Editor’s Note: With this post we welcome Karim Velasco, a
lawyer based in Lima, to Rewire. Karim will join our
Global Perspectives team reporting on reproductive and sexual health
and rights issues internationally.

After more than a hundred years of legally allowing women access to a
therapeutic abortion if her life or health was in danger, in October 2006 the Nicaraguan National Assembly
banned this procedure in all circumstances under pressure from conservative
movements and the church. A year later,
despite international pressure and claims to respect the human rights of women,
the hopes and efforts of women’s rights organizations and medical associations
were shattered when a new Penal Code reaffirming the ban was approved in
September 2007 by the National Assembly.

Although
in January 2007 a
group of civil society organizations filed an appeal to the Supreme Court to
declare the amended provision unconstitutional, the appeal had to be
resubmitted since the Penal Code had been rewritten.

Besides the importance of drawing a legal strategy to challenge the ban on
constitutional grounds, it is necessary to think of the consequences and
challenges that this ban is already bringing to public health. The CEDAW
Committee, Pan-American Health Organization (PAHO), UNFPA and the Interamerican Commission of Human Rights
among others warned the Nicaraguan government of the alarming effects that the
ban on therapeutic abortion would have not only on women’s lives and health
but also on health service providers’ behavior.
And it is now clear that clandestine abortions and maternal mortality rates
have spiraled since the ban was introduced.

According
to UNICEF,
the adjusted maternal mortality ratio is estimated to be 170 deaths for every
100,000 live births, one of the highest in the region. PAHO, Human Rights Watch (HRW), and IPAS have
documented cases of women who died because they were denied or delayed
treatment for obstetric emergencies, mainly because of the fear of prosecution or
misperception of the law on the part of medical personnel. Some women have reportedly
tried to get medical treatment because of constant bleeding or proved ectopic pregnancies
but were left unattended for hours or transferred to a different health center,
which in some cases led to their deaths. Women
have no choice but to look for emergency obstetric care elsewhere, even though
in many cases they need to be treated for incomplete miscarriages that have
nothing to do with induced abortions.

The
ban on therapeutic abortion is not only affecting the access to emergency
obstetric care, it is also affecting the quality in delivering the service. For
IPAS
the ban has a double impact on the health system: i) the economic costs of
treating these preventable emergencies, caused by delays in care, consume a
major portion of the health sector’s limited budget, and ii) health
providers find themselves having to choose between appropriately treating the
patients by ignoring the law or denying them the necessary care to preserve
their health and lives.

It
is also important to highlight the fact that not only medical staff fear
prosecution. Women also fear seeking treatment because they are afraid of
being accused of having induced an abortion themselves. This vicious circle is
certainly affecting the most vulnerable women, that is, young poor women. IPAS
has even pointed out that "75 percent of the maternal deaths recorded this year
[2007] were women who lived in rural areas and more than 80 percent were
adolescents and youth." Although the
strong link between adolescent pregnancy and poverty is not new, the ban on
therapeutic abortion severely worsens the risks for these women.

Up
to now the only serious attempt carried out by the government to mitigate
consequences of the ban was the issue of "mandatory protocols for the provision
of emergency obstetric care." In December
2006 the Ministry of Health issued the Norms
and Protocols for Treatment of Obstetric Emergencies. According to Human Rights Watch these
guidelines "cover most if not all obstetric emergencies, including ectopic
pregnancies and post-abortion care. If fully implemented, it is possible that
these guidelines could overcome a good part of the negative consequences of the
blanket ban." However, HRW’s research also shows that doctors and health
officials are not willing to implement the guidelines; they usually ignore them
or delay their implementation due to fear of prosecution. It is not clear to them
whether the protocols are compatible with the ban or not, which usually leads
to leaving patients unattended or turning them away from the hospital. Unfortunately, the Ministry of Health "does
not monitor the full implementation of protocols, does not systematize complaints
received for the delay or denial of care, and so far has not studied the impact
of the law on the lives and health of women."

PAHO
and Human Rights Watch
have issued a list of recommendations to the Nicaraguan government to amend the
Penal Code and decriminalize
therapeutic abortion, guarantee women immediate access to emergency
obstetric services and postabortion care and appropriately implement the
guidelines on emergency obstetric care. HRW
additionally called on donors and United Nations agencies to expand funding for
reproductive health related programs in Nicaragua and to support campaigns
seeking to educate women about their right to access contraception.

In
an attempt to lessen the impact of the ban IPAS Central America‘s
work is not only focusing on "ensuring access to high-quality postabortion care
(PAC)", but has also included among its activities "improving the availability
and quality of abortion-care services in the context of comprehensive
reproductive health care."

Similarly,
it is imperative that additional initiatives are implemented to mitigate
the impact of the ban on women’s lives and mental and physical health,
especially by the government and national organizations.