On the Front Lines of El Salvador’s Underground Abortion Economy

Amid an indifferent state and an activist Church, a defiant network of health workers struggle to offer a reprieve from the world’s most restrictive abortion laws.

People gather outside the National Maternity Hospital in El Salvador on May 30, 2013. (Jose Cabezas/AFP/Getty Images)
People gather outside the National Maternity Hospital in El Salvador on May 30, 2013. (Jose Cabezas/AFP/Getty Images)

SAN SALVADOR, El Salvador — The doctor doesn’t want his real name used, and when asked what he’d like to be called instead he laughs. “Dr. Hell,” he says. With a straw fedora, white Ralph Lauren button-down, and trimmed goatee, he looks better suited to the Hamptons than performing illegal underground abortions in El Salvador, a violence-wracked sliver of Central America that was recently crowned the world’s murder capital.

But halfway through August, he’d already helped three women get abortions under the most restrictive circumstances in the world. Since 1998, El Salvador has been one of six countries where abortion is banned under all circumstances, regardless of whether the mother’s life is at risk, the fetus is viable, or the pregnancy is a result of rape or incest. Under the guidance of the Catholic Church, legislators took the ban a step further the following year and changed the Salvadoran Constitution to state that life begins at conception — securing its legal standing and enshrining the strict interpretation in the country’s political DNA.

Since then, more than 150 women have been prosecuted under the country’s harsh law, some as young as 12 years old. Abortion carries a maximum sentence of 12 years, but depending on the stage of the pregnancy, prosecutors can increase the charge to homicide, which carries up to 40 years behind bars. Compared with other countries that have an absolute ban, like the Dominican Republic and Nicaragua, El Salvador is considered the strongest enforcer by activist groups like the U.S.-based Center for Reproductive Rights.

The country is already a difficult place to be a woman: Sexual violence is built into the country’s endemic gang warfare, the teenage pregnancy rate is Latin America’s highest, and contraception is hard to come by and religiously taboo. But activists say the abortion ban compounds these threats and then punishes the victims, putting marginalized women in prison, undermining trust in the medical system, and leading some desperate young girls to seek desperate options.

The strict laws and lack of alternatives have fueled an underground abortion economy. Between 2005 and 2008, the Ministry of Health counted 19,290 underground abortions. Other estimates put that number as the annual average. Forced into the shadows, many are exposed to poor medical conditions during the procedure, while others are unable to deal with the consequences of being young and pregnant in El Salvador. According to 2011 World Health Organization data, 11 percent of women and girls who underwent an illegal abortion in the country died. Suicide, meanwhile, is the leading cause of death for pregnant teenagers in El Salvador.

Even for a country as religious as El Salvador, the adoption of such a restrictive ban was unexpected. In the 1980s, the country was brutalized by a decade of civil war. When the smoke cleared in 1992, the Farabundo Martí National Liberation Front, a leftist rebel movement, had displaced the right-wing government. The group opposed the abortion ban when it came up as legislation throughout the 1990s but ultimately failed to outweigh the influence of the Catholic Church in 1998 after a lobbying effort by the country’s archbishop. The government and the Ministry of Health never supported the ban, and in October, the ruling party submitted a bill to relax the law under extreme circumstances. But before this, there was little political will to tackle the issue and anti-abortion groups and medical professionals fought it alone, with few government allies.

Doctors, nurses, and pharmacists who offer a defiant reprieve from the law find themselves on the front lines of this underground industry. They risk prison terms to provide clandestine abortions inside public hospitals, private clinics, or outside facilities. Many of them operate independently or in small groups, unaware of the others. If they’re caught, they face six to 12 years in jail.

Dr. Hell says he is compelled by his medical oath to do this work. “Unwanted pregnancy is a health issue, and as a doctor I’m obligated to help a patient with a health issue,” he says. “If I don’t do it — and I’m trained to do it — someone else would do it.” Sometimes, he says, opportunists sell fake drugs or sexually abuse women who come to them for abortions, knowing that reporting the mistreatment would incriminate the women. Medical professionals are bound by law to call the police if they suspect a woman of having an abortion, placing them in an ethically difficult and legally risky position if they don’t report it. But some have taken the law into their own hands.

