Should Therapeutic Abortion Be Legal in Nicaragua: The Response of Nicaraguan Obstetrician–Gynaecologists

Abstract

Abstract

Abortion is legal in Nicaragua only to save the life of the woman. In 2002, amendments to the Penal Code to change the penalties for obtaining and providing illegal abortions and regulations on the authorisation of legal abortions are due to be debated in the legislature. In a context of extensive media coverage and debate between women's health and rights groups and a powerful movement to make all abortions illegal, medical professionals have also been effective in influencing law and policy. In May 2001, the Nicaraguan Society of Obstetrics and Gynecology presented the results of a study of the views of 198 obstetrician–gynaecologists on pending legislation regulating therapeutic abortion and the medical and ethical implications of providing therapeutic abortion services. All but nine of the 198 participants in the study, who comprised 76% of all registered obstetrician–gynaecologists in Nicaragua, believed that therapeutic abortion should not be criminalised and over 90% believed that there were cases in which therapeutic abortion was necessary to save women's lives. Some also supported legislative reform to allow abortion in cases of rape and fetal malformation. These results countered claims by the Nicaraguan Medical Association (AMN), taken up by the Church and anti-abortion legislators and groups, that therapeutic abortion was no longer necessary due to modern medicine. The election of anti-abortion politicians to powerful positions in early 2002 has created a formidable challenge when the proposed revisions to the Penal Code are debated.

Résumé

Au Nicaragua, l'avortement n'est autorisé que pour sauver la vie de la femme. En 2002, le pouvoir législatif examinera des amendements du code pénal qui changent les peines infligées pour avoir subi ou pratiqué un avortement illégal et la réglementation sur les avortements légaux. Dans un contexte trés médiatisé et face au débat entre les groupes pour la santéet les droits des femmes et un mouvement puissant voulant interdire tous les avortements, les professionnels médicaux ont influencé la loi et la politique. En mai 2001, la Société nicaraguayenne d'obstétrique et de gynécologie a présenté les résultats d'une étude auprès de 198 obstétriciens-gynécologues sur le projet de loi régissant l'avortement thérapeutique et les conséquences médicales et éthiques des avortements thérapeutiques. A l'exception de neuf d'entre eux, les 198 participants à l'étude, qui représentaient 76% des obstétriciens-gynécologues au Nicaragua, pensaient qu'il ne fallait pas pénaliser l'avortement thérapeutique; pour plus de 90%, l'avortement thérapeutique était parfois nécessaire pour sauver la vie de la femme. Certains soutenaient également la réforme autorisant l'avortement en cas de viol ou de malformation fœtale. Ces résultats ont pondéré les déclarations de l'Association médicale nicaraguayenne, dominée par l'Eglise et les législateurs et groupes anti-avortement, affirmant que l'avortement thérapeutique n'était plus nécessaire grâce á la médecine moderne. L'élection de politiciens opposés á l'avortement á de hautes fonctions au début de 2002 a créé un formidable défi pour le débat sur le projet de révision du code pénal.

