August 23, 2013

Impact of Ecuador’s Abortion Ban on Women and Girls

Human Rights Watch evaluated the impact of Ecuador’s existing abortion law on the basis of interviews with individual women and girls, health care professionals, government officials, and other experts (described in the methodology section). We found that Ecuador’s criminal ban on abortions, including in the case of rape (except for so-called “idiot or demented” women), (1) hinders medical professionals’ ability to detect sexual violence or other forms of gender-based violence, (2) contributes to Ecuador’s high maternal mortality and morbidity rates, (3) creates delays or obstacles for women and girls needing potentially life-saving care, and (4) perpetuates negative stereotypes about and discrimination against women and girls living with disabilities, which may risk depriving them of their legal right to make decisions about when and whether to have children.

Detection and Prevention of Sexual Violence and Other Forms of Gender-Based Violence

Ecuador has high rates of violence against women, including sexual violence. A 2011 government-conducted nationwide survey of almost 19,000 households in all of Ecuador’s 24 provinces found that 60 percent of Ecuadoran women respondents had experienced some type of gender-based violence in their lifetimes.[15] According to government estimates based on its analysis of data from the survey, one out of every four women in Ecuador has suffered sexual violence in her lifetime.[16] Of women who reported sexual violence in the survey, 53.3 percent said their partner or ex-partner was the perpetrator, while 46.5 percent reported that the perpetrator was someone other than a partner or ex-partner.[17]

Although Ecuador is actively taking steps to address gender-based violence,[18] the criminalization of abortion after rape creates obstacles for Ecuador to effectively tackle the high rates of violence against women.

The Ecuadoran Ministry of Public Health has developed detailed norms for the comprehensive treatment and care of pregnant and post-partum women and girls, including the detection of sexual abuse and intra-familial violence.[19] However, when victims of sexual violence seek post-abortion medical care for complications from clandestine, illegal abortions, the current abortion law serves as a disincentive to reporting the violence, because the victims fear that clinic or hospital staff will conclude they illegally induced the abortions themselves. As detailed below, this makes detection of violence against women and girls more difficult, and contributes to impunity for such violence.

The majority of medical professionals interviewed by Human Rights Watch said that they believe fear of criminal penalties distorts what women and girls are willing to tell them, and thus leads them to miss opportunities to refer the women and girls to appropriate services. These professionals said that if women or girls arriving at clinics or hospitals with abortions in process or needing post-abortion care tell doctors that they were raped, medical professionals and state authorities may suspect that the women or girls intentionally and illegally terminated their pregnancy.

According to a 2013 WHO report on gender-based violence globally, women who have been physically or sexually abused by their partners are more likely to seek an abortion than women who have not experienced partner violence.[20] In its analysis, the WHO emphasizes the importance of health-care providers “identify[ing] opportunities to provide support and link women with other services they need....”[21] But as the WHO notes, and Human Rights Watch interviews in Ecuador confirm, women and girl survivors of violence may seek health care, particularly sexual and reproductive services including post-abortion care, and not disclose information about the violence to providers.[22]

For example, at a health clinic in the city of Santo Domingo in Tsachilas, two medical professionals in separate interviews told Human Rights Watch about a woman they jointly treated twice for reproductive post-abortion care, in April 2013 and in June 2013.[23] The patient did not report that the pregnancies were the product of sexual violence; however, the woman had in previous routine medical visits told the medical professionals that her partner was sometimes violent.[24] The professionals suspected that both abortions were punishable under Ecuadorian law. They did not question the woman further about violence by her partner or ask whether the pregnancies resulted from rape, nor did they refer the case to authorities for fear the woman could be subject to prosecution.[25] The clinic provided the woman with necessary medical post-abortion treatment, but did not refer her to services for victims of sexual violence. The current status of the patient is unknown.

A counselor at the same clinic recounted a similar case within the last 10 years of a 13-year-old girl. The child came to the clinic needing post-abortion care for three separate pregnancies in the course of one year.[26] The criminal ban on abortion was in effect at the time. Each time, the girl’s father accompanied her to the clinic, raising questions in the professional judgment of health professionals as to how much he knew about who was sexually abusing and impregnating his daughter. Under the law the age of consent is 14, meaning at the very least each of these pregnancies resulted from statutory rape. When the counselor tried to speak with the girl about her pregnancies, the abortion, and the potential abuse, she refused to speak. The counselor did not refer the case to authorities for further investigation because medical evidence strongly suggested that the child’s abortions were induced in all three cases, opening her up to potential juvenile justice consequences.[27] The clinic did not conduct follow-up in the patient’s case, and had no information about the girl’s current circumstances.

