MANAGUA, Nicaragua — On a warm day in June, at the start of the rainy season, Ixelis waits outside of Managua’s German Nicaraguan Hospital. She is homeless, and several months pregnant. The 21-year-old has been waiting for several hours to see what the doctors will tell her.
Ixelis is addicted to drugs. She has a gentle smile and her pregnant belly shows from underneath her short-sleeve shirt. She already has two children and is desperately hoping for an abortion so she won’t need to give birth to a third in the near future.
“I know it’s illegal,” she said of her desire to seek out an abortion, “but I have a 5-year-old girl and a 3-year-old boy to take care of already.”
As a single mother raising two children on the streets of Managua, without an abortion, Ixelis, who asked that her full name not be used for fear of legal repercussions, knows the already difficult task of feeding her children will become even more trying. The problem is, the laws in this country are uncompromisingly rigid when it comes to situations like hers. Women with unwanted pregnancies must instead pin their hopes on a far more uncertain ― and unorthodox ― solution.
Earlier that morning, an ultrasound showed that the fetus growing inside of Ixelis has no chance of surviving on its own, a suspected result of drug use during her pregnancy. It has no arms, feet or cranium ― and its heart is compromised. But because Nicaragua has a total ban on any form of abortion, Ixelis will have to carry the fetus until she either gives birth ― or until its heart stops beating completely.
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For doctors like Carla Cerrato Tellez, the woman who first admitted Ixelis to the hospital, situations like this are sadly all too common in Nicaragua. Women who seek to terminate a pregnancy are faced with an impossible choice ― and the physicians they come to for help don’t fare much better.
As an OB/GYN in Nicaragua, Tellez faces daily challenges treating women in a country where all forms of abortion are illegal — even when there are severe medical complications, like in Ixelis’s case, or if a pregnancy threatens the life of the pregnant woman.
Teenage girls make up a large number of her patients, and Tellez often finds herself alternating between lending a comforting, motherly ear to the young women, and sternly laying out the medical and legal realities they face. Many underage pregnancies in Nicaragua — like Ixelis’s first child, who she had when she was 15 — are the product of rape.
It hasn’t always been this way. Under an 1837 law that lasted up until 2006, abortion was allowed in Nicaragua in cases that involved rape, or when the mother’s life was at risk. But today, the young doctors who Tellez trains have only ever worked in a world where any form of abortion is against the law. This means physicians are often forced into situations where they are legally required to take actions that go against the best interest of the patient’s health.
Still, Tellez said she urges the doctors under her watch to always honor their medical oaths first, and tries to prepare them for a time when, inevitably, their medical obligations will conflict with the law.
From revolution to religious conservatism
For most of Tellez’s medical career, abortions were legally performed in hospitals. She is a product of Nicaragua’s 1978 revolution, a movement that promised equality and opportunity. She comes from the same town as Nicaragua’s revolutionary hero, Augusto César Sandino, who led a rebellion against the United States occupation of Nicaragua from 1912 to 1933, and formed the political party Sandinista National Liberation Front, or FSLN. The party’s affirmative action programs allowed Tellez to attend medical school at a time when few women were in the field. She has worked for the Nicaraguan Ministry of Health since 1986.
“I am a Sandinista till death,” she said.
But in her career as a physician, Tellez has seen a drastic change in her country since Nicaragua’s president, Daniel Ortega, supported the zero-tolerance law on abortion.
By 2006, Ortega, once a devoted atheist, publicly declared himself a devout Catholic in what critics considered a bid to appeal to the country’s large number of conservative religious voters. In a move that surprised many of his one-time supporters, he threw his support behind passing a law that would make all forms of abortion a criminal act. The measure passed, and days later Ortega rode his new popularity to victory in the presidential election.
Under the law, women who consent to an abortion face up to two years in prison, and anyone performing the procedure faces up to six years in prison. A physician charged with performing an abortion faces up to a 10-year banfrom practicing medicine.
It is a reality few thought was possible after Nicaragua’s left-wing revolution in the 1980s, when condoms were freely distributed by the government and the right to an abortion was reportedly being considered for inclusion in the country’s new constitution.
