Nicaragua update: Doctors Respond to the Criminalization of Therapeutic Abortion

Andrea Lynch

October 26th, the Nicaraguan National Assembly voted to criminalize therapeutic abortion, making Nicaragua one of only three countries in the Western Hemisphere where abortion is illegal even in cases where a pregnant woman's life is in danger. Nineteen medical associations opposed the ban, and now that it's likely to be signed into law, physicians are understandably alarmed. The proposed ban carries four- to eight-year prison sentences for women who seek abortions, as well as anyone who assists them - a scenario that could force doctors to choose between upholding the Hippocratic Oath and respecting the Nicaraguan Penal Code.

Two days after the National Assembly voted, the Nicaraguan Society of Obstetricians and Gynecologists (SONIGOB) sent an urgent letter to President Enrique Bolaños and the Minister of Health asking what actions would be taken to protect both patients and health workers in light of the new law.

October 26th, the Nicaraguan National Assembly voted to criminalize therapeutic abortion, making Nicaragua one of only three countries in the Western Hemisphere where abortion is illegal even in cases where a pregnant woman's life is in danger. Nineteen medical associations opposed the ban, and now that it's likely to be signed into law, physicians are understandably alarmed. The proposed ban carries four- to eight-year prison sentences for women who seek abortions, as well as anyone who assists them – a scenario that could force doctors to choose between upholding the Hippocratic Oath and respecting the Nicaraguan Penal Code.

Two days after the National Assembly voted, the Nicaraguan Society of Obstetricians and Gynecologists (SONIGOB) sent an urgent letter to President Enrique Bolaños and the Minister of Health asking what actions would be taken to protect both patients and health workers in light of the new law. First, the letter requests that 24-hour functioning Ultrasound machines be installed in any health facility serving women who are admitted for complications from unsafe, illegal abortions (an estimated 36,000 Nicaraguan women seek illegal abortions every year, and the Ministry of Health reports that 1,800 wound up in the hospital with complications from unsafe procedures last year alone). Ultrasound machines are necessary because, as the letter argues, the new law will require physicians to establish whether or not a fetus is viable before they can take urgent action to save a pregnant woman's life. This is particularly essential in light of the harsh penalties that accompany the new law, which may make women even more reluctant to admit to having sought or provoked an abortion.

The letter from SONIGOB goes on to request 24-hour legal support for physicians trying to determine if providing the best care for their female patients will require them to break the law, as well as physical protection for health workers against family members who have been informed that a doctor cannot intervene to save their wife's, daughter's, sister's, or mother's life because of the prohibition against therapeutic abortion. SONIGOB's request may sound alarmist, but consider the case of ectopic pregnancies, of which there were 400 in 2005 alone, according to the Nicaraguan Ministry of Health. In an ectopic pregnancy, the egg implants outside the uterus, most commonly in the fallopian tube, with close to zero chance of survival for the fetus. With very rare exceptions, if left untreated, ectopic pregnancies end when the woman's fallopian tube bursts, destroying the fetus's chances for survival, and potentially killing the woman. The standard treatment for an ectopic pregnancy is a therapeutic abortion, as a means to save the woman's life as well as preserve her future fertility. In Nicaragua, however, that option is now illegal – so doctors will have to wait for the fallopian tube to rupture, risking the woman's life without increasing the fetus's chances for survival. No wonder doctors are seeking protection from angry family members.

SONIGOB has already estimated that the new law could increase pregnancy- and childbirth-related deaths in Nicaragua by as much as 65 percent. If that happens, it will be a tough pill to swallow for the anti-abortion activists who rallied support for this measure by falsely claiming that medical technology has advanced to the point where life-threatening pregnancies need never be resolved by therapeutic abortion (in a strategy somewhat reminiscent of the one currently employed by anti-abortion doctors in South Dakota).

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The letter from SONIGOB should be enough to put that myth to rest. But even if the myth were true, let's come back down to reality for a few moments. This is Nicaragua, the second poorest country in the Western Hemisphere, where people can't afford basic health care, where my friend's neighbor was recently charged up front for her 16-year-old son's emergency appendectomy. In the same issue of La Prensa where I read about SONIGOB's letter, the front-page article was about a fire that had raged for four hours in Managua's central marketplace the day before because there were no working fire hydrants in the vicinity. Given these realities, I doubt that the average Nicaraguan woman will be enjoying the benefits of state-of-the-art medical technology any time soon.

