“It’s Your Decision, It’s Your Life”

The Total Criminalization of Abortion in the Dominican Republic

 

Summary

Abortion is illegal in the Dominican Republic in all circumstances, even when the life of the pregnant woman or girl is in danger. The country’s total abortion ban has devastating consequences. Women and girls facing unplanned or unwanted pregnancies—including those resulting from rape or incest, or when the fetus will not survive—are forced to choose between clandestine abortion or continuing their pregnancies, even if they do not want to and even if they face serious health risks, including death. Some women and girls can afford to travel to another country where abortion is legal or find safe providers to help them to end a pregnancy, but many, especially those from poor and rural communities risk their health and lives to have clandestine abortions, often without any guidance from trained providers. Some suffer serious health complications, and even death, from unsafe abortion.

Melina, 26, told Human Rights Watch she had an unwanted pregnancy in 2017 when her contraceptive method failed. Already a mother of four young children, she was deeply distressed when she learned she was pregnant. She tried to end the pregnancy by drinking a tea made from herbs and plants—one of many home remedies women use to try to end pregnancies clandestinely. She began bleeding and felt intense pain in her back and abdomen. Melina felt something had gone wrong but delayed seeking medical attention because she feared being reported to authorities, or facing abuse by medical providers, for having an illegal abortion. When the pain became unbearable, she went to a public hospital and explained that she made a tea to try to end a pregnancy. The abortion was incomplete: the pregnancy had ended, but tissue remained in her uterus, putting her at risk of serious complications. The provider prescribed a medication that helps the body expel tissue from the uterus and sent her away without examining her or giving her anything to manage the pain. Melina took the medication, but the pain persisted for ten days, and she developed an infection. “I started thinking I was not going to survive it.” When she spoke with Human Rights Watch, six months later, she still suffered chronic pain and other health effects from the ordeal. “It was really intense. I suffered a lot,” she said.

The criminal code in the Dominican Republic imposes prison sentences of up to two years on women and girls who induce abortions and up to 20 years for medical professionals who provide them. Although criminal actions against women and girls who seek abortions, and those who help them, are relatively rare, the law has created pervasive fear that drives women and girls to desperate measures to end unwanted pregnancies, and leaves healthcare providers unable to protect the health and lives of their patients.

For more than two decades, legislators in the Dominican Republic have debated a new penal code. President Danilo Medina has urged legislators to decriminalize abortion in three circumstances: when the life of the woman or girl is in danger, when the pregnancy resulted from rape or incest, or when the fetus has serious complications incompatible with life outside of the womb. He twice vetoed penal code reforms that maintained the total abortion ban without exceptions. As of October 2018, the National Congress had not enacted any changes to the country’s criminal code on this issue, and the total criminalization of abortion in all circumstances remained in effect.

Key government officials recognize that there is a problem. Dr. José Mordán, head of the Department of Family Health at the Ministry of Public Health, told Human Rights Watch,

Abortion is a phenomenon that’s penalized by law in all its forms, with no exceptions. But we’ve always recognized that unsafe abortion is an important health problem because women have to appeal to clandestine methods to find an answer to their situation [an unwanted pregnancy]. And that creates the phenomenon of unsafe abortion.

Recent research by the Guttmacher Institute showed that restrictive laws and criminal penalties do not reduce the incidence or rate of abortions, but they make them less safe. Human Rights Watch conducted research in the Dominican Republic in early 2018 to investigate the human rights impacts of the total abortion ban. We spoke with 167 people, including women and girls, healthcare providers, and experts across four provinces. Their accounts reveal the brutal consequences of the country’s harsh abortion law.

Survey data from the Ministry of Public Health suggest that nearly half of pregnancies in the Dominican Republic are either unplanned or unwanted. For this report, Human Rights Watch sought to interview women and girls of reproductive age who had had unplanned or unwanted pregnancies. We interviewed 50 women and girls of reproductive age, 47 of whom said they had experienced an unplanned or unwanted pregnancy. Interviewees reported a variety of reasons for such pregnancies, including barriers accessing contraceptive methods, contraceptive failures, and sexual violence.

Overwhelmingly, women and girls described experiencing distress upon learning of an unplanned pregnancy, saying they felt “depressed,” “terrified,” “desperate,” or “trapped, with no future.” Some women chose to continue unplanned pregnancies that were also unwanted, either due to their personal beliefs about abortion, or because they feared clandestine abortion. More than half of the women and girls interviewed, however, attempted to have clandestine abortions and described these experiences to Human Rights Watch.

Some women and girls interviewed for this report might have been eligible for a safe and legal abortion if authorities in the Dominican Republic had decriminalized abortion in the three circumstances discussed above—when the life of a woman is in danger, when the pregnancy resulted from rape or incest, or when the fetus will not survive outside the womb. Most interviewees, however, said they wanted to end a pregnancy due to socioeconomic difficulties, instability or violence in their relationships, or because they already had other children and felt unable to care for any more.

Women and girls interviewed for this report described using a variety of methods to try to end pregnancies, including taking or inserting pills (most commonly misoprostol, often called by the brand name Cytotec); using teas, beverages, and other home remedies; trying to induce poor health, for example by denying themselves food or water; taking prescription medications contraindicated during pregnancy; or trying to induce physical trauma that ends the pregnancy (for example, one woman described beating her belly with a concrete block).

Several women said the methods they used to try to terminate pregnancies clandestinely failed, forcing them to continue pregnancies against their wishes. A few reported experiencing post-partum depression after they had been unsuccessful at terminating unwanted pregnancies.

Some clandestine abortions present more serious health risks to the woman or girl than others. The off-label use of misoprostol—a medication used to induce labor and to treat stomach ulcers—for medical abortion has reduced the risk of abortion-related complications in countries where legal access is restricted. Even with misoprostol, however, women and girls can experience complications related to clandestine abortion if they lack reliable information from trained providers on the correct dosage for safe and effective use.

According to the World Health Organization, complications from unsafe abortion include: “incomplete abortion (failure to remove or expel all of the pregnancy tissue from the uterus); haemorrhage (heavy bleeding); infection; uterine perforation (caused when the uterus is pierced by a sharp object); [and] damage to the genital tract and internal organs.”

An estimated 25,000 women and girls are treated for complications from miscarriage or abortion in the public health system in the Dominican Republic each year. One obstetrician-gynecologist at a public hospital in Santo Domingo estimated that 10 to 12 patients arrived at the hospital each day with incomplete abortions: “They come with pain, bleeding. Once we see them in the emergency room, then we do the procedure [to remove tissue from the uterus].” Failure to treat incomplete abortion can lead to serious infections and even sepsis and death.

Severe, untreated complications from unsafe abortion can be life-threatening. In the Dominican Republic, complications from abortion or miscarriage account for at least eight percent of maternal deaths, according to the Ministry of Public Health. Women and girls, healthcare and social service providers, and advocates interviewed for this report described deaths from unsafe abortion. Recent reports published by the Center for Gender Studies (Centro de Estudios de Género, CEG-INTEC) and Women’s Link Worldwide have also documented deaths from unsafe abortion.

Dominican authorities have pledged to eliminate preventable maternal death and have set a goal of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. The country’s 2014 maternal mortality ratio was 96.8 deaths per 100,000 live births. Research has shown that expanding legal grounds for abortion can lead to significant reductions in maternal mortality.

In the Dominican Republic, 35 percent of women and girls ages 15 to 49, who were ever married or in a union, have experienced some form of domestic violence, including physical, emotional, or sexual violence by an intimate partner, according to the government’s 2013 demographic and health survey (ENDESA-2013). In addition, approximately one in ten women and girls in the Dominican Republic has experienced sexual violence in her lifetime. The Dominican Republic has laws addressing domestic and sexual violence, as well as policies and protocols to implement those laws, but these protections are undermined by the blanket prohibition on abortion.

Human Rights Watch documented some cases of women and girls who became pregnant from rape and incest and did not have the option to safely and legally terminate their pregnancies. For example, one healthcare provider told Human Rights Watch that she had recently counseled a pregnant 11-year-old girl who had been raped by her stepfather. The girl was already 15 weeks pregnant and had pelvic pain. “She’s just a little girl,” the provider said. “She doesn’t know what’s going on in her life or in her body.” Because abortion is illegal, the provider had no options aside from referring the girl to prenatal care. International experts have stated that denial of safe abortion for survivors of rape and incest may amount to torture or cruel, inhuman, or degrading treatment. In some cases, survivors of violence had clandestine abortions, but the secrecy around abortion due to the country’s total ban kept them isolated from supportive and professional services, leaving them without a channel for reporting abuse. In one case, a provider said she felt unable to refer a patient she suspected was suffering abuse to appropriate services, because she encountered the patient in the context of a clandestine abortion and did not have formal avenues for follow-up.

We also documented several cases in which the law prevented pregnant women and girls from accessing a safe abortion, despite their pregnancies presenting serious risks to their health or lives. Medical providers explained that criminal penalties for abortion made it difficult for them to exercise their best judgment and provide the best standard of care when their pregnant patients faced serious health risks. Human Rights Watch asked one provider whether he could use his discretion to end pregnancy in such a circumstance: “In our country, the law doesn’t allow it.” He explained, “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], that pregnancy has to be preserved from conception to delivery…. But it doesn’t work like that. The pregnancy can put a woman’s life at risk.” A recent report published by the Coalition for the Rights and Life of Women (Coalición por los Derechos y la Vida de las Mujeres) documented the experiences of five women and girls in the Dominican Republic who had clandestine abortions either because the pregnancy threatened their lives, they were pregnant from rape or incest, or they learned the fetus would not survive outside of the womb.

Some women and girls interviewed for this report said that they faced negligence, mistreatment, or abusive behavior by health personnel when they sought medical attention for urgent sexual and reproductive health concerns, including being turned away from medical facilities; facing unreasonable delays in receiving care, sometimes to the extent that their lives were in danger; and being treated without anesthesia or pain management, causing severe pain and suffering. In some cases, women said that they experienced or witnessed abusive behavior following miscarriages or clandestine abortions. Two women said they experienced reproductive health emergencies unrelated to pregnancy, but health workers assumed they had attempted abortion and mistreated them. In one case, a woman described being left waiting for hours while she bled heavily, to the point that her life was in danger. In the other case, a woman had a painful medical procedure with no anesthesia. Some interviewees told Human Rights Watch that criminal penalties for abortion in the Dominican Republic, as well as reports of abuse by health care professionals, led them to delay or go without seeking care following complications from clandestine abortions or during miscarriages.

