Commentary Abortion

How Many Amalias, Karinas, and Savitas Must There Be? Las Savitas de Centroamérica

Marta María Blandón

Here in Central America, women are denied life-saving treatment every day. Women with life-threatening illnesses are denied treatment because to do so might harm their pregnancy—just the same explanation that Savita’s husband received from their doctors in Galway.  [This article is published in both English and Spanish.]

See all our coverage of the tragic case of Savita Halappanavar here.

For the past two weeks, women’s rights advocates in Nicaragua have been watching with sorrow and frustration as the news about Savita Halappanavar has been unfolding. Savita, an Indian national living in Ireland, died of septicemia following a miscarriage—a miscarriage that was undeniable and unpreventable, and yet doctors denied her appropriate medical treatment rather than end a doomed pregnancy.

Here in Central America, women are denied life-saving treatment every day.

In Nicaragua and El Salvador, abortion is outlawed under any and all conditions—two of only four countries in the world to do so. And while the laws of other countries in the region may allow for abortion under certain, very narrow conditions, in practice very few women can receive an abortion under such “exceptions.” Women who have suffered from pregnancy complications are accused of trying to “murder” their unborn children. Women with life-threatening illnesses are denied treatment because to do so might harm their pregnancy—just the same explanation that Savita’s husband received from their doctors in Galway.

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At Ipas, we saw this firsthand with a young woman called Amalia. Amalia was 27, and eight-weeks pregnant with her second child when she was diagnosed with cancer—an aggressive recurrence of a cancer treated 10 years earlier. Because she was pregnant, the public health service denied her treatment because it might harm the fetus. Ipas and other human rights groups brought the case to the Inter-American Commission on Human Rights, to seek a precautionary measure that would compel the state to provide treatment—a request that was quickly granted. Under public and international scrutiny, the state then provided Amalia with the gold standard of care—treatment received by few others in Nicaragua. Under this treatment, the government maintained, the fetus would survive and thrive.

Sadly, the government was proven incorrect. Amalia delivered a severely malformed baby at seven months. She lived another 17 months. Throughout the case, the government maintained that an abortion was not necessary. The result of Amalia’s case speaks for itself; women undergoing cancer treatment still need the option of therapeutic abortion.

In El Salvador we met Karina, a woman with three children who was arrested after she was found hemorrhaging as a result of an unsafe abortion. She had become pregnant after receiving a tubal ligation (a procedure that is almost, but not entirely, 100 percent effective). Her mother had told her she would not be allowed home if she became pregnant again, and she was so ashamed that she told no one. Police determined that she’d induced an abortion, and she was prosecuted and sentenced to 30 years in prison without ever being allowed to speak to a lawyer, or testify on her own behalf.

After we learned about her, Ipas, the Center for Reproductive Rights and a number of other NGOs worked with Karina to bring a review of her case. With the legal representation and fact finding that she had been denied eight years earlier, we were able to win her freedom. But other women continue to face scrutiny and harassment over their pregnancy complications: Approximately 600 women in El Salvador are under investigation or being prosecuted for suspected abortion.

Women and doctors alike live in a culture of fear in countries that outlaw abortion. Doctors are afraid to provide any medical treatment that might harm or end a pregnancy. And women who have pregnancy complications are afraid to seek treatment for fear that they will be accused of inducing an abortion. The result? Women, like Savita, who are unnecessarily injured or die.

What is more frustrating is that numerous human rights bodies have ruled that to deny abortions to women whose lives and health are endangered by their pregnancies is a violation of their human rights. Ireland was told directly by the European Court of Human Rights that they must provide mechanisms to provide abortions under the law (abortion is legal in Ireland if a woman’s life is in danger). Nicaragua has been questioned repeatedly by international human rights bodies about its total ban on abortion, which runs contrary to multiple international agreements.

