Nicaragua 2003: rights, health, education and development.

In the first year of the new Nicaraguan government headed by President Enrique Bolanos, government agencies, the women's movement and other social organizations are facing a number of serious obstacles, as we anticipated in an earlier critical review: (1)

* Weakening of the separation of Church and State: The imposition of policies based on the religious beliefs of public officials;

* Lack of concrete actions by the State recognizing the rights of women, adolescents and youth;

* Lack of political will to guarantee citizen participation and especially of women's health organizations in decision-making.

I. Weakening of the Separation of Church and State

In January 2002, a new government took charge of Nicaragua once again under the banner of neoliberalism. Although numerous officials in the Ministries of Health, Education and the Family are staunch supporters of the Catholic hierarchy and previous governments, others have demonstrated a disposition to incorporate civil society into the decision-making process even though this process appears to be weakened by internal power struggles within the ruling party.

As is common in Latin America and the Caribbean, the Nicaraguan Catholic Church is influential with the government, especially in the key areas of education, social services and issues related to sexuality and reproduction. (2)

Although Article 14 of the Nicaraguan Constitution guarantees separation of Church and State, (3) the Catholic hierarchy, the elite fundamentalist group Opus Dei self-styled "pro-life" groups and strategic allies among evangelical Protestant sects invest significant resources to sway public opinion and influence decision-makers order to prevent any sort of legal reform favorable to sexual and reproductive rights. The Catholic hierarchy has been successful in three priority areas that are being monitored by the September 28 Campaign for the Decriminalization of Abortion in Latin America and the Caribbean:

* Creation of the Day of the Unborn Child;

* Persecution of individuals and institutions that support the right to abortion;

* Legislative proposals that would establish the right to life from the moment of conception.

Creation of the Day of the Unborn Child

In January 2000, following in the lead of the Vatican and (former) President Carlos Menem of Argentina, President Aleman issued Decree No. 10-2000, declaring March 25 the National Day of the Unborn Child in support of efforts to eliminate therapeutic abortion from Nicaragua's Penal Code. This decree stated that "the Political Constitution of the Republic of Nicaragua declares in Article 23 that the right to life is inviolable and inherent to all human beings and establishes in Article 74 that the State will provide special protection to the process of human reproduction, even including the pregnant woman."

But the decree's interpretation of the Constitution is based on two articles that neither uphold the right of the unborn nor establish that life begins at conception.

On March 25, 2000, justices from Supreme Court, legislators from the National Assembly and Ministers joined in an open-air mass organized by Nicaragua's Catholic bishops. Instead of a sermon, the Minister of the Family read aloud the decree establishing the National Day of the Unborn Child; that is, a government official presented an official decree in the context of a religious ceremony. One year later, the Papel Nuncio and the Archbishop of Managua, Nicaragua's only Cardinal, officiated at another open air mass at which the Vatican's Ambassador to the UN gave the sermon. Guests of honor included the President of the Republic, Ministers of State, legislators from the National Assembly and representatives of Anprovida, the national branch of Pro-Life International.

For four hours, the official government television channel transmitted the ceremony of the National Day of the Unborn Child. Like in an ancient Roman ceremony, lines of pregnant women crossed the lawns of the National Stadium under the blazing sun to present offerings to the priests. At this event, the President promised to "veto the Penal Code or any other law that includes abortion because even within their mothers' womb, all babies have the right to be born and the State must protect them." One of the nation's most widely read newspapers, La Prensa, covered the celebration exhaustively.

Based on the Presidential Decree of the Day of the Unborn Child, the new Penal Code approved in mid-2001 establishes in its Article 148, On Injuries to the Unborn Child: "Whosoever causes an injury or illness to an unborn child that provokes serious physical or psychological alteration shall be sentenced to from two to eight years in prison and a three- to eight-year suspension from practicing any medical or health profession or from providing services of any sort in any public or private gynecological clinic, establishment or office for a period of two to eight years."