In countries where abortion is safe, legal, and accessible, women and girls facing unplanned pregnancies can freely seek confidential, professional medical advice and counseling about their options. Pre-abortion counseling can uncover undue pressure or coercion women may be experiencing from partners, parents, or other sources to terminate pregnancies, allowing providers to help patients to delay decision-making or receive additional counseling or referrals, as needed. When abortion is criminalized, pregnant women and girls often cannot access factual, unbiased, and confidential information from qualified professionals about a full range of options, leaving them more susceptible to pressure, coercion, or even abuse from partners or others who may want to control their reproductive health.

Human Rights Watch interviewed some women and girls who said they were pressured, abused, or misled by their partners, family members, or neighbors to terminate unplanned pregnancies they wanted to continue. While women and girls may face coercion around pregnancy decisions even in settings where abortion is legal and accessible, criminalization denies women and the girls access to standardized, reliable, and confidential reproductive health counseling that can help them make the best decisions for their health and lives.

The criminalization of abortion is incompatible with the Dominican Republic’s international human rights obligations. Denying women and girls access to abortion is a form of discrimination that jeopardizes human rights including the rights to life; health; freedom from cruel, inhuman and degrading treatment; nondiscrimination and equality; privacy; information; and freedom to decide the number and spacing of children. Human rights treaty bodies and other authorities now consistently urge states to decriminalize abortion in all cases, and the bare minimum to at least ensure safe and legal access when the life or health of the pregnant woman is threatened, and for pregnancies resulting from rape or incest, or involving severe fetal impairment.

Decriminalizing abortion is an urgent public health and human rights imperative. Authorities should act swiftly to protect the health, human rights, dignity, and lives of women and girls in the Dominican Republic.

Many countries around the world have eased abortion restrictions in recent years. The Guttmacher Institute reported that 27 countries around the world reformed their abortion laws to expand legal access to abortion between 2000 and 2017. The Dominican Republic should join this global trend.

 

Recommendations

To the National Congress

  • Decriminalize abortion as a matter of urgency, by removing all criminal penalties for abortion from the penal code.
  • At a minimum, reform the penal code to provide women and girls with access to safe and legal abortion services when the pregnancy poses a risk to the life or health of the woman or girl, when the fetus has a serious condition incompatible with life outside the womb, or when the pregnancy resulted from any form of sexual violence.
  • Enact the proposed Sexual and Reproductive Health Law to expand legal protections for women’s and girls’ sexual and reproductive health and rights.

To President Danilo Medina

  • Continue to urge Congress to reform the penal code to make it consistent with the Dominican Republic’s international human rights obligations by decriminalizing abortion in all circumstances and ensuring safe and legal access to abortion, at a minimum, when the pregnancy poses a risk to the life or health of the woman or girl, when the fetus has a serious condition incompatible with life outside the womb, or when the pregnancy resulted from any form of sexual violence.
  • Veto any version of the penal code that maintains full criminalization of abortion in all circumstances.

 

To the Supreme Court of the Dominican Republic

  • Give appropriate consideration to all of the Dominican Republic’s obligations under international and regional human rights treaties when ruling on any petitions related to the constitutionality of the country’s laws on abortion.

 

To the Ministry of Public Health

  • Ensure that all national sexual and reproductive health protocols include the following:
    • A screening process to determine whether pregnant women and girls planned and want their pregnancies, and a discussion of their options and referrals for psychosocial support, in the event that the pregnancy is unwanted;
    • Harm reduction counseling on the safety and risk of different measures used to induce abortion and information on when and how to access post-abortion care for women and girls who may wish to terminate pregnancies clandestinely;
    • Guidelines for attending to patients with incomplete abortions or post-abortion complications in a prompt, neutral, professional, rights-respecting, and non-discriminatory manner, including a specific requirement that patients not be denied pain management as “punishment;”
    • Routine post-delivery and post-abortion contraceptive counseling to ensure all women and girls have comprehensive and accurate information about how to prevent pregnancy;
    • Referrals to psychosocial support services for pregnant adolescent girls.
  • Develop and implement an extensive training program to ensure all health care providers competently and consistently implement sexual and reproductive health protocols, including the provisions listed above.
  • Develop or strengthen measures to inform patients of their rights, including the right to prompt, professional, and respectful post-abortion care. Strengthen complaint mechanisms for patients, the friends and family members accompanying them, and medical personnel to report neglectful or abusive treatment of women and girls seeking, or believed to be seeking, post-abortion care. Inform patients about how to file complaints, and investigate all complaints of mistreatment promptly, thoroughly, and fairly. Sanction staff found to have engaged in neglectful or abusive behavior.
  • Conduct research on the sexual and reproductive health needs of women and adolescent girls, to identify factors contributing to unintended and early pregnancies. Investigate barriers in access to, and consistent use of, the contraceptive methods provided by the National Health System, including long-acting reversible contraceptives (such as intrauterine devices) and voluntary sterilization. Modify national health policies as needed to expand contraceptive options and address these barriers.
  • Ensure health centers do not stigmatize adolescents who are sexually active, and that they are staffed with medical personnel qualified to provide confidential and comprehensive adolescent health services.
  • Strengthen measures to reach out to adolescents to raise their awareness about access to contraception and reassure them of the availability and confidentiality of adolescent-friendly, non-judgmental services.
  • Implement public information and awareness-raising campaigns that address the stigma around adolescent sexuality and promote healthy adolescent sexual practices. Ensure such campaigns make clear that adolescent children do not need an adult’s authorization to access sexual and reproductive health information and services.
  • Strengthen services for women and girls facing sexual violence, domestic violence, and other forms of abuse. Ensure links between services for survivors of violence and medical providers, so that survivors of abuse can easily access specialized medical care. Ensure that medical providers consistently refer patients they know, or suspect, are experiencing abuse to comprehensive, supportive services.
  • Work with the Ministry of Education to implement a mandatory comprehensive sexuality education curriculum nationwide.

To the Ministry of Education

  • Implement a mandatory comprehensive sexuality education curriculum in primary and secondary schools that complies with international standards and is scientifically accurate, rights-based, and age-appropriate. Ensure the curriculum reaches students from an early age and builds incrementally to equip them with developmentally relevant information about their health and wellbeing. As part of the curriculum, provide children with practical information about how to use contraceptive methods and where they can obtain contraceptive supplies.
  • Train educators to teach the curriculum impartially.

To the Ministry of Women

  • Work with the Ministry of Public Health and the Ministry of Education to implement the recommendations detailed above.

To Donors and United Nations Agencies

  • Advocate for the Dominican Republic to remove all criminal penalties for abortion and to ensure that women and girls have safe and legal access to abortion.
  • Encourage states to fulfill their obligations under international law regarding sexual and reproductive rights and eliminate restrictions on overseas development assistance that serve to limit the exercise of those rights.
  • Advocate for the government of the Dominican Republic to implement the recommendations above and support it in doing so.

To the Inter-American Commission on Human Rights

  • Hold a thematic hearing on access to comprehensive sexual and reproductive health services and information, including access to safe and legal abortion, in Latin American and the Caribbean. Ensure that the rights and needs of adolescent children and young adults are included.
  • Consider appropriate steps to prioritize the petition filed by Rosa Hernández, with support from Colectiva Mujer y Salud and Women’s Link Worldwide, regarding the death of her 16-year-old daughter Rosaura Almonte Hernández (known as “Esperancita”).
  • Consider the findings and recommendations of this report during the deliberations of the Working Group on Implementation of Human Rights Policies in the Dominican Republic. Ensure that the Working Group’s final report includes a detailed discussion on the public health and human rights impacts of the criminalization of abortion in the country.
 

Methodology

Human Rights Watch conducted research for this report in February and April 2018 in four provinces of the Dominican Republic: Santo Domingo, Santiago, San Cristóbal, and Monte Plata. Most interviews were carried out in the country’s two largest cities: Santo Domingo and Santiago de los Caballeros.

Human Rights Watch identified interviewees with the assistance of nongovernmental organizations (NGOs), advocates, researchers, and service providers. We sought to interview women and girls who had experienced unplanned or unwanted pregnancies, including some from specific populations that may be particularly vulnerable to harm from the criminalization of abortion, such as adolescent girls and young women, Dominicans of Haitian descent, Haitian immigrants, women or girls involved in sex work, survivors of violence, and those living in poor communities.

We interviewed 50 women and girls of reproductive age, ages 15 to 43, who had been pregnant at least once in their lives. Among them, 47 had an unplanned or unwanted pregnancy, and 29 attempted abortion. In addition, we spoke with 21 healthcare and social service providers, including psychologists, obstetrician-gynecologists, case workers, and health outreach workers; and 33 other experts, such as academic researchers, lawyers, and representatives of NGOs. For additional contextual information, Human Rights Watch interviewed six children and young adults ages 17 to 24 and one older woman, and held focus group discussions with 54 other individuals, including adolescent children, health outreach workers, and members of a community-based organization. Human Rights Watch also interviewed representatives of the Ministry of Public Health and the Ministry of Education. In total, Human Rights Watch spoke with 167 people for this report.

Most interviews were conducted in Spanish through an interpreter. A few interviews were conducted in Haitian Kreyòl with the help of an additional interpreter. In most cases, Human Rights Watch held interviews individually and in private, though in a few cases, interviewees preferred to have another person present. Interviews were primarily held in private areas in community spaces or the offices of local organizations.

Human Rights Watch informed all interviewees of the purpose of the interview, its voluntary nature, and the ways in which the information would be collected and used. Interviewers assured participants that they could end the interview at any time or decline to answer any questions, without any negative consequences. All interviewees provided verbal informed consent to participate.