When it comes down to it, however, the fundamental truth of Nicaragua's abortion ban is this: rich women, including the wives and girlfriends and family members of the same politicians who voted for the ban, will still be able to fly to Miami for safe, legal abortions – therapeutic or not (despite anti-abortion National Assembly member Wilfred Navarro's declaration that he had "never sent one of his women to have an abortion," in a clear bid for the Bill Napoli award for Outrageous Statements about Abortion Made by a Parliamentarian). Meanwhile, poor women – and 45 percent of Nicaraguans live in extreme poverty – will be stuck here, forced to choose between seeking an unsafe, illegal abortion, and continuing a pregnancy that could end their lives. I hate to borrow a phrase from Feminists for Life, but really – don't women deserve better than choices like these?

Analysis Politics

The 2016 Republican Platform Is Riddled With Conservative Abortion Myths

Ally Boguhn

Anti-choice activists and leaders have embraced the Republican platform, which relies on a series of falsehoods about reproductive health care.

Republicans voted to ratify their 2016 platform this week, codifying what many deem one of the most extreme platforms ever accepted by the party.

“Platforms are traditionally written by and for the party faithful and largely ignored by everyone else,” wrote the New York Times‘ editorial board Monday. “But this year, the Republicans are putting out an agenda that demands notice.”

“It is as though, rather than trying to reconcile Mr. Trump’s heretical views with conservative orthodoxy, the writers of the platform simply opted to go with the most extreme version of every position,” it continued. “Tailored to Mr. Trump’s impulsive bluster, this document lays bare just how much the G.O.P. is driven by a regressive, extremist inner core.”

Tucked away in the 66-page document accepted by Republicans as their official guide to “the Party’s principles and policies” are countless resolutions that seem to back up the Times‘ assertion that the platform is “the most extreme” ever put forth by the party, including: rolling back marriage equalitydeclaring pornography a “public health crisis”; and codifying the Hyde Amendment to permanently block federal funding for abortion.

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Anti-choice activists and leaders have embraced the platform, which the Susan B. Anthony List deemed the “Most Pro-life Platform Ever” in a press release upon the GOP’s Monday vote at the convention. “The Republican platform has always been strong when it comes to protecting unborn children, their mothers, and the conscience rights of pro-life Americans,” said the organization’s president, Marjorie Dannenfelser, in a statement. “The platform ratified today takes that stand from good to great.”  

Operation Rescue, an organization known for its radical tactics and links to violence, similarly declared the platform a “victory,” noting its inclusion of so-called personhood language, which could ban abortion and many forms of contraception. “We are celebrating today on the streets of Cleveland. We got everything we have asked for in the party platform,” said Troy Newman, president of Operation Rescue, in a statement posted to the group’s website.

But what stands out most in the Republicans’ document is the series of falsehoods and myths relied upon to push their conservative agenda. Here are just a few of the most egregious pieces of misinformation about abortion to be found within the pages of the 2016 platform:

Myth #1: Planned Parenthood Profits From Fetal Tissue Donations

Featured in multiple sections of the Republican platform is the tired and repeatedly debunked claim that Planned Parenthood profits from fetal tissue donations. In the subsection on “protecting human life,” the platform says:

We oppose the use of public funds to perform or promote abortion or to fund organizations, like Planned Parenthood, so long as they provide or refer for elective abortions or sell fetal body parts rather than provide healthcare. We urge all states and Congress to make it a crime to acquire, transfer, or sell fetal tissues from elective abortions for research, and we call on Congress to enact a ban on any sale of fetal body parts. In the meantime, we call on Congress to ban the practice of misleading women on so-called fetal harvesting consent forms, a fact revealed by a 2015 investigation. We will not fund or subsidize healthcare that includes abortion coverage.

Later in the document, under a section titled “Preserving Medicare and Medicaid,” the platform again asserts that abortion providers are selling “the body parts of aborted children”—presumably again referring to the controversy surrounding Planned Parenthood:

We respect the states’ authority and flexibility to exclude abortion providers from federal programs such as Medicaid and other healthcare and family planning programs so long as they continue to perform or refer for elective abortions or sell the body parts of aborted children.

The platform appears to reference the widely discredited videos produced by anti-choice organization Center for Medical Progress (CMP) as part of its smear campaign against Planned Parenthood. The videos were deceptively edited, as Rewire has extensively reported. CMP’s leader David Daleiden is currently under federal indictment for tampering with government documents in connection with obtaining the footage. Republicans have nonetheless steadfastly clung to the group’s claims in an effort to block access to reproductive health care.

Since CMP began releasing its videos last year, 13 state and three congressional inquiries into allegations based on the videos have turned up no evidence of wrongdoing on behalf of Planned Parenthood.