How many Amalias, Karinas or Savitas must there be before nations take women’s human rights seriously?


en Español

Durante las últimas dos semanas, defensoras y defensores de los derechos de las mujeres en Nicaragua han estado obervando con angustia y frustración el desenlace de las noticas sobre Savita Halappanavar. Savita, ciudadana de la India que vive en Irlanda, falleció a causa de una septicemia después de una pérdida del embarazo, la cual fue innegable e inevitable. Sin embargo, los médicos le negaron el tratamiento médico que necesitaba en vez de poner fin a un embarazo predestinado al fracaso. Pero aquí en Centroamérica, todos los días se les niega a las mujeres tratamiento esencial para salvar vidas.

La interrupción del embarazo es ilegal bajo todas las circunstancias en Nicaragua y El Salvador: dos de solo cuatro países del mundo donde existe una prohibición total del aborto. Y mientras que las leyes de otros países en la región permiten el aborto bajo ciertas condiciones muy limitadas, en la práctica se concede la excepción necesaria a muy pocas mujeres. A las mujeres que sufren complicaciones del embarazo se les acusa de tratar de “asesinar” a sus hijos no natos. A las mujeres con enfermedades con riesgo de muerte se les niega tratamiento porque éste podría poner en peligro su embarazo, justo la misma explicación que el esposo de Savita recibió de sus médicos en Galway.

En Ipas, presenciamos esto de primera mano con una joven llamada Amalia. Amalia tenía 27 años de edad y ocho semanas de embarazo de su segundo hijo, cuando fue diagnosticada con cáncer: una agresiva reaparición de un cáncer tratado 10 años antes. Debido a su embarazo, en el servicio de salud  pública se le negó tratamiento porque éste podría perjudicar al feto. Ipas y otros grupos de derechos humanos presentaron el caso ante la Comisión Interamericana de Derechos Humanos, en búsqueda de una medida cautelar para convencer al Estado de brindarle tratamiento, una petición que rápidamente fue concedida. Una vez bajo tela de juicio del público tanto a nivel nacional como internacional, el Estado le brindó a Amalia la mejor atención posible: tratamiento que reciben muy pocas personas en Nicaragua. Con este tratamiento, sostuvo el gobierno, el feto sobreviviría y se desarrollaría.

Infelizmente, se comprobó que el gobierno estaba equivocado. Amalia dio a luz a un bebé con graves malformaciones a los siete meses. Ella vivió otros 17 meses. A lo largo del caso, el gobierno sostuvo que no era necesario realizar un aborto. El resultado del caso de Amalia habla por sí solo; a las mujeres que reciben tratamiento del cáncer también se les debe ofrecer la opción de tener un aborto terapéutico. 

En El Salvador, conocimos a Karina, una mujer con tres hijos que fue arrestada después que fue encontrada desangrando producto de la práctica de un aborto inseguro. Había quedado embarazada después de tener una ligadura tubaria (un procedimiento que es casi, pero no totalmente, el 100% eficaz). Su madre le había dicho que no podría regresar a la casa si quedara embarazada de nuevo y ella estaba tan avergonzada que no se lo contó a nadie. La policía determinó que ella se indujo un aborto y fue enjuiciada y condenada a 30 años de prisión, ni siquiera le permitieron hablar con un abogado o testificar a su favor.

Después que en Ipas nos enteramos de su caso, el Centro de Derechos Reproductivos y varias otras ONG trabajaron con Karina para presentar una revisión de su caso. Con la representación procesal y la investigación que le negaron ocho años antes, logramos ganar su libertad. Pero otras mujeres continúan enfrentando acoso y siendo enjuicidas por complicaciones del embarazo: aproximadamente 600 mujeres en El Salvador están siendo investigadas o enjuiciadas por sospecha de aborto.

Tanto las mujeres como los profesionales médicos viven en una cultura de temor en los países donde el aborto es ilegal. Los médicos temen brindar cualquier tratamiento médico que pueda perjudicar o poner fin a un embarazo. Y las mujeres que presentan complicaciones del embarazo temen buscar tratamiento por temor a ser acusadas de inducirse un aborto. ¿El resultado? Mujeres como Savita son lesionadas o mueren innecesariamente.