Interviews were semi-structured and covered topics related to sexual and reproductive health and rights, as well as access to information and services. Most interviews lasted 45 to 60 minutes, and all interviews took place in person. Care was taken with victims of trauma to minimize the risk that recounting their experiences could further traumatize them. Where appropriate, Human Rights Watch provided contact information for organizations offering legal, counseling, health, or social services. Human Rights Watch did not provide anyone with compensation or other incentives for participating.

All interviewees were already connected in some way to local organizations or service providers. We did not seek to access those outside of these networks, due in part to a commitment to ensure interviewees had access to support following their participation in the research. As a result, the accounts in this report do not reflect the experiences of some of the most vulnerable and isolated women and girls in the Dominican Republic—women and girls with no connection to services.

Human Rights Watch also analyzed relevant laws and policies and conducted a review of secondary sources, including epidemiological data, public health studies, reports from the World Health Organization and the Ministry of Public Health, and other sources.

Human Rights Watch met with government officials in Santo Domingo in April and September 2018, including representatives of the Ministry of Public Health and the Ministry of Education.

The names of the women and girls interviewed, as well as service providers, have been changed to protect their privacy and safety. The names of other experts have not been changed. In a few cases, Human Rights Watch withheld the date and location of an interview for security reasons.

Terminology

In this report, the word “child” refers to anyone under the age of 18, with “girl” referring to a female child.[1]

The term “adolescent” is used to describe children and young adults ages 10 to 19, consistent with the definition used by the World Health Organization (WHO).[2]

 

I. Background: Abortion in the Dominican Republic

Abortion is criminalized in the Dominican Republic in all circumstances, even when the life of the pregnant woman or girl is in danger. The Dominican Republic is one of only six countries in Latin America and the Caribbean to maintain a total abortion ban; the others are El Salvador, Haiti, Honduras, Nicaragua, and Suriname.[3] For many years, women’s rights groups have fought for access to safe and legal abortion.

Legal Framework

The criminal code in the Dominican Republic penalizes women and girls who induce abortions and anyone who assists them.[4] Under article 317 of the criminal code, doctors, surgeons, midwives, nurses, pharmacists, and “other medical professionals” who provide abortions face prison terms of five to 20 years.[5] Pregnant women who induce or consent to abortions, and any individuals who relay information to pregnant women about obtaining an abortion, if the abortion occurs, face six months to two years in prison.[6]

There are no exceptions provided in the language of criminal code, or any other laws or regulations, to allow for legal abortion in any circumstance. According to the Center for Reproductive Rights, criminal laws like those in the Dominican Republic, when challenged in court, “are normally interpreted to permit life-saving abortions on the grounds of the general criminal law defense of ‘necessity,’” suggesting that a provider could be exempt from criminal liability if she or he performed an abortion to save a pregnant patient’s life.[7] Advocates told Human Rights Watch that they had not seen this type of challenge to the law reach the justice system in the Dominican Republic.[8]

In 2010, lawmakers in the Dominican Republic reformed the constitution to establish a right to life from conception. Article 37 of the constitution states, “The right to life is inviolable from conception until death.”[9]

Women’s rights experts told Human Rights Watch that arrests and prosecutions for abortion-related crimes in the Dominican Republic are rare, despite the strict criminal laws.[10] “Even though abortion is illegal under the framework, there are not prosecutions,” one doctor explained.[11] Dr. José De Lancer, an obstetrician-gynecologist who worked in the public health system for many years, told Human Rights Watch, “It’s not like El Salvador. We don’t throw doctors and women in jail. We’re far from that.”[12]

In early 2018, however, a court ordered a 20-year-old woman in San José de Ocoa to serve three months of “preventive detention” while authorities investigated whether she had an illegal abortion. The woman maintained that she fell down and that her partner gave her a medication, claiming it would help with the pain. She said she did not realize until afterward that it was a medication that could induce abortion. After experiencing pain, she sought medical attention at a hospital for a miscarriage, and her medical provider reported her to authorities for inducing an abortion.[13] At the time of writing, she was at home awaiting trial.

According to advocates, the woman’s arrest and sentence for abortion-related crimes were highly unusual in the country.[14] “We’ve never seen them put someone in jail for an abortion,” said Fátima Lorenzo, director of the nongovernmental organization Ciudad Alternativa.[15] Some advocates said they feared the 2018 case could signal a move toward greater enforcement of criminal penalties for abortion.[16]

Abortion Incidence and Safety

Research from around the world shows that restrictive laws and criminal penalties do not reduce the incidence or rate of abortions, but they make them less safe. A recent study by the Guttmacher Institute found little difference between the rate of abortion in countries that restricted access and countries that did not:

Women living under the most restrictive laws (i.e., where abortion is prohibited altogether or allowed only to save a woman’s life) have abortions at about the same rate as those living where the procedure is available without restriction as to reason (37 and 34 abortions per 1,000, respectively).[17]

It is difficult to obtain reliable data on the incidence or rate of abortion in countries where it is criminalized, such as the Dominican Republic. According to the Guttmacher Institute, 97 percent of women in Latin America and the Caribbean live in countries with restrictive abortion laws.[18] Despite restrictions, Latin America and the Caribbean also has the highest estimated abortion rate: 44 abortions per 1,000 women and girls ages 15 to 44, compared to an estimated global rate of 35 per 1,000. The estimated abortion rate in the Caribbean is 59 abortions per 1,000 women and girls.[19]

Human Rights Watch could not locate any recent, comprehensive, country-specific estimates of the abortion rate in the Dominican Republic.[20] A survey of 2,436 university students by the organization Profamilia found that more than two-thirds of participants said they knew someone who had had an abortion, though only 126 (about 5.2 percent) reported having had an abortion themselves. According to Profamilia, a 2013 demographic and health survey (ENDESA-2013) found 9.8 percent of women and girls ages 15 to 49 reported having had an abortion or a miscarriage in their lifetime, though it did not distinguish between spontaneous and induced terminations.[21]

Under the legal framework described above, all abortions occurring in the Dominican Republic are considered illegal, and therefore, performed clandestinely. Some clandestine abortions present more serious health risks than others. In a 2017 study published in The Lancet, researchers with the World Health Organization (WHO) presented a three-tiered classification of abortion as safe, less safe, and least safe. By their definitions, abortions are classified as safe if they are provided by trained healthcare workers using methods recommended by WHO such as medical abortion or vacuum aspiration (a procedure using suction to remove tissue from the uterus) appropriate for the stage of the pregnancy. Less safe abortions are those done by trained providers using outdated or less safe methods (such as curettage, a procedure to remove tissue from the uterus by scraping with a sharp tool), or abortions done with safe methods (such as misoprostol, a medication that can induce abortion), but “without adequate information or support from a trained individual.” Least safe abortions are those done by untrained people using dangerous or invasive methods, “such as ingestion of caustic substances, insertion of foreign bodies, or use of traditional concoctions.”[22]

The vast majority of abortions in Latin America and the Caribbean—more than three-quarters—are unsafe (less safe or least safe, according to the model above). Nearly five million unsafe abortions occur in the region each year, and more than one million of those are considered “least safe” under the criteria described above.[23]

Unsafe abortion can cause serious health complications, including death. According to the WHO, complications from unsafe abortion include “incomplete abortion (failure to remove or expel all of the pregnancy tissue from the uterus); haemorrhage (heavy bleeding); infection; uterine perforation (caused when the uterus is pierced by a sharp object); damage to the genital tract and internal organs by inserting dangerous objects such as sticks, knitting needles, or broken glass into the vagina or anus.”[24]

In Latin America and the Caribbean, unsafe abortion is the cause of at least 10 percent of maternal deaths, and more than 760,000 women are treated for abortion-related complications in the region each year.[25] The Pan American Health Organization estimates an average of 68 maternal deaths per 100,000 live births in Latin America and the Caribbean.[26]

The Dominican Republic has a higher maternal death ratio than the regional average. According to a 2015 report from the Ministry of Public Health, the maternal mortality ratio in the Dominican Republic was 96.8 per 100,000 live births in 2014.[27] At least eight percent of maternal deaths in the country are attributed to complications from miscarriage or abortion.[28] At least 96 women died from such complications between 2010 and 2015, though this number is likely an undercounting, excluding women whose abortion-related deaths were registered under other causes.[29] According to the Ministry of Public Health, there are an estimated 25,000 hospitalizations for abortion or miscarriage in the public health system each year, many of which are women needing care after a clandestine abortion.[30]

The off-label use of misoprostol—a medication used to induce labor and to treat stomach ulcers—for medical abortion has reduced the risk of abortion-related complications in countries where legal access to abortion is restricted.[31] The WHO recommends the use of misoprostol in combination with mifepristone, another drug used in medical abortion.[32] Misoprostol is much more widely available and accessible, and research has shown that it can be safe and effective when used alone to terminate pregnancies.[33]

Misoprostol is included in the Dominican Republic’s essential medicines list, the national list of medicines that satisfy the priority healthcare needs of the population, and should be available and accessible through the health system.[34] A 2005 study published in the International Journal of Obstetrics and Gynaecology found a 75 percent decline in serious abortion-related complications at one of the largest maternity hospitals in Santo Domingo between 1986—the year the misoprostol was introduced in the country—and 2001.[35]

Public Opinion on Abortion

Though a majority of the population in the Dominican Republic is Roman Catholic, and conservative religious authorities have opposed public policies that would advance sexual and reproductive rights, new public opinion research shows a clear majority of the population favors easing restrictions on abortion. A 2018 public opinion study involving more than 2,000 people in the Dominican Republic found that 79 percent of respondents believe abortion should not be criminalized when the life or health of the woman is at risk, 76 percent when the pregnancy is not viable, and 67 percent when the pregnancy resulted from rape or incest.[36]

Proposals for Reform

For more than two decades, legislators in the Dominican Republic have debated a new penal code, incorporating a number of reforms, which would replace the current criminal code. In recent years, conflict between the president and some legislators over whether to ease restrictions on abortion has arisen in the context of the penal code reform process and has become an obstacle to the new code being adopted.

