Report from Nicaragua: midwifery and structural adjustment

INTERNATIONAL EXCHANGE — Jeanne Raisler,

CNM, DrPh, FACNM

REPORT FROM NICARAGUA: MIDWIFERY AND STRUCTURAL ADJUSTMENT Carol J. Cruickshank,

CNM, MS

ABSTRACT A brief review of recent Nicaraguan political history and its impact on health care is presented. Interviews with midwives, nurses, and physicians are reported to illustrate the current health situation in Nicaragua. The effects of structural adjustment and foreign debt repayment on health in Nicaragua are discussed. J Midwifery Womens Health 2000;45:411–5 © 2000 by the American College of Nurse-Midwives.

This report is based on interviews conducted in Nicaragua in September of 1998 and subsequent telephone interviews. The author first traveled to Nicaragua in 1986; lived and worked in Leo´n, Nicaragua, in 1991– 1993; and has had ongoing professional involvement in Nicaragua throughout the past 14 years. HISTORY

It is impossible to separate recent development in health care and in midwifery from the general political situation in Nicaragua. Although there are unique aspects to Nicaragua’s history, there is also much to be learned from Nicaragua’s example about the health status of the world’s poorer countries and the challenges they face in maintaining maternal-infant and other essential health care services. The 20th century in Nicaragua has been characterized by repeated military and political intervention by the United States. The Somoza family dictatorship (1936 – 1979) was ended in 1979 by a revolution led by the Sandinistas. President Carter’s restraint in the face of the Nicaraguan revolution was swept aside by the election of Ronald Reagan. Nicaragua’s attempts to develop progressive social programs were consistently thwarted by the U.S.-funded Contras and the destabilization campaign between 1981–1990. Both the progress made in the early 1980s and the destructiveness of the U.S. policy have been welldocumented in the world literature (1– 6). Particularly impressive were the gains made in health care in Nicaragua during that decade. Infant mortality fell from 120

Address correspondence to Carol J. Cruickshank, 125 Fickle Hill Rd., Arcata, CA 95521.

per 1,000 live births in 1979 to 60 per 1,000 in 1990. Immunization coverage improved from 20 – 80% for poliomyelitis in the same period, and the last case of polio reported in Nicaragua occurred in 1982. Health care, education, and land reform were Nicaraguan government priorities in the 1980s, but the U.S. economic blockade imposed in 1985 by the United States and the ongoing U.S.-supported war disrupted these fragile plans. Sandinista dependence on Cuba and the Soviet block, because of Nicaragua’s subservient position in Cold War politics, also made the independent stabilization of these programs more difficult (7–11). National elections were held in 1990, and many Nicaraguans felt their choice was to vote for the Sandinistas and incur the continued wrath and war of the United States or vote for the Unio´n Nacional Opositora (UNO), a coalition promoted by the United States, and see the end of the war. The Sandinistas lost, but the United States has not relinquished its involvement in Nicaraguan domestic policies. STRUCTURAL ADJUSTMENT: HARSH MEDICINE FOR DEVELOPING COUNTRIES

In 1990, when UNO was elected, the International Monetary Fund and the World Bank economic programs were introduced, although some structural adjustment had begun in 1988 under the Sandinistas. The International Monetary Fund (IMF) was set up after World War II to maintain currency stability and develop world trade. The Fund is now the main advocate of the belief that free market reforms that substantially reduce government economic involvement and regulation are the best medicine for poor countries’ ailing economies. The World Bank was founded at the same time as the IMF with the intention of reviving war-damaged European economies. This original plan succeeded well, but unfortunately, when extended to developing nations, the World Bank’s activities continue to strengthen the economies of the developed countries at the expense of poor nations. Structural adjustment aims to decrease government intervention in the economy, encourage private foreign

