Nicaragua: Abortion Ban Threatens Health and Lives

Nicaragua's total ban on abortion is putting women and girls' health and lives at risk, Human Rights Watch said today. The country's 2006 law punishing abortion - without any exceptions, even if pregnancies are life-threatening or resulted from rape - has driven abortions underground. The ban has not stopped abortion, but has made it more unsafe.

Women and girls with crisis pregnancies are getting unsafe clandestine abortions. Often too afraid to seek medical care when complications arise from such abortions, some women and girls delay seeking care and do not disclose to doctors the cause of complications. Medical providers, caught in a conflict between the law and medical ethics, have reported women and girls to police for suspected abortions. Under Nicaragua's criminal code, women and girls who terminate pregnancies face sentences of up to two years in prison, and medical professionals can be sentenced to up to six years for providing abortions.

"Nicaragua's ban on abortion has sown fear and uncertainty among women and girls, endangering their lives, denying them autonomy and privacy, and interfering with medical care," said Sarah Taylor, women's rights advocate at Human Rights Watch. "Guaranteeing women and girls access to safe and legal abortions would go a long way toward fulfilling their right to health and will help stop preventable maternal deaths."

In early 2017, HRW interviewed six women in Nicaragua who had had unwanted and crisis pregnancies, all of whom had sought illegal abortions. Human Rights Watch also interviewed 23 medical providers, lawyers, representatives of organizations providing support and services to women and girls, and women's rights activists. The interviews took place in urban and rural areas, and on both coasts of Nicaragua. Due to the threat of prosecution and social stigma, Human Rights Watch is not identifying individuals, organizations, or the locations of these interviews.

Nicaragua has high rates of domestic and sexual violence, which can result in unwanted pregnancies. Available data indicates that young women and adolescent girls are at particular risk of unwanted pregnancy from rape.

One woman Human Rights Watch interviewed reported that her partner raped her repeatedly, resulting in two unwanted pregnancies. She gave birth after the first unwanted pregnancy, and had a clandestine abortion after the second. Service providers and activists said this is a common problem affecting women and girls, and victims face stigma and blame. "They are called names, told they asked for it, that rape is their fault," one legal professional told Human Rights Watch.

"Sexual violence is a serious threat for women and girls in Nicaragua," said Taylor. "They should not be doubly victimized by being forced to carry to term the pregnancies that can result from rape."

Medical and psychosocial service providers described the impact the ban is having on the life and health of their patients, especially women with low incomes, and girls, who have less ability to make decisions regarding their health care. A medical provider told Human Rights Watch that wealthier women can pay for safer abortions - even if illegal - but poorer women often use riskier methods or lack funds to pay for safer procedures. She said that "poor women suffer most" from the ban. One psychologist told Human Rights Watch that patients with unwanted pregnancies, many of whom suffered sexual abuse, talk to her about their fear and anxiety about their pregnancies and the ban. Some have attempted suicide after realizing they were pregnant, she said.

Stigma is a significant barrier to women and girls requesting and receiving medical care, including post-rape and post-abortion care. Religion exerts a powerful influence on everyday life in Nicaragua, and there is intense religious opposition to abortion. Numerous activists, providers, and women and girls who had terminated their pregnancies told Human Rights Watch that stigma, including condemnation from religious leaders, was a source of fear and shame.

The Nicaraguan government has published little data on enforcement of the abortion ban, and no information on the health effects, including on maternal mortality. But information from other countries has established that restrictive abortion laws are not associated with fewer abortions; they just make abortions less safe.

The Nicaraguan government does not publish data on the estimated number of illegal abortions, nor the number of women, girls, or abortion providers who face arrest, criminal charges, convictions, or sentences. Some activists said that, without the kind of high-profile convictions for abortion seen in neighboring El Salvador, people assume that the Nicaraguan government is not applying the ban. But a 2016 report, drawing on the scant data that exists, concluded that between 2003 and 2013, some 290 people were denounced (accused in a police report or complaint) or detained pursuant to the abortion ban. The data, drawn from police records, did not cover further criminal proceedings.