In 2014, the Chamber of Deputies—the lower house of the country’s bicameral National Congress—approved a version of the new code that maintained the criminalization of abortion in all circumstances. President Danilo Medina vetoed it and sent it back to Congress, requesting changes to the articles regarding abortion.[37] In a letter to the president of the Chamber of Deputies explaining his veto (“observation”[38]), President Medina argued that the penal code should decriminalize abortion in three circumstances: when the life of the woman or girl is in danger, when the pregnancy resulted from rape or incest, or when the fetus has serious complications incompatible with life outside of the womb. He stated that such a policy was “the most just, balanced, and consistent with the spirit of protection of rights and humanity that should govern the State.”[39] A diverse coalition of women’s rights groups, the Coalition for the Rights and Life of Women (Coalición por los Derechos y la Vida de las Mujeres), has for several years urged authorities to decriminalize abortion in those three circumstances (tres causales).[40]

The Chamber of Deputies responded to President Medina by passing a revised version of new penal code that decriminalized abortion when the life of the woman was in danger, and said the other two circumstances (unviable pregnancies, and those resulting from sexual violence) should be determined by a special law. But this version of the code was not sent to the Senate for a vote. This opened the door to several religious and socially conservative organizations challenging the constitutionality of the new criminal code in court, denouncing procedural irregularities in the approval process, and arguing that the new code was incompatible with the constitutional protection for the right to life from conception.

In late 2015, just before the new penal code was set to take effect, the Constitutional Court ruled that it was unconstitutional due to procedural irregularities in the approval process, reinstating the old criminal code.[41] The court did not rule on the question of whether this easing of restrictions on abortion could be reconciled with the constitutional protection for the right to life from conception.[42]

In 2016, the Senate approved a version of the penal code leaving in place the criminalization of abortion in all circumstances. President Medina again vetoed the proposed penal code and issued another “observation” objecting to the total abortion ban.[43] In a letter to the president of the Senate, President Medina argued again for decriminalization in the same three circumstances, stating that they were “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 own values.”[44] Due to this disagreement, the penal code reform failed to pass in 2016.

In 2017, the Senate again approved a penal code with total criminalization of abortion, rejecting the changes requested in President Medina’s 2016 observation. The Senate sent the proposed penal code to the Chamber of Deputies, where it was voted down. As of October 2018, the penal code’s criminalization of abortion in all circumstances remained in effect.

Aside from the ongoing penal code reform process, another bill currently pending in the Chamber of Deputies, the Proposed Law on Sexual and Reproductive Health (Proyecto de ley de salud sexual y reproductiva), could help to ease restrictions on abortion. The stated purpose of the bill is “to establish the legal framework for the guarantee and full exercise of sexual rights and reproductive rights, through the regulation of public policies aimed at the prevention and care of sexual and reproductive health, as well as to the establishment of sanctions for their violation.” It outlines roles and responsibilities for various government entities and establishes a process for legal abortion in the first 12 weeks of gestation if there is a “grave risk” to the life or health of the pregnant woman, if the fetus has complications incompatible with life, or if the pregnancy resulted from sexual violence.[45] The bill would also formalize and institutionalize rights-based sexual and reproductive health information and services, such as adolescent-friendly health services, and comprehensive care for survivors of violence. At the time of writing, the Proposed Law on Sexual and Reproductive Health had not been brought for a vote.

 

II. Findings: Unplanned Pregnancies and the Impacts of the Total Abortion Ban

Almost half of pregnancies in the Dominican Republic are either unplanned or unwanted. Human Rights Watch found that that women and girls experience significant distress around unplanned pregnancies, but criminal laws prohibiting abortion in all circumstances force them to turn to clandestine, and often unsafe, methods to terminate pregnancies. Many women and girls experience health complications from clandestine and unsafe abortion, and some die. Some face abuse, neglect or mistreatment by healthcare providers when they seek medical attention for reproductive healthcare emergencies. Even women or girls who become pregnant from sexual violence, or who face serious health risks during their pregnancies, do not have the option to access safe and legal abortion. The Dominican Republic’s abortion ban denies women and girls their reproductive rights and endangers their health and lives.

Unplanned Pregnancies

The national health system in the Dominican Republic offers women and girls a range of free or low-cost contraceptive methods, including oral contraceptive pills, implants, injections, and the intrauterine device (IUD).[46] According to a 2013 demographic and health survey (ENDESA-2013), 68.6 percent of women and girls ages 15 to 49 who were married or in unions (living with their partners in the same household), and 63.4 percent of those who were sexually active but not in unions, said they used a modern contraceptive method.[47] Emergency contraception (often called the “morning after pill”) is included on the essential medicines list and available at pharmacies without a prescription, and condoms are widely available at health centers, pharmacies, and convenience stores.[48]

Despite this, survey data suggest that nearly half of pregnancies in the Dominican Republic are either unplanned or unwanted.[49] Though only 11 percent of women and girls ages 15 to 49 who are married or in unions have an unmet need for contraception (meaning they wish to delay or prevent pregnancy but are not using any method of contraception), adolescent girls and younger women are disproportionately affected. More than one-quarter (27 percent) of adolescent girls and young women ages 15 to 19, and more than one-fifth (21 percent) of women ages 20 to 24 have an unmet need for contraception.[50] The women and girls of reproductive age interviewed for this report who had had unplanned or unwanted pregnancies cited a variety of reasons for such pregnancies, including barriers to accessing contraceptive methods, contraceptive failures, and sexual violence.

Though most interviewees had information about contraception and knew where to go for services, some encountered barriers in accessing their preferred family planning methods, including supply shortages.[51] For example, Madelyn, 28, said she started using an oral contraceptive pill to prevent pregnancy after she gave birth to her second child. “I went to the public hospital for pills every month. When I went one time, there were none.” She said she did not have the money to buy contraceptive pills at the pharmacy: “We were in a very difficult economic situation.” It took two days for the pills to become available in the public health system, but even a short interruption in oral contraceptive use can dramatically reduce effectiveness at preventing pregnancy. A few weeks later Madelyn learned she was pregnant.[52]

Daralis, a 24-year-old mother of two, tried using an implant to prevent pregnancy, but she said it caused complications in one of her ovaries. After two years, she had the implant removed. “When I took the implant out, I started taking [oral contraceptive] pills, but they didn’t work, and I got pregnant.” After giving birth to her second child, she tried to get injections to prevent pregnancy at the public maternity hospital near her home. “Every time I go, they don’t have it,” she said.[53]

A few interviewees said they got pregnant when they missed doses of their daily oral contraceptive pills.[54] Others became pregnant while switching from one contraceptive method to another.[55] Some women and girls said their methods failed to prevent pregnancy for reasons they did not understand.[56] Samantha, 18, said she started getting injections when she turned 17 to prevent pregnancy. She had to submit a pregnancy test as part of a medical examination for a new job. When she learned she was five months pregnant, she was shocked. “I was one of those people that unfortunately the injection doesn’t work properly for,” she said. “I believed that I was protected. I thought this couldn’t happen to me.”[57]

Lisbeth, a 16-year-old girl who was three months pregnant when she met with Human Rights Watch, said she got an implant to prevent pregnancy after she gave birth at age 14. After a year, she got the implant removed because it interfered with her period, and she switched to an oral contraceptive pill. She became pregnant while taking an oral contraceptive pill.[58]

Many women said they found it difficult or impossible to use family planning methods due to health conditions, such as hypertension, or unpleasant side effects, including changes in weight, irregular periods, cysts or myomas, or other sicknesses.[59]

A few women said they tried to access tubal ligation but were told they were too young, including one woman who had been advised that she should not have any more children because she has hypertension and nearly died in childbirth.[60] While there is evidence that younger women have a higher risk of a failed tubal ligation (that is, a pregnancy occurs),[61] providers often deny young women tubal ligations because they believe they will regret having the procedure, as it is difficult, or impossible, to reverse.

Some adolescent girls and young women said they did not seek family planning information or services prior to becoming pregnant, either because they felt uncomfortable, or they did not have adequate information.[62] “I started having sex at 14,” said Lucely, an 18-year-old woman with a 2-year-old daughter. “I didn’t want to [ask for family planning options]. They say, ‘Oh, you’re so young. You’re already doing it?’”[63]

In addition, some women and girls interviewed for this report became pregnant from rape or incest. Their accounts are detailed below (under the section on “Lack of Access to Legal Abortion Even in Cases of Rape, Incest, and Serious Health Risks”).

Regardless of the circumstances, overwhelmingly women and girls experienced distress upon learning of an unplanned pregnancy, saying they felt “depressed,” “terrified,” “desperate,” or “trapped, with no future.”[64] “I couldn’t leave the house. I was crying, and crying, and crying,” said Melina, 26, describing how she felt when she learned she was pregnant three months after giving birth to her third child.[65] Nayely, 29, told Human Rights Watch she “wanted to die,” when at age 18, she learned she was pregnant for the second time. She had recently separated from her partner. “Imagine, with a two-year-old and pregnant.”[66]

“When the doctor told me I was pregnant, my world crumbled,” said Camila, 24, describing learning of an unplanned pregnancy at age 22. Her family kicked her out of the house for having a pregnancy while she was unmarried. “It almost made me crazy.”[67]

One psychologist interviewed by Human Rights Watch counseled women coping with the news of unplanned pregnancies. She said women often exhibited, “despair, depression about their economic situation, fear of facing a pregnancy. I had a case in 2016 of one girl who wanted to kill herself when she became pregnant because she was underage, and her parents didn’t accept her when she got pregnant. She was 16.”[68] One 22-year-old woman interviewed for this report explained it simply: “When you don’t want to have a baby, you feel bad.”[69]

Some women chose to continue unplanned pregnancies that were also unwanted, either due to their personal beliefs about abortion, or because they feared clandestine abortion. Daralis, 24, told Human Rights Watch, “If you attempt to stop a pregnancy, you can end up dead.”[70] Adelyn, 20, said she considered having a clandestine abortion, but decided not to try to interrupt the pregnancy, “because I thought of myself too. Because you can die.”[71] More than half of the women and girls interviewed for this report who had unplanned or unwanted pregnancies, however, said they had had or tried to have clandestine abortions.