* * *

Sitting in the courtyard of a brightly muraled building that holds a collection of pro-abortion rights and feminist groups, Dr. Hell scrolls through his phone to the vague text he’s just sent a new patient. “Good day I’m the doctor contacted from the organization from which you requested help. I called,” he wrote in Spanish. Now he’s waiting for a confirmation call. All arrangements from that point on must be face to face. To ensure an undercover officer isn’t setting him up, Dr. Hell always asks a new patient for the referrer’s name or to do an examination. (An officer would never allow it, he says.) The average woman has made up her mind long before they first speak, so he’s suspicious of those who call too many times or ask too many questions.

Each month, Dr. Hell gets a handful of referrals, along with small packages of Misoprostol and Mifepristone, prescription drugs used to induce medical abortions. Four to eight pills can abort a fetus up to 12 weeks with few complications. Before these pills became popular a decade ago, women would sometimes seek treatment in hospitals bearing the signs of using wires or other dangerous methods to abort a pregnancy. Because the pills leave less evidence, it’s now become harder for a hospital to determine if a woman had an abortion and would be criminally liable.

The packages and patient information come from Veronica Fernandez-Montes, an Amsterdam-based employee of the online medical abortion facilitator Women on Web, which mails pills to countries around the world with restricted abortion access. It would be impossible to operate in El Salvador without doctors like him, she says, because many Salvadoran women don’t have access to the internet. If they do manage to order the pills, the package can get delayed for weeks or months in the Salvadoran post, likely arriving too late to be effective.

Dr. Hell wasn’t always opposed to the abortion law. A decade ago, when he was just a fifth-year medical student, his gynecology professor approached him after class. “What do you think about the abortion issue?” he asked. Dr. Hell replied that the medical oath instructed him not to take life away. His professor scoffed, “Do you know anything about reproductive rights?”

The professor told him he’d been performing clandestine abortions, but the demand was getting too high and he was looking for a protégé. He warned his student that they risked losing their license to practice and could face jail time. But the young Dr. Hell was swayed and joined his teacher’s underground practice. At the hospital, they would check in the patient and write in her file that she had a natural miscarriage under their care. Then they would provide her with a dose of Misoprostol to induce the abortion. Four hours later, depending on the woman’s condition, they would give a second dose or do a cleaning to remove the fetus.

Now the 39-year-old doctor runs a public clinic in eastern El Salvador and refers patients who need abortions to his nearby private practice. On weekends, women from the rest of the country are treated in a small clinic he built in his family’s home in San Salvador. He used to perform abortions only within 12 weeks of pregnancy, but after a recent training abroad he can now assist surgically up to 20 weeks. Depending on the woman’s means, he charges between nothing and $1,000.

* * *

In 2013, an influential doctor decided to challenge the ban’s limits. That year, a woman known as Beatriz came under the care of Dr. Guillermo Ortiz, the director of obstetrics at El Salvador’s main maternity hospital. Beatriz was 22 years old and pregnant with her second child. But when she arrived for an exam at three months, Ortiz had bad news: Tests showed the fetus was missing parts of its brain and head. It had no chance of survival. Beatriz suffered from lupus and kidney problems, and the pregnancy was causing her health to decline rapidly. The next day, Ortiz says, she came and asked him to abort the pregnancy. “I’m afraid to die,” she told him.

Almost anywhere else in the world, Ortiz, 48, would have been able to help. But in hospitals in El Salvador, women die as doctors find themselves frozen between taking a fetus’s life and saving a mother’s. Doctors can’t even legally operate on an ectopic pregnancy, a condition where it is impossible for the baby to grow and dangerous for the woman, until there’s no heartbeat. Sometimes, Ortiz says, patients with non-viable pregnancies died after being sent home and told to come back when a fetus’s heart stopped. Ortiz, like many of the medical professionals doing underground abortions, grew tired of watching.

