pregnancy and family violence Sexual and Reproductive Health in Nicaragua: An Analysis  Increase the number of female obstetricians and using a Sexual and Reproductive Health Framework and Human Rights Based Approach. gynecologists in indigenous areas (due to cultural background); Geraldine Benéitez, (2012a). Revisión de los currículos  Ensure that adolescent SRH care is provided in educativos nicaragüenses de Ciencias Naturales y Convivencia indigenous areas and is culturally sensitive through y Civismo en materia de Salud Sexual y Reproductiva. training and guidelines;  Promote access to contraception among adolescents Geraldine Benéitez, William Waters and Amparo Elena Gordillo- Tobar, (2012b), Estudio cualitativo de Salud Sexual y through health care settings; Reproductiva:  Improve Maternal Waiting Homes by training Resultados de grupos focales en adolescentes nicaragüenses. midwives and nurses, and educating the women through literacy and job skills courses. Juana Ortega. (2012). Pre-Estudio de Salud Sexual y Reproductiva en el contexto de Derechos Humanos, y énfasis en Adolescentes en Nicaragua Legal Policía Nacional de Nicaragua, (2011) Reporte anual de  Update the special justice administration system (law estadísticas. 789) to bring justice to victims of intra-family violence; MINSA,(2013) Estrategia de Salud y Desarrollo Integral para Adolescentes 2015-2017 (ENSDIA).  Provide comprehensive training to judicial officers on intra-family violence and gender-based violence; World Bank Group (2012). Adolescent sexual and reproductive  Develop mechanisms for the operationalization and health and rights Study (Focal Groups) Nicaragua. 2012. effective enforcement of laws, especially in the promotion, protection, and defense of human rights. Cross-sectoral work for key stakeholders:  Close cooperation between municipalities, This HNP Knowledge Brief highlights the key findings from a Study “Adolescent community, local health units (SILAIS) and schools in Sexual and Reproductive health in Nicaragua” Health, Nutrition and Population the area in order to ensure inclusion of all (Forthcoming), by Amparo Gordillo, Geraldine Beneitez, Rafael Cortez and Juana Ortega. This work was funded by the Nordic Trust Fund and the World Bank- adolescents, including those who have dropped out or Netherlands Trust Fund managed by the World Bank. have never gone to school;  Legal instruments that articulate the necessary inter- institutional coordination;  Develop reporting processes and public discussions on adolescent SRH rights, in order to ensure that they are addressed with ease and opportunity in all social and working spaces;  Expand mechanisms used in the National Police The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4