Almost half of the medical professionals interviewed by Human Rights Watch described cases they had handled of adolescent girls or young women that came to clinics seeking abortions after what the patients described as cases of rape.[28] These girls and young women were not what the medical professionals thought might be considered “idiot or demented” under the law, a phrase nowhere defined in Ecuadorian law, nor, in their view, did the pregnancies threaten the lives or health of the women and girls. The medical professionals had to turn away these women and girls, some as young as 12 years old, because abortion was not legal in their cases. These professionals did encourage the victims of violence to report the rapes to prosecutors, but none were aware of the victims having done so. As one peer counselor told Human Rights Watch, “these girls [and women] want to end the pregnancy” more than they want justice.[29] Reporting the cases to prosecutors would make securing an illegal abortion more difficult, because authorities would be aware of the pregnancy. They would then know if the pregnancy was terminated, and could prosecute the woman or girl for undergoing an abortion. For example, one Ministry of Health official told Human Rights Watch about a case of an 11-year-old girl whose pregnancy became a source of evidence for prosecutors in the rape case against the suspect.[30] The alleged perpetrator, a close family member, remained free until the child could give birth and a DNA test could be conducted on the baby to establish paternity.[31]

Maternal Mortality and Morbidity

Global studies underscore that the criminalization of abortion does not reduce the number of abortions,[32] but instead drives women and girls to seek clandestine and unsafe abortions that contribute to maternal mortality and morbidity. This is a major concern for Ecuador, which has high rates of maternal mortality and morbidity.

Though lauded by development organizations as a success story in meeting many of its Millennium Development Goals (development goals agreed upon states and institutions in 2000 with targets and benchmarks through 2015),[33] recent government statistics indicate Ecuador is not on track to meet its goal of reducing maternal deaths by 75 percent from 1990 levels—from estimates as high as 150— to 29 maternal deaths per 100,000 live births.[34] Since 2008, the Ministry of Health has undertaken significant efforts to reduce the maternal mortality ratio, including the development of detailed norms and technical guides on maternal health.[35] Such efforts have led to a reduction in maternal deaths caused by post-partum hemorrhaging.[36] Nevertheless, maternal mortality in Ecuador remains stubbornly high.[37] Lack of data and differences in the methodologies used by the government and international agencies in their calculations have led to conflicting estimates of maternal mortality ratios, but none of the government’s most recent calculations reported by the National Institute for Statistics and Census put Ecuador on track to meet its goal.

In 2011 the government-reported maternal mortality ratio was 105 maternal deaths for every 100,000 live births—more than three times its target ratio.[38] According to government statistics using the same ratio of maternal deaths to 100,000 live births, the 2011 ratio of maternal death is more than twice as the high as the ratio in 2006, which was 48 maternal deaths per 100,000 live births.[39] In 2011, the maternal mortality ratio was as high as 290 for every 100,000 live births in the province of Sucumbios,[40] a higher ratio than in Bangladesh, Pakistan, and some countries in sub-Saharan Africa.[41]

According to government data, complications from abortion—whether a legal abortion or one procured illegally—killed at least 10 women or girls in Ecuador in 2011.[42] The number of women or girls that died from unsafe abortions in fact is likely to be higher, because few doctors report the actual cause of death or morbidity, instead reporting cases of abortion as sepsis, hemorrhaging, and other pregnancy and post-partum complications.[43] Therefore, the actual number of deaths related to abortion in 2011 likely includes the 10 known cases plus some of the 93 deaths listed as due to post-partum hemorrhaging, sepsis, and unspecified causes.[44]

One former Ministry of Health official told Human Rights Watch that he believes the ministry has reached the maximum that it is able to do within the law to prevent maternal injury and deaths by producing detailed norms, protocols, and practical guides.[45] In the opinion of this former government official, a legal and political change through criminal code reform broadening exceptions to penalties for abortion is needed to protect the health and lives of Ecuador’s women and girls from maternal mortality and morbidity.[46] Allowing abortion in the case of sexual violence is an important legal change that could reduce the number of illegal and unsafe abortions.