Many of the women and girls interviewed by Human Rights Watch said they feared possible imprisonment for terminating crisis pregnancies. Activists and service providers told of cases in which doctors or hospital administrators turned women and girls with suspected abortion complications over to the police.

Civil society is mobilizing to support women and girls with unplanned pregnancies, and to change the law. A citizens' initiative submitted to the National Assembly in 2015 sought to decriminalize abortion when a pregnant woman or girl's health is at risk, including in the case of rape. This proposal was signed by over 6,000 people. In April 2017, the Assembly rejected the initiative without debate.

The government has also been obstructing international funding for civil society. Activists told Human Rights Watch that this is blocking valuable support for women's organizations, including those supporting women with crisis pregnancies. Lawyers and service providers said this has resulted in groups reducing or ending programs, including for rape survivors. "We know that anyone who speaks about this must be very brave and prepared for the consequences," one activist told Human Rights Watch.

"Civil society organizations are providing vital information and support to women and girls," said Taylor. "International donors need to back this vital work, and the Nicaraguan government should not block it."

Background on Nicaragua's Abortion Ban and Medical Protocol
In 2006, Nicaragua adopted a penal code that completely banned abortion, even in cases of rape, incest, life- or health-threatening pregnancies, or severe fetal impairment. A 2008 legal challenge submitted to the Supreme Court argued that the ban was unconstitutional. The Court never ruled on this case, nor on a similar one regarding the 2014 constitution.

The 2006 law removed the few options that existed for women and girls to obtain a legal abortion. For 169 years - from 1837 to 2006 - abortion was partially decriminalized in Nicaragua. During that time, a pregnant woman could in theory obtain a so-called "therapeutic" abortion, in which abortion was allowed for a restricted set of health reasons. This legislation was partially applied in the last years of the Sandinista Revolution, but after 1990, the health system ceased therapeutic abortion. In practice, there was little access to abortion even before 2006, and this narrow exception did not enable women to make independent reproductive health decisions.

The 2006 total abortion ban penalizes women and girls who procure an abortion, those who provide abortion services, and anyone who assists a woman or girl in seeking an abortion. Women face between one and two years in prison. The penalties for medical professionals range from one to six years in prison for providing abortion, with the disqualification of medical professionals for two to ten years.

The Nicaragua Ministry of Health (Ministerio de Salud, or MINSA) has a protocol to guide medical providers treating post-abortion complications. It explains what medical professionals should do when women and girls present at medical facilities with medical emergencies related to abortion, or grave pregnancy complications that require providers to treat women in order to save their lives, even if this could result in terminating the pregnancy. However, according to one medical service provider, not all MINSA personnel have been trained on this protocol.

Human Rights Watch wrote to the Nicaraguan Ministry of Foreign Relations in June 2017, requesting comment on the inconsistency between the ban and the medical protocol, and requesting information on the training of medical professionals on the ban and protocol and other information related to the ban. The government did not respond to these requests.

Women and Girls Especially Affected by the Ban
Many of the organizations and experts interviewed by Human Rights Watch spoke about the disparity in access to abortion in the context of illegality. For women and girls with more financial means, abortions are more accessible, though illegal.

Nicaragua has high rates of domestic and sexual violence, which can result in unwanted pregnancies. A government demographic and health survey published in 2014 found that approximately 22.5 percent of women and girls (ages 15-49) who were ever married or in a union reported physical or sexual violence by a current or former husband or partner, and 10 percent reported that they had suffered forced (penetrative) sex or sexual abuse without penetration, by anyone, in their lifetimes. Of women who reported experiencing forced sex, 23 percent said the first occurrence was before age 15, and of those reporting non-penetrative sexual abuse, 41 percent said the first occurrence was before age 15.