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investment, and decrease government spending overall. A Structural Adjustment Program (SAP) is designed by the World Bank and the International Monetary Fund and must be implemented by debtor countries so that they can qualify for debt relief and new loans. SAP reforms include harsh economic austerity measures such as cutting social welfare budgets, privatizing public utilities, and dismantling health and education systems to make debt payments and attract foreign investment. Structural adjustment continues to devastate Nicaragua today. For example, under structural adjustment, annual health care spending in Nicaragua fell from $58 per person in 1988 to $16 in 1995. Structural Adjustment Programs hit Nicaraguans living in poverty the hardest. Rising unemployment and decreasing government services become life and death issues for the extremely poor, who have no margin for cutbacks (12–15). In 1997, Nicaragua had a foreign debt of $6.11 billion and as a result of the SAP requirements the government spent 39% of the national budget expenditure on foreign debt repayments and only 18% on health and education services. The $6.11 billion debt means that every Nicaraguan owes $1,300 in foreign debt, in sad contrast to a per capita annual income of $500. The health of the nation has deteriorated as the health budget has been cut to make payments on the debt. Approximately 40% of the population is without clean drinking water, and the number of children finishing primary school is declining. Today, an estimated 74% of the total population lives in poverty, with about 48% of that number living in extreme poverty (16,17). To put the policy of structural adjustment in context, it is important to remember that in 1986 the World Court ruled that the United States owed Nicaragua $17 billion in reparations resulting from the Contra war against Nicaragua. The United States refused to pay this judgment, and in 1991 the government of Violeta Chamorro withdrew the claim. The problem of malnutrition in Nicaragua offers one concrete example of the effects of structural adjustment. During the 1980s, because of government support to agriculture, subsidized food, and feeding programs in the Health Centers, malnutrition was unusual. When it was identified, health care workers had resources for eliminating it. As part of the Structural Adjustment Program, the government feeding programs were eliminated in the 1990s, and there remain only a few small programs supported by internationally based nongovernmental organizations (NGOs). By 1994, it was reported that 27.2%

Carol J. Cruickshank practices midwifery in Northern California and works with international projects in Argentina and Nicaragua. She received her midwifery education at Columbia University in New York City.

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of children less than 5 years of age were suffering from malnourished (15). Nicaragua is not alone in its economic crisis. Internationally, for every $1 in aid paid by the rich countries to the developing world, $3 is sent back by poor countries in debt repayment. In 1997, the IMF received $600 million more in debt payments from Africa than it returned in loans. Wealth continues to be transferred from the poorest countries to the wealthiest. NICARAGUAN HEALTH PROFESSIONALS FACE DIFFICULT TIMES

Despite the current grim reality, Nicaraguan health professionals continue to work with high standards and dedication under conditions that are difficult for care providers in the United States to imagine. The Nicaraguan midwives, nurses, and physicians described in this report are reminders of the ongoing dedication of progressive individuals around the world. LA PAZ CENTRO

Romelia La Costa is a professional nurse who for many years has been the Director of Nursing at the Health Center in the town of La Paz Centro, about 35 miles northeast of Managua (See Figure 1). Five rural health posts feed into the principal Health Center in town. Ms. La Costa is a dynamic, skilled, and compassionate nurse. She is an excellent teacher and over the years has also been in charge of teaching the rural midwives in her district. Since 1983, she has offered classes for midwives through the Health Center, as well as professional backup, emergency delivery facilities, emergency transportation, and encouragement. At present 35 midwives are active in La Paz Centro, and they attend about 20% of the births in the district. In this area and throughout Nicaragua, many midwives are older and illiterate. La Costa reported that in her district in the first 9 months of the year, there was only one maternal death, resulting from a septic abortion. Maternal mortality as a whole is about 250 per 100,000 (United States, 7.7 per 100,000). In discussing the future of midwifery in Nicaragua, La Costa stated, “Once the women have had a birth with a midwife, they do not want to go back to the hospitals. There will always be midwives in Nicaragua. The women come to the midwives for kindness and care.” Ms. Fermina Parrales is a 62-year-old midwife who works in the town of La Paz Centro and lives a short walk from the Health Center (See Figure 2). She started working as a midwife at the age of 15. She has worked with Ms. La Costa for many years and identifies her as both a teacher and a friend. In discussing her work, Fermina Parrales identified the most serious problems

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FIGURE 1. Map of Nicaragua and region, insert shows La Paz Centro and Leo´n. Map by C. Talmadge.

