New report explores what total abortion ban means in the Dominican Republic

Before her daughter died, Rosa Hernández unsuccessfully pleaded with doctors to give the 16-year-old a therapeutic abortion so she could get needed chemotherapy.

(CNN)A woman spoke of her 16-year-old daughter who died after being denied chemotherapy for leukemia because she was in the early weeks of pregnancy. A nurse described how a woman who was experiencing heavy bleeding after self-inducing an abortion was forced by medical providers to wait for treatment as "punishment" -- only to lose too much blood to be saved. An outreach worker remembered the mentally disabled 14-year-old girl who became pregnant at 12, probably by her father, and received no care.

Stories like these are revealed in a new Human Rights Watch report, released Monday, that focuses on the effect of a total government ban on abortions in the Dominican Republic.
The Caribbean nation is one of just 26 countries around the globe that prohibit -- even criminalize -- the procedure with no exceptions, according to the Guttmacher Institute, a research and policy group focused on reproductive health and rights. And the Dominican Republic is one of six countries in the Caribbean and Latin America to maintain restrictions, no matter the circumstances.
    Article 37 in the country's Constitution, which also prohibits the death penalty in all circumstances, reads, "The right to life is inviolable from conception until death."
    But just because abortions are outlawed doesn't mean they don't happen. In fact, Guttmacher has reported that incidence of abortions are no less frequent -- but are less safe -- when they are restricted. And in Latin America and the Caribbean, where 97% of women and girls of reproductive age live in a place with restrictive abortion laws, the rate of abortion has increased, rising 9 percentage points between the early 1990s and 20 years later, Guttmacher found.
    Rosaura Almonte Hernández, known as "Esperancita," died in 2012 after initally being denied chemotherapy because she was pregnant.
    In a nation where the Ministry of Public Health and Social Assistance reports that nearly half of all pregnancies are unplanned or unwanted, the lack of safe and legal options for abortion has real consequences, the report shows.
    "Women and girls in the Dominican Republic have always defied the abortion ban, but they have been forced to put their health and lives on the line to end pregnancies clandestinely," said Margaret Wurth, senior women's rights researcher at Human Rights Watch and the report's author.
    They've tried home remedies, sipped special teas and denied themselves food or water. They've taken prescriptions that aren't supposed to be taken while pregnant, have ingested or inserted other pills to terminate their pregnancies and have tried to harm themselves. One woman reported using a concrete block to beat her belly.

    'Fear that permeates everything'

    Human Rights Watch interviewed 167 people for this report. Included were 50 women and girls who'd experienced unplanned or unwanted pregnancies and dozens of others -- such as health providers, social service professionals and other officials.
    Women with resources who want to terminate their pregnancies may be able to travel outside the country or, with the help of their connections, arrange for abortions through safe clandestine providers. But those who are poor or living in rural parts of the country don't have these options, Wurth said. They are left with two choices: have babies they don't want or fend for themselves to end their pregnancies. Adolescent girls, who often lack access to contraception and information, she said, are especially vulnerable.
    Add to this Article 317 in the Dominican Republic's penal code, which threatens prison sentences when it comes to abortion. Women and girls who self-induce or consent to abortions, and medical providers who provide illegal abortions, face the risk of serving time behind bars.
    In practice, while abortions are against the law even to save the life of a woman or girl, the United Nations reports that "general principles of criminal legislation allow abortions to be performed for this reason on the grounds of necessity."
    But this exception doesn't help every woman or girl who feels she needs an abortion.
    Prosecutions and arrests are rare, but fear of both persists -- often preventing people from seeking or offering help, Wurth explained. Even women who have had miscarriages, she said, admit being afraid to enter hospitals because they might be falsely accused of having induced an abortion.
    "Criminal penalties create fear that permeates everything," the report's author said. It means women and girls believe that "Going to the hospital and saying I had an abortion means I'm going to jail."
    As a result, complications like heavy bleeding or pain go untended to and, in the worst cases, kill. A perforated uterus and tissue remaining in the uterus that leads to sepsis are two examples of what can go horribly wrong.
    Even with the fear of arrest, "there are an estimated 25,000 hospitalizations for abortion and miscarriage in the public health system every year, many of which are women needing care after a clandestine abortion," the report says.
    This information came from Dr. José Mordán, the head of the Department of Family Health at the Ministry of Public Health, in an email he sent this month to Human Rights Watch, the report states. He also said that at least 8% of maternal deaths in the Dominican Republic result from illegal abortions or miscarriages.
    Some of the girls and women who did seek medical help after experiencing complications talked to Human Rights Watch about being mistreated and abused by care providers. They reported name-calling, being denied pain medications and even undergoing surgical procedures without anesthesia.
    But mixed in too are those in the medical community who put their patients first, laws be damned, the report shows.
    "Sometimes you have your hands tied. You don't know what to do. You have the law telling you that you can't do it [perform an abortion]," one doctor told Human Rights Watch researchers. "But it doesn't work like that. ... My job is to preserve the woman's life. If I have to violate the law, I will."

    'A starting point'

    A poll taken in the Dominican Republic by a research organization shows that 79% of those surveyed believe abortion should be decriminalized in certain cases. And protesters, demanding change, took to the streets in July.
    Thousands march in Santo Domingo in July, calling for the decriminalization of abortion in the Dominican Republic.
    A coalition of groups, ob-gyns, the ministry of health and even President Danilo Medina support legalizing abortion in three circumstances, Wurth said: when the life of a woman or girl is endangered, when the pregnancy is a result of rape or incest, and when the pregnancy is unviable and the fetus won't survive outside the womb.
    Medina has objected to the penal code a number of times, encouraging decriminalization in these three circumstances. In a letter to the president of the Senate in 2016, obtained by Human Rights Watch, he called these exceptions "extreme circumstances, terrible, but that occur in daily life, and which we as legitimate representatives of the people, should give responses in accordance with the Constitution and with our values."
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    So far, though, the laws remain the same. It's on the National Congress to enact this kind of reform -- and Wurth is hopeful that it will. Other countries, like Ireland this year and Chile last year, have eased abortion restrictions. And the Guttmacher Institute reports that 27 countries, between 2000 and 2017, reformed their laws to increase legal abortion access.
      Why not the Dominican Republic too, Wurth asked, even if it's limited to three circumstances?
      "It would be a starting point," she said. "There's no place in modern democracy for a ban on abortion."