Resumen

En Nicaragua, el aborto es legal cuando es para salvar la vida de una mujer. Este año 2002, la Asamblea Nacional discutirá posibles emiendas al código penal que cambian las penas de personas que se hacen o practican un aborto ilegal tanto como la regulación del aborto legal. Los médicos y profesionales de la salud han ejercitado su influencia sobre la ley y la polı́tica en un ámbito cubierto extensivamente por la prensa y la televisión/radio y con un debate entre los activistas por la salud de la mujer y por sus derechos y un poderoso grupo que quisiera prohibir el aborto por completo. En mayo de 2001, la Sociedad Nicaragüense de Obstetricia y Ginecologı́a (SNGO) anunciólos resultados de un estudio de las opiniones de 198 gı́neco-obstetras acerca de una legislación pendiente que regulara el aborto terapéutico y las consequencias médicas y éticas del mismo. Solo nueve de los 198 participantes en el estudio, quienes representaban el 76% de todos los gı́neco-obstetras registrados en Nicaragua, creı́an que el aborto terapéutico debe ser penalizado, y más de 90% creı́an que existan casos en que el aborto terapéutico serı́a necesario para salvar la vida de una mujer. Muchos de los participantes también apoyaban una reforma legislativa que permitiera el aborto en casos de violación y malformación del feto. Estos resultados contradicen las declaraciones de la Asociación Médica Nicaragüense, reiteradas por la Iglesia y grupos y legisladores que se oponen al aborto, de que el aborto terapéutico ya no es necesario debido a los avances de la medicina. La elección de polı́ticos anti-aborto a puestos de poder a principios de 2002 crea una fuerza formidable la cual será confrontada cuando se abra el debate sobre las revisiones al Código Penal en la Asamblea Nacional.

Key Words:

• abortion law and policy
• advocacy and political process
• obstetrician–gynaecologists
• Nicaragua

“You cannot condemn a doctor for saving the life of his patient.” (Study participant)

In April 2000, abortion law moved to the top of the media and policy agenda in Nicaragua when various groups, including the Nicaraguan Committee for the Defence of Life (Comité nicaragüense pro defensa de la vida), began lobbying for amendments making therapeutic abortion legal to be eliminated from the draft bill to reform the Penal Code, which is being considered by legislators as part of broader efforts to modernise Nicaragua's justice system. In May 2000, the National Assembly approved the proposed changes as a whole. However, legislators must still debate and vote on changes to specific statutes, including those regulating abortion, before the Penal Code can receive full legislative approval.

Changes to Chapter V, which deals with abortion, have stimulated intense public debate in Nicaragua. During the 2000 and 2001 legislative sessions, there was a flurry of newspaper articles, political marches, television and radio talk shows and public debates about abortion and the law. The revisions related to abortion law have not reached the Assembly floor for debate [1] but if they are considered in 2002, different legislators are expected to submit both restrictive and progressive amendments.

Current abortion law in Nicaragua

According to the 1891 Penal Code, “women who induce their own abortions or give consent to someone else to induce an abortion; persons who induce abortion without a woman's consent or who obtain consent through violence or deception; persons who cause a miscarriage of pregnancy due to acts of violence against a woman; and doctors, pharmacists, midwives or other health care workers who practice abortion” are liable to prosecution. The only exception is if abortion is carried out to save the woman's life, and this must be with the approval of a committee of three doctors and with the consent of the spouse or nearest relative of the woman. Depending on the circumstances (with or without consent, provider or woman) sentences of 1–16 years in prison may be imposed on anyone found violating the law [2].

The revisions to these statutes currently being proposed would decrease the penalties imposed on women who have abortions, increase penalties for doctors and pharmacists who purposefully cause damage to a fetus, and change the requirements for the authorisation of a legal abortion such that women would need authorisation from three Ministry of Health specialists rather than from three doctors, and could give their own consent [3].

The definition of “therapeutic abortion” and the specific medical guidelines for physicians diagnosing therapeutic abortion are not included in the language of the Penal Code. The term is understood by legislators in Nicaragua to refer to cases where pregnancy must be terminated because it poses a danger to the woman's life. Official interpretation and regulation of the procedure however, has been left to the Ministry of Health (MINSA). MINSA defined “therapeutic abortion” and when it can be authorised in guidelines for the treatment of abortion of 1989, established by the Infant and Maternal Health division, as follows:

“The termination of pregnancy before 20 weeks gestation … due to maternal pathologies that are made worse by the pregnancy or for maternal pathologies that have a negative effect on the development and growth of the fetus and compromise the mother–child dyad.” [4]

The guidelines also state that in accordance with article 165 of the Penal Code, abortion can be performed if the life of the woman or the fetus is threatened by a pathology that are aggravated or caused by the pregnancy, if there is no other remedy for the woman or when all other treatment has failed, and if it is certain that her health will not worsen or will improve as a result of the abortion.