among her clients as: 1) lack of food, 2) lack of money to prepare for the birth, “not even clothes for the baby,” and 3) lack of the father’s ongoing involvement. Parrales commented that the women she cares for are in general

more educated now than before the Sandinista revolution, but their economic resources have decreased over the past 5 years. Despite the cutbacks in the National Health System, La Costa has continued ongoing classes and meetings for the midwives and supplies them with minimal equipment (ie, gloves, cotton balls, and UNICEF pictogram birth records). Ms. Parrales had her UNICEF birth kit, “maletı´n”, at hand: stocked, clean, and well organized. As a teaching exercise, Parrales demonstrated the equipment in the birth kit, carefully explaining how she used and maintained it. She talked about how she had changed her method of cord care and commented that she no longer sees neonatal tetanus because of these improvements and the success in vaccinating pregnant women against tetanus over the past 17 years. Increasing corruption and politicized appointments in the National Health System are another major concern of health care workers in Nicaragua. Recently, Ms. La Costa was replaced as Director of Nursing, and shunted to a smaller health post in the same district. She wryly commented that, “midwives follow me in the street so I am not going to have any less work to do!” However, demoralization and stress result from this sort of professional instability, and the emotional toll is considerable. ´N LEO

FIGURE 2. Midwife Fermina Parrales, holding UNICEF birth kit, and nurse Romelia LaCosta (left) in front of Ms. Parrales’s home. La Paz Centro. Photograph by F. Adler.

Nubia Navas is the Director of Nursing at Ma´ntica Health Center in Leo´n, a university city with a population of about 185,000. Ms. Navas has been active in the political

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changes in Nicaragua throughout her 25 years of professional nursing. Her personal sacrifice and commitment to improving health care have been enormous. A professional nurse’s salary in Nicaragua now is about $100 a month, and a physician in the health service is paid between $130 and $250 a month. To put these salaries in context, Ms. Navas’s household, which consists of six adults and teenagers, spends about $250 a month on food for a diet of local foods that is simple, adequate, and nutritious. Because one cannot support a family in Nicaragua on such salaries, health professionals seek work outside of the National Health System. A few work for nongovernmental agencies or in private practices. However, unemployment in Leo´n is a staggering 70%, which means that not many can afford private health care. Consequently, many health professionals work outside of the health care field if they can find work at all. It is also common for health professionals to hold several jobs. In a country that desperately needs expert care, psychologists, nurses, physicians, and midwives are working as moneychangers, selling cotton candy, making yogurt, and farming to support their families. In addition to her heavy workload as Nursing Director, Ms. Navas sells life insurance. Like Romelia La Costa, Ms. Navas is in charge of midwifery education in her district. However, her analysis of the future of midwifery is quite different than Ms. La Costa’s. Navas says: “The midwives do fewer and fewer births; only if the women can’t get to the hospital or at night. It is a tradition that is dying out in Nicaragua.” There are 16 active midwives in Ms. Nava’s district, and they attend about 15–17% of the total births. Among this group of midwives, only one has a granddaughter who is apprenticing as a midwife. However, it should be noted that in Region II as a whole, where Leo´n and La Paz Centro are located, it is estimated that almost half of the births are out of hospital and attended by midwives. It may be difficult for Ms. Navas, who has invested so much in improving health care in Nicaragua, to admit that as the health care system deteriorates, midwives with relatively little training may once again provide the only available care for pregnant women. In the Ma´ntica Health District, which Ms. Navas supervises, there is one principal urban clinic and seven neighborhood and rural health stations covering a population of about 65,000. The goal for vaccination coverage for the children in this district is 90%, and in practice, it is almost 100% (compared with 64.4% in the Northern California area, where the author lives, and 62.9% for the State of California as a whole [18]). Navas said, “I have 1,800 children under one year of age now, and we run after them to make sure they complete their vaccinations.” The national vaccination program is funded mainly by international sources, principally UNICEF.