“He did it for the votes,” Tellez said. Like many Nicaraguans, she believes Ortega’s public conversion to Catholicism and his move to ban abortion was nothing more than an attempt to take advantage of populism.
Critics say the divide between church and state has since continued to erode. In Tellez’s hospital — founded as Karl Marx Hospital by the East German government in 1985 — notice boards are prominently displayed, bearing Ortega’s slogan: “Christian, socialist, solidarity.” A Catholic chapel was built on hospital grounds in 2014.
Abortion as a political tool
Nicaragua is part of a wider trend of shrinking access to abortion in the developing world, with close ties to policy decisions in the developed world as well. In January, U.S. President Donald Trump issued an order to reinstate the Mexico City policy. Implementing the policy would cut $8.8 billion in existing foreign health aid from any organization that uses its own non-U.S. funds to provide abortion services, counsel patients about the option of abortion, or advocate for the loosening of abortion laws.
This push to limit reproductive rights abroad mirrors an attempt to roll back rights in the United States. The U.S. House of Representatives approved a measure banning most abortions for pregnancies longer than 20 weeks in October, and Trump has said he supports a ban on abortion — although he excludes instances of rape, incest or when the life of the mother is at risk.
A recent report published in the Lancet medical journal indicatesthat banning abortion does not stop people from seeking or performing the operation. Rather, it decreases options for safe abortions and creates situations where women receive unregulated, often unsafe means of terminating unwanted or unviable pregnancies. The risk of death, birth defects and severe infection are far greater when procedures are performed outside of hospitals or medical centers, the study says.
The abortion ban has led to Kafkaesque dilemmas for Nicaraguan women, with countless stories shared. In 2010, a 27-year-old woman known to the public only as ”Amalia” sought an abortion after learning she was suffering from advanced stages of metastasized cancer. She was 10 weeks pregnant, yet doctors in a state hospital refused to perform an abortion or allow her to start chemotherapy out of fear of being prosecuted for killing the fetus. After months of delays, public pressure finally forced the hospital to allow her to start chemotherapy. The fetus was stillborn eight months later, and Amalia died from the cancer shortly after.
Today, Nicaragua — one of only a few countries that has a total abortion ban — has one of the highest teen pregnancy rates in Latin America. Tellez sees a steady flow of women suffering from infections and other complications after clandestine abortions. Many of the patients she sees are under 14 years old.
“The law forces a child to give birth to another child,” she said. Because their bodies are not fully developed, complications from pregnancy often threaten the young women’s lives.
“They come to me complaining of health problems but won’t say they are from abortions because they fear prosecution,” she said. “It makes it harder because you don’t know for sure what has happened, wasting valuable time.”
The threat of jail time and losing the right to practice is enough to keep most doctors from performing abortions. But some, like Tellez, still help support these women where they can.
“If you can’t change the law, you have to adapt,” Tellez said, back at the Managua hospital. “Trying to make sure women are respected is my way of trying to keep the spirit of the revolution alive.”
When Ixelis’s ultrasound revealed the extent of the birth defects, Tellez convinced one of her residents to write in Ixelis’s chart that the fetus had no pulse. This would legally allow the fetus to be surgically removed with minimal risk in the hospital, and would not technically have been an abortion because according to law, only removing a living fetus constitutes an abortion.
At the last minute, the specialist assigned to operate performed one more ultrasound and detected a fetal heartbeat. That’s when Ixelis was made to wait, day after day, as nurses checked every few hours to see if the fetus still had a pulse. Unless the heartbeat stopped, there was nothing they could legally do for her.
That’s “the worst part” of the abortion ban in Nicaragua, Tellez said ― “when you feel like you can’t help someone.”
It was a Sunday when Ixelis was finally given her answer. It was Tellez’s day off, and another doctor made the decision to discharge Ixelis, likely eager to release her and avoid the legal complications of her case.
Ixelis returned to the streets of Managua. No one at the hospital knows what happened to her.
The reporting was made possible through a grant from the International Reporting Project.