Aun más frustrante es el hecho de que numerosos organismos de derechos humanos han determinado que negar un aborto a una mujer cuya vida y salud corren peligro a causa de su embarazo es una violación de sus derechos humanos. La Corte Europea de Derechos Humanos le dijo directamente a Irlanda que deben ofrecer mecanismos para realizar abortos permitidos por la ley (la interrupción del embarazo es legal en Irlanda si la vida de la mujer corre peligro). Nicaragua ha sido cuestionada repetidas veces por los organismos internacionales de derechos humanos respecto a su prohibición total del aborto, la cual va en contra de múltiples acuerdos internacionales.

¿Cuántas Amalias, Karinas o Savitas debe haber antes que las naciones tomen en serio los derechos humanos de las mujeres?

Analysis Maternity and Birthing

Government Recommendations on Zika Virus Not Grounded in Reality, Say El Salvador Locals

Kathy Bougher

The country’s Ministry of Health recommended last week that women should avoid becoming pregnant until 2018. But local feminist groups say this guidance doesn’t reflect the needs of Salvadoran women, especially where reproductive health is concerned.

Read more of our articles on the Zika virus here.

The presence of the Zika virus in El Salvador, along with the evidence that it may be causing microcephaly in fetuses and babies, led the country’s Ministry of Health to recommend last week that women should avoid becoming pregnant until 2018. But local feminist groups say this guidance doesn’t reflect the needs of Salvadoran women, especially where reproductive health is concerned.

Last May, there was a Zika outbreak in Brazil; in October, a large number of babies there were born with microcephaly, a condition in whichthe head is smaller than normal because the brain has not developed properly or has stopped growing.” According to the New York Times, Zika has existed since about 1947 in Africa. It was not particularly linked to microcephaly until last year, however, because most people had mild cases as children, and had immunity when they reached childbearing age. Still, as the Times notes, “Investigators may even find that Zika virus is not the main cause [of microcephaly], although right now circumstantial evidence strongly suggests that it is.”

The Centers for Disease Control and Prevention reports that an understanding of the links between Zika and microcephaly is “evolving,” but that preventive measures, such as avoiding mosquito bites, are appropriate.

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Since the virus has only recently arrived in El Salvador, the Ministry of Health does not yet have records of fetuses diagnosed with microcephaly as a possible result of the Zika virus. However, the data reflect that 96 pregnant women have the virus, and the total number of cases continues to rise.  

El Salvador Vice Minister of Health Eduardo Espinoza announced on behalf of the Ministry of Health last week that “We are recommending that women of childbearing age take the precaution of planning their pregnancies and try to avoid pregnancy this year and next.”  

As reported in Spanish by La Prensa Gráfica, “The official also [reissued] the call that the Ministry made a few months earlier to women who were already pregnant and could be susceptible to acquiring Zika to ‘cover as much of the body as possible, use pants and long-sleeve blouses to limit the possibility that mosquitoes infected with Zika can affect them.’”

Sara García, coordinator of the feminist group Agrupación Ciudadana por la Despenalización del Aborto (Citizen Group for the Decriminalization of Abortion), says that the recommendation seems directed primarily at adult married women or women who have a stable, cooperative male partner. She noted to Rewire in an on-the-ground interview, “Paternal responsibility is not included. Where are the men in this process?”

Furthermore, about 31 percent of females with pregnancies registered with the El Salvador Ministry of Health in 2014 were ages 10 to 19. Many of these pregnancies, García argued, could have been “imposed,” or nonconsensual. “What happens with an imposed pregnancy?” she said. “What happens when contraceptives fail?  We can’t just think about the ideal and assume that everyone can plan pregnancies.”  

“This recommendation is not grounded in the realities and the context of El Salvador,” García concluded.

The potential inability to plan for pregnancies—or prevent them—is exacerbated by El Salvador’s weak policies around sexual and reproductive health services. Both García and Salvadoran OB-GYN and specialist in women’s health, Dr. Aleida Marroquín, noted to Rewire that comprehensive sexual education that includes contraception is not available in schools.

Such barriers to access are not limited to education, however. Contraception is not legally restricted in the country. Even so, in a study-in-progress carried out by the feminist organization Organización de Mujeres Salvadoreñas por la Paz (Organization of Salvadoran Women for Peace, known as ORMUSA), which shared a preliminary draft with Rewire, early findings based on interviews indicate that although local health centers might prescribe contraceptives, centers can go for months at a time without actually having any in stock. Young women say they routinely encounter humiliating treatment or have their requests to purchase contraception denied at public clinics and private pharmacies.  