Dawn Laguens, executive vice president of Planned Parenthood Action Fund—which has endorsed Hillary Clinton—called the Republicans’ inclusion of CMP’s allegation in their platform “despicable” in a statement to the Huffington Post. “This isn’t just an attack on Planned Parenthood health centers,” said Laguens. “It’s an attack on the millions of patients who rely on Planned Parenthood each year for basic health care. It’s an attack on the brave doctors and nurses who have been facing down violent rhetoric and threats just to provide people with cancer screenings, birth control, and well-woman exams.”

Myth #2: The Supreme Court Struck Down “Commonsense” Laws About “Basic Health and Safety” in Whole Woman’s Health v. Hellerstedt

In the section focusing on the party’s opposition to abortion, the GOP’s platform also reaffirms their commitment to targeted regulation of abortion providers (TRAP) laws. According to the platform:

We salute the many states that now protect women and girls through laws requiring informed consent, parental consent, waiting periods, and clinic regulation. We condemn the Supreme Court’s activist decision in Whole Woman’s Health v. Hellerstedt striking down commonsense Texas laws providing for basic health and safety standards in abortion clinics.

The idea that TRAP laws, such as those struck down by the recent Supreme Court decision in Whole Woman’s Health, are solely for protecting women and keeping them safe is just as common among conservatives as it is false. However, as Rewire explained when Paul Ryan agreed with a nearly identical claim last week about Texas’ clinic regulations, “the provisions of the law in question were not about keeping anybody safe”:

As Justice Stephen Breyer noted in the opinion declaring them unconstitutional, “When directly asked at oral argument whether Texas knew of a single instance in which the new requirement would have helped even one woman obtain better treatment, Texas admitted that there was no evidence in the record of such a case.”

All the provisions actually did, according to Breyer on behalf of the Court majority, was put “a substantial obstacle in the path of women seeking a previability abortion,” and “constitute an undue burden on abortion access.”

Myth #3: 20-Week Abortion Bans Are Justified By “Current Medical Research” Suggesting That Is When a Fetus Can Feel Pain

The platform went on to point to Republicans’ Pain-Capable Unborn Child Protection Act, a piece of anti-choice legislation already passed in several states that, if approved in Congress, would create a federal ban on abortion after 20 weeks based on junk science claiming fetuses can feel pain at that point in pregnancy:

Over a dozen states have passed Pain-Capable Unborn Child Protection Acts prohibiting abortion after twenty weeks, the point at which current medical research shows that unborn babies can feel excruciating pain during abortions, and we call on Congress to enact the federal version.

Major medical groups and experts, however, agree that a fetus has not developed to the point where it can feel pain until the third trimester. According to a 2013 letter from the American Congress of Obstetricians and Gynecologists, “A rigorous 2005 scientific review of evidence published in the Journal of the American Medical Association (JAMA) concluded that fetal perception of pain is unlikely before the third trimester,” which begins around the 28th week of pregnancy. A 2010 review of the scientific evidence on the issue conducted by the British Royal College of Obstetricians and Gynaecologists similarly found “that the fetus cannot experience pain in any sense prior” to 24 weeks’ gestation.

Doctors who testify otherwise often have a history of anti-choice activism. For example, a letter read aloud during a debate over West Virginia’s ultimately failed 20-week abortion ban was drafted by Dr. Byron Calhoun, who was caught lying about the number of abortion-related complications he saw in Charleston.

Myth #4: Abortion “Endangers the Health and Well-being of Women”

In an apparent effort to criticize the Affordable Care Act for promoting “the notion of abortion as healthcare,” the platform baselessly claimed that abortion “endangers the health and well-being” of those who receive care:

Through Obamacare, the current Administration has promoted the notion of abortion as healthcare. We, however, affirm the dignity of women by protecting the sanctity of human life. Numerous studies have shown that abortion endangers the health and well-being of women, and we stand firmly against it.

Scientific evidence overwhelmingly supports the conclusion that abortion is safe. Research shows that a first-trimester abortion carries less than 0.05 percent risk of major complications, according to the Guttmacher Institute, and “pose[s] virtually no long-term risk of problems such as infertility, ectopic pregnancy, spontaneous abortion (miscarriage) or birth defect, and little or no risk of preterm or low-birth-weight deliveries.”

There is similarly no evidence to back up the GOP’s claim that abortion endangers the well-being of women. A 2008 study from the American Psychological Association’s Task Force on Mental Health and Abortion, an expansive analysis on current research regarding the issue, found that while those who have an abortion may experience a variety of feelings, “no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors.”