According to government data, abortion (no breakdown was provided differentiating between legally and illegally procured abortions) was the leading cause of morbidity in women in Ecuador’s hospitals in 2011, with over 23,000 cases of disease, disability, or physical harm.[47] This classification is widely understood by medical professionals to be one of the categories under which health facilities report treatment of women who have complications arising from unsafe, induced abortion (as opposed to spontaneous miscarriages). Several doctors and former officials said they believe the true number of abortion-related injuries is much higher, and expressed frustration that doctors and hospitals are vague and inaccurate when reporting such morbidity because they fear criminal penalties against their patients.[48] As one doctor told Human Rights Watch, “decriminalizing abortion [in the case of rape] would mean we could accurately report on the reproductive health of women. There would be more transparency about what is going on and [ability to] help.”[49]

The impact on health-care costs for post-abortion care for clandestine abortions in Ecuador is unknown, but may in fact be very high given the reported numbers of hospitalizations related to abortion. According to a general estimate, the cost in Latin American countries in 2006 was as high as $109 dollars per patient seeking post-abortion care, or an inflation-adjusted cost of $126 per patient in 2013.[50]

Of great concern is the number of cases of abortion-related morbidity affecting girls and adolescents. Ecuador estimates that in 2011, there were 258 cases of abortion-related morbidity in girls ages 10 to 14, and over 4,000 cases in girls and women ages 15 to 19.[51] The WHO has warned that pregnant adolescents are more likely than adults to have unsafe abortions, and that such abortions contribute substantially to lasting health problems and maternal deaths.[52] Government statistics show a 74 percent increase in pregnancies among 10- to 14-year-olds in the last decade, and childbirth is the second leading cause of morbidity in girls ages 10 to 14 in Ecuador.[53] Women’s rights organizations in Ecuador note that there is a high likelihood that many of these girls became pregnant due to sexual abuse.[54] According to the age of consent, any pregnancy in a girl under the age of 14 would be a product of statutory rape.[55]

The limited availability of misoprostol, a multi-use drug that can be used to perform generally safe, medical abortions, has reduced the number of abortions performed with instruments in the region. Nevertheless, medical professionals in Ecuador confirmed that “even with misoprostol available, very grave cases still exist—uterine perforations, infections, sepsis, bleeding—from [surgical abortions]. [And] [w]ith misoprostol, women still come in bleeding.”[56]

All of the medical professionals with whom Human Rights Watch spoke had treated or provided post-abortion care to women and girls who had complications arising from illegal abortions, while a few had patients who had died from an illegal abortion.[57] One doctor in Quito told Human Rights Watch about a case dating from approximately 2007 of a 24-year-old woman who arrived at the main maternity hospital in Quito too late to be saved.[58] She had a uterine perforation and internal bleeding from an unsafe abortion, and blood filled her abdomen. Though the doctor and colleagues took emergency measures immediately, the woman died in this doctor’s arms. He does not have any idea about the events that caused her death. When abortion is illegal, he said, “women live through abortion alone. All the information about the abortion died with her,” he told Human Rights Watch. Doctors at the hospital did not know why she had the abortion, or if she had been victim of rape. They also did not know where she received the abortion, information which could have helped them dissuade other women from using the same provider, or if it was self-induced.

A counselor working at a women’s health clinic in the town of Latacunga, Cotopaxi province, told Human Rights Watch of an incident in which a woman was left with a permanent disability after an attempted abortion.[59] The woman first sought an abortion at a private health clinic in Latacunga. The woman explained that her husband was abusive, and would not allow her to practice family planning. The counselor said she explained to the woman that it was illegal to perform an abortion, but in the future they could work with her to find a family planning method for her situation. The woman did not disclose further information, including whether the pregnancy was the result of intimate partner violence. The woman eventually found a clandestine clinic in the nearby town of Ambato to perform the abortion.

The clandestine abortion did not end the woman’s suffering, as the counselor discovered in a subsequent conversation with her. Instead, the abuse continued and, when the woman became pregnant again several months later, she climbed the tallest tree she could find and threw herself from the highest branch she could reach—hoping to induce an abortion. Rushed to the hospital, she did not disclose she was pregnant. The fall did not induce an abortion. She received x-rays to evaluate injuries as a result of her fall, exposing the fetus to high levels of radiation. Under these circumstances, she was able to secure a safe abortion.[60] The woman, however, broke her spine in the fall and is confined to a wheelchair for the rest of her life.[61]

Medical professionals who spoke to Human Rights Watch also lamented the cases they did not treat. Many of them recounted stories of adolescent girls or young women who sought abortions after what their patients described as rape.[62] The professionals said that after they informed their patients that abortion is not legal even after rape, the patients left and did not return—leaving them without any knowledge of the fate of the girls and young women.

