Amelia, a 27 year-old Nicaraguan woman, was diagnosed with cancer and like any other patient she should have been offered medical treatment. But, instead the young woman was denied what should have been a most basic right. Amelia was pregnant and Nicaraguan law makes it illegal for doctors to provide her with cancer treatment.
In 2008, a controversial law came into effect after amendments to the Penal Code began in 2006. The new law prohibits all abortions, even when a woman requires a therapeutic abortion to save her life or when a woman has become pregnant as a result of rape. It also makes it illegal to provide life-saving treatment to a pregnant woman if there is any risk of harm to the fetus. Doctors and other medical staff who fail to follow the law risk prosecution. Any pregnant woman or girl who suffers from cancer, malaria, HIV/AIDS or cardiac emergencies can no longer expect to be treated by her doctors because in the eyes of the law the life of her unborn child comes before hers.
Prior to the ban, therapeutic abortion had been legal in Nicaragua for more than 100 years and many international bodies, such as the Pan-American Health Organization (PAHO) and the World Health Organization (WHO), expressed concern that the new law would be detrimental to the health of pregnant women and girls. National and international women’s and human rights groups have since been campaigning for the government to repeal what has been described as a “draconian” law.
But according to a Ministry of Health (MINSA) report released in July, Nicaragua it is in fact “winning the battle against maternal deaths”. Government statistics state that the number of maternal deaths in Nicaragua has dropped significantly since 2005 with 50.6 maternal deaths per 100, 000 live births in 2012 compared to 84.47 per 100,000 in 2005. And those in support of Nicaragua’s new abortion law suggest that these new figures show that the law has had no negative impact upon maternal health.
Back in 2010, the Nicaraguan government also released statistics which appeared to show a dramatic decrease in maternal deaths, 70 deaths per 100,000 compared to a 140 death per 100,000 live births in 2006. But the data was called into question by several Nicaraguan non-governmental organisations.
Francis Bustos, an independent clinical pathology researcher, told the Inter Press Service (IPS) that the figure quoted by the government “seems hard to believe”. Juanita Jimenez from the Autonomous Women’s Movement (MAM) also said: “There has been strong international pressure to reinstate therapeutic abortion, and one way or another the government is seeking to improve its image (with this new data).”
Another women’s rights activist, Fátima Millón, from the Central American organisation Network of Women against Violence (RMCV), also had her doubts, telling IPS: “The government generally tells lies, hides and manipulates figures when it doesn’t want them to become public knowledge, so I doubt that it’s true.”
But maternal mortality statistics can be unreliable and maternal death is often under-reported. Nicaragua’s country report to United Nations Economic and Social Council in 2008 admitted that although it was making progress in recording maternal mortality, MINSA recognized that “maternal deaths are under-recorded“ and that “In some cases, this is because deaths occur at home and are not reported”. The latest statistics from the World Health Organization (WHO) are from 2005 and it puts the maternal death rate at 170 per 100,000 live births. An estimated figure for 2010 from the Mortality Inter-Agency Group, which is made up of data from the WHO, The World Bank, The United Nations Population Fund (UNFPA), UNICEF, and the UN Population Division Maternal, puts the maternal death rate at 95 per 100,000.
The ‘real’ maternal death figures are not known. Although government rates are substantially lower than the most recent estimates provided by the WHO.
Amnesty International’s 2010 report on the abortion law maintains that poor quality data means maternal mortality trends are difficult to measure in Nicaragua and, “this is compounded in a situation where abortion is criminalized and stigmatized, making it impossible to account for deaths resulting from unsafe abortion”. The criminalisation of abortion in Nicaragua encourages women to seek clandestine alternatives, thus avoiding the public healthcare system altogether. Furthermore, doctors and other healthcare professionals, fearing prosecution, are less inclined to keep accurate data related to abortion and the treatment of other obstetric complications.
Many women and girls, some of whom were raped, now face prosecution. Victims become criminals. Adolescent girls are particularly vulnerable with more than half of all rape cases in Nicaragua involving victims under the age of 18, and according to national police records, from 2008 2010, 79 women were charged with having an illegal abortion. 32.87 per cent of these women were under 18.
Indeed, the relationship between unsafe abortions and maternal mortality is well established. According to the WHO, 13 per cent of pregnancy-related deaths worldwide are attributed to complications due to unsafe abortions and the Central America Women’s Network’s (CAWN) report on maternal health, published in September 2012, states that this is the leading cause of maternal deaths in the country.
With one of highest rates of teenage pregnancy in the world, the abortion ban is especially disastrous for adolescent girls. According to data from the United Nations Population Fund (UNFPA), between 2000 and 2012 22% of maternal deaths were teenagers. The likelihood of developing complications that require therapeutic abortions is increased in adolescent girls. One complication includes cephalo-pelvic disproportion, which is often seen in girls who have not reached physical maturity and is when the pelvis is not wide enough to allow the fetus through. Data from MINSA also indicates that pre-eclampsia and the ingestion of poison, to induce miscarriage or commit suicide, were the leading causes of adolescent maternal mortality between 2007 and 2008.
Girls, some as young as nine, are being compelled to become mothers. Or they risk a dangerous and illegal abortion, which could either kill or criminalize them.
Both poor girls and women are disproportionately affected by the law and as Nicaraguan women’s rights activist and member of Latin American and Caribbean Women’s Health Network Ana Maria Pizarro has said that “the anti-abortion policy was particularly cruel given the poverty of the majority of women, the lack of information about sex and reproduction, and the fact that Nicaragua has one of the highest levels of adolescent pregnancy in Latin America.”
The government claims that the introduction of rural healthcare clinics for pregnant women, ‘Casa Maternas,’ is helping to reduce maternal deaths and provide better healthcare in deprived rural areas.
But Kenia Morales, a PhD student from Columbia University who is researching reproduction rights in Nicaragua, told CAWN that the “Casas Maternas are but a band aid to a gashing wound”. Morles says that they the clinics, which receive funding from US based pro-life groups, “seek to reduce infant mortality and maternal death, but by doing so also reinforces these notions that parenting responsibility falls on women, and that victims of rape and incest should accept their god-given gift”.
Nicaragua is a devoutly Catholic county which places great importance on the fertility and the motherhood. “Abortar es Matar,”(abortion is murder) is a common expression in Nicaragua, women on street talked in hush tones about the death of ‘gods child,’ and murals depicting Jesus with a bleeding heart all reinforce Nicaragua’s pro-life message. But desperate women will always find a way to obtain an abortion even if it puts their live at risk.
“Whether abortions are legal or not, women will (have always) find a way to control their natality and make decisions about the number of children they bear, the difference, and scary aspect, is how safely it will be done,” said Morales.
The abortion law is adversely affecting the health of pregnant women and girls. Despite taking steps towards reducing maternal deaths and improving family planning services, the abortion law contradicts a body of medical evidence that clearly demonstrates a relationship between maternal deaths and unsafe abortions.
The government claims that it is successfully combating the country’s high maternal death rate. But in a country where there is poverty, lack of accessible health services and a ban on abortion under any circumstance, death during childbirth remains a stark reality for many vulnerable women and girls.