Two-thirds of the world’s women live in countries where abortion can be obtained for a variety of social, economic or personal reasons. In other nations it is allowed only in cases of rape, foetal abnormality or when a woman’s life is at risk.
But El Salvador bans abortion in all circumstances and criminalises women suspected of procuring one, along with those believed to have been complicit in the process. In some cases, suspects have been charged with murder.
People & Power sent filmmakers Sarah Spiller and Camilla French to find out why.
By Sarah Spiller
The director of the hospital had come to a halt in the corridor. In his hand was a sheaf of papers detailing how women had died here. Among the causes of maternal death were pre-eclampsia, sepsis, and then, rat poison - used to end unwanted pregnancies in a country where abortion is forbidden.
In an ante-room away from the wards, we had been told that any mention of this country’s abortion law was strictly off limits. Instead, Dr Roberto Ochoa, the director of the Maternity Hospital in El Salvador’s capital, discussed the challenges facing a country where 30 percent of pregnancies are to women and girls under the age of 19. Last year, seven nine-year-olds became pregnant.
But standing near the hospital’s mother and baby unit, where a queue of young women waited to see their newborn children, it was clear the director was discomforted. He had more to say. He began telling us about a 10-year-old patient who had given birth. She was the victim of rape.
"Our law doesn’t allow abortion in rape cases. It doesn’t allow any type of abortion," he told us.
Asked what he thought about this, he explained: "I can't give my opinion, I'm restricted by the law."
Only when probed further about his personal views on the matter did he say: "The law should be reviewed."
Introduced in 1998, El Salvador’s abortion law criminalises terminations in all cases, including rape, foetal abnormality, and even when a woman’s life is at risk. In this devoutly Catholic country the impact of this ban rarely registered as a national issue, until one case ignited debate.
From the agonising death of Savita Halappanavar in Ireland, to recent soul searching over an 11-year-old rape victim in Chile, rightly or wrongly, it is human stories that can so often frame the argument on this most visceral of issues. El Salvador’s story was about Beatriz.
Beatriz, a pseudonym, was a 22-year-old who made an emotional appeal to her country’s president, asking him to let her have a termination. She was suffering from an auto-immune condition and doctors said her 18-week pregnancy posed a risk to her health. In addition to this, scans revealed that her baby had anencephaly, a condition where part of its brain was missing, and would not survive birth.
For pro-choice activists the case was emblematic, demonstrating the effects of criminalising all forms of termination; for pro-life groups and the Catholic Church it represented a challenge to a constitution that protects life from the moment of conception.
For the doctors caring for the young mother, who along with the Ministry of Health appealed to judges to let a termination go ahead, it was about a patient and prison. If they performed a termination both doctors and mother could end up in jail.
At the offices of the Association of Gynaecologists and Obstetricians in San Salvador, Dr Miran de Navarrete clasped her wrists together to make her point. This was not just about Beatriz. El Salvador’s law also left doctors hands tied in cases of serious medical emergency.
Her colleague, Dr Miguel Guidos, gave an example; the case of an ectopic pregnancy, where a foetus can develop inside a woman’s fallopian tube. Under the country’s law, he said, he must wait to intervene: "As long as there is a sign of life, the doctor can’t do anything until it puts the mother’s life at risk. She can die before I can do surgery to save her life."
"Because if you do the surgery before," de Navarrete explained, "the law says you will be in jail for two to 12 years. You come out of the operating theatre [and go] straight to prison."
An official at El Salvador’s Ministry of Health denied that any women had died as a result of doctors failing to intervene over ectopic pregnancies. But she did acknowledge that other lives could have been saved if doctors were allowed to perform therapeutic abortions.
Prior to the 1998 law, doctors monitored patients at risk of maternal death and then decided whether they should be offered a termination, but, the official explained: "Now the ministry is banned from following this process. We are one of the few countries where because of religious fundamentalism, any kind of abortion is penalised."
El Salvador is one of three Latin American states, along with Nicaragua and Chile, where terminations are outlawed in all cases and the Catholic Church played a key role in pushing for the abortion ban.
As the case of Beatriz reached the front pages of El Salvador’s papers, San Salvador’s Archbishop Jose Luis Escobar Alas made his position clear at his weekly Sunday press conference. Any move to reform the law would open the door to "the scalpel killing babies".
Over at the country’s leading evangelical church, Pastor Dr Edgar Lopez suggested medical opinion that the young mother’s life was in danger was merely "a very good excuse". He insisted that the high risk pregnancy should go ahead: "If that baby’s born and he or she dies for some reason, then that was God’s will."
Such vehement opposition to abortion in all its forms is hardly new on this pro-life continent. But, for pro-choice activists, what marks El Salvador out is the way the state polices the abortion ban and the sentences women can receive.
Under the country’s penal code, women can face up to eight years in jail if they induce a termination. But human rights lawyers point to cases where women have been charged not with procuring an abortion, but with aggravated homicide, which carries a sentence of 30 years or more.
Most disturbing of all are allegations that some of these women - incarcerated for what are effectively life sentences - have in fact suffered late miscarriages.