Clandestine and Unsafe Abortions

Despite the criminalization of abortion, women and girls in the Dominican Republic seek to terminate unwanted pregnancies, and because of the ban on abortion are often forced to risk their health and lives doing so clandestinely. “In the Dominican Republic, women have always defied this denial of their rights,” said Sergia Galván, a leading women’s rights advocate in Santo Domingo.[72]

Human Rights Watch interviewed women and girls who reported attempting abortion in various ways, including taking or inserting pills (most commonly misoprostol, often called by the brand name Cytotec); using teas, beverages, and other home remedies; trying to induce poor health, for example by denying themselves food, water, or sufficient rest; taking prescription medications contraindicated during pregnancy; or trying to induce physical trauma that ends the pregnancy.

Liliana Dolis, general coordinator of the Movimiento de Mujeres Dominico-Haitianas (MUDHA), told Human Rights Watch that women and girls spoke openly about clandestine abortion at events her organization hosted: “Many of our women know what to do, but they put their lives in danger…. In the workshops, they talk about all the methods they use: teas, letting yourself fall down, beating the belly, squeezing the uterus, taking aspirin, inserting other things.”[73]

Dr. José Mordán, head of the Department of Family Health at the Ministry of Public Health, told Human Rights Watch:

Abortion is a phenomenon that’s penalized by law in all its forms, with no exceptions. But we’ve always recognized that unsafe abortion is an important health problem because women have to appeal to clandestine methods to find an answer to their situation [an unwanted pregnancy]. And that creates the phenomenon of unsafe abortion.[74]

Some women and girls interviewed for this report might have been eligible for safe and legal abortion if authorities in the Dominican Republic had decriminalized abortion in the three circumstances (“tres causales”) discussed above—when the life of a woman is in danger, when the pregnancy resulted from rape or incest, or when the fetus will not survive outside the womb. Most interviewees, however, said they wanted to end pregnancies due to socioeconomic difficulties, instability or violence in their relationships, or because they already had other children and felt unable to care for any more. “If women don’t want to have it [a child], it’s for a reason,” explained Camila, 24, who ended a pregnancy at age 22 when her son was 1 year old. “Everyone has a reason.”[75]

The experience of Juliana, a 16-year-old mother of two, was typical among the women and girls interviewed for this report. “I have a hard economic situation. Sometimes I don’t even know what we’ll have for dinner.” She became pregnant unexpectedly in early 2018, when her children were 3 and 1: “I was terrified. I was going crazy, thinking if I can’t even find food for these two babies [I already have], how will I feed a third?” She took pills and a tea that she believed would induce abortion, and experienced “a lot of pain.” When she went to the doctor, she was told that the abortion was incomplete, but her cervix had closed, and she was referred for additional testing. When she met with Human Rights Watch, she had not received further treatment and was still experiencing pain and dizziness, which she believed could have been related to the clandestine abortion she underwent four weeks prior.[76]

Gabriela, 27, had a similar experience. She told Human Rights Watch she had a clandestine abortion three years ago, when her second child was only a few months old. “I was using [contraceptive] pills, but they failed,” she said. “I didn’t want to have a baby. My husband was not working, and there was nothing in the house to eat, and I wasn’t working. I [already] had the baby girl [my second child].” She took pills that someone bought for her at a pharmacy and terminated the pregnancy, without telling anyone except her husband and the person who bought the medication.[77]

Some interviewees said they feared criminal penalties, even though abortion-related arrests and prosecutions in the Dominican Republic are rare. Isamar, 31, became pregnant unexpectedly in early 2018. As a single mother of four children, with the youngest only 10 months old, she felt unable to care for another child.

I decided to go to the pharmacy to buy a pill to abort [the pregnancy]. I asked the pharmacist for the pill to get an abortion. They didn’t want to sell it to me. They said they couldn’t sell pills for that, so I sent someone else to get them for me … and I bought a malt drink. I heated it with cinnamon and nutmeg on the stove, and I took it at night … with the pills. At dawn, I felt a strong pain, and I started bleeding. By the next day, the bleeding had stopped, but the pain continued. I decided to go to the doctor.
 

At the hospital, she received medical attention for an incomplete abortion and said she was treated well. “I was really afraid,” she said, explaining that she knew there were criminal penalties for abortion. She did not tell anyone what she went through: “Not my family, not anyone. Because my family would criticize me a lot for the situation I’m going through. I did what I did. I didn’t even tell my family I went to the hospital.” She said she felt very alone, “especially when I came out of surgery.”[78]

Human Rights Watch asked one clandestine abortion provider whether she feared criminal prosecution for helping patients terminate unwanted or risky pregnancies. “Every single day,” she said. “It’s always a risk.… But we are willing to exchange [information and services], willing to hope that at some point we will be able to look backwards [at the time when abortion was criminalized] and say, ‘Do you remember when we had to do this under the table?’”[79]

Stephany’s Story

Though most women and girls interviewed for this report used medication or home remedies to end pregnancies, one woman had a traumatic experience getting a surgical abortion at a clandestine clinic. Stephany, 24, told Human Rights Watch she had an unwanted pregnancy at 21. When she found out she was pregnant, she said it felt like “the world was tumbling down,” and she immediately sought a way to end the pregnancy. “I didn’t know how to end it, where to go, where to ask for help. I didn’t want to tell other friends, for fear they would judge me. I didn’t know anyone who had gone through it.”

Stephany learned about a clandestine abortion provider from her partner’s friend. “Everything was wrong with the health facility,” she said. “It was not clean at all. It was an old house. It was very big. It was dark. Everything was old. The chairs were old, the television was from the 1990s, the bathroom was a mess. But I was desperate.” She paid over RD$10,000 pesos (US$200) to have an abortion at the clinic. “The house had two levels. We went to the second level. The papers [on the wall] were so old, they were yellow.… It was dirty and dusty. There were two seats, and we waited in the dark. It was really dark. There was no natural light. It was a like a horror movie in every sense…. I was desperate, totally anxious, shaking, sitting there doing nothing.… He took me to a room at the back. It was a room with a toilet and a sink. There was no running water. He told me to go to the bathroom and put on a robe, so I took off my clothes. He asked me to sit on the metal table, without any sheets or pillows.”

Stephany said the provider administered local anesthesia, and the procedure lasted only five to seven minutes. She recounted it in vivid detail: “I was seeing lights. I could hear a radio. I was conscious, but I didn’t feel pain. I could feel the edge of the table on my lower back. I felt everything. It was a spatula [tool] scraping the uterus. I was screaming. He did the curettage and then put a hose with water inside my uterus. I was screaming the whole time. I was very uncomfortable.”

She had no complications and recovered physically from the procedure, but she wished she had more information about her options when she became pregnant. “At that time, I didn’t know anything. I didn’t want to ask.” Stephany had no regret about ending the pregnancy: “I regret the way I did it. I don’t regret doing it,” she said. “I was relieved because it was over…. It was a relief, even though the process was so horrific.… The circumstances were bad, but it was the right decision.”

Afterward, she spoke with a friend who had information about safer options for ending pregnancies clandestinely. “She told me, ‘You didn’t have to go through that.’ … That’s when I started to talk more about it. I want people not to have shame.… I don’t want other women feeling like I did.” Now Stephany speaks openly with friends about her experience and provides information about safer options for ending pregnancies clandestinely.[80]

Legal restrictions on access to abortion disproportionately harm women and girls from poor communities, and those with less access to accurate information and support to terminate unwanted pregnancies safely.[81] Many experts interviewed for this report described a double standard, or doble moral, around abortion in the Dominican Republic, due to criminalization: women with resources can safely terminate pregnancies with trained and competent clandestine providers, or by traveling abroad, while poor women must resort to less safe methods, without support from reliably qualified providers. “If you are poor, you are lost,” explained one doctor interviewed for this report. “If you have money, you can do it [have a safe abortion] anyplace. The problem is poor women go to any doctors, unknown doctors, and they are not adequate.”[82] Another doctor had a similar observation: “For very rich women, it’s not a problem [to have a safe abortion]. The problem is with poor women.”[83]

Human Rights Watch interviewed two women who had safe—though clandestine and illegal—abortions.[84] Both women had medical abortions under the care and supervision of trained providers.[85] One woman, Nicole, had private insurance, a high level of education, and a stable job, and she was able to find a safe and reliable provider to help her terminate the pregnancy. “I had the privilege of networks. I knew people and reached out to them. I had a medical abortion. It went well. I had no problems, not even getting the pills. The provider gave them to me and gave me all the information about how to use the pills.” Describing the interaction with her provider, she said, “It calmed me to see her.… She told me what to expect. She said, ‘If these things happen, it’s a sign you should get medical attention.’… To know you’re with someone who will give you time and information, it gives you a lot of confidence and reassurance.” Nicole said the experience solidified her belief in the importance of access to safe and legal abortion: “All women should have the same process. For me, [this experience] was fundamental to understand the importance of the fight for safe abortion.”[86]

Camila, the other woman, had a medical abortion under the care of a trusted provider. She contrasted her experience with that of a friend who experienced complications after a clandestine abortion and had to seek post-abortion care in the public health system. “They treated me well because, in reality, it was a clinic I could pay for…. But she [my friend] didn’t have money,” Camila said, explaining how her friend took pills and drank a beverage to end a pregnancy alone, without support from a medical provider. She later had to seek emergency attention in the public health system for post-abortion complications. “She was admitted [to the hospital] for a week.… It was a really painful process.”[87]

Post-Abortion Complications

Though the use of misoprostol has made clandestine abortion safer than it was in the past, criminalization still prevents women from accessing the information, services, and support they need to terminate pregnancies safely.