In addition, the study reports, although the country’s policies direct that there be specialized services and personnel trained to serve adolescents and young adults, in reality those services rarely exist. Gang violence and territoriality also impact clients’ ability to physically access clinics, and the reporting of rapes for fear of retribution.  

And if a person does not prevent pregnancy and discovers that her fetus is showing signs of microcephaly—which, as Marroquín noted, is not possible until the second trimester—El Salvador’s absolute ban on abortion means that she has no choice apart from giving birth.

Marroquín explained, “The symptoms [of microcephaly] can run a continuum from extremely severe with an early death to practically non-detectable and a relatively normal life.  However, most babies affected need specialized care from birth, and some will need round-the-clock care all their lives.”  

She emphasized that El Salvador has “almost no resources to meet such extensive medical and social needs. What happens to a woman who is an agricultural worker or a vender in the market who must work long hours every day to feed her children?”

Although a woman may or may not wish to interrupt the pregnancy if she were to discover that her fetus was microcephalic, the option does not even exist in the country. This, activists say, reflects the broader problem of denying women access to potentially life-saving care.  

“In addition to Zika,” García pointed out, “When we talk about a nonviable pregnancy, about risk, Salvadoran women are confronting other situations too. A major example is ectopic pregnancy, where any medical textbook will tell you that the only way to treat it is to interrupt the pregnancy. Otherwise the fallopian tubes can rupture and cause much graver problems, including the possible death of the woman.”

“What happens in this country?” García continued, referencing anecdotes medical providers had relayed to the Agrupación. “The woman arrives at the hospital. The doctor tells her that they cannot interrupt the pregnancy as long as they can detect a heartbeat. ‘You can stay here in the hospital and wait,’ the doctor tells her. But she has other children to care for at home.  If she doesn’t work, they don’t eat. So she goes home and runs the serious risk of having her fallopian tube rupture at home, far from medical help. In cases of ectopic pregnancies, there is no question about what is going to happen, but doctors have their hands tied by the law.”  

García also mentioned Beatriz, who turned to international courts for help in 2013 when medical personnel refused to let her terminate a pregnancy of an anencephalic fetus. Beatriz was threatened with prison if she took any action to do so; many other women in the country are currently incarcerated on abortion-related charges because of pregnancy complications.

García linked the Zika issues to the long-term work of the Agrupación to decriminalize abortion and recognize the negative health consequences for women of the absolute ban.

“We need to push the conversation beyond the question of Zika, and talk about the consequences of a law that gives women no options for interrupting a pregnancy, especially when the conditions to prevent pregnancies are almost nonexistent,” she said.

“Other countries in the region have laws that permit therapeutic abortions, abortions in case of rape or incest, and abortions in case of severe fetal abnormalities. We used to have that,” García said.

Since making its initial recommendation that women avoid becoming pregnant, the Ministry of Health has backed off a bit from that stance, instead emphasizing its campaign to eradicate the breeding grounds of the Aedes aegypti mosquitoes that carry Zika. The same insects also transmit dengue fever and Chikungunya, related viruses that have been present for much longer in the country. The government has also recommended that female students be allowed to wear pants as part of their school uniforms rather than the required skirts as one more preventive measure.  

However, public officials have yet to suggest proposals for workable policies and practices to prevent unwanted pregnancies, and to provide women options that include abortion.

Analysis Human Rights

Inside El Salvador’s Women’s Prison: What ‘Las 17’ Face for Their Abortion-Related Charges

Kathy Bougher

Last week, Rewire met with six of the 17 Salvadoran women imprisoned for what amount to pregnancy complications. The women discussed the challenges they face, including harassment from other inmates and overcrowded conditions.

Read more of our coverage on the campaign for Las 17, the 17 Salvadoran women imprisoned on abortion-related charges, here.

