In El Salvador, 17 women imprisoned after experiencing miscarriages or stillbirths began a campaign against reproductive injustice. “The 17” were sentenced for up to 40 years in prison for miscarriages or complications during delivery, after being convicted of attempted or aggravated homicide. This was the outcome of a total ban on abortion: young, often unmarried, women of lower socioeconomic status are suspected of inducing illegal abortion when experiencing emergent obstetric complications. Stigma and misogyny play into the result, in which a woman’s health during pregnancy is viewed with distrust. Two of the women, Salvadora and Guadalupe, were interrogated while they were receiving emergency medical care in the hospital. Tragically, medical providers are complicit in this violation of women’s reproductive rights.
There is a total ban on abortion in El Salvador and several other countries around the world, meaning that abortion is criminalized without exception: even in cases of rape, endangerment of a woman’s health, inviability of the fetus and even ectopic pregnancy — at least until there are signs of hemorrhage. Aside from being a basic violation of women’s reproductive rights, this legislation severely impacts women’s health and well-being. According to the World Health Organization, 11 percent of women who have illegal abortions in El Salvador die as a result of the procedure, although the actual figure is expected to be higher. Latin America and the Caribbean has the highest rate of unsafe abortion of any region in the world, resulting in a significant percentage of overall maternal mortality. High rates of adolescent pregnancy, poor access to contraceptive methods, and the illegality of abortion together lead to a situation in which pregnancy is a leading cause of teenage suicide.
Due to the highly restrictive anti-abortion legislation in El Salvador, women who present to health care facilities with obstetric complications may be suspected of inducing an abortion by medical staff. While this may seem to be an extreme scenario, it is the result of policies restricting reproductive options. In these situations, health care providers have reported such cases to the police, in a clear violation of the patient’s right to privacy. Pregnant women are thus deterred from seeking emergency medical care. The participation of health care providers in the criminalization of abortion and miscarriage by reporting their patients to legal authorities is a violation of our professional ethics.
The social impact of abortion and miscarriage-related convictions is significant due to the ostracization that occurs within families and communities. Poor women are disproportionately affected by anti-abortion legislation, as wealthier women have greater access to contraceptive methods and can receive an abortion outside the country or in a private, safer clinic. The cases of The 17 tragically highlight the culture of fear and criminalization that arises when abortion is restricted without exception. In the United States, too, a person’s right to bodily autonomy is restricted as anti-abortion legislation increasingly makes it harder to access safe, legal abortion. As many as 240,000 women have attempted to induce abortions without medical assistance in Texas.
As physicians-in-training, it is our obligation to advocate for our patients’ health, including through calling attention to human rights violations that impact health outcomes. We cannot claim that legal issues are outside our sphere as medical providers; in fact, policy decisions may impact our patients’ health more than any direct services we provide. Advocating for human rights and speaking out with our unique understanding of how political decisions can impact health is not only an option, but our duty.
Medical school doesn’t teach us to do advocacy in our state medical societies, on a national level, or within international bodies. Yet through such mechanisms, we may promote community health on a greater level than we ever could as just providers. A Salvadoran tribunal overturned one woman’s sentence in May of 2016, and currently 14 women remain serving 30 to 40 year sentences. Advocacy efforts have taken place among local and international organizations, governmental bodies, and the Inter-American Commission of Human Rights. Anti-abortion legislation has significant negative health impacts, whether in the United States where abortion access is increasingly restricted or in El Salvador where there is a complete ban. In these countries, and elsewhere, physicians’ voices are needed to ensure that our profession stands for justice.
Author’s note: For more information about reproductive rights in El Salvador, see the Center for Reproductive Rights report “Marginalized, Persecuted, and Imprisoned: The Effects of El Salvador’s Total Criminalization of Abortion”