Obstacles to Obtaining Potentially Life-Saving Care

The illegality of abortion, including after rape, leads some women and girls who experience abortion-related complications to delay seeking important medical care. Their reluctance to speak about the abortion can also compromise the quality of treatment they receive.[63]

All of the medical professionals interviewed by Human Rights Watch said that when women and girls who have had illegal abortions do seek care, most often they do not tell healthcare professionals how they went about trying to induce an abortion. Medical professionals told us that women and girls come in bleeding, sometimes with infections, yet offer little information. They said this forces them to guess what happened to their patients, and undermines their ability to provide timely, quality care.[64] As one doctor described, “women don’t tell you what happened; there is fear and it is illegal. [But] women still die from induced abortion.”[65] Lack of information about what occurred makes treatment difficult. A certified midwife told Human Rights Watch, “[t]hey say ‘I fell’ or ‘I hit something.’ Rarely will they tell the truth.”[66] Another doctor said, “[p]atients don’t tell us the truth when they come in with abortions in progress. In their clinical history, they don't say they took anything.”[67]

Some women and girls, even if they are not afraid to disclose that they intentionally induced the abortion, do not have complete information about how the abortion was performed in order to inform the doctor’s treatment. One doctor explained that the abortions she sees can be induced with anything from unknown injections, herbs, malaria pills, anti-parasite drugs, and other methods. “Women don’t even know what they are most of the time,” the doctor said.[68] A counselor Human Rights Watch interviewed described the fear this instilled in patients she saw: “[The women come in with] fever, pain, infections and bleeding; they don’t know what they took, or what was injected, or what will happen to them.”[69]

Negative Stereotypes and Discrimination against Women and Girls Living with Disabilities

The current criminal code article related to abortion perpetuates negative stereotypes about women and girls living with disabilities, implying that they are more likely to be “unfit” mothers, and thus eligible for abortion after sexual violence even when other women and girls are not. The application of this provision is rare, and none of the medical professionals interviewed by Human Rights Watch said they had been involved in providing abortions for so-called “idiot or demented” women or girls. Independent of how often it is applied, though, the provision uses outmoded and offensive terms and, as described below, may in some cases contribute to human rights violations.

The terms “idiota” and “demente” do not have modern medical significance and are not defined in the law.[70] These terms are inconsistent with Ecuador’s disability-rights respecting Constitution, its disability laws, and its obligations under the Convention on the Rights of Persons with Disabilities (CRPD), which calls for equal treatment under the law.[71] Moreover, medical professionals told Human Rights Watch that the vagueness of these terms makes it difficult for them to assess the legality of abortion when women and girls with disabilities become pregnant as a result of sexual violence.[72]

To operate within the law in assessing whether rape victims are eligible for abortions, doctors must determine whether a woman or girl in question falls within the anachronistic terms “idiota” or “demente”—conditions without modern medical diagnostics. Some doctors with whom Human Rights Watch spoke literally threw up their hands in disgust at the idea of having to ask a woman, who has admitted to being pregnant from an act of sexual violence, if she is an “idiota” or “demente.”

In addition, this challenge may lead some doctors to choose to rely on a woman or girl’s legal guardian to make decisions about her health, making it more likely they will undergo abortions without their consent. This would be contrary to Article 23 of the CRPD and the call from the Committee on the Rights of Persons with Disabilities for the “abolition of surgery and treatment without the full and informed consent of the patient.”[73]

Uncertainty around the definition of “idiot” and “demented” may also create delays in processing requests for legal abortion. A Ministry of Health official in Cotopaxi told Human Rights Watch that she was aware of at least two cases in the last few years of children under the age of 14 (one was 11) with disabilities who filed for legal abortions. Although the official was not certain of the reason for the delays, she believed they were due to confusion in determining whether the girls met the definition. Neither of the requests was processed in time and both children carried the pregnancies to term, she said.[74]

[15]The survey was conducted in accordance with Ecuador’s 2007 National Plan for the Eradication of Gender-based Violence. It defined gender-based violence as physical, psychological, or sexual violence, as defined in domestic law, and patrimonial violence, as defined by Ecuador’s international obligations under the American Convention Belém do Pará. See Ley contra la violencia a la mujer y la familia, 2007, art. 4, literal a, b, y c. INEC, Encuesta Nacional sobre Relaciones Familiares y Violencia de Género contra las Mujeres, 2011.