“Complications from unsafe abortion haven’t disappeared, but they’ve reduced dramatically,” said Dr. José De Lancer, an obstetrician-gynecologist in Santo Domingo who worked in the public health system for many years.[88] An obstetrician-gynecologist in Santiago de los Caballeros had a similar observation: “Back when I was a student at the hospital in the 1980s, in my specialty [obstetrics and gynecology], we saw perforations [of the uterus], infections. The use of technology has helped people. Misoprostol has avoided a lot of complications.”[89]

Even with the availability of misoprostol, however, many women and girls attempt abortion using less safe means and experience complications as a result. Those who use misoprostol also often face risks when they lack reliable information from medical providers on correct dosage for safe and effective use. An estimated 25,000 patients are treated for complications from miscarriage or abortion in the public health system each year. One obstetrician-gynecologist at a public hospital in Santo Domingo estimated that 10 to 12 patients arrived at the hospital each day with incomplete abortions: “They come with pain, bleeding. Once we see them in the emergency room, then we do the procedure [to remove tissue from the uterus].”[90]

Many people interviewed for this report experienced or witnessed complications from unsafe abortion. For example, Melina, a 26-year-old woman with four young children, said she had become pregnant unexpectedly six months earlier when her contraceptive method failed. She was very upset when she learned she was pregnant. “I felt bad. All I could think about was getting an abortion.” She tried to end the pregnancy by drinking a tea made from herbs and plants and suffered intense pain. “I had a lot of pain in the front [abdomen] and back. I couldn’t sleep, and I was bleeding only a little. I endured the pain at home alone because I didn’t want to seek [medical] attention because I had taken home [abortion] remedies.” Melina said she feared being reported to authorities, or facing abuse by medical providers, for having an illegal abortion. When the pain became unbearable, she went to a public hospital and explained that she made a tea to try to end a pregnancy. Melina said the doctor prescribed her misoprostol and sent her home without examining her or providing anything for the pain. Melina took the pills as instructed, but the pain persisted for ten days. “I started thinking I was not going to survive it.” She went to see a doctor again and was told she had an infection. When she spoke with Human Rights Watch, six months later, she still suffered chronic pain and other health effects from the ordeal. “It was really intense. I suffered a lot,” she said.[91]

Alejandro, a 24-year-old man, told Human Rights Watch that he brought a 28-year-old friend to the hospital with post-abortion complications in 2017 after she drank a beverage she thought would induce abortion. “When I went to see her, she had a fever, and she was shaking. She drank it [the beverage], and she was supposed to expel everything [from her uterus], but everything didn’t come out. I remember it was horrible. There were blood clots in the bathroom.” After five days, Alejandro said his friend agreed to go to a hospital, even though they both feared criminal penalties for seeking medical care.

She was afraid, but she couldn’t endure the pain. She was afraid to say she had an abortion…. When we went to the doctor, I stayed outside.… I dropped her off and left. And I went back for her. But I didn’t stay because it’s illegal, and I didn’t know if there could be consequences.

Alejandro’s friend received medical attention and recovered.[92]

Kendra, a health outreach worker with a health center in Santo Domingo, told Human Rights Watch about a woman she visited who had serious complications from unsafe abortion. The woman decided to end a pregnancy after finding out that her partner was already married. “She used a home remedy [to induce abortion],” Kendra explained. The woman developed a serious infection, but delayed seeking care: “After 15 days of being silent, alone, she started to have a fever and a lot of pain… I accompanied her to the maternity [hospital], and after the extraction she was hospitalized for 10 days receiving antibiotics [to treat the infection].”[93] She recovered.

Paola, 31, told Human Rights Watch that her younger sister is unable to have children after an unsafe abortion a year ago. “She made a tea and took pills.” Paola was with her afterward, and said her sister experienced heavy bleeding and infection. One week later, she had to have emergency surgery and is no longer able to have children.[94]  

Alicia, 17, told Human Rights Watch that a 16-year-old friend had serious complications after taking pills and a tea made from herbs to try to terminate a pregnancy.

She was on the verge of death because of near gangrene [tissue death due to serious infection]…. I wasn’t there at the time [that she took the pills], but when I came back, she was vomiting, pale, feeling weak. She had to go to the hospital for the cleaning. She was afraid they were going to put her in prison, because it’s illegal. She thought they’d ask about what happened.[95]

In some countries with restrictions on legal access to abortion, programs exist to provide pregnant women and girls with access to accurate information about safer options for clandestine abortion, in order to reduce morbidity and mortality associated with unsafe abortion.[96] Authorities in the Dominican Republic should implement a risk reduction program nationwide to provide women and girls with information on the safety and risk of different measures used to induce abortion clandestinely.

Abusive Behavior by Health Care Providers Following Clandestine Abortion

Some women and girls interviewed for this report faced obstetric violence—negligence, mistreatment, or abuse by health personnel—when they sought medical attention for urgent reproductive and sexual health needs, including following miscarriages or clandestine abortions.[97] In two cases, women experienced reproductive health emergencies unrelated to pregnancy, but health workers assumed they had abortions and mistreated them. Interviewees reported the following types of abuse in the health sector: extreme delays in medical attention, or discharging or dismissing women and girls without sufficient examination, sometimes to the extent that their lives were in danger; inadequate or non-provision of anesthesia or pain relief, specifically while performing dilatation and curettage to remove tissue from the uterus,[98] causing severe pain and suffering; and hostile, threatening, or disrespectful questions or comments.

The Ministry of Public Health has detailed protocols for the provision obstetric and gynecological care, including treatment for miscarriages or incomplete abortions. The protocol instructs all health personnel to “offer the client dignified, respectful and sensitive treatment, with a neutral attitude, and free from discrimination of any kind,” and specifies that providers should take a clinical history, do a detailed examination, administer care appropriate for the duration of the pregnancy, treat any post-abortion complications, and refer patients for counseling about contraceptive methods.[99]

Human Rights Watch research, as well as research by other organizations, suggest a discrepancy between the protocol and the treatment women and girls receive in some health facilities. The Center for Gender Studies (Centro de Estudios de Género, CEG-INTEC) and Women’s Link Worldwide have documented obstetric violence in the context of post-abortion care in the Dominican Republic.[100]

Several women and girls said that they were not attended to promptly or were not given adequate anesthesia or pain management when they had miscarriages. Lidia Ferrer Paredes and Vanessa Rodriguez from Confederación Nacional de Mujeres Campesinas (CONAMUCA), a nongovernmental organization that represents rural women, explained this abuse: “We suffer a lot of violence when we go to the hospitals. Even when women go to hospitals with miscarriages, they [hospital staff] say it was induced [abortion], and they do procedures to clean the uterus in cold blood [without anesthesia].”[101]

Rayneli, 15, told Human Rights Watch she had a miscarriage at age 13 after she was in a motorcycle accident: “I fell, and I was having pain. That’s how I learned I was pregnant.” She went to the hospital for the pain, and learned that she had been three months pregnant, but had miscarried, and that the tissue inside her uterus had caused infection. “I went to the hospital and they did a curettage. I didn’t know I was pregnant…. They didn’t provide care right away. It lasted a while. And they did it without anesthesia, because they thought it was [a] provoked [abortion]…. It was very painful.”[102]

Bianca, a 30-year-old mother of three, found out she was pregnant after missing a dose of her daily contraceptive pill. Three weeks into the pregnancy, she had a sonogram, and her health provider told her that she had a high risk of miscarriage. Two months into the pregnancy, she miscarried.

I started bleeding, and I went to the doctor.… They didn’t give me a cleaning right away. They tried to protect themselves on suspicion that it was provoked. I was at the hospital for three days…. I was in pain and bleeding. I think they didn’t care for me because they always say when they receive cases like that it’s the woman who provoked it.

After three days, she left and went to a private clinic, where they attended to her immediately.[103]

One young woman said she was questioned and threatened with criminal penalties while under anesthesia. Adelyn, 20, became pregnant for the first time at age 15. She did not know she was pregnant until she miscarried. She went to the hospital bleeding and in pain. “When I was under anesthesia, they asked me how I had the abortion, how I had provoked it. They asked a lot of questions…They told me, ‘Be careful. If you did it on purpose, we can put you in jail.’” Adelyn believed the doctors had no choice but to interrogate her. “They have to ask because that [abortion] is a crime,” she said simply.[104]

Human Rights Watch also documented cases of women and girls who were mistreated when seeking post-abortion care. Four years ago, Camila, 24, accompanied a 20-year-old friend who had a clandestine abortion in the second trimester of pregnancy. The woman took pills and drank a beverage (“botella”) to try to terminate the pregnancy: “She’d done it at home, and she got to my house saying, ‘I feel terrible.’” Camila helped her friend into bed and saw that she was bleeding heavily. “My bed was completely soaked with liquid. We had to go to the emergency room.” Camila said her friend was treated poorly by the medical personnel when she got to the hospital. “The lady doing the cleaning [removal of tissue] told her she was an abuser who killed her son [by inducing the abortion], and said, ‘They should kill you too.’ She yelled at her and treated her harshly, without anesthesia. The treatment shouldn’t be like that. Everyone has to make their decision.”[105]

Madelyn, 28, said she had a friend who suffered severe complications after being turned away from a maternity hospital when she sought post-abortion care.

She started bleeding and went to the hospital in a lot of pain. They told her to go back home. They told her, “We don’t have beds. When you start bleeding more, come back.” They sent her away. She couldn’t stand the pain, and at midnight she was in a lot of pain and started bleeding nonstop, it didn’t stop. She wouldn’t stop bleeding. She called a taxi and had to take a cloth between her legs [to absorb the blood]. When she arrived at the hospital, she wouldn’t stop bleeding. She was hemorrhaging, and she was dizzy. They [the hospital staff] were running all over the place because they knew they could lose her…. They were scared because she had been there earlier and hadn’t received care.

Her friend had to stay overnight in the hospital to recover from the blood loss.[106]

Aury recounted the experience of a close friend who had an abortion three years earlier at age 19, after she became pregnant from rape. She had a clandestine abortion and sought medical treatment when she experienced complications. Aury said the medical professional she saw mistreated her and threatened to report her to the authorities for having an abortion: “They left her in pain, bleeding, they didn’t pay attention to her. The one who did the cleaning was rough with her.” Aury said her friend was kept at the hospital for three days, essentially so that she could be detained while the health providers decided whether to report her to police. In the end, they let her leave. Aury said the trauma of the rape and clandestine abortion were compounded by her treatment at the medical facility: “She was depressed because she was raped. And everything was mixed together in her head. She wanted to kill herself. They treated her like a dog. Worse than a dog.”[107]

Mayerlin, 38, told Human Rights Watch that she was neglected and mistreated at a hospital when she experienced irregular bleeding that was not related to her period or a pregnancy.