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Nurses, physicians, and midwives consistently emphasize the successful Nicaraguan vaccination campaigns that were started by the Sandinistas and have since been maintained. Ms. Navas reviewed her experience in the 1980s of going door-to-door, educating individuals about the importance of vaccination and vaccinating. This very successful approach continues today. EFFECT OF STRUCTURAL ADJUSTMENT ON MATERNAL-CHILD HEALTH SERVICES

Dr. Jairo Garcı´a, an obstetrician gynecologist, and Dr. Ofelia Rojas, a pathologist at the university teaching hospital in Leo´n, emphasize the decrease in basic services in Nicaragua under SAP policies of the past 8 years. Dr. Rojas points out that as the rural health posts are dismantled, no one is keeping health statistics in those areas. Consequently, the presumed increases in morbidity and mortality in rural districts are essentially undocumented. Although care for pregnant women and children less than 5 years of age is still free at the remaining health centers, there is a strong tendency toward privatization and increasing charges at the public hospitals and health centers. For example, Rh immune globulin is now available in Nicaragua, and blood typing is done free for women having their first baby, but women must pay for the Rh immune globulin themselves. Most patients leaving the hospital cannot afford the Rh immune globulin (about $5) and those for whom it is indicated quietly say, “I will get it later,” thereby saving everyone the pain of admitting it is inaccessible. Infant mortality is again on the rise and in 1993 was 83 per 1,000 births. Under ideal conditions, the future of women in Nicaragua would be complex. Women have less access to secondary education, often bear economic responsibility for child raising, have difficulty obtaining safe contraception, and suffer the consequences of illegal abortions, which cause an estimated 27% of the high maternal mortality rate. In Leo´n, there are relatively large medical, nursing, and dental schools at the University (UNAN-Leo´n, the Autonomous National University of Nicaragua at Leo´n). Both Dr. Garcı´a and Dr. Rojas emphasized that the students and the faculty at the university are an important and unique factor in maintaining the level of health care in Region II. Other districts are suffering more severely from the current cutbacks in the National Health System. FUTURE CHALLENGES

Nicaragua is now second only to Haiti as the poorest country in the Western hemisphere. However, not all Nicaraguans are poor, and the nation has many natural resources, including fertile agricultural land, forests,

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abundant coastal waters, and mineral resources. Lucrative profits are being made by a small number of wealthy Nicaraguans and foreigners, and enormous sums are being spent to pay off the foreign debt. The devastation Hurricane Mitch caused in Nicaragua in October of 1998 helped bring the debt issue to the forefront. At that time, Honduras and Nicaragua, the two hardest hit countries, were together paying back $2 million a day in debt. By contrast, the International Red Cross sought to raise a total of $7.4 million in emergency aid. Major creditors now agree that there should be a 2-year freeze on debt repayments, but it will take decades to repair the damage done to the previously fragile infrastructures of the countries (19). There is no simplistic solution to Nicaragua’s economic and health problems; however, an important proposal has been put forth by the international Jubilee 2000 (www.j2000usa.org), a global effort to cancel the debts of the world’s poorest countries by the year 2000 under a fair and transparent process. It is based on the concept of jubilee set forth in the book of Leviticus in Hebrew Scriptures, where it is said that every 50 years slaves are to be freed and debt is to be cancelled. The United Nations estimates that if funds now used for debt repayment were used for health and education, the lives of 7 million children could be saved worldwide within a year (20). The Jubilee 2000 campaign has been rapidly growing with national campaigns in almost every country including England, Scotland, Canada, the Philippines, Australia, the United States, Sweden, and South Africa. Archbishop Emeritus Desmond Tutu is among the many religious leaders and organizations endorsing the proposal. In the United States, Jubilee 2000 has been endorsed by a long list of organizations including the Fellowship of Reconciliation, Pax Christi USA, American Friends Service Committee, AFL-CIO, RainbowPUSH, Union of American Hebrew Congregations, and the Episcopal Church. An international citizens movement may be a successful way to convince states and international institutions to act in the interests of the people least able to defend themselves. Individual national governments like Nicaragua are simply too needy and too weak to have significant influence. For the midwives, nurses, and physicians mentioned in this article, the foreign policy of the United States and the economic policies of the IMF and the World Bank are not abstract issues, but day-to-day components of their lives.

Recognizing that the support and concern of the U.S. health professionals for colleagues in the Third World help break their intellectual isolation and at the same time nurture mutual ideals, it is essential that the political relationships that lie behind health care statistics continue to be examined.

This article was supported and partially funded by The Training Exchange, a project of the Committee for Health Rights in the Americas ([email protected]).

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