He decided to ask permission to perform an abortion on Beatriz. He appealed to the maternity hospital’s director and they agreed to take Beatriz’s case to El Salvador’s highest court. Before placing himself in the epicenter of a battle with law enforcement over reproductive rights, Ortiz discussed it with his wife and two teenage daughters and hired a personal lawyer.

At the trial, a dozen nurses and doctors testified that Beatriz should be granted an abortion. The court ruled against them 4-to-1, noting the government’s “absolute impediment to authorize the practice of abortion.” But in their decision, the judges wrote that doctors could medically intervene to keep the child and patient alive. Ortiz decided to perform a cesarean section. He removed the 7-month-old baby and placed it in an incubator, where it died a few hours later. “When I came out from the operation room I didn’t know if the police would be outside,” he says. Though he wasn’t prosecuted, he considers the procedure a late-term abortion.

Ortiz was working in the hospital when the ban took effect in 1998 and the experience quickly shaped his views on the restrictive law. Sometimes, he had to examine women while they were handcuffed to a hospital bed, knowing full well where they could end up after his examination. The women’s prison outside San Salvador, which holds at least 21 women serving multidecade sentences for what they say was a miscarriage, is one likely destination. Salvadoran women with means may travel abroad or pay hundreds of dollars for an abortion in a private clinic, which is not required to submit data to the government, but poor women have few options and are disproportionately represented among those imprisoned under the abortion law. In a 2014 report, Amnesty International called the ban “akin to torture” and said that it targets low-income, uneducated women who don’t have access to contraception or prenatal care. Some of the women who are later prosecuted never had a prenatal checkup, or miscarried without even realizing they were pregnant.

Maria Teresa Rivera is one of those women. Five years ago, she woke up handcuffed to a hospital bed with seven police officers surrounding her. She’d been found passed out and bleeding in her bathroom, unaware that she was pregnant with the baby she lost. Rivera, a single mother and garment factory worker, received the longest sentence the courts had issued yet: 40 years in prison for homicide. Rivera recalls walking into her trial confident that it was all a mistake. “I felt things going wrong at the moment the judge argued that I had a middle-school education and knew what was happening,” she says. During one hearing, she was represented by a lawyer from the prosecution. When the guilty verdict was announced she did a quick calculation of how old her son would be at her release: 47.

“We face one of the toughest laws and inequalities,” Rivera says, sitting in the courtyard offices of the pro-abortion rights group that successfully fought for her release. “They steal our rights, and we don’t even have the opportunity to say that those are our rights.”

Rivera has become one of the faces of the abortion ban. This year her sentence was overturned, and she now awaits the attorney general’s appeal. Dr. Ortiz, meanwhile, has since left El Salvador for North Carolina, where he works with a pro-abortion rights organization called IPAS and hopes to raise his son and two teenage daughters under more liberal reproductive rights. But those who remain still face prosecution under the harsh abortion ban back in El Salvador, and an untold number of medical providers still work desperately to reach them.

Along with a few other sympathetic physicians, Dr. Hell is working to combat the lack of abortion providers by creating a network of trained professionals across the country, including legal council and administrative help. There’s only one thing that could stop him. In July, an amendment to the law was introduced to parliament. It would raise abortion sentences from a minimum of two years to a minimum of 30 years — the equivalent to a sentence for aggravated homicide with extreme cruelty. “I would risk doing this for $3,000 to $4,000,” he says. “Then women who don’t have money — I can’t help them.”

For now, the law waits for a full congressional vote, and Dr. Hell continues his crusade, but before long he may be forced to make a difficult decision. “El Salvador is a country where anything could happen,” he offers, when asked if he thinks the law will be enacted.

The International Women’s Media Foundation supported Nina Strochlic’s reporting from El Salvador.

Photo credit: The National Maternity Hospital in San Salvador. JOSE CABEZAS/AFP/Getty Images

Nina Strochlic is a staff writer covering culture, adventure, and science for National Geographic.

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