As is the case for many of the anti-abortion myths perpetuated within the platform, many of the so-called experts who claim there is a link between abortion and mental illness are discredited anti-choice activists.

Myth #5: Mifepristone, a Drug Used for Medical Abortions, Is “Dangerous”

Both anti-choice activists and conservative Republicans have been vocal opponents of the Food and Drug Administration (FDA’s) March update to the regulations for mifepristone, a drug also known as Mifeprex and RU-486 that is used in medication abortions. However, in this year’s platform, the GOP goes a step further to claim that both the drug and its general approval by the FDA are “dangerous”:

We believe the FDA’s approval of Mifeprex, a dangerous abortifacient formerly known as RU-486, threatens women’s health, as does the agency’s endorsement of over-the-counter sales of powerful contraceptives without a physician’s recommendation. We support cutting federal and state funding for entities that endanger women’s health by performing abortions in a manner inconsistent with federal or state law.

Studies, however, have overwhelmingly found mifepristone to be safe. In fact, the Association of Reproductive Health Professionals says mifepristone “is safer than acetaminophen,” aspirin, and Viagra. When the FDA conducted a 2011 post-market study of those who have used the drug since it was approved by the agency, they found that more than 1.5 million women in the U.S. had used it to end a pregnancy, only 2,200 of whom had experienced an “adverse event” after.

The platform also appears to reference the FDA’s approval of making emergency contraception such as Plan B available over the counter, claiming that it too is a threat to women’s health. However, studies show that emergency contraception is safe and effective at preventing pregnancy. According to the World Health Organization, side effects are “uncommon and generally mild.”

Analysis Abortion

Data Shows Surge in Texans Traveling Out of State to Get an Abortion

Teddy Wilson

A Rewire analysis has found that while Texas data shows there has been a decline in the number of abortions in the state, data from other neighboring states suggests there has been a dramatic increase in the number of Texans traveling out of state to access abortion care since the passage of HB 2 in 2013.

Last week, the Texas Department of State Health Services (DSHS) was accused by the American Civil Liberties Union (ACLU) of Texas of deliberately attempting to conceal abortion statistics from 2014, the first full year provisions of the state’s omnibus abortion law were in effect.

DSHS has yet to respond to a letter from the ACLU of Texas demanding that the agency make those statistics available to the public.

The news comes as the Supreme Court is set to issue a ruling on Whole Woman’s Health v. Hellerstedt, which challenges provisions of the abortion law, HB 2, which lawyers of the abortion clinics argue place an undue burden on patients and providers in the state, impeding their ability to provide or access constitutionally protected health care.

DSHS officials finalized the statistics in March, according to the ACLU in a statement, but they have yet to release the full statistics to the public.

“The details are being reviewed for accuracy,” Carrie Williams, director of media relations for DSHS, told Rewire. “We did release the provisional total several months ago but can’t release the underlying details until they are final.”

Even without those details, a Rewire analysis has found that while DSHS data shows there has been a decline in the number of abortions in the state, data from other neighboring states suggests there has been a dramatic increase in the number of Texans traveling out of state to access abortion care since the passage of HB 2 in 2013.

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The number of abortions in Texas has been steadily decreasing since 2008, according to data from DSHS: Over the six-year period, the number has declined by nearly 22 percent. There were 81,591 abortions in 2008, 77,850 in 2009, 77,592 in 2010, 72,470 in 2011, 68,298 in 2012, and 63,849 in 2013.

Around that time, the number of Texans who traveled out of state to have abortions also steadily decreased, by nearly 57 percent from 2008 to 2012. There were 225 patients who had abortions out of state in 2008, 220 in 2009, 129 in 2010, 138 in 2011, and 97 in 2012, according to DSHS.

In 2013, the year Gov. Rick Perry (R) signed HB 2 into law, the number of Texans who traveled out of state to have an abortion increased to 681more than the previous four years combined. Prior to the implementation of HB 2, there were 41 facilities providing abortion services in the state, and 16 of those facilities had either closed or stopped providing abortion services by the end of 2013.

Trisha Trigilio, staff attorney at the ACLU of Texas, told Rewire that the statistics for out-of-state abortions for Texans are concerning. “This is more evidence of what was already proven in court: Texas’ onerous regulations unnecessarily block access to safe, legal abortion in our state,” Trigilio said in an email to Rewire.

Specifically, a study from the Texas Policy Evaluation Project showed the implementation of HB 2 has increased travel distances to clinics, out-of-pocket costs, and overnight stays.