I wasn’t pregnant, but I was bleeding. I went to the hospital, and … they assumed I took something to start the period…. I said, “I’m in pain, and I’m bleeding,” and they asked if I was pregnant and got an abortion, and I said, “No.” I was waiting and waiting, and they were leaving me there…. They left me waiting until the next day.

Mayerlin eventually gave up and went home, still in pain and bleeding, but hours later, she returned to the emergency department. “The pain was unbearable,” she said. When she was finally examined, the doctor determined that she had torn a cyst. “For them, I’d had an abortion, and I had to accept the consequences.” By the time she received care, she had lost so much blood that her life was in danger. “I almost lost my life because of medical negligence,” she said.[108]

Elizabeth Velez with Catholics for Choice, a reproductive rights advocacy group, explained how the criminalization of abortion fuels abuse by health providers: “Health personnel know they can question, mistreat, and judge patients [with post-abortion complications], especially adolescents.”[109]

Dr. José Mordán, head of the Department of Family Health at the Ministry of Public Health, acknowledged the discrepancy between official protocols and practices in the health system: “There are important gaps in implementation [of the protocol],” he said, adding that some providers may not provide adequate counseling, or may use methods that are outdated and pose greater risks to patients (for example, curettage instead of aspiration to remove tissue from the uterus).[110]

Reluctance to Seek Medical Care

In countries where abortion is treated as a crime, women and girls may delay seeking post-abortion care for fear of being reported to authorities. They may also delay or go without care due to the reasonable fear of judgmental or abusive behavior by medical professionals.[111]  

Delaying treatment following a miscarriage or an abortion can significantly increase the risk of serious and life-threatening complications.[112] In a 2018 report, the Guttmacher Institute summarized the consequences of delaying treatment for post-abortion complications:

Delays in seeking treatment can have life-threatening consequences, given that the sever­ity of complications and the related risk of death rise the longer a woman goes without care. And should a woman suffer discriminatory treatment, sometimes in the form of excessive wait times, her prognosis can worsen further.[113]

Some women and girls told Human Rights Watch that fear of prosecution, as well as fear of obstetric violence, led them to delay or refrain from seeking care following clandestine abortions or miscarriages. For example, Carolina, 30, told Human Rights Watch that she had a clandestine abortion two years earlier using pills she bought at a pharmacy. “I felt weak, like I was going to fall. I had a bad taste in my throat. I fell asleep for a while, then the pain woke me up. It was like menstrual cramps at the beginning. I was bleeding a little bit. After a couple of hours, the pain got stronger.” She said the next day she experienced “very strong” pain, but she remained at home, and took more pills, rather than seeking help from a medical professional, because she feared abuse. “I’ve seen and heard about mistreatment when women go to the hospital with an abortion.”

Nine years ago, Carolina was in a hospital delivering one of her children, when she said she overheard an interaction between a doctor and another patient—a young woman who arrived at the hospital in great pain and said she had miscarried. Carolina said the provider accused the young woman of inducing an abortion: “The doctor told her, ‘That blood color doesn’t look like you fell this morning.’… They neglected her and left her in pain. She was screaming.” A few years later, Carolina accompanied a friend to the hospital who had serious complications from an unsafe abortion. “I was with her. I thought she was going to die…. I went with her to the hospital. They didn’t want to give her attention because she had problems from an induced abortion.” Carolina said her friend was not given any kind of anesthesia: “She told me she felt everything they were doing to her body.” Having witnessed these two experiences, Carolina was unwilling to seek medical care when she had a clandestine abortion. “I thought of going to the doctor, but I didn’t want to, because of the mistreatment.”[114]

Yamaira, 39, told Human Rights Watch she had an unwanted pregnancy 17 years earlier, when she was a young woman. She already had two children: “I was depressed, really worried about providing for three kids. I got desperate. A friend gave me pills—Cytotec—and a horrible tea.… I bled but I didn’t want to go to the doctor because I was afraid. I was afraid I’d go to jail because they noticed when you did an abortion.” She continued bleeding, but she did not seek medical attention. She remained pregnant.[115]

The fear of mistreatment by medical professionals following induced abortion is so pervasive that it deters some women and girls from seeking care when they are carrying one of the estimated 10 to 20 percent of known pregnancies that results in miscarriage.[116]

Aury, a 24-year-old mother of two, told Human Rights Watch she had two miscarriages in the span of three months when she was around 20. She experienced tremendous pain and heavy bleeding in the second miscarriage, but she refused to seek medical care in the public health system:
I was in so much pain, bleeding, depressed…. I was in pain for three days. My mom was with me. I was bleeding a lot, and I was really afraid. I thought I was going to die. But I know in the public hospital they do the abortion [post-abortion care] without anesthesia. My mom wanted to take me there, but I said no.
Instead she drank tea and tried to endure the pain at home. Eventually, Aury’s mother convinced her to go to a private clinic where she received medical attention.[117]

Failed Abortions

Several women and girls interviewed for this report tried to terminate unwanted pregnancies, but the methods they used did not work. A few reported experiencing post-partum depression after failed abortions, and all lived with the consequences of having a child against their wishes.[118]

Rebeca, 26, gave birth to her first child at age 17. When the baby was 18 months old, she learned she was pregnant again. “I felt depressed because I was not prepared for the pregnancy,” she said. One month into the pregnancy, she tried to end it: “I tried to abort, but all the methods I tried failed. I prepared a tea. I bought pills. I sent the man who got me pregnant to get pills at the pharmacy. The more I tried, the more it failed.” She never sought medical advice on terminating her pregnancy, because she knew it was illegal. “I was afraid,” she said. “That’s why I didn’t want to confide in anyone, so they would not denounce me [to the authorities].”[119]

Larissa, 22, told Human Rights Watch she married at age 12, and by age 18, she already had two children and was pregnant for a third time.[120] “I didn’t want to have it,” she said. She attempted to end the pregnancy: “I took pills, and teas, and I bled various times, but it didn’t work.” She had very little information and thought that taking the placebo pills from her oral contraceptive pack—the pills that women and girls take while they are menstruating—would induce abortion. “I didn’t have any support. A friend of mine knew, but she didn’t agree with what I was doing. I’d heard people saying things about mango tea and such…. I was afraid. I thought something would happen to me, attempting the abortion. Sometimes things get complicated.”[121]

Mayerlin, 38, told Human Rights Watch that she attempted to terminate an unwanted pregnancy at age 20. “I tried various methods: teas, pills. I would beat my belly with concrete blocks. I spent long periods of time without eating or drinking water to make myself weak. They said Cytotec [misoprostol] was the best. I got it, and drank some, inserted others into my vagina.” She found a doctor who could perform an abortion, but she could not afford to pay him. “He was asking for RD$20,000 [approximately US$400]…. If I’d had the facility to go to a clinic, I would have gotten it [an abortion].” She remained pregnant, against her wishes.[122]

Aury, 24, said she became pregnant for the first time at age 17. She was in high school and using injections to prevent pregnancy. She took pills and tea to try to induce abortion, but they did not work. “I wanted to stay in school. I was only three months away from finishing high school.” Aury said the director of her school told her to stop attending when her pregnancy became obvious. “You couldn’t be pregnant in school, the director told me.” She negotiated to be allowed to attend classes once a week and managed to finish high school, but the experience took a toll on her emotional health. “I got depressed with the belly [pregnancy]. I had high blood pressure. It was the most tormenting thing I’ve lived in my life.” After giving birth, she had an intrauterine device (IUD) inserted but became pregnant again when the IUD migrated, rendering it ineffective. Again, she drank tea to try to induce abortion, but it didn’t work. She gave birth again. “I was 18 with two kids. It was difficult. I had the help of my husband, but you feel like the world is crumbling around you, especially when you have goal you want to reach, and dreams you want to achieve. I was too young.”[123]

Ana Paula, 16, had given birth one month before she spoke with Human Rights Watch in April 2018. She said she had tried to terminate the pregnancy:

I prepared a lot of remedies, beverages. But nothing happened. Every day, I took German malt. I would drink one every day.… I prepared it with other things, baking soda. I’d heat it.… I had an expulsion [of tissue from the uterus] after a few days, and I thought it was gone, but then I felt something moving. I went for a second sonogram, and I found out it was girl.

As soon as she left, she started crying. “All I could think about was the situation I was going through,” she said, explaining that her partner, age 29, did not have a job or a home for them.[124]

Noelia, a 33-year-old mother of four, told Human Rights Watch that when she became pregnant for the fourth time, her husband’s family accused her of infidelity, and she decided to end the pregnancy. “I took pills, those that pregnant women are not allowed to take. I got them at the corner store. It didn’t do anything to me…. I had to keep going with the pregnancy,” she said.[125]

The consequences of having a child against your will are lifelong. Yamaira, 39, tried to terminate an unwanted pregnancy 17 years ago, as a young mother with two children. She drank tea and took pills, but she was unable to terminate the pregnancy. It affected her life profoundly to have a third child: “I went through a lot of difficulty getting money. I’d even go hungry…. My health was affected. I got post-partum depression. I never recovered from it. I cried a lot. The doctor told me to be calm,… but I couldn’t calm down.”[126] She told Human Rights Watch that since giving birth to her third child, she has continually struggled with depression.