A direct contradiction of Article 146 of the same Penal Code that allows therapeutic abortion, Article 148 is a dream come true for the Holy See. This situation promotes clandestine abortion to the risk of women's health and lives and guarantees that abortion will continue to be a lucrative business for those who offer illicit services.

Persecution of Individuals and Institutions that Support the Right to Abortion

Leaders of the Autonomous Women's Movement and women's centers and organizations were the target of systematic attacks during the administration of President Aleman. (4)

During May 2001, spokespersons for President Aleman, leaders of the Evangelical Alliance, parliamentarians from the "Christian Way" Party and the Liberal Alliance, and a lawyer from the Social Christian Party waged a campaign on Channel Six, the government's official television station, accusing the doctors of SI MUJER and leaders of the feminist movement of being "murderers and promoters of abortion" They urged the government to revoke the charter of SI MUJER and demanded that the Attorney General issue an arrest order for the author, the Center's director. A criminal case was filed in one of Managua's criminal courts against three of the Center's health professionals, (5) requesting that they be prevented from leaving the country, that their licenses be revoked and that they be sentenced to three years of prison. One year later, after a grueling trial, the original case and an appeal were both resolved in favor of the medical professionals.

SI MUJER's case was taken to the International Observatory for the Protection of Human Rights Defenders by the Centro Nicaraguense de Derechos Humanos (CENIDH, Nicaraguan Center for Human Rights). The Observatory undertook a fact-checking mission in Nicaragua, and its report recommended that the government respect human rights and guarantee "in particular that women are not the object of reprisal because of their peaceful commitment to defending all rights for all persons."

At the same time, an arrest order was issued for Dorothy Granados, a 70-year-old North American nurse who had been the director of a women's cooperative and rural clinic in the Autonomous Region of the North Atlantic for ten years. Accused of participating in political activities and performing abortions, Dorothy went underground at the threat of deportation. Members of her community--despite their situation of extreme poverty--marched hundreds of kilometers to Managua demanding that the government cease this persecution. Finally, even though the Appellate Court found in her favor, Dorothy's resident visa was not renewed in 2001. She returned to the United States and was only able come back to Nicaragua after the new president took office.

In April 2001, during the Debate Forum "Sexual and Reproductive Rights: The Pending Commitments of Cairo and Beijing" held in Managua, one participant identified the "need to eliminate the opinions of cardinals, bishops and priests in the application of health and education policies, since their proposals are of extremely high risk for women, adolescents and youths." This statement only served to fan the flame of the Catholic Church's campaign against women's organizations and feminist leaders. Interpreting this phrase as a threat against the Catholic hierarchy, the Criminal Investigations Department of the National Police interrogated feminist leaders and dozens of individuals who had attended the event.

In response, the Autonomous Women's Movement held a press conference to demand that government officials, legislative representatives and leaders of the political parties take a stand against this harassment and persecution of women. They urged the hierarchy of the Catholic Church and the Cardinal to behave responsibly towards the citizenry and to present proof of this supposed conspiracy to eliminate cardinals and priests.

Legislative Proposals that Would Establish the Right to Life from the Moment of Conception

Even though Article 74 of the Constitution only mentions that the State will "provide special protection to the process of human reproduction" and Article 23 states that "the right to life is inherent to all human beings," the past two governments in Nicaragua (6) have promoted the right to life from conception, "based on the Constitution." (7) These interpretations of the Constitution seek to eliminate therapeutic abortion from the Penal Code.

Since March 2000, legislators from the ALCON Conservative Alliance party and the ruling Liberal Constitutionalist Party proposed an amendment of Article 23 of the Constitution to incorporate the notion of life beginning with conception: "The right to life is inherent to all human beings from the moment of conception."