[16] Ibid., According to the survey, s 25.7 percent of women in Ecuador have suffered sexual violence in their lifetimes.

[17]Ibid.

[18] See, for example, Resolución 057-2013, http://www.funcionjudicial.gob.ec/www/pdf/resoluciones/2013cj/057-2013.PDF (accessed July 22, 2013). This resolution creates legal units for victims of domestic and gender-based violence, removing the competency for enforcement of Law 103 from the Comisarias de la mujer y la familia and situating it in the Justice Council. See also “Las Unidades Judiciales de Violencia contra la Mujer empezaron a trabajar,” El Ciudadano, July 17, 2013, http://www.elciudadano.gob.ec/index.php?option=com_content&view=article&id=43899:el-tramite-judicial-de-los-casos-de-violencia-contra-la-mujer-seran-mas-agiles&catid=40:actualidad&Itemid=63 (accessed July 17, 2013). The objective of this change is to provide a comprehensive attention to victims of gender-based violence. These units will have judicial officers, and will also provide psycho-social support and other services to survivors of violence.

[19] Ministry of Public Health, Componente Normativo Materno, 2008, p. 27, https://aplicaciones.msp.gob.ec/salud/archivosdigitales/documentosDirecciones/dnn/archivos/COMPONENTE%20NORMATIVO%20MATERNO.pdf (accessed July 20, 2013). See also Ministerio de Salud Publica, Norma y protocolos de atención integral a la violencia de género, intrafamiliar y sexual por ciclos de vida, 2011, http://aplicaciones.msp.gob.ec/salud/archivosdigitales/documentosDirecciones/dnn/archivos/NORMAS%20Y%20PROTOCOLOS%20DE%20ATENCI%C3%93N%20INTEGRAL%20A%20LA%20VIOLENCIA%20DE%20G%C3%89NERO.pdf (accessed July 22, 2013); Ministerio de Salud Publica, Guia de atención integral en violencia de género, 2012, http://aplicaciones.msp.gob.ec/salud/archivosdigitales/documentosDirecciones/dnn/archivos/GU%C3%8DA%20DE%20ATENCI%C3%93N%20INTEGRAL%20EN%20VIOLENCIA%20DE%20G%C3%89NERO.pdf (accessed July 22, 2013).

[20] The study states that victims of sexual or physical violence are two times more likely to seek an abortion than women who have not experienced partner violence, but the impact of the legal status of abortion on this decision is not clear. World Health Organization, Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence, 2013, p. 2, http://apps.who.int/iris/bitstream/10665/85239/1/9789241564625_eng.pdf (accessed July 20, 2013) [hereinafter WHO Report]. A Spanish summary of the report can be found at: http://apps.who.int/iris/bitstream/10665/85243/1/WHO_RHR_HRP_13.06_spa.pdf (accessed July 20, 2013). WHO also identifies other poor health outcomes for women victims of violence, including increased “incident HIV infection, incident sexually transmitted infections (STIs), […], low birth weight, premature birth, growth restriction in utero and/or small for gestational age, alcohol use, depression and suicide, injuries, and death from homicide. WHO Report, p. 21.

[21] Ibid., p. 3.

[22] Ibid., p. 35. Almost all 45 health care professionals who provide post-abortion care interviewed by Human Rights Watch between June and July 2013 confirmed this. For example, Dra. G in Quito told Human Rights Watch that “many of the cases [I treat for post-abortion care] are due to sexual violence, but patients never tell [me] that.” Human Rights Watch interview with Dra. G., Quito, June 26, 2013. See also, Human Rights Watch skype interview with Obst. D., Guayaquil, July 9, 2013.

[23] Human Rights Watch interview with Lcda. N.Z., consejera, Santo Domingo, July 5, 2013. See also Human Rights Watch interview with Dra. L. T., gynecologist, Santa Domingo, July 5, 2013.

[24] Ibid.

[25] Ibid.