The abortion ban also harms girls subjected to child marriage, which is common in Nicaragua, or forced partnerships. Under the law girls are permitted to marry at age 17 with parental approval, but many marry younger. UNICEF, drawing on government data, reports that 10 percent of children are married by age 15, and 41 percent are married by age 18. Sex with children under the age of 14 is considered rape, and sex with children between the ages of 14 and 18 is considered "estupro," a form of statutory rape. Child marriage is associated with health dangers associated with early pregnancy, lower educational achievement for girls who marry earlier, a higher incidence of domestic violence, and an increased likelihood of poverty.

Human Rights Watch spoke with medical service providers and lawyers who said they worked with girls subjected to child marriage and statutory rape, some of whom have gotten pregnant. Several said they knew of girls as young as 12 who had gotten pregnant by and were then forced to marry or cohabit with their rapists. Some sought illegal abortions, and faced complications. One medical provider told Human Rights Watch that she was currently treating five 13-year-old girls for post-abortion complications, one of whom was impregnated by a pastor. A lawyer said that between the abortion ban and other pressures, it is practically "an order of the state to force these girls to become mothers."

The International Pregnancy Advisory Services (IPAS) and the International Planned Parenthood Federation (IPPF) have conducted research on the impact of the abortion ban on girls. The report emphasized that the ban has a negative effect on the mental and physical health of girls who are not able to get an abortion when they wish to.

Cases of Women and Girls Who Sought to Terminate Crisis Pregnancies
Human Rights Watch interviewed five women and girls who sought to terminate a pregnancy after the abortion ban was enacted, and documented several additional cases described by lawyers, activists, and others with first-hand knowledge of the cases. The cases below illustrate the secrecy, fear, and stigma surrounding abortion. Due to the risks to women, girls, and providers, the cases do not describe steps they took to procure clandestine abortions, but rather the circumstances and impact of the crisis pregnancies. The names are pseudonyms.

"Ana" said her partner had raped her repeatedly over the past six years, and continued to subject her to daily verbal abuse. The rapes resulted in two pregnancies. The first time Ana became pregnant from rape, she said she wanted to get an abortion, but "he said he would kill me." After a difficult pregnancy and labor, she gave birth to her daughter, now 5 years old. Ana found out her partner was cheating on her in 2016, and told him to leave the house. He would not leave, and continued raping her. They separated in November 2016, at which point she stopped getting her birth control shot. But he returned and raped her again in January 2017, and she became pregnant again. "I decided to end the pregnancy because of my health… If I had another pregnancy, it would be dangerous," she told Human Rights Watch, describing how her physician told her another pregnancy would put her life at risk. She has not told her friends or family about getting a clandestine abortion, as she believed they would condemn her. She said they criticized her when she tried to break up with her abusive partner. She told Human Rights Watch, "people look at you sideways, but they don't know. They don't put themselves in your shoes."

In September 2016, "Patricia" became pregnant with her partner of four years. Then she found out he had impregnated another woman, and she became very depressed and broke up with him. She already had a child, and felt that she could not care for another as a single mother. She told Human Rights Watch, "I felt forced to withstand the situation." Then she thought, "I cannot have this child." She managed to terminate the pregnancy. She said she "worried about law. But [I] had to do it to avoid bigger problems. Yes, I was scared."

Around 2007, "Soraya" realized she was pregnant, and knew she did not want to continue the pregnancy. She told her sisters, and they took her to have a clandestine abortion. She had to travel far from home to obtain the procedure. Although she works on women's rights, she has told very few people about her own abortion. She told Human Rights Watch, "We know there are women who have been detained."

In 2014, "Cristina" had an unwanted pregnancy, and knew she "wanted it to be over." She had to travel a long distance for the procedure, enduring considerable pain and incurring significant cost. She said that ever since then, she had severe pain every time she had her period but did not tell her doctor, "because then I'd have to tell them about the procedure." She spoke to her mother about the abortion but did not tell any other family members, believing they would judge her.

"Daniela" had an unplanned pregnancy in 2015, which resulted in a clandestine abortion. She already had two children, and had no plans for more. She regularly experienced pain during her period, but did not want to tell her doctor. She told Human Rights Watch that she does not regret having the procedure, although the only two people she has told about it have criticized her.

