However, the particular situation in countries like Nicaragua and El Salvador ought to concern those who consider themselves to be pro-life.
In April 2006, the New York Times published a long and heart-wrenching article on the abortion situation in El Salvador in April, 2006. Interestingly, Archbishop Oscar Romero is mentioned; they say that while he was opposed to abortion, as expected, he acted as if he were more concerned with poverty and government oppression. In his time, the country allowed exception to save the life of the mother. That exception has now, astonishingly, been overturned, and stricter criminal penalties and surveillance have been introduced.
The result is now a culture of fear. Women coming in with uterine lacerations indicating an unsafe abortion are required to be reported to the police. Several women have been charged with homicide. And doctors are now required to put the fetus' lives above women's lives in the hospital, which is of particular concern when women present with ectopic pregnancies.
The reported attitude seems to be that now, technology is advanced enough that abortions aren't necessary. From this AP article:
"When two lives are in danger, you must try to save both the woman and the child. It's difficult to say now that it isn't possible to save both."
Henry Romero, a priest who led El Salvador's anti-abortion campaign
More damningly, from the NY Times article:
Julia Regina de Cardenal runs the Yes to Life Foundation in San Salvador, which provides prenatal care and job training to poor pregnant women. She was a key advocate for the passage of the ban. She argued that the existing law's exception for the life of the mother was outdated. As she explained to me, "There does not exist any case in which the life of the mother would be in danger, because technology has advanced so far."
These attitudes are incredible. Ectopic pregnancies occur in about 1% of all pregnancies, when the fertilized egg implants in the fallopian tube, not the uterine wall. There is a recorded case where a pregnancy implanted in the abdomen, outside the uterus, and was successfully delivered; perhaps this is what fuels the attitudes above. There is no technology that can save an ectopic pregnancy in a fallopian tube. About half of such pregnancies spontaneously resolve, with the embryo dying and being reabsorbed; previous ectopic pregnancy is a risk factor for future ectopic pregnancy.
If the pregnancy doesn't spontaneously terminate, the tube may rupture, and this poses a grave risk to the health of the woman. In US Catholic hospitals, ectopic pregnancies may be treated by removing the affected section of the fallopian tube. Direct abortion is never allowed in Catholic medical ethics. However, an action intended to save the life of the mother that nonetheless causes a pregnancy to end is acceptable, if not exactly something to be happy about. I have read one Catholic ethics opinion that states that using methotrexate, a cancer drug, is also acceptable, but I have read several that suggests it is not. The positive opinion argued that methotrexate did not attack the embryo directly, it attacked the tissues that connected it to the fallopian tube. In any case, treatment with methotrexate will kill the fetus and cause its spontaneous reabsorption.
The two articles describe a culture of fear in Latin America among doctors. They fear that typical treatments for ectopic pregnancies might be considered abortion, which has severe criminal penalties. It seems they are waiting for either the fetal heartbeat to cease or for the tube to rupture; the latter is a medical emergency. Eliette Valladares, a doctor and researcher with the Pan American Health Organization, contends that at least 3 Salvadoran women have died because of the ban and 12 are under investigation. Hemorrhaging is not an uncommon cause of death, and with less advanced medical equipment, it can be difficult to tell.
According to Sara Valdés, the director of the Hospital de Maternidad, women coming to her hospital with ectopic pregnancies cannot be operated on until fetal death or a rupture of the fallopian tube. "That is our policy," Valdés told me. She was plainly in torment about the subject. "That is the law," she said. "The D.A.'s office told us that this was the law." Valdés estimated that her hospital treated more than a hundred ectopic pregnancies each year. She described the hospital's practice. "Once we determine that they have an ectopic pregnancy, we make sure they stay in the hospital," she said. The women are sent to the dispensary, where they receive a daily ultrasound to check the fetus. "If it's dead, we can operate," she said. "Before that, we can't." If there is a persistent fetal heartbeat, then they have to wait for the fallopian tube to rupture. If they are able to persuade the patient to stay, though, doctors can operate the minute any signs of early rupturing are detected. Even a few drops of blood seeping from a fallopian tube will "irritate the abdominal wall and cause pain," Valdés explained. By operating at the earliest signs of a potential rupture, she said, her doctors are able to minimize the risk to the woman.
One doctor, who asked to remain anonymous because of the risk of prosecution, explained that there are creative solutions to the problem of ectopic pregnancies: "Sometimes when an ectopic pregnancy comes in, the attendant will say, 'Send this patient to the best ultrasound doctor.' And I'll say, 'No, send her to the least-experienced ultrasound doctor.' He'll say, 'I can't find a heartbeat here.' Then we can operate."
This doctor also told me that there are ways to avoid reporting an abortion. "I can only say what I saw when I examined the patient," the doctor said. "If I can see lacerations or cuts, I cannot say what that means if the patient says, 'I have done nothing.' I can describe what I saw, but I cannot say she has or has not had an abortion."
The doctor pondered a hypothetical situation: "If the patient says, 'Yes, I did it, but please keep that between us'?" There was a pause. "I keep that promise. The confidentiality right is more important than the legal duty to report."