Data on abortion: legal and illegal

As a result of the restrictive laws on abortion, data on abortion incidence and mortality is unreliable and estimates vary greatly according to source. An estimated 8% of registered maternal deaths in 1993 were due to complications of unsafe abortion [5]. ¹ According to UNICEF, the maternal mortality ratio in Nicaragua rose by 59% between 1993 and 1998, reaching 200 deaths per 100,000 births [6]. Many newspaper articles have cited government estimates that 36,000 women had abortions in Nicaragua in 1995 [7]. UNFPA estimated that 6000 women had unsafe abortions in 1998, of whom a quarter were adolescent girls [8]. However, the Ministry of Health has identified abortion as one of the three main reasons why women are hospitalised and a 1998 study by PRIME-Ipas estimated that 14,706 women are hospitalised each year in Nicaragua for complications of abortion [9].

According to a June 2001 report by the National Feminist Committee (CNF) to the commission monitoring Nicaragua's compliance with the Convention on the Elimination of All Forms Discrimination against Women (CEDAW), therapeutic abortion has practically ceased to exist in Nicaragua since 1990 [10]. The Bertha Calderon Hospital, Managua's major maternity hospital, reports that the committee regulating therapeutic abortion receives about five requests for authorisation every month. Hospital records indicate that no authorisation has been granted since 1997 [11]. Doctors from Bertha Calderon report that their commission does receive cases that merit review [12] and some of the obstetrician–gynaecologists who participated in this study reported that they have performed therapeutic abortions to save their patients' lives [13]. However, there are no national data on the actual number of women whose lives are in danger from pathologies that are aggravated or caused by pregnancy.

Actions and reactions

Some of the first reactions to the proposed reforms came after an April 2000 meeting between the then Minister of Family and the Commission for Women's Affairs, during which the Commission asked the Ministry to give more attention to policies that promote women's sexual and reproductive health and education. Afterwards the Minister expressed concern in the press that the reform would lighten penalties for women who induce their own abortions. An angry response from the chairwoman of the Commission [14] kicked off a series of public declarations by various high-level government officials against the proposed revisions to the Penal Code and calls to prohibit abortion totally. These leaders included officials from the Ministries of Family and Education, President Alemán and the first lady, the president of the National Assembly and legislators from two right-wing political parties, the Alianza Conservador (Conservative Alliance) and Camino Cristiano (Christian Way). They asserted that therapeutic abortion to save a woman's life no longer existed due to advances in prevention and treatment of health conditions during pregnancy. As a result, they argued, maintaining provisions for therapeutic abortion in the Penal Code can only be seen as a tactic used by pro-choice groups seeking to broaden the interpretation of “therapeutic” [15].

There has been extensive media coverage of abortion since April 2000. The two foremost daily newspapers, La Prensa and El Nuevo Diario, published 464 articles on abortion in 2000–2001, many of them on the activities of anti-abortion groups opposing therapeutic abortion [16][17]. A number of prominent academics, health care professionals, medical professional groups, legal and juridical scholars, church leaders and ordinary citizens published editorials and commentaries on both sides of the arguments. An August 2000 opinion poll (n=1245) by La Prensa showed that just over half of Nicaraguans (52%) supported the elimination of therapeutic abortion from the Penal Code [18].

The CNF and a right-wing Catholic group, the Yes-to-Life Foundation, have been at loggerheads in the media, publishing advertisements and radio announcements with opposing views on the ethics of abortion and the impact of unsafe abortion on public health in Nicaragua. At least seven television programmes, 14 radio shows, and one academic debate presented the views of legislators, health care providers and representatives of women's health and rights groups about the proposed legislation [19].