[26] Human Rights Watch interview with Lcda. N.Z., Consejera, Santo Domingo, July 5, 2013. The counselor could not remember the exact date of the case, but approximated it took place in the last 10 years.

[27] Ibid. According to Ecuador’s Code for Children and Adolescents, children under the age of 12 years will not be subject to any form of liability. Adolescents over the age of 12 years who commit an infraction of criminal law cannot be held liable in a criminal court of ordinary jurisdiction. Instead, adolescents may be subject to social-educative measures. See Code for Children and Adolescents, 2003, arts. 305-07.  

[28] See, for example, Human Rights Watch interview with M.C., Quito, June 3, 2013, referring to a pregnant 13-year-old victim of sexual abuse by step-father; Human Rights Watch interview with Obst. M., Riobamba, July 15, 2013, referring to a pregnant 14-year-old victim of sexual abuse; Human Rights Watch telephone interview with Dra. M.C., Rio Verde, July 4, 2013, referring to a pregnant 12-year-old victim of sexual violence, assaulted after being drugged at a party; Human Rights Watch interview with S., peer counselor, July 10, 2013, referring to a case of a pregnant 14- or 16–year-old victim of sexual violence, assaulted after being drugged at a party, and to a pregnant 22-year-old victim of kidnapping and sexual violence. All of these cases occurred within the last three to four years.

[29] Human Rights Watch interview with S., peer counselor, July 10, 2013, referring to a case of a pregnant 14- or 16-year-old victim of sexual violence, assaulted after being drugged at a party, and to a pregnant 22-year-old victim of kidnapping and sexual violence.

[30] Human Rights Watch interview with Lcda. G, Latacunga, July 16, 2013.

[31] Ibid.

[32] See, G. Sedgh, S. Singh, S. K. Henshaw, and, A. Bankole, “Induced abortion: incidence and trends worldwide from 1995 to 2008,” The Lancet, February 18, 2012, vol. 379, issue 9816, pp. 625632. WHO, Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008, 6th ed. (WHO: Geneva, 2011), p. 6.

[33] For example, the Center for Global Development (CDG) ranked Ecuador first in the world, tied with Egypt and Honduras, in progress toward meeting its Millennium Development Goals in 2011. See Center for Global Development, “MDG Progress Index: Gauging Country-Level Achievements,” 2011, http://www.cgdev.org/page/mdg-progress-index-gauging-country-level-achievements (accessed July 22, 2013).

[34] The target maternal mortality ratio for Ecuador by 2015 is 29 maternal deaths per 100,000 live births. See United Nations Development Programme, Second National Report of the Millennium Development Goals- Ecuador, 2007, p. 18, http://www.undp.org.ec/odm/II_INFORME_NACIONAL.pdf (accessed July 22, 2013). National data on maternal mortality was not available in 1990; the 1990 estimate is a modeled ration from the United Nations Statistic Division. In 2011, Ecuador had a ratio of 105 deaths per 100,000 live births. INEC-Estadistícas Vitales: Nacimientos y Defunciones 2011, p. 15, http://www.inec.gob.ec/estadisticas_sociales/nac_def_2011/anuario.pdf (accessed July 22, 2013). In contrast, the ratios used in the Center for Global Development (CGD) report referenced in previous footnote, which concluded Ecuador was on track to meet its target maternal mortality ratio, were taken from a study which projected maternal morality ratios in 181 countries. The projections were calculated from preexisting estimated maternal morality ratios collected from vital registration data, censuses, surveys, and verbal autopsy studies dated from 1980-2008. See Margaret C Hogan, Kyle J Foreman, Mohsen Naghavi, Stephanie Y, Mengru Wang, Susanna M Makela, Alan D Lopez, Rafael Lozano, and Christopher JL Murray, “Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5,”The Lancet, Volume 375, Issue 9726, Pages 1609 - 1623 (2010). The more recent government statistics from Ecuador show an increase in the maternal morality ratios, rather than the projected decrease reported by CGD, based on the Lancet study. See discussion below.