II. Failure to Recognize Women's Rights 

Sexual Health, Reproductive Health 

With a population of 5.4 million people in mid-2002), (8) Nicaragua continues to be one of the poorest countries in the hemisphere. The General Health Budget for 2003 is only US$22 per person annually. (9) While this is the highest amount allocated in the past three years, it is totally insufficient for the needs of a young population with a high fertility rate (3.2 children per woman), (10) in a context of poverty, poor hygiene and nutrition, low social status of women, poor transportation infrastructure and inadequate medical services. (11)

In January 2002, the first actions of the Ministry of Health generated a great deal of expectation: the recently-named officials announced the public presentation of the National Sexual and Reproductive Health Program. However, someone "tactlessly" mentioned sexual and reproductive rights in the prologue to the official document (although this concept did not appear in the rest of the document's contents). A public servant employed in the Ministry of Health alerted Catholic Church authorities of this gaffe. The predictable result was the withdrawal of the program in February 2002 and all the copies of the original document. Once again, the concept of "sin" triumphed over the rights and awareness of five million people. It is not clear a year later if the Ministry of Health has a functioning Sexual and Reproductive Health Program.

In recent years, the General Department of Comprehensive Care for Women, Children and Adolescents has been downgraded within the government bureaucracy. Early in 2002, in the "new era," this department was assimilated into the Department of Primary Health Care. As a result, issues related to sexuality and reproduction of over half the population are mixed with a hodgepodge of illnesses and services: dengue, fumigations, immunizations, epidemics, diarrheas and endemics swallow up the health care budget of our poor, malnourished Nicaragua.

The year 2002 witnessed attempts to combat internal corruption in the health service administration, theft of medications, labor and union conflicts, denunciations of wrongful death due to poor quality care and lack of supplies, combined with civil discontent due to increased cost and the progressive deterioration of the health care services.

Sexual Rights, Reproductive Rights

Mindless of the controversy, in February of 2003, the Minister of Health took action supporting the agenda of the Catholic bishops conference and the mandate publicly given her by the Cardinal, thus causing a serious crisis of credibility for the Ministry. The pregnancy of a nine-year-old girl, the result of a rape she had suffered in Costa Rica, revealed the existence of ghettos of power that exercised a parallel authority, overriding the decisions of acting Minister Margarita Gurdian, who in the absence of the Minister of Health, had attempted to follow the mandate to protect life and health. (12)

In response to the petition presented by the girl and her parents requesting a therapeutic abortion allowed by law for over 130 years in cases of rape, the Ministry of Health formed a mega-commission of 15 experts who were responsible for determining "if the girl was at any risk."

The Red de Mujeres Contra la Violencia (Women's Network Against Violence) demanded that the law be fulfilled, and the commission was reduced to three physicians who issued a ruling that timidly determined that continuing or terminating the pregnancy implied equal risks. The Minister of Health publicly declared that she would not allow the abortion to take place, that she considered it "murder," in contradiction of the Commission's findings. (13)

The girl was released from the public hospital where she had been kept by the Ministry of Health, and she was left to her own devices. The government passed its responsibility on to the girl's parents, illiterate farm workers who with great dignity chose to protect their child, exposing the specialists and officials to the public eye. Under the scrutiny of the citizenry, these experts and government representatives displayed the confusion of their religious beliefs above and beyond their duties and even common sense.

Maternal Mortality

The State of World Population 2001 reports Nicaragua's maternal mortality rate as 250 maternal deaths per 100,000 live births, one of the highest in Latin America. (14)

However, Nicaragua's Ministry of Health stated in March 2001 that the country's maternal mortality rate is less than half this figure: 93 per 100,000. At the same time that this statistic was released, the Office of the President issued a statement to publicize the government's intention to reduce maternal mortality from 148 to 129 maternal deaths per 100,000 live births by the year 2005. (15) Occasionally, officials admit that they do not have precise figures on maternal mortality in Nicaragua, but the government hastens to reassert that it "assumes the commitment made in Cairo to reduce this indicator by half by 2000, and by half again by 2015."