The anti-choice campaign in Nicaragua is using many of the same messages as were used in El Salvador prior to legislative changes there that criminalised all abortions in 1998, including for therapeutic reasons. The campaign to penalise therapeutic abortion in El Salvador claimed that the causes of abortion were promiscuity and premarital sex, and branded those in favour of abortion as being part of a “culture of death” forced upon Latin America by foreign governments promoting population control. Salvadorean women's groups who defended therapeutic abortion did not have the public forums, support or strength to make a significant impact on public opinion [20, p. 30]. In Nicaragua, however, the CNF and the National Women's Movement have a presence, including in the press, and demanded that journalists and other media professionals include women's perspectives in their coverage of the debates [21]. Their media campaign has emphasised a woman's right to health and life and a public health perspective on the impact of unsafe abortion.

In May 2000 the 96 organizations who make up the Nicaraguan Women's Health Network drafted a declaration to the citizens of Nicaragua with their views on the draft Penal Code amendments, and disseminated it through the media [22]. The declaration applauded the proposed revisions for recognising women's autonomy in making reproductive health decisions. On the other hand, it argued that requiring three Ministry of Health specialists to authorise a therapeutic abortion would present significant barriers to women who wished to be treated in a private clinic and those in rural areas where three specialists were unlikely to be available at all. Finally, it advocated that the new Penal Code should allow therapeutic abortion in order to save the life and health of a woman, and that health be defined as “physical, social and mental well-being”. It proposed that the Penal Code read as follows:

“Therapeutic abortion may be authorised to save a woman's physical and mental health and life when requested from a health care provider.” [22] ²

The president of the Nicaraguan Evangelical Alliance, the Roman Catholic Bishop's Conference and Nicaraguan Cardinal Miguel Obando y Bravo publicly expressed opposition to legal therapeutic abortion. In a public statement on behalf of the Church, the Cardinal said that while there may be just cause for therapeutic abortion where the woman's life is clearly endangered by pregnancy, advances in medical technology had made such cases practically obsolete. Furthermore, he said: “… the elimination of a child, in order to protect a women's health, is never justified.” [23]. ³

Leaders from both Protestant and Catholic churches participated in events organised by anti-choice groups [16][17]. In an anti-abortion march in September 2000, the second that year, President Alemán, the head of the National Assembly and Cardinal Obando y Bravo joined together to call on legislators to criminalise all abortions [16], and presented a petition with 100,000 signatures to the legislature.

In May 2000 the AMN had disseminated an official statement to legislators in the National Assembly, which stated that there were currently no medical conditions for which abortion would be required to save the life of a pregnant woman [24]. In a newspaper article, Dr Aldo Martinez Campos, then president of the AMN was quoted as saying that “therapeutic abortion is a farce with no basis in modern medicine” and suggested that legislators should take stock of their moral and ethical principles, eliminate therapeutic abortion from the penal code, and give thanks that they were not aborted. In another article, the current AMN president stated: “Abortion does not cure any illness, what it does is kill a human being.” [25]. ⁴

Individual medical professionals, including a prominent Nicaraguan oncologist, have disputed this claim by giving examples, such as ectopic pregnancy and advanced cervical or uterine cancer, where abortion is necessary to save a woman's life [26]. Despite this, the AMN's “expert opinion” was used by both religious leaders and government officials to justify their call to prohibit therapeutic abortion in virtually all their statements [27]. ⁵ The AMN's former and current presidents have participated in anti-choice events and public debates and published a great many opinion pieces arguing for the penalisation of therapeutic abortion.

Bringing the views of obstetrician–gynaecologists into the debate

“Abortion is a public health problem and our government is a secular one. The public health perspective should therefore [influence legislation] and not a religious point of view.” (Study participant)

Many obstetrician–gynaecologists in Nicaragua felt that their professional views as experts on sexual and reproductive health should be influential in shaping the regulations governing their work. The International Federation of Obstetrics and Gynecology (FIGO) also recommends that its affiliates promote discussion amongst their members so as to put forward representative views on the medical implications and determinants of abortion for stakeholders in sexual and reproductive health, including lawmakers [28].