[35]See, for example, Ley de Maternidad Gratuita y Atención a la Infancia, 1994, http://www.gparlamentario.org/spip/IMG/pdf/Ley_de_Maternidad_y_proteccion_a_la_infancia.pdf (accessed July 22, 2013); Ministerio de Salud Pública, Componente Normativo Materno, 2008; Ministerio de Salud Pública, Guía técnica para la atención del parto culturalmente adecuado, 2008, http://aecid.lac.unfpa.org/webdav/site/AECID/shared/files/Gu%C3%ADa%20T%C3%A9cnica%20para%20la%20Atenci%C3%B3n%20del%20Parto%20Culturalmente%20Adecuado.pdf (accessed July 22, 2013); Ministerio de Salud Pública, Normas y Protocolo de planificación familiar, 2010, http://aplicaciones.msp.gob.ec/salud/archivosdigitales/documentosDirecciones/dnn/archivos/NORMA%20Y%20PROTOCOLO%20DE%20PLANIFICACION%20FAMILIAR.pdf (accessed July 22, 2013); Ministerio de Salud Pública, Reglamento para regular el acceso de métodos anticonceptivos, 2013, http://www.lexis.com.ec/webtools/biblioteca_silec/documentos/noticias/2013-04-22Acuerdo%20Ministerial%202490.pdf (accessed July 22, 2013).

[36]Human Rights Watch interview with former Ministry of Health official, Quito, June 6, 2013.

[37] The Pan-American Health Organization has claimed that the maternal mortality ratio in Ecuador is “one of the hardest indicators to assess because of the diversity of sources and inaccuracies in selecting both the numerator and denominator.” Pan-American Health Organization, Health in the Americas, Ecuador Chapter, 2012 Edition, p. 291, http://www.paho.org/saludenlasamericas/index.php?option=com_docman&task=doc_view&gid=128&Itemid= (accessed July 20, 2013). None of the government’s most recent calculations reported by the National Institute for Statistics and Census put Ecuador on track to meet its goal.

[38] INEC-Estadistícas Vitales: Nacimientos y Defunciones 2011, p. 15, http://www.inec.gob.ec/estadisticas_sociales/nac_def_2011/anuario.pdf (accessed July 22, 2013).

[39] Ibid.

[40] Ibid., p. 24. This number was calculated by Human Rights Watch by converting the rate provided by the government, which used an estimate of live births in the region for 2011 as a denominator, to the more standard calculation of deaths per 100,000 live births.

[41] This is based on comparison of 2010 data, not 2011 data. World Bank, Maternal mortality ratio (modeled estimate, per 100,000 live births), 2010, http://data.worldbank.org/indicator/SH.STA.MMRT?order=wbapi_data_value_2010+wbapi_data_value+wbapi_data_value-first&sort=desc (accessed July 22, 2013).

[42] INEC-Estadistícas Vitales: Nacimientos y Defunciones 2011, p. 195.

[43] See, for example, Human Rights Watch interview with Ministry of Public Health official, Quito, June 25, 2013.

[44] There are 41 post-partum hemorrhaging deaths; 2o deaths from sepsis; and 32 non-specific deaths, including deaths related to labor or complications with labor, hemorrhage not listed anywhere else, death by other direct obstetric causes, and unclassified obstetric death. INEC-Estadistícas Vitales: Nacimientos y Defunciones 2011, p. 29.

[45] Human Rights Watch interview with former Ministry of Health official, Quito, July 9, 2013.

[46] Ibid.

[47]INEC, Anuario de Estadisticas Hospitalarias Egresos, 2011, http://www.inec.gob.ec/estadisticas_sociales/Cam_Egre_Hos_2011/anuario.pdf (accessed July 22, 2013).

[48]See, for example, Human Rights Watch interview with Gynecologist previously associated with Ministry of Health and the country’s largest maternity hospital, Quito, June 10, 2013; and Human Rights Watch interview with Ministry of Health official, June 25, 2013.

[49]Human Rights Watch interview with Dr. A.M., Santo Domingo, July 4, 2013.

[50]Michael Vlassoff, et al, “Estimates of Health Care System Costs of Unsafe Abortion in Africa and Latin America,” vol. 35, no. 3, September 2009, p.114-121.

[51]INEC, Anuario de Estadísticas Hospitalarias: Camas y Egresos, 2011, http://www.inec.gob.ec/estadisticas_sociales/Cam_Egre_Hos_2011/anuario.pdf (accessed July 22, 2013).

[52]World Health Organization. Adolescent pregnancy, Geneva, World Health Organization, 2012. 2012. http://www.who.int/mediacentre/factsheets/fs364/en/index.html, (accessed July 27, 2013).