During 2002, no maternal mortality figures were made public, and plans to reduce high risk pregnancies or to increase provision of services that would protect the health and lives of pregnant women were notoriously absent from the programs of the Ministry of Health. Most recently, the director of Matagalpa's Sistema Local de Atencion Integral en Salud (SILAIS, Local Comprehensive Health Care System) declared that in the first two months of 2003, 13 maternal deaths were registered in his region, which he called "one of the highest rates in the country." (16)

Unsafe Abortion 

Unsafe abortion and its complications are the consequence of pregnancy resulting from rape, adolescent pregnancy, pregnancy in advanced age, or in extenuating circumstances of illness or danger to the woman's life, extreme poverty or being HIV-positive, among other reasons. Throughout the country, medical personnel do not register the causes nor the consequences of clandestine abortion, and as a result, the official statistics fail to illustrate the magnitude of this public health concern. Maternal mortality due to hemorrhage, sepsis or violence often hides deaths or complications resulting from unwanted pregnancies that are terminated through unsafe abortions.

According to statistics available since 1997, maternal deaths due to "violent causes" are on the rise. Many of these deaths are actually cases of poisoning: women who resorted to pesticides, drugs, poisonous plants and other toxic substances in an attempt to terminate an unwanted pregnancy, resulting in their serious illness or death. The health system registers these complications of abortion as "suicide" or "attempted suicide."

Therapeutic Abortion

The public health system denies women the right to therapeutic abortion, which costs approximately US$28. (17) On the other hand, the public health services have to spend US$1,000-5,000 to care for the complications of each case of clandestine abortion treated in the intensive care units. It is ironic that the same system that rejects petitions for legal terminations of pregnancy later must treat the complications resulting from clandestine abortions.

Since April 2000, the Catholic hierarchy and the Evangelical Alliance have undertaken a huge campaign against the inclusion of therapeutic abortion in the new Penal Code currently under discussion. As it stands, (18) Articles 143 through 149 of the new Code threaten the lives and health of Nicaraguan women of today and tomorrow, and the religious leaders intend to see even this eliminated completely. Despite the efforts of women's organizations, the legislators that drafted this section of the Penal Code refused even to consider the proposal of the Autonomous Women's Movement: "therapeutic abortion will be decided scientifically to preserve women's comprehensive health and life, and women will be able to request this procedure in a medical office"

Cervical Cancer 

Only 10.7% of women at risk have Papanicolau exams to detect cervical cancer in the health systems. (19) The health care services have shown that they are not prepared to collect and read the test and manage its results. The center that treats advanced stages of gynecological cancer has radiation therapy but no chemotherapy nor medication. (20) Nearly half (45%) of all women who die from cervical cancer are 20 to 34 years old.

HIV/AIDS Among Women

According to the 2001 Demographic and Health Survey prepared by the National Institute of Statistics and Census, only 6.6% of all women have been tested for HIV although 40% say that they know where to get the test. This report also found that 41.1% of the women surveyed had discussed HIV/ AIDS prevention with their partner at some time, and 70.5% stated that they would provide homecare for a family member with AIDS. (21)

Of the women known to be HIV-positive in Nicaragua, 88.57% (217) are of reproductive age which could mean over 690 pregnancies a year (22) and an estimated 277 HIV-positive newborns if approximately 40% are born with the virus. However, the Ministry of Health has only registered 24 cases of vertical transmission since 1987, 6.4% of what could be expected.

The opportunity provided by the Comision Nacional del SIDA (CONISIDA, National Commission on AIDS) (23) could be put to better use. Applying Law 238 demands real political will from official institutions. While the Ministry of Health attempts to coordinate community efforts and NGO activities for prevention, the Ministry of Education, Culture and Sports concentrates on the promotion of self-control through sexual abstinence as the only form of stopping transmission of the virus. Education policies reject the use and promotion of condoms to such an extent that certain official and most religious spheres even go so far as to argue that the condom is ineffective and endangers those who use it.

Sexual Violence

Of all crimes against persons committed in Nicaragua, 10.94% are considered sex crimes. While there is no complete register that reports the full magnitude of sexual violence, in 2001 the National Police listed 3,568 sex crimes. Of these, 65.77% were instances of rape or attempted rape, statutory rape or incest, and 34.22% were other sex crimes such as kidnapping, sexual harassment or molestation. (24)

As usual, the statistics show that the attackers are usually close relatives of the victim. The family home is not a safe place for women or children: 56.14% of the rapes and 62.23% of rapes involving minors occurred in the home. In 53% of the cases of child abuse, the aggressor was a family member, and in 27% of the cases, an acquaintance (25) Rape victims were girls or adolescents in 64.95% of the cases; 50.12% of the women who were raped were students.