Leaders of the Nicaraguan Society of Obstetrics and Gynecology (SNGO), whose members comprise 41% of practising obstetrician–gynaecologists in Nicaragua, sponsored a forum in 2000 for its members, entitled “Abortion and the practice of obstetrics and gynaecology”. Its aim was to draw up an official statement of SNGO's position on therapeutic abortion. However, the participants were unable to achieve a consensus and recommended that the Society consult the field more widely and provide space for the issues to be explored in greater depth. In October 2000, a working group of four SNGO members was convened by the SNGO president, and decided to examine the scientific and technical reasons for therapeutic abortion, which most of them believed was medically justified in some cases. They decided to invite all obstetrician–gynaecologists in Nicaragua to participate, SNGO members or not, so as to achieve the broadest possible consensus.

They called the study “Una Jornada Nacional de Reflexión Cientı́fica: El Aborto Terapéutico y la Práctica de la Gı́neco-Obstetricia” (A National Journey of Scientific Reflection: Therapeutic Abortion and the Practice of Obstetrics and Gynecology). Its aims were to stimulate debate, carry out a survey of obstetrician–gynaecologists and provide expert guidance on regulating abortion provision.

Study methodology and participants

Because of the controversial nature of abortion, the SNGO working group decided to focus on scientific and technical issues only. The decided to use small focus group discussions, facilitated by people able to create an atmosphere of respect for diverse opinions and to keep discussion centred on the objectives of the study. They agreed that these sessions would not be recorded or transcribed and that the opinions of the participants would be collected through a self-administered questionnaire with closed-ended questions after each discussion.

Reference materials were selected to aid discussion on the medical and technical aspects of therapeutic abortion and the implications of the legislative changes under debate. The materials included a videotaped debate between prominent Nicaraguan public figures on the issue of therapeutic abortion, the current and proposed Penal Code articles, the MINSA protocols regulating the procedure, the FIGO guidelines for the ethical practice of obstetrics–gynaecology, and literature on medical conditions which pose a grave danger to the health and life of pregnant women. The questionnaire was to collect opinions on the issues addressed in these materials and in the focus group discussions.

Twenty obstetrician–gynaecologists from around the country, including members of the working group, volunteered to be focus group leaders and were trained in facilitation methods, administration of the survey and the contents of the reference materials. A total of 15 focus group discussions were held, composed of 4–25 physicians each, with sessions lasting about three hours. The discussions covered provider's practical experiences with therapeutic abortion and the medical conditions that necessitate it, the impact of unsafe abortion on health services and the implications of revisions to the Penal Code for the practice of obstetrics and gynaecology in Nicaragua.

The questionnaire included eight yes–no questions and an optional page for comments. The questions covered: whether abortion for medical causes was justifiable for certain conditions or not; what the role of the SNGO should be as regards expertise on this issue; whether abortion for medical causes would help to reduce maternal mortality; and whether the SNGO should submit a law proposal regulating abortion for medical causes. The questionnaires were administered and collected at the end of each group session. The reference materials and a questionnaire were also sent to those who could not attend a session but wished to participate in the study.

Results

Invitations to participate in the study were issued to all specialists for whom contact information could be obtained (240). A total of 198 physicians responded to the two-page survey. They were almost equally divided between men and women and about half lived in Managua (51%). Together they represented 76% of all practising obstetrician–gynaecologists in Nicaragua. (This estimate is based on the register of the SNGO, which includes 260 obstetrician–gynaecologists.)

The focus group discussion leaders reported that the delicacy of the topic of abortion manifested itself in various ways. Some physicians, while not in agreement with penalising therapeutic abortion, said they could never perform one themselves. Others requested that the SNGO add to its recommendations a stipulation that abortion performed for any reason other than to save the life of the pregnant woman should be criminally proscribed. In contrast, others felt that the SNGO should press for a wider interpretation of therapeutic abortion, i.e. to allow for abortions in cases of fetal malformation.