Human Rights Watch also interviewed medical service providers and legal professionals who described cases they knew of first hand, including the following:

"Ida," a 19-year-old woman with an intellectual disability, was raped by an acquaintance. Though she did not tell anyone, her mother realized Ida was pregnant. Ida's mother went to a women's rights organization and asked about an abortion, but was told it could not be done. Ida, attempting to terminate the pregnancy, threw herself down a staircase, but she remained pregnant. She gave birth, and completely rejects the child. Ida's mother is concerned her daughter might harm the baby she did not want. The rapist is now serving 15 years in prison.

Thirteen-year-old "Luisa" was raped repeatedly by her uncle. He threatened the girl and said he would kill her mother if she told anyone. Finally, the girl told her mother, "Mama, my uncle is raping me. It's been two months since my period." The girl was pregnant, and managed to get an abortion. The uncle was arrested for the rape.

Denunciation and Detention for Abortion
Prosecutions stemming from the ban seem to be rare in Nicaragua. Unlike in El Salvador, there appears to be a reluctance to pursue criminal charges. However, it is impossible to confirm how many prosecutions and convictions for abortion there are since the government has not disclosed information about this. What is clear, from news articles and a 2016 report on denunciations and detention for abortion, is that family members or medical providers have denounced many women and girls who they suspect had induced abortions.

In 2016, a specialist in gynecology and obstetrics research published a report on "persons who have been denounced or detained" for having abortions, and for providing abortions, including during the period when there was limited legal access to therapeutic abortions. The report, which analyzed police reports filed between 2003 and 2013, found that 290 people were denounced or detained under the conditions of the 2006 abortion ban: 186 women and 104 men. Those who assisted the women and girls also bore the brunt, with 43 percent of those detained being a family member of those seeking the abortion.

International Law
International human rights treaties require governments to respect women's reproductive rights. Authoritative interpretations of these treaties by United Nations experts and bodies call for the removal of criminal penalties for abortion.

Nicaragua's total ban on abortion violates or poses a threat to a wide range of human rights recognized under international law, including women's rights to life, health, nondiscrimination and equality, privacy, to decide the number and spacing of children, and to be free from torture and from cruel, inhuman, or degrading punishment or treatment.

UN human rights bodies and experts consistently call on states to legalize or remove criminal penalties for abortion. For example, the UN Committee on the Rights of the Child frequently recommends that governments decriminalize abortions in all circumstances. The UN Committee on the Elimination of Discrimination against Women (CEDAW Committee) has repeatedly called on states to remove punitive provisions for abortion. In a 2014 statement, the CEDAW Committee said:

Unsafe abortion is a leading cause of maternal mortality and morbidity. As such, States parties should legalize abortion at least in cases of rape, incest, threats to the life and/or health of the mother, or severe foetal impairment, as well as provide women with access to quality post-abortion care, especially in cases of complications resulting from unsafe abortions. States parties should also remove punitive measures for women who undergo abortion.

Other UN treaty bodies and experts, along with experts from regional human rights bodies, have made similar recommendations.

UN treaty bodies have specifically criticized Nicaragua's total abortion ban and called for reforms. For example, the Committee on the Rights of the Child has specifically urged Nicaragua to "Repeal the articles of the Penal Code that criminalize abortion and ensure that girls are not subject to criminal sanctions for seeking or obtaining an abortion under any circumstances." In the CEDAW Committee's 2007 review of the country, the committee stated its concern regarding the criminalization of therapeutic abortion, specifically because of the health and safety risks to women and girls, and the potential sanctions on them and on providers. The committee recommended that the State party move toward "removing punitive provisions imposed on women who have abortions and provide them with access to quality services for the management of complications arising from unsafe abortions."

In 2010, the case of a pregnant woman with metastatic cancer was brought before the Inter-American Commission on Human Rights, seeking precautionary measures that would enable her to obtain an abortion. Her doctors had refused to treat her cancer because of potential risk to the fetus, and refused to provide an abortion. The woman was given chemotherapy, and had a stillbirth at 8 months. She died shortly thereafter.