In her fourth month of pregnancy, 18-year-old Jazmina sought emergency care at a public hospital in Managua, Nicaragua, on Oct. 31, 2006, just one week after the Nicaraguan legislature had voted to ban all abortions. Although she was feverish, bleeding and in severe pain, her doctors had no imaging technology to confirm a miscarriage — and intervening without such proof, even to save the patient’s life, could mean years of imprisonment. Thirty-six hours later, after undergoing two hospital transfers and, finally, ultrasound testing that revealed a detached placenta, Jazmina was taken to the operating room for an emergency cesarean section. But it was too late: Her uterus had already filled with blood, and she went into fatal septic shock. Several days after her simple hillside burial, Jazmina’s distraught husband reflected on the tragedy, saying: “Now I've lost not just our baby, but my whole family.”

Key maternal health indicators throughout much of Central America generally indicate a bleak reality for women. For every 100,000 live births, about 230-240 maternal deaths occur in Nicaragua and Guatemala, and 150-160 in El Salvador and Panama. In each of the countries in this region, complications of unsafe abortion is one of the top three causes of maternal deaths. As in other parts of the developing world, vulnerable populations — such as women who are poor, undereducated, rural residents, young, indigenous, internal migrant workers or undocumented immigrants — are at especially high risk for unsafe abortion, its resulting complications, and death or permanent injury from such complications.

Despite punitive abortion laws in the region, an estimated 700,000 abortions, most of them unsafe, take place annually in Central America. In late 2006, the Nicaraguan National Assembly approved a bill to amend the country’s penal-code provision allowing for therapeutic abortion. In so doing, Nicaragua became the second Central American country, behind El Salvador, to eliminate all legal indications for induced abortion; now, a woman cannot have an abortion even when a pregnancy threatens her life or health. The four additional Central American countries in which Ipas works — Costa Rica, Guatemala, Honduras and Panama — have highly restrictive abortion laws that permit induced abortion under one or more circumstances. Nonetheless, very few women can obtain safe abortion care, especially if they lack the means to afford services in the private sector.

Restrictive abortion laws endanger women’s health, especially when coupled with a substantial unmet need for family-planning services among women and their partners. Approximately one-quarter of all pregnancies in Nicaragua, El Salvador and Honduras are unwanted, and roughly one-third in Guatemala are unplanned. In all four of these countries, the proportion of married women reporting current use of a modern contraceptive method is fairly low and is typically exceeded by the demand for such services. As a recent U.S. interagency report on Central America notes, “Many women are nowhere close to achieving their reproductive goals.” In rural Honduras, for example, the number of children a woman has over her lifetime is, on average, about double what she would consider ideal. Finally, youth and other vulnerable populations often receive no formal sex education.

Since the late 1980s, Ipas has worked in close partnership with public-health institutions and nongovernmental organizations throughout Central America to catalyze the commitment, action and resources needed to protect women’s health and rights, with a focus on ensuring access to high-quality postabortion care (PAC). Managua-based Ipas Central America’s activities have included improving the availability and quality of abortion-care services in the context of comprehensive reproductive health care; developing monitoring tools to measure progress toward those goals; and promoting sustainable access to reproductive health technologies.

Recognizing a need to promote a broader understanding of sexual and reproductive health and rights in the public-health sector, Ipas Central America has collaborated with schools of medicine, nursing and public health to integrate a human rights approach to reproductive health issues into their curricula. This effort is part of a long-term strategy for increasing future medical professionals’ commitments to women’s rights and health-care services.

• increasing the availability of manual vacuum aspiration (MVA), a safe technology for postabortion care, in the public and private health systems through selected donations and the strengthening of distribution systems;
• conducting training in comprehensive, woman-centered PAC, especially at secondary- and tertiary-care facilities;
• expanding monitoring of the PAC model in the public health systems of selected countries;
• developing, publishing and disseminating guidelines for the use of medications for various obstetric uses;
• training graduating medical students in PAC, sexual violence and women’s sexual and reproductive rights before their obligatory year of social service, to expand rural women’s access to essential reproductive health care at the local level;
• strengthening the capacity of local leaders in the women’s movement to advocate effectively for change and to reach women directly with information concerning their right to a safe abortion;
• working with influential leaders in universities and obstetric-gynecological societies to train and expand the number and types of groups advocating for safe abortion care and sexual and reproductive rights;
• forging alliances with and training selected journalists on women’s sexual and reproductive health and rights, and on the tragedy of unsafe abortion;
• conducting and reporting results of research evaluating the health outcomes and other effects of highly restrictive abortion policies.