Although the Ministry of Health declared violence to be a "public health problem" in 1996, very little has been achieved. On very few occasions do survivors of rape bring charges against their attackers: the judicial process requires "proof" of the rape to convict rapists who all too often cite extenuating circumstances or other pretexts to escape conviction.

Court officials themselves encourage the parties to agree to "out-of-court settlements" at the police stations: 34 to 50% of all rape cases are settled in this fashion. (26) The belief that it is better to preserve family unity before sending a relative to jail still holds sway, Only 12% of all cases ever go to trial. In light of this reality, Nicaraguan women's organizations and the Red de Mujeres Contra la Violencia (Women's Network Against Violence) continue their efforts to demand an end to impunity for rapists and the enforcement of justice for women and girls.

III. Failure to Recognize the Rights of Adolescents and Youth

Health: Poor Access to Services, High Maternity and Mortality Rates

Although the Law to Promote the Comprehensive Development of Young People (27) states that health care institutions should ensure the provision of services for young people to decrease the rates of preventable contagious diseases, sexually transmitted diseases and maternal mortality due to early pregnancy, most adolescents and youths of both sexes are unaware of this law.

Although the Ministry of Health's Comprehensive Health Care Program for Adolescents includes reproductive care, very few health centers offer this service. As a result, 40.6% of sexually-active adolescents do not use any form of contraception. (28)

Nearly a third (30%) of all maternal deaths occur among adolescent women, (29) and 26% of all abortions are performed on women and girls under age 19. (30) The miserable status of sexual and reproductive health in Nicaragua results in the highest adolescent pregnancy rate in Latin America: 27% of all adolescent women are mothers. (31) There are an estimated 115 births to every 1,000 women aged 15 to 19. (32) Young women are also at high risk for STDs and HIV/AIDS since less than 30% of sexually-active youths use condoms. (34)

As of December 2002, the HIV infection rate was one woman to 2.94 men. (35) Women comprise 25.33% of all people living with HIV/AIDS in Nicaragua. However, among adolescents aged 15 to 19, 44.4% of those living with the virus are young women, The social vulnerability of adolescents in particular and women in general is the basis for the feminization of the epidemic in our country which has yet to agree upon a prevention strategy to combat the pandemic.

Education: Values Rather than Information

Since 1990, the government discourse has opposed comprehensive sex education for adolescents and youth in the educational institutions. Towards the mid-1990s, the decree that established the Ministry of the Family declared that "the State recognizes the parents as the primary and principle educators" (36) without any concern that this imaginary paternal "autonomy" has just been granted to people who themselves generally lack the information and ability to educate the next generation.

We have also witnessed a lack of inter-sectoral collaboration on this issue. For example, the Ministry of Health and the Ministry of Education each have outlined different goals and objectives. The Sex Education Program of the Ministry of Education, Culture and Sports puts an emphasis on "moral values for family life" and fails to include the necessary information and sex education to help adolescents and youths prevent unplanned pregnancy and abortion.

Before assuming her position in 2001, the recently-named Minster of Education promised to place a high priority on moral values. With regard to sex education, she declared that she would not tolerate promiscuity among adolescents and youths. In September 2002 in celebration of the nation's independence holidays, she waged a holy war against the miniskirts to be worn by high school girls in the parade, decrying the "perversions" that they provoked and justifying potential sexual aggression: the girls "prance about half naked and then complain about the consequences," she declared.

The current plans and programs of the Ministry of Education have not changed under the new administration, confirming the tutelage of the Catholic hierarchy in educational affairs, even though the Constitution guarantees separation of Church and State.

Fundamentalists in Intersectoral Instances of Civic Participation

Officials from the former Department of Moral Values (renamed the Department of Human Values in 1998) continue to send representatives to key multi-sectoral commissions, such as CONISIDA, where they exercise their right to veto any mention of condom use to prevent HIV/AIDS.