At least 400 more patients traveled outside of Texas to have an abortion in 2014 than did in 2013, according to Rewire‘s analysis. Data collected by the state health departments of Arkansas, Kansas, Oklahoma, and Louisiana shows that at least 1,086 patients traveled to those states from Texas to obtain an abortion after portions of HB 2 took effect.

“Based on this [analysis from Rewire], it’s clear that this law doesn’t make women safer, it forces them to travel across the Texas border to get the care they need—and for women who can’t afford to leave the state, Texas law may prevent them from seeing a doctor at all,” Trigilio continued.

Texas Patients Seeking Out-of-State Abortions

In the wake of HB 2, more than half of the clinics that provide abortion services in Texas have been forced to close, leaving large swaths of the state without access to legal abortion care. The majority of the clinics that have remained open are located in major metropolitan areas: Austin, Dallas/Fort Worth, Houston, and San Antonio.

As clinics that once served rural areas have closed, patients have been forced to drive hundreds of miles away from their homes to one of the state’s major cities or cross the border into neighboring states. 

Arkansas has seen a slight increase since the passage of HB 2 in the number of patients from Texas seeking abortion care.

Arkansas’ Health Statistics Branch of the state health department tracks the number of patients from out of state who have abortions. There were 21 from Texas in 2012, 25 in 2013, 41 in 2014, and 33 in 2015.

Kansas has also seen a slight increase in the number of Texas patients seeking abortion care, according to statistics published by the Kansas Department of Health and Environment. There were two patients from Texas who traveled to Kansas to obtain an abortion during 2012, 13 in 2013,  23 in 2014, and 24 in 2015.

Oklahoma saw a noticeable increase in the number of patients from Texas seeking abortion care there after the passage of HB 2, according to data from the Oklahoma State Department of Health annual abortion surveillance report.

There were 21 patients from Texas who had an abortion during 2012 in Oklahoma, 59 in 2013, 136 in 2014, and 131 in 2015.

Based on Rewire‘s analysis, it seems as if no other state has seen a larger increase in patients from Texas seeking abortion care than Louisiana.

The Louisiana Department of Health and Hospitals (DHH) publishes data on abortions performed there collected by the State Center for Health Statistics (SCHS), but has typically not published data on the number of patients who live outside the state who have an abortion in Louisiana.

Preliminary SCHS figures for 2015 provided to Louisiana Right to Life, a state affiliate of the anti-choice organization National Right to Life Committee, included data on patients from out of state who obtained abortions in Louisiana.

There were 9,311 abortions performed in Louisiana during 2015, and patients from out of state accounted for 1,362 of all abortions performed in the state, according to DHH data published by Louisiana Right to Life.

The data did not include the states of residency for the patients from out of state, which the organization noted is “not available at this time.”

However, preliminary SCHS figures for 2014 provided to the Louisiana Right to Life did include details on the states of residency for patients who had an abortion in Louisiana. There were 10,211 abortions performed in Louisiana during 2014, and patients from out of state accounted for 1,432 of all abortions performed in the state.

Out of the 1,432 abortions had by residents from out of state, 886 were from Texas.

More and more pregnant people are traveling to New Mexico to access abortion care. About 20 percent of the roughly 4,500 abortions performed there in 2014 involved out-of-state patients, according to state health department data reported by the Albuquerque Journal.

Brittany Defeo, program manager with the aid group New Mexico Religious Coalition for Reproductive Choice, previously told Rewire that the people she assists represent a wide range of ages and backgrounds. “They’re ages 18 to 40. It’s all walks of life,” Defeo said.

Defeo estimates that approximately one third of those seeking abortion services in New Mexico from out of state are from Texas. If estimates are correct, that would suggest that approximately 300 patients traveled from Texas to New Mexico to obtain abortion care in 2014. 

Natalie St. Clair, who assists patients seeking abortion care with nonprofit Fund Texas Choice, told the Texas Observer that she helps about ten clients per month travel to New Mexico to access abortion care. St. Clair explained to the Observer that clients often express shock over the barriers in Texas to accessing  abortion care.

“I hear a lot of ‘I had no idea that the laws were this way. I have to go out of state?’ There’s a lot of shame and guilt because people think it’s their fault, or they weren’t prepared enough,” St. Clair said. “I explain that [Texas laws] are set up this way on purpose … [They’re] making abortion inaccessible on purpose.”

Trigilio told Rewire that this data shows that HB 2 was never about protecting patients’s health and safety as proponents have claimed. “When a woman makes the deeply personal decision to have an abortion, she needs access to safe medical care and respect for the decision she has made. HB 2 impedes that,” the ACLU of Texas staff attorney said.