The overwhelming majority of respondents believed that ectopic pregnancy and reproductive cancers were pathologies affecting pregnancy that justified abortion on medical grounds (91%) [29]. Additional comments on this question centred on the need to be more specific and comprehensive about the medical conditions justifying therapeutic abortion. Ectopic pregnancy and cancer, mentioned in the questionnaire and the focus groups, were obvious examples, and most respondents (86%) believed legal abortion would contribute to the reduction of maternal mortality as a result. Conditions where pregnancy might endanger the woman's health but not her life were not included in the survey question in order to achieve consensus according to the most conservative of interpretations.

Almost all respondents thought that abortion for medical causes should not be criminalised (96%). Some commented that abortion should only be legal if the woman's life was in immediate danger, but a significant number believed that other indications for abortion should be legalised as well – rape and fetal abnormality were frequently mentioned. Some said they were opposed to decriminalising abortion for socio-economic reasons.

Almost all respondents (98%) believed that the SNGO should be the principal expert group consulted on the medical and technical issues related to regulation of abortion, and 87% agreed with the following draft wording for presentation to the National Assembly, developed by the SNGO working group:

“Abortion for medical causes will not be penalised if it is performed to treat a grave illness, if there is no better treatment available or if the embryo itself is the cause of maternal illness.” [29, p. 60]

Discussion

The role of law is at the core of the abortion debate in Nicaragua. For countries that follow a civil law tradition, like those in Central America, legal reform is a fundamental part of the process of modernising outdated laws and procedures, whether in criminal, family or juvenile law. In these countries, the Penal Code is the principal source of definitions of criminal acts, the criteria for deciding guilt or innocence and the sanctions to be applied. In contrast, in countries that follow a common law tradition, laws are only one source of authority along with judicial interpretation, custom and precedent. In Latin American cultures especially, laws are often highly symbolic in signifying societal values [30].

Distinct and conflicting lines of reasoning are being promoted by the Church and women's health and rights groups in Nicaragua to justify reform of the abortion law. Anti-abortion advocates have argued that allowing abortion at all would be to abandon a sacred principle – the protection of human life – by allowing the wishes of one individual (the woman) to negate the life of another (the fetus):

“The rights of the individual end where the rights of another begin.” [27]

This is in contrast to arguments by women's health and rights groups and medical professionals based on public health and pragmatic considerations, which seek to guarantee women's right to life and to reproductive health as the first priority.

Furthermore, the anti-abortion argument that therapeutic abortion is no longer needed in modern medicine is fundamental to proposals to criminalise it in the new Penal Code. In this context, the AMN's statement that therapeutic abortion is no longer necessary medically has been a powerful tool for influencing legislators and the Nicaraguan public. Given the possible re-criminalisation of therapeutic abortion, the SNGO study – which demonstrates that a high proportion of obstetrician–gynaecologists in Nicaragua consider there to be a need for legal therapeutic abortion – is critical to the debate and counterbalances the declaration of the AMN.

In El Salvador, in contrast, the public health consequences of criminalising therapeutic abortion never received public attention during the reform process, and the denunciation of therapeutic abortion as unjustifiable was never debated or challenged by the medical community. Only after the law was changed did doctors in El Salvador reflect that:

“It was a serious mistake for gynaecologists and the Society of Gynaecologists and Obstetricians, as a legal entity, not to get involved in the debate at the time … the Society should have informed and educated legislators, giving medical reasons for not prohibiting therapeutic abortion and not criminalising abortions in other circumstances.” [20, p. 39]

SNGO recommendations and the current political situation in Nicaragua

The National Assembly has yet to consider the Penal Code revisions on abortion. However, the study succeeded in raising consciousness in the medical community about the law reform proposals and was able to provide a space in which information could be shared and discussed regarding the medical and ethical implications at the core of the debate.