They also participate in the Consejo Nacional de Atencion y Proteccion Integral a la Ninez y la Adolescencia (CONAPINA, National Council on the Comprehensive Treatment and Protection of Children and Adolescents), the Department of Youth, (38) the National Commission for the Prevention of Maternal Mortality, the National Health Council, and the Ministry of Health's Commission on Adolescents, where they oppose all mention of comprehensive sexual education, the use of contraceptive methods, the prevention of abortion or therapeutic abortion and they aggressively reject the recognition of sexual orientation.

IV. Civic Participation of Women's Health Organizations

Although the Bolanos government and officials at the Ministry of Health have expressed their willingness to incorporate women's organizations and other groups from civil society in all the levels of decision-making, little has been done in practice. Budget limitations, general lack of resources (the legacy of corruption), conflicts with workers, one untreated epidemic after another, and obvious inexperience prevent the Ministry from discovering a path towards development.

The devotion of the head of the Ministry to the Catholic hierarchy made a sham out of her term. Minister Lucia Salvo demonstrated the lack of an official political will to reach consensus with the women's movement: opportunities for collaboration were closed or kept inactive, and all the while, the factors that endanger women's health and lives continued to grow.

National Commission for the Prevention of Maternal Mortality

In February 2002, the Comision Nacional de Lucha contra la Mortalidad Materna (National Commission for the Prevention of Maternal Mortality), a multi-sectoral and multidisciplinary body created in February 1992, was reactivated under the presidential decree originally issued during President Aleman's term in office. (39) This 1997 decree eliminated the participation of women's organizations that not only were founding members but also the mainstay of the Commission until 1996. The political leadership of the Commission operationalized through the Executive Secretariat originally was comprised of representatives from women's centers, but their activities were reduced to simple secretarial roles of issuing invitations and keeping minutes of the meetings.

The failure to include leaders of the women's health movement throughout the country in the new Commission has played a part in the suspension of the Commission's activities since April 2002. The lack of consensus within the women's health movement also conspires against any attempt at real participation.

"Six Urgent Actions" Campaign

On May 28 International Day of Action for Women's Health, SI MUJER promoted the National Campaign entitled "Six Urgent Actions to Reduce Maternal Mortality and Unsafe Abortion," which was supported by 18 national networks, commissions, movements and unions and 43 women's collectives, NGOs, universities and associations. The campaign (40) publicized the urgent need for:

* Reliable statistics on maternal mortality and abortion;

* Agreements for collaboration among women's centers;

* Care for the complications of clandestine abortions;

* Education and services especially designed for adolescents;

* Access to emergency contraception;

* Prevention and treatment of sexual violence;

* Review of punitive abortion laws.

The women's health movement presented the Campaign's objectives to the Minister of Health who expressed a commitment to opening a dialogue with broader representation of the movement. Ten months later, this promise has still not been fulfilled. (41)

Paradoxically, in August 2002, the Ministry reactivated the National Health Council which had been closed by the Aleman government in 1997. The Council includes representatives from 11 official institutions and an endless number of medical groups but has not invited participation by representatives from the women's health organizations that provide services or comprehensive medical care throughout the nation. The National Health Council exists formally but it does not fulfill the objective for which it was created.

Notes

(1.) Ana Maria Pizarro, "El Gobierno de la 'Nueva Era': Los Derechos Sexuales y los Derechos Reproductivos. Le participacion ciudadana" (Managua, Nicaragua, October 2002).

(2.) From the report prepared by SI MUJER, the September 28 Campaign's focal point in Nicaragua.

(3.) Article 14 of Nicaragua's Political Constitution establishes that "the State has no official religion."

(4.) Dorothy Granada, Monica Baltodano, Vilma Nunez de Escorcia, Aria Quiros, Grethel Sequeira and Ana Maria Pizarro.

(5.) Georgina Paredes, Ana Maria Pizarro and Edilia Lovaco, specialists from SI MUJER.