[53]Dirección de Normatización del Sistema Nacional de Salud, Normas y Procedimientos para la atención integral de salud a adolescentes, annex 1, p. 70, 2009.

[54]For example, Movimeinto Nacional de Mujeres y Feministas del Ecuador, Propuestas de Las Mujeres al Proyecto de Codigo Organico Integral Penal, September 2012, p. 12; see also Human Rights Watch interview with women’s rights specialist, Quito, June 13, 2013.

[55] Criminal Code of Ecuador, art. 512.1.

[56] Human Rights Watch interview with Dr. C.A., Quito, June 24, 2013.

[57] See, for example, Human Rights Watch interview with Dra. A., July 2, 2013, Esmeraldas; Human Rights Watch interview with Dr. W., Quito, July 9, 2013.

[58] Ibid.

[59] Human Rights Watch interview with counselor, Latacunga, July 13, 2013. The interviewee could not recall the exact dates of this case, but estimated the first abortion occurred about eight years ago.

[60] There is no exception provided for in the Ecuador Criminal Code for abortions on the basis of fetal malformation or poor health. There are, however, regulations within the health code that allow doctors to perform abortions in the case of fetal malformations upon the consent of two doctors. While this leads many people to believe the procedures are exempt under the criminal code, there is no such explicit exemption.

[61] Human Rights Watch interview with counselor, Latacunga, July 13, 2013.

[62] See, for example, Human Rights Watch interview with M.C., Quito, June 3, 2013, referring to a pregnant 13-year-old victim of sexual abuse by step-father; Human Rights Watch interview with Obst. M., Riobamba, July 15, 2013, referring to a pregnant 14-year-old victim of sexual abuse; Human Rights Watch telephonic interview with Dra. M.C., Rio Verde, July 4, 2013, referring to a pregnant 12-year-old victim of sexual violence, assaulted after being drugged at a party; Human Rights Watch interview with S., peer counselor, July 10, 2013, referring to a case of a pregnant 14- or 16–year-old victim of sexual violence, assaulted after being drugged at a party, and to a pregnant 22-year-old victim of kidnapping and sexual violence. All of these cases occurred within the last three to four years.

[63] See, for example, Human Rights Watch interview with Dr. W., Quito, July 9, 2013.

[64] See, for example, Human Rights Watch interview with Dra. A., Esmeraldas, July 2, 2013; Human Rights Watch interview with Dr. W., Quito, July 9, 2013; Human Rights Watch interview with Dra. S, Quinindé, July 1, 2013; Human Rights Watch interview with Lcda. A.M., Santo Domingo, July 4, 2013; Human Rights Watch interview with Obst. C., Cajabamba, July 14, 2013.

[65] Human Rights Watch interview with Dr. A.M., Santo Domingo, July 4, 2013.

[66] Human Rights Watch interview with Obst. M., Riobamba, July 15, 2013.

[67] Human Rights Watch interview with Dra. M.M., Quito, June 24, 2013.

[68] Human Rights Watch interview with Dra. S, Quinindé, July 1, 2013.

[69] Human Rights Watch interview with Lcda. A.M., Santo Domingo, July 4, 2013.

[70] In 2012, the UN Committee on Economic, Social and Cultural Rights urged Ecuador to expunge these anachronistic terms from it criminal code. UN Committee on Economic, Social and Cultural Rights, “Observaciones finales del Comité sobre el tercer informe de Ecuador, aprobada por el Comité de Derechos Económicos, Sociales y Culturales en su cuadragésimo noveno período de sesiones,” General Comment No.29, Abortion, U.N. Doc. E/C.12/ECU/CO/3 (2012), http://www2.ohchr.org/english/bodies/cescr/docs/E.C.12.ECU.CO.3_sp.pdf (accessed July 22, 2013).

[71] Convention on the Rights  of  Persons with Disabilities, art. 12.

[72] See, for example, Human Rights Watch interview with Dr. E., former Ministry of Health official, Quito, June 6, 2013; Human Rights Watch interview with Dra. M., Quito, June 20, 2013; and Human Rights Watch interview with Dr. A, Quito, June 24, 2013.

[73] CRPD, art. 23(b); and UN Committee on the Rights of Persons with Disabilities (CRPD Committee), Concluding Observations: Tunisia, para. 29, U.N. Doc. CRPD/C/TUN/CO/1 (2011).

[74] Human Rights Watch interview with Lcda. G, Latacunga, July 16, 2013.