Opinion / Inequality

The Other Beatrices

Courtesy CEJIL
Courtesy CEJIL

Tuesday, March 7, 2023
Natasha Reifenberg and Jocelyn Viterna

El Faro published this column in Spanish on Nov. 10, 2017.

Beatriz, the woman who captured the attention of El Salvador and the world in 2013, passed away on October 8. Her pregnancy had aggravated the effects of a preexisting disease (systemic lupus erythematosus) and damaged her kidneys. Established medical protocols indicated that Beatriz needed to terminate her pregnancy immediately to prevent further harm and save her life. However, El Salvador's laws prohibited her from receiving the necessary treatment.

The Salvadoran state did not care that Beatriz’s pregnancy was killing her. Nor was it concerned that Beatriz's baby was missing parts of its brain and had no chance of surviving outside the womb. The state ordered that Beatriz be confined to her hospital bed for 81 days as her own organs failed so that she could carry her pregnancy to full term. The baby would not survive outside the womb for more than a few hours. In other words, the Salvadoran state decreed that Beatriz's fundamental right to life was not to be protected.

Perhaps many will be surprised to learn that Beatriz's seemingly extraordinary case is tragically common in El Salvador. In honor of her memory, we are sharing the stories of other mothers forced to sacrifice their own health and lives by a law that criminalizes the termination of pregnancy in all circumstances.

Let’s begin with a case similar to Beatriz. A poor young woman who was ten weeks pregnant and had severe kidney disease was admitted to a public hospital. There, the nephrologist explained to her and her family that the pregnancy put her life at risk. Two months later, the seventeen-year-old girl arrived at the hospital in even worse condition. The family asked the doctor to terminate the pregnancy, but he told them that he would not do so for fear of going to jail. The next day, a pulmonary embolism caused the young woman's lungs to fail. The patient was taken to the intensive care unit, but ultimately both the young woman and the 20-week-old fetus she was carrying died. The father wept and blamed the state’s absolute abortion ban.

A few months ago, a 20-week-pregnant mother of three was admitted to a national hospital. The woman had a serious cardiac condition, which her pregnancy exacerbated, dramatically increasing her risk of death. Upon learning of her heart failure, the mother asked her medical team to induce early labor; she did not want to die and leave her three children orphaned. But the hospital refused to induce her because they did not want to violate the total abortion ban. The woman only made it 26 weeks into her pregnancy before her heart could no longer bear the extra exertion that her pregnancy required. Both the woman and her baby died, and her three children were left without a mother.

There’s also the case of a woman who arrived in the ICU at 23 weeks pregnant with a damaged reproductive system. Understanding that there was no way to save the fetus, her family pleaded with the medical team to terminate the pregnancy. The doctors responded that they could not do the procedure as a “matter of law.” The woman died, as did the fetus she was carrying. Her devastated husband asked the doctor, “How am I going to raise these 8 kids alone?”

In truth, Beatriz’s experience is extraordinary in only one respect: The doctors decided to perform a cesarean section to induce premature labor at 7 months. We were unable to find any other case in which a public hospital induced early labor to terminate a woman’s life-threatening pregnancy.

Instead, we learned about a woman who was 18-weeks pregnant with twins and arrived at the hospital fully dilated. The expulsion of the first baby caused membranes to rupture, but the second baby remained inside her uterus 24 hours later. The woman knew that her 18-week-old fetus had no chance of surviving outside the womb and wanted her doctor to induce contractions to remove it; she was told that if they did she would be “put in jail.” She had to wait and endure severe pain, while the fetus caused a serious infection in her uterus. Eventually, the fetus’s heart stopped beating and was removed.

In addition, because of the law, women who have a tubal ectopic pregnancy —when an embryo implants in the fallopian tubes, not the uterus, and therefore has no chance of developing— cannot terminate their pregnancies immediately. In such cases, the protocol at public hospitals is always to wait to operate until the embryo no longer has a heartbeat. But delaying treatment increases the risk of a tubal rupture, which invariably damages the woman's reproductive ability, causes a serious infection in her abdomen, and endangers her life.

To be clear, Salvadoran law has created a practice incompatible with ethical medicine. It demands that doctors let a pregnant woman die so that an embryo or fetus, which will inevitably die, expires inside the mother’s body, not outside it.

Undoubtedly, the public scrutiny surrounding Beatriz’s case enabled her to terminate her pregnancy, while other women had no choice but to die. Three factors differentiated Beatriz’s situation from the other women’s experiences: the stance of Maternity Hospital’s Medical Committee at the time, which was waiting for the state to authorize the termination of Beatriz’s pregnancy; the social organizations that gave Beatriz legal and emotional support and aid and publicized her lawsuit; and her team of doctors who ultimately accepted the legal risks that ending her pregnancy entailed. Perhaps because the case played out in public, the stakes for the state were too high and it had to relent; the public might see her die before their very eyes, which may explain why the state decided not to charge the doctors who induced Beatriz’s labor.

The Beatriz case marked an important precedent in the fight to decriminalize abortion in El Salvador. Photo courtesy of Cejil.
The Beatriz case marked an important precedent in the fight to decriminalize abortion in El Salvador. Photo courtesy of Cejil.

José Miguel Fortín Magaña, the former director of the Institute of Legal Medicine, tried to explain the exception made for Beatriz by saying that the induction of labor differs from abortion in that its objective is “to save the mother’s life,” while “an abortion is done with the intention of killing the baby.” But his argument contradicts Salvadoran law, which does not allow for any exceptions based on a doctor's “intentions” in terminating a pregnancy. Moreover, his justification is inconsistent with the practices that the doctors at public hospitals described to us. Physicians are afraid to terminate any pregnancy at any time using any method because Salvadoran law prohibits abortion under any circumstance.

Certainly, women with high-risk pregnancies suffer the most under El Salvador’s abortion law, but the prohibition also takes a psychological toll on doctors. They feel paralyzed and fearful, caught in a dilemma between helping their patients and breaking the law. As one put it, “having a case where you know you have to do something but the law forbids it, and then having to watch a life snuffed out right before your eyes, is frustrating and painful.”

Beatriz suffered 81 days during which her kidneys deteriorated; 81 days during which she waited to give birth to her baby, who would assuredly die after delivery; 81 sleepless nights during which she feared that she would never wake up again; 81 days during which she was separated from her one-year-old son. It is hard to believe that she was lucky in any way. But compared to other women, Beatriz was fortunate in the sense that, ultimately, her pregnancy was terminated so that she could survive.

A few months ago, we interviewed Beatriz about her infamous 81-day confinement. She told us about the trauma she endured at the time and the ongoing health problems that she experienced thereafter. But Beatriz also spoke of hope and of her desire to keep fighting until women in El Salvador have access to safe and legal therapeutic abortion.

In our last interview, Beatriz said, “I wouldn't want another woman to go through what I went through.”

As we remember Beatriz, we must also think of the other “Beatrices,” women whose stories were not publicized when they suffered their fates under the law’s terminal prohibition of abortion. The debate over reintroducing therapeutic abortion in El Salvador must continue in the name of those women.

*Translation by Jessica Kirstein

Natasha Reifenberg is a J.D. candidate at Yale Law School. Jocelyn Viterna is a professor of sociology at Harvard University.

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