(6.) Chamorro Government, Documento Politica de Poblacion (September 1996).

(7.) Aleman Government, Documento Politica de Poblacion (December 1997).

(8.) Population Reference Bureau, World Population Data Sheet (Washington, D.C.: Population Reference Bureau, 2002).

(9.) La Prensa (Managua), October 16, 2002.

(10.) INEC, Encuesta de Demografia y Salud (Managua: INEC, 2001).

(11.) UNFPA, Poblacion, pobreza y oportunidades. Panorama Nacional. Informe Nacional de Nicaragua (2002).

(12.) The Minister's obedience to the Cardinal and the discrepancy in her treatment of the girl-child rape victim pitted the Vice-Minister of Health against the head of the Health Ministry and, according to the Minister of Health, this was the reason for her resignation.

(13.) La Prensa, February 21,2002.

(14.) From SI MUJER's report on the September 28 Campaign for the Decriminalization of Abortion in Latin America and the Caribbean. SI MUJER is the campaign's focal point in Nicaragua.

(15.) ERCERP, Estrategia Reforzada de Crecimiento Economico y Reduccion de la Pobreza (Managua: ERCERP, 2001).

(16.) La Prensa, March 5, 2003.

(17.) Ana Maria Pizarro, "El aborto inducido ilegalmente. Costos y consecuencias" (Managua, Nicaragua, 1988).

(18.) Title 1, Crimes against life, physical integrity and personal safety in the new Penal Code.

(19.) MINSA, Programa Nacional de Salud Sexual y Reproductiva (2001).

(20.) Centro Nacional de Radioterapia Nora Astorga (Nora Astorga National Center for Radiation Therapy).

(21.) INEC, Encuesta de Demografia y Salud (Managua: INEC, 2002).

(22.) The national fertility rate is 3.2 children per women (ENDESA, 2001).

(23.) CONISIDA was created by Law 238 in 1996 and has been in operation since 1999.

(24.) Policia Nacional de Nicaragua, Anuario Estadistico (Nicaragua: Policia National de Nicaragua, 2001).

(25.) INEC, Encuesta de Demografia y Salud (Managua: INEC, 1998).

(26.) Data from the Centro Nicaraguense de Derechos Humanos (CENIDH, Nicaraguan Center for Human Rights) to November 1998.

(27.) Passed by the National Assembly in June 2001.

(28.) INEC, Encuesta de Demografia y Salud (Managua: INEC, 1999).

(29.) MINSA, Programa Nacional de Salud Sexual y Reproductiva (2001).

(30.) MINSA, Direccion de Atencion Integral a la Mujer, Ninez y Adolescencia (2000).

(31.) INEC, Encuesta de Demografia y Salud (Managua: INEC, 1998).

(32.) The section on adolescent fertility and maternity in INEC, Encuesta de Demografia y Salud (Managua: INEC, 2001).

(33.) Campana 6 Acciones Urgentes para reducir la Mortalidad Materna y el Aborto Inseguro en Nicaragua (2002).

(34.) MINSA, Departamento de Atencion Integral a la Adolescencia (2001).

(35.) MINSA, Programa Nacional de ITS/VIH/ SIDA (1987-2002).

(36.) Ana Maria Pizarro, "Nuevos Escenarios y Politicas de Poblacion" (July 1999).

(37.) Ministerio de Educacion Cultura y Deportes.

(38.) In the Youth Department's Working Group on Education and Recreation during the formulation of the Youth Policy Plan of Action.

(39.) According to Presidential Decree no. 202000 of March 5, 2000, the new Comision Nacional de Lucha contra la Mortalidad Materna (National Commission for the Prevention of Maternal Mortality) includes the Health Ministry, the Ministry of the Family, the Ministry of Education, the Nicaraguan Institute of Women, the Nicaraguan Institute of Social Security and "a representative" of the NGOs working in the area of health.

(40.) Based on the campaign organized in Peru by DEMUS and Flora Tristan in 1999.

(41.) Ten months later, in March 2003, the Minister of Health resigned her position without having held this dialogue with the women's health movement.