The El Salvadoran Legislative Assembly voted last month to grant a pardon to Guadalupe, one of “Las 17” imprisoned for what amounted to pregnancy complications. But 15 other women are still incarcerated on abortion-related charges, with 13 serving their sentences in Ilopango, the country’s single designated women’s prison. Last week, Rewire met with six of these women, accompanied by Ivonne Polanco, a member of the local advocacy group Agrupación Ciudadana por la Despenalización del Aborto (Citizen Group for the Decriminalization of Abortion), and La Agrupación attorney Dennis Munoz.

The imprisoned women didn’t always see themselves as part of a unit, let alone the focus of a campaign for pardons that has grown to attract global attention. But on April 1, 2014, they heard about the demonstration La Agrupación held outside the prison gates to mark the beginning of the organization’s formal request for pardons on their behalf. After that, they began to identify as “Las 17”—and with that identity has come a sense of connection among the women and toward La Agrupación. All have taken part in numerous interviews with journalists, as well as with groups such as Amnesty International, which visited the prison in September 2014.

“The work of La Agrupación opens doors for us. If it weren’t for La Agrupación, we know we would all be here for 30 years,” commented Theodora, now in the eighth year of her three-decade sentence for aggravated homicide.

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Still, being identified as part of Las 17—and by extension, one of the women in jail on abortion-related charges—has its downsides. The women say that when they first entered prison, they attempted to keep secret the nature of the crime with which they had been charged. It is common, they say, for other prisoners to stigmatize, verbally harass, and sometimes physically assault women convicted of aggravated homicide in the death of a child, so they wanted to downplay their history with the justice system.

However, their trials were frequently featured on television news, which prisoners can watch. Then, the name-calling and physical threats would begin. “We have to live with these people,” reflected Theodora. “When I was first here, but before I had actually been convicted, I didn’t tell anyone why I was here, but they figured it out from the television. To protect me, the prison put me in the section for older women. … Now when I do talk with those people I tell them, ‘Only the woman herself knows what really happened. Others don’t know.’ But when there is a woman who has a baby that died, then [other prisoners] assume it was a homicide committed by the woman.”

“Sometimes we know we’re being discriminated against for the type of conviction we have,” affirmed Marina, who, at 31, has served eight of her 30 years in prison.

Guadalupe, who expects to be released within the next few weeks, described what she too called “psychological discrimination” from the other prisoners: “They call us ‘assassins’ or ‘animals,’ or they say we eat children. Several women have been beaten. Fortunately, I haven’t been.”

Two women noted that they have changed the first names they use among the other prisoners so they cannot be identified by TV news reports.

Still, things are improving—in part because Las 17 have begun to help other women facing similar struggles. Teresa, the only one of Las 17 with a 40-year sentence, notes that earlier in her prison term, she experienced much greater rejection and mistreatment than she does now. Now, she provides moral support for another woman who just entered prison on abortion-related charges, whose preliminary hearing was featured on TV news in recent days.

“I try to help her deal with the derogatory comments she started receiving once other women found out what the charges against her were,” she said.

In addition to the treatment from other inmates, Las 17—and all the women in Ilopango—must overcome the miserable conditions of their facility. All prisons in El Salvador are notoriously overcrowded, as Nelson Rauda, then-director of the National Penal System explained in a 2012 interview, in which he noted that the women’s prison was at 945 percent of capacity.

Three years prior, the Salvadoran Attorney General for the Defense of Human Rights had reported that the Women’s Prison in Ilopango population had been at 1,125 in a facility meant for 220, or about 511 percent of capacity. Notably, of those 1,125 women, only 430 had been convicted; the rest were still going through trials or appeals. In 2014, La Agrupación requested updated figures from the attorney general, but that office responded with its 2009 report.

According to the women Rewire interviewed, such overcrowding means they often wait years to have access to a bed. As Alba, who has been in prison for five years, put it, “The prison doesn’t have enough mats for those who sleep on the floor. When I first entered prison I had a mat, but they took it away, saying it was falling apart, and they were going to give me a new one. But that was years ago and I never got anything. Three of us sleep in the corner with one thin blanket.”