Ectopic pregnancies aside, complete abortion bans drive poor women underground. Rich women can fly elsewhere, as they have always done. Many women seek clandestine, unsafe abortions performed by non-medical personnel, and many die.
In prosecutors' offices in El Salvador, as in prosecutors' offices anywhere, longer sentences are considered better sentences. "The more years one can send someone away for," I was told by Margarita Sanabria, a magistrate who has handled several abortion cases, "the better it is for the prosecutors." She cited this motivation to account for what she has observed recently: more later-term abortions being reclassified as "aggravated homicide." If an aborted fetus is found to have been viable, the higher charge can be filed. The penalty for abortion can be as low as two years in prison. Aggravated homicide has a minimum sentence of 30 years and a maximum of 50 years.
The issue of proving viability after an abortion is a tricky one, of course. There is no legal standard. But many of the people I talked to in El Salvador, including Tópez, the prosecutor, said there was a rule of thumb: if an aborted fetus weighs more than 500 grams, or a little more than a pound, then you can argue that the fetus was viable. When I mentioned this to Judge Sanabria, she said she wished she had known more about the rule before. She recalled one case, that of a 20-year-old mother named Carmen Climaco, whose abortion of a fetus estimated at 18 weeks had been recast by the prosecutor as aggravated homicide. The judge admitted that if she had known this rule of thumb, she might not have sent the case to trial. "I feel bad about it," she said.
But the case did go to trial, and the prosecutor won a conviction for aggravated homicide. At trial, the evidence included lifting Climaco's fingerprints from the fetus, which was found under her bed. The prosecutor's accusation was infanticide by strangling.
The women's prison where convicted murderers are sent is in the outer district of Tonacatepeque. I visited it in January. It's an old, creaky facility that inspires the kind of dread that comes of seeing concertina wire and much-painted cinder blocks, made all the creepier by a paint choice of baby-boy blue. Inside the first gate is a neutral area. It's filled with almond trees that provide a flickering shade on a hot winter afternoon. All the women are kept in a deeper jail, walled off inside. Through a small window, I could see an open area crisscrossed by laundry lines and arrayed by different women lying around smoking.
I was there to see Carmen Climaco. She is now 26 years old, four years into her 30-year sentence. She has three children, who today are 11, 8 and 6 years old. We talked about them for a while. Since she was the only person in the family who worked, her children's financial situation is precarious; they now stay with their grandmother. Climaco said she lives for their visits, which are brief and come only twice a month. She was dressed in red jeans and a white polo shirt. We sat with an interpreter in the half-shade in green plastic yard chairs. Climaco had a paper napkin with her that she folded and folded into a familiar-looking pill. She had light brown hair, and occasionally a smile steadied her trembling lips.
"I became pregnant at a time when my smallest child was in the hospital," she said. "I never thought I could get pregnant because I had been sterilized. Suddenly I saw two doors shutting at the same time. There was nothing I could do. My mother said she'd toss me out of the house if I got pregnant."
Her story came out in fits and starts. She said that she was innocent and had never done anything illegal. Then she said, "I keep asking God to pardon me for what I've done." She said that the day it happened, she felt dizzy and collapsed at home. She woke up covered in blood. "I stood up and it felt like something fell out of me." It took her a while to understand just what had happened. "I put my hand on its throat to see if it was moving," she said, "which is why my fingerprints were found on its neck."
I spent the better part of an hour watching Carmen Climaco's face, listening to her whimpering pleas to Jesus Christ for forgiveness and tiny prayers to me to believe in her innocence. Like anyone serving time in prison, she has inhabited the details of her story to the point that they no longer sound true or false. She has compressed her story into a dense, simple tale of innocence — she just woke up covered in blood — to hold up against the public accusation of baby-strangling. I kept looking at her face, incapable of seeing the innocent girl she described or the murderer the prosecutor sent to prison. The truth was certainly — well, not in the "middle" so much as somewhere else entirely. Somewhere like this: She'd had a clandestine abortion at 18 weeks, not all that different from D.C.'s, something defined as absolutely legal in the United States. It's just that she'd had an abortion in El Salvador.
A doctor who practices at Planned Parenthood in the US, and who recently lectured at one of my classes, spoke of the protesters who hold up the signs with all the gory pictures of torn-apart fetuses. She also said the pro-choice side ought to own those images.
We ought to do that, because I don't think anyone is pro-abortion. I think we can both agree that we would all be better off if there were no abortions. I think we all have reverence for human life, whenever it begins. Even if we say that human life may not equal human personhood and full rights before a certain point in development, I think we all respect human life. And I think that because of pro-life arguments, we are afraid to say that. But reproductive rights, under which I filed this post, is much more than abortion rights. If we want fewer ripped-apart fetuses, we should use comprehensive sex education, access to contraception, and access to abortion. Fewer women will have unintended pregnancies, and if they do, they will seek abortion earlier, when it is less morally problematic.
That, however, was a bit of an aside. I think that anyone with the least bit of sense, pro-choice or pro-life, should agree that ectopic pregnancies should be handled as they are in US Catholic hospitals. I believe that the handling of ectopic pregnancy in El Salvador, and presumably in other Latin American countries, is in contravention of Catholic medical ethics as practiced in the US, as well as being damn stupid.
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