The lush countryside to the east of El Salvador is one of the state’s poorest areas, and for those living in isolated rural villages, access to healthcare can be limited.
In 2008, a 32-year-old woman who lived with her parents and two sons in one such village went into labour, struggling to reach an outside toilet in which she gave birth. When she was admitted to hospital, the doctors reported her to the authorities. The next day the police arrived to find her dead baby. They asked her illiterate father to put a fingerprint on a witness statement implicating his daughter, who was subsequently convicted of murder and sentenced to 30 years imprisonment.
Sitting with children’s toys scattered around him, her father explained how his daughter had been diagnosed with Hodgkin’s Lymphoma a few months into her prison sentence. Her cancer was not detected during her pregnancy, nor in hospital or during her trial.
When he visited her in jail she had lost her hair.
"We said we would go back," he said. "When they called us, they told us she was already dead."
His daughter left two sons that her family now struggles to provide for.
"Life is pretty bad here because we don’t have means. We don’t have any other kids, just them. And we love them."
The case, which is also anonymous because of the cultural stigma surrounding abortion in El Salvador, galvanised pro-choice campaigners. ACDATEE, a Salvadorean Women’s group, funded an independent forensic report to examine the state’s evidence. The expert found that a lymphoma present on the woman’s neck, along with pre-eclampsia, could have contributed to the death of her child.
"Poor girls don’t have an option other than the public health system," says human rights lawyer Denis Munoz. "Basically they’re told to save their life and the life of their newborn child, regardless of whether the conditions of birth outside the hospital are safe or not."
In addition to this, says Munoz, there are serious concerns about forensic evidence used by the state to prosecute such cases.
Cristina Quintanilla had her 30-year sentence commuted to three years but maintains she also had a miscarriage. An autopsy stated that the cause of her baby’s death was ‘undetermined’. Nevertheless, she says that in court, state prosecutors still asked her why she had not done more to keep her son alive.
Marlene Ponce had just turned 18 when she says she went into labour at between three and four months gestation. She too was accused of murder. The forensic evidence in her case included animal remains.
"What they did was to show the bones of an animal and to say they were from the baby I’d had. A lot of things are taken for granted. They are not being investigated. Nobody asks, why, what happened?"
Ponce spent over six months in custody before she was released. The experience left the young student deeply traumatised. "There are situations that remind me a lot of it," she says tearfully. "All I do is cry."
Karina Climaco, another mother imprisoned in the state’s crowded jail on the outskirts of the country’s capital, described the abuse from inmates once they discovered the nature of her ‘crime’.
"They said I was going to rot in jail. When I got out I would be strangled just as I did with the baby. They called me pig, piece of filth."
An independent forensic report commissioned by ACDATEE challenged state evidence that Climaco had strangled her newborn child. She was released seven years into a 30-year sentence.
"Here in El Salvador we live under such injustice towards women regarding the abortion issue," says Climaco. "Here it’s just a matter of punishment, of jail."
Battery acid and crochet needles
ACDATEE estimates that following the abortion ban, in a period from 2000 to 2011, up to 130 women may have faced the courts. But in a country where abortion is criminalised, there are naturally no statistics on how many women actively seek illegal terminations to end their pregnancies. Neither are there any figures on how many women may have died as a result.
According to Rosa Gutierrez from Catholics for Choice, an NGO that campaigns for women to have access to legal terminations, the methods women have used to induce illegal abortions include battery acid, crochet needles and anti–parasitic drugs. They have also used the sticks of an umbrella.
"They’ll insert them putting cotton on the ends. The cotton gets stuck inside the uterus. The cotton decomposes and that causes a pelvic inflammatory disease. They end up dying," she explains.
One woman who supplies a stomach drug that can induce an abortion up until 12 weeks gestation described the kinds of women who approach her. "In the majority of cases we’ve seen, the women are young and ill-informed, or sexually abused. We had a case of a 14-year-old who was raped by her grandfather."
If discovered, this woman and others in her underground network face a prison sentence of up to eight years.
"In terms of the law, we are putting ourselves at risk," she says, adding "really, there is no-one else who will do it."
Back at San Salvador’s Maternity Hospital Beatriz was finally allowed a caesarean section in her 27th week of pregnancy. After weeks of deliberation, judges at the country’s Supreme Court had ruled against a termination. The decision led to international protest, the intervention of the Inter-American Court of Human Rights, and demonstrations outside El Salvador’s embassies abroad.
El Salvador’s Ministry of Health described the surgery as an ‘induced birth’, allowing both sides to claim a victory of sorts. For pro-life campaigners a law protecting the unborn had been upheld; for pro-choice activists a woman had finally been given the operation she needed.
For a time too, Beatriz’s story had led to a debate about the impact of this country’s law. Doctors are now investigating the effects of the pregnancy on her health. Her baby lived for five hours.
Special thanks to Maria Cilleros, filmmaker, for allowing use of archive footage from documentary 'El Salvador: From the moment of conception' Holon Films 2010.
People & Power can be seen each week at the following times GMT: Wednesday: 2230; Thursday: 0930; Friday: 0330; Saturday: 1630; Sunday: 2230; Monday: 0930.
Click here for more People & Power