A report of the study was disseminated in 2001 to women's health advocates and members of societies of obstetrics and gynaecology throughout Latin America, local and international media and the Nicaraguan legislative commissions concerned with health and rights. In the report, the SNGO states that penalisation of therapeutic abortion would pose a serious ethical dilemma for providers, who would be put at risk of imprisonment for providing life-saving treatment. The report proposes that “therapeutic abortion” be replaced with “abortion for medical reasons” (aborto por causa médica) in the new Penal Code. This change in terminology was proposed to defuse the arguments of some conservatives that there are no conditions where abortion should or could be prescribed as curative or therapeutic. The SNGO agreed that “abortion for medical reasons” is a clearer term. The report also proposed that the amended article regulating therapeutic abortion read as follows:

“Abortion for medical causes will be determined scientifically by three medical specialists from the Ministry of Health. It will be done with the consent of the woman and will not be punishable in any case. The Nicaraguan Society of Obstetrics and Gynecology will be responsible for the regulations governing its provision.” [29, p. 70]

The results of the study stimulated quite a lot of controversy within the board of directors of the SNGO and amongst anti-abortion advocates. Two members of the SNGO board denounced the results and said they had not been consulted on the design of the study (though both had been invited to participate). Anti-abortion leaders said that the sponsors of the study, Ipas and the SNGO, were promoting a “culture of death”, that the study had been biased and excluded specialists with anti-abortion views. Carlos Hurtado, one of the principal legislators calling for the penalisation of therapeutic abortion said that he respected the study results, but did not believe it got to the root of the issue because it did not address whether “what is in the woman's womb is a living being or not” [31].

The presidential and legislative elections in September 2001 have changed some of the political actors involved. Conservative parties are more heavily represented in the 2002 Assembly, which may influence the new president Bolaños. In a serious blow for pro-choice advocates, former President Alemán was elected president of the National Assembly in January 2002. He is expected to use his position to lobby for the total prohibition of abortion and also to push for constitutional reforms that would define human life as beginning from conception.

In March 2002 the National Assembly re-initiated debate on the new Penal Code. While it is not yet known when the articles relating to abortion will reach the Assembly floor, the SNGO has presented the results of its study and its recommendations to the Justice Commission in charge of the Penal Code revisions. In addition, the women's movement is actively lobbying members of the Commission and its allies in the Assembly to revise the stipulation that a committee of three specialists needs to authorise therapeutic abortions, arguing that it puts undue restrictions on women in need of life-saving treatment.

Acknowledgements

A summary of the SNGO study was published in Revista Mujer Salud (Women's Health Journal), July 2001, and presented at the conference, Unwanted pregnancy and abortion in Latin America, Cuernavaca, November 2001. We would like to thank Dr Diony Fuentes, Norman Goco and Dr Oscar Flores for their contributions to the study. Translation of text and quotes from Spanish to English were by Heathe Luz McNaughton.

Notes

1 The population in 1997 was 4.4 million, female population 51.2% [5].

2 “El aborto terapéutico será determinado cientı́ficamente, para preservar la salud integral y la vida de las mujeres, la que podrán solicitarlo en una consulta médica [22].” Health here is based on the WHO definition.

3 “Jamás es justificable la eliminación del hijo, para evitar un agravamiento en la salud de la madre.” [23].

4 “El aborto por causa medica sera determinado cientı́ficamente, con la intervención de tres médicos especialistas del Ministerio de Salud y el consentimiento de la mujer. Este no será punible en ningún caso. La Sociedad Nicaragüense de Ginecologı́a y Obstetricia de acuerdo con el Ministerio de Salud, serán los responsables de su normatización [29].”

5 This declaration falsely claims that the US Centers for Disease Control (CDC) has published studies showing that maternal mortality due to abortion has increased in countries where abortion has been legalised [27].