Newcomers sleep on the floor for years before getting a bed. Over time, a woman’s increased tenure lets her move from the crowded open floor to the space under the lower bunk, then to a lower bunk shared by two-to-four women, and eventually to a shared upper bunk.

These anecdotes confirmed the findings in the Human Rights report, which stated:

The dormitories in all the sections provide bunk beds; nevertheless, due to the overpopulation a significant number of women were found to be sleeping on mats and on the floor.  … Many … share a bed with another inmate.

And the high population numbers affect provisions too. In a 2011 letter to El Salvador’s legislative representatives, then-Human Rights ombudsman Oscar Humberto Luna emphasized, “The overcrowding of detained individuals becomes in itself an additional punishment … and brings with it … problems with … the quality and quantity of food.”

The report from the Attorney General for Human Rights further explained:

The [Human Rights] office checks regularly the food situation due to the constant complaints from the prisoners.  In this observation … it was not abundant but sufficient in proportion to the Salvadoran diet. Nevertheless, it was detected that some foods, such as the beverages, contain iodine, which was easily detected by smell.

The water from the public system … serves for consumption by the inmates and their children. They store it in plastic bottles … The inmates affirmed that the water generally comes from the tap dirty and with a bad odor.

This impression was also reinforced by the interviews from Las 17. The food “is nasty,” Alba told Rewire. “I’m thankful to God that we have food, understand that, but sometimes it’s really bad. The beans are foul and the plantains are so hard we can’t eat them.”

The women also say that shortages of water for bathing occur frequently and that the only drinking water comes from a cistern, which they say is not always clean.

Salvadoran prisons do not provide hygiene supplies such as soap, shampoo, toilet paper, and sanitary napkins, nor do they provide clothing, sheets, or towels, as the Human Rights report documented and the six women confirmed. (Prisoners do not wear uniforms.) Incarcerated women depend on family to bring them these basic personal items. In addition, family can bring in designated amounts of money so that women can make other purchases inside the prison. But for those who do not have supportive relatives who are able to make the trip to the prison to visit, life inside is much more difficult.

Theodora explained that her family, who lives several hours by bus from the prison, is very poor: “They work to eat that day, but they try to give me some money and things I need.” Her mother comes to see her once a year. That visit actually takes three days: one for travel, the second to get in the long line by 7 a.m. so that by the afternoon Theodora’s mother can get inside to have a few hours with her daughter, and the third to return home. In a country where a minimum wage income for a poor rural family can be as low as $118 a month, the $8 to $10 for bus fare and meals present a huge obstacle. Theodora’s older sister, who lives closer, does her best to meet her younger sister’s needs.

Meanwhile, Mayra, who has served 12 out of 30 years, explained that it has been a year and three months since her family visited. As with most of the women, she could provide the exact date of the last time she’d seen her loved ones. They also live in a distant part of the country, and are very poor. She depends on friends in the prison to help her with personal needs such as shampoo and clothing.

Guadalupe’s mother, for her part, tries to visit every two-to-four weeks, as her mother explained in a separate interview with Rewire on the day the legislature voted to pardon her daughter. “But first I have to go to friends and relatives and ask them to help me buy the personal items and food I need to take to Guadalupe,” she said.

Occupying one’s time inside the prison is a challenge too. The prison offers workshops and programs, and all of the women try to enroll, but it can take five-to-ten years or more to get admitted to the more desirable programs. In addition, the rules for enrolling are complicated, and some of the women believe they are discriminated against because of the nature of their convictions. The workshops are mostly pursuits such as crocheting and embroidery, cosmetology, and piñata-making.

Catholic and Protestant church groups who come to the prison also offer religious services, which many of the women Rewire met have taken advantage of. Most have also participated in the prison’s elementary and secondary education programs: Several of the women hope to join La Agrupación’s efforts as soon as they have the opportunity. Guadalupe, who entered prison with a third-grade education and has now completed high school, wants to go to college when she is released. When Polanco asked her what career she would like to study, she grinned at La Agrupación attorney Munoz. “Lawyer!” she said.

Overall, many of Las 17 continue to take solace from the efforts of the activists standing up on their behalf. As Marina put it, “Knowing that so many people are fighting for us gives me great hope.”