Deaths from Unsafe Abortion

Complications from unsafe abortion can be life-threatening. Globally, unsafe abortion accounts for 8 to 11 percent of maternal deaths each year.[127] In the Dominican Republic, at least eight percent of maternal deaths are attributed to complications from miscarriage or abortion.[128] Deaths from unsafe abortion can be prevented through safe and legal access to abortion. “The law [criminalizing abortion] reinforces unsafe abortion and maternal death,” said one doctor interviewed for this report. “It’s an issue related to death or survival.”[129]

In a 2018 study, the Center for Gender Studies (Centro de Estudios de Género, CEG-INTEC), with support from the Ministry of Public Health and the United Nations Population Fund (UNFPA), analyzed six maternal deaths that occurred in a hospital in the Dominican Republic between 2013 and 2014.[130] Two of the women died from sepsis. In one case, the woman died after arriving at a hospital in septic shock following a clandestine abortion with uterine perforation.[131] In the other case, it was unclear whether the woman induced an abortion or had a miscarriage.[132]

In a 2017 report, Women’s Link Worldwide documented seven maternal deaths in the Dominican Republic.[133] Two of the women died from serious infection linked to incomplete abortion. In one case, a 24-year-old woman died in 2015 from a serious infection following a clandestine abortion. Before her death, the infection caused gangrene in her extremities and she had to have both legs amputated.[134] In the other case, a woman did not know she was pregnant, and after drinking tea to regulate her menstrual cycle, she experienced bleeding and sought attention at a hospital, where she was treated for an incomplete abortion. She died of sepsis several weeks later.[135]

Some of the women and girls, as well as providers and advocates, interviewed for this report described deaths from unsafe abortion. One obstetrician-gynecologist at a public hospital said, “We had a patient referred to the hospital two years ago, where she had practiced an unsafe abortion, and because of that she had sepsis. She was in septic shock. She died. She was 19…. Since it’s illegal, the family would not say who or where it was done. It’s awful.”[136]

Catalina, a licensed nurse, told Human Rights Watch about a case she witnessed at a maternity hospital in Santo Domingo five years earlier. She said a woman arrived at the hospital with heavy bleeding after taking misoprostol to induce an abortion, and the medical providers at the hospital delayed treating her.

They use it as a type of punishment for abortion, and they don’t provide immediate attention.... She lost so much blood, and they couldn’t find a vein [to give her a blood transfusion]. She was awake, and saying, “Don’t let me die. Give me water.” She lost a lot of liquid, and she was thirsty. But they couldn’t find a vein, and it was too late.

By the time Catalina arrived, the medical providers were trying to save the woman’s life, but she had lost too much blood, and she died.[137]

Melina, 26, lost a friend in 2017. “She inserted Cytotec [misoprostol], and thought she expelled everything [from her uterus], but by the time she got to the hospital, there was no time because the residues had already damaged her internal organs. It caused her death.”[138] Raquel, 38, said a 19-year-old woman in her neighborhood died four years earlier due to hemorrhaging after she had an unsafe abortion.[139]

Dominican authorities have pledged to eliminate preventable maternal death and have set a goal of reducing the maternal mortality ratio to 70 per 100,000 live births.[140] Research has shown that expanding legal access to abortion can lead to significant reductions in maternal mortality.[141] Authorities in the Dominican Republic should decriminalize abortion without delay to prevent additional deaths from unsafe abortion.

Lack of Access to Legal Abortion Even in Cases of Rape, Incest, and Serious Health Risks

Rape and Incest

The Dominican Republic’s total ban on abortion has particularly harsh consequences for the significant number of women and girls who are survivors of domestic and sexual violence. According to the government’s 2013 demographic and health survey (ENDESA-2013), 35 percent of women and girls ages 15 to 49 who were ever married or in a union said they experienced some form of domestic violence, including physical, emotional, or sexual violence by an intimate partner.[142] One in ten women and girls in the Dominican Republic reported surviving sexual violence in her lifetime.[143] Of women who reported sexual violence, 61 percent said their partner or ex-partner was the perpetrator.[144] More than 60 percent of women and girls who said they experienced physical or sexual violence never sought help, and more than half of those who never sought help said they never told anyone about the abuse.[145] When women can engage with the health system without fear of prosecution or abuse, providers can more effectively screen for violence and connect their patients to services.

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.[146] In its analysis, the WHO emphasizes the importance of healthcare providers “identify[ing] opportunities to provide support and link women with other services they need.”[147] Although the Dominican Republic is taking steps to address gender-based violence,[148] the total criminalization of abortion, including for pregnancies from rape and incest, undermines these efforts by removing possible pathways for survivors to report abuse and access support.

Human Rights Watch documented several cases of women and girls who became pregnant as a result of rape or incest and did not have the option to safely and legally terminate their pregnancies. In some cases, women and girls found ways to clandestinely end these pregnancies, but secrecy around abortion due to the country’s total ban kept them isolated from supportive and professional services, leaving them without a channel for reporting abuse. In other cases, survivors of violence were forced to continue pregnancies resulting from rape and incest.

International experts have advised that denial of safe abortion for survivors of rape and incest may amount to torture or cruel, inhuman, or degrading treatment.[149] The Committee against Torture, which monitors states’ compliance with the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) has noted that the prohibition of abortion in cases of rape means that “women concerned are constantly reminded of the violation committed against them, which causes serious traumatic stress and carries a risk of long-lasting psychological problems.”[150]

Several service providers interviewed for this report described cases of pregnancy from rape and incest they encountered through their work. When Human Rights Watch spoke with Antonella, a health educator in Santiago de los Caballeros, she had recently counseled a pregnant 11-year-old girl who had been raped by her stepfather. The girl came to a clinic with her mother, and she was 15 weeks pregnant. “She had pelvic pain,” Antonella said. “She didn’t even want to get shots. She’s just a little girl. She doesn’t know what’s going on in her life or in her body.” Antonella said that because abortion is illegal, she had no options except to refer the girl for prenatal care. “We’re going to refer her to the children’s hospital for nutritional advice.” She explained that the pregnancy was risky because the girl’s body was not yet developed. The case affected Antonella deeply, even after years of work with vulnerable and marginalized women and girls. “It got me so worried. I told my boss I don’t want to do work [with survivors of violence] anymore.”[151]

A lawyer with a nongovernmental organization in Monte Plata province who assists survivors of violence said she had worked on 39 child rape cases in the last year. She knew of four girls who became pregnant from rape or incest, between the ages of 12 and 16. Two had clandestine abortions. The lawyer said one, a 14-year-old rape survivor, suffered complications including fever and heavy bleeding. “She hemorrhaged,” she said. The other two girls continued the pregnancies and faced difficulties that pushed them out of school. “One of them got ostracized at school, by society. She dropped her regular life…. They isolate themselves. We’re trying to get them to reintegrate into the communities.”[152]

A doctor interviewed by Human Rights Watch said that she treated a 14-year-old rape survivor who was four months pregnant. She suspected the girl’s father was abusing her, but because of the ban on abortion, she felt that she could not give the girl the type of care she needed: “I could not take her to a hospital,” she explained. She told the patient and her father how to use medication to induce an abortion, but she could not refer the girl for other services.[153]

Regina, a psychologist in Santiago de los Caballeros, told Human Rights Watch that she had 10 women and girls under her care who were pregnant from rape—most of them girls under 18. She said she worked with survivors of violence to help them accept these pregnancies. “They cry every time they bring up the topic.” She described one case:

I have a mother [as a client in my practice] who has a son with her own father. She was 15 when he abused her [for the first time]. She was quiet for a long time because he threatened her. But when she became pregnant, she left home and moved in with an aunt. She was 16 when she got pregnant.[154]

Mary, an outreach worker in rural communities in Monte Plata province, told Human Rights Watch about a case she followed of a 14-year-old girl with a mental disability who became pregnant following a rape two years earlier. Mary suspected incest and believed the girl’s father had raped her, although the father had accused another man of being the rapist. When asked if the family had considered abortion, Mary said the family was very poor: “They live on the streets. She got pregnant like that. You know there’s no doctor [to help her]. We don’t have that law here [to permit abortion after rape].”[155]

Susi Pola, founder of the nongovernmental organization Núcleo de Apoyo a la Mujer (NAM), told Human Rights Watch that she recently spoke with a woman whose husband raped her. After suffering serious domestic violence, she obtained a restraining order against him. He violated the order, raped her, and she became pregnant again—she had already had three children in four years with him. She ended the pregnancy clandestinely by taking pills.[156] The woman’s story was one of five cases documented in a September 2018 report published by the Coalition for the Rights and Life of Women (Coalición por los Derechos y la Vida de las Mujeres). The report described the experiences of five women and girls who had clandestine abortions either because the pregnancy threatened their lives, they were pregnant from rape or incest, or they learned the fetus would not survive outside of the womb.[157]

Several women interviewed for this report recounted personal experiences with pregnancies from rape or incest. Dayelin, 22, had a clandestine abortion when she became pregnant after she was raped at age 12 by a 25-year-old man. “It was the first time I had intercourse. I didn’t want to have sex. I didn’t agree.” When she learned she was pregnant, she was deeply distraught: “I was crying and desperate. I didn’t want to have it. I was a girl. What would I do with a baby? A friend gave me a tea, and I had an abortion. I didn’t go to the doctor. I stayed at home. I was afraid to go to jail.” She said she experienced a lot of pain, but her friend warned her not to seek medical attention: “My friend told me to stay at home and endure to the pain. Going to the hospital would mean going to jail.” She had very little support and told only one friend about the experience. She became deeply depressed afterward, “I thought about killing myself. I drank Clorox [bleach].”[158]

Yesenia, 37, told Human Rights Watch that at age 20 she was in a relationship with an abusive partner. He raped her repeatedly, and she became pregnant. At first, she was reluctant to end the pregnancy, as she knew it was treated as a crime. “At that time, they were starting to promote the idea that if you had an abortion, you could go to jail,” she said. After delaying until the second trimester, she decided to try to terminate the pregnancy using home remedies, including a tea and a malt beverage. She suffered such serious complications that she had to stay in the hospital for a month. “There was so much blood,” she said. “I couldn’t tell them I had taken anything. I said it was a miscarriage, not an abortion.”[159]

Carmen, 33, was raped by her father starting at age 9. At 15, she became pregnant. Her father realized she was pregnant before she did. “He was counting my period. He knew the date it started and the date it ended…. I felt bad and tricked. He said he was going to say I got pregnant by one of his workers.” She said her father gave her pills to induce abortion, and he lied to her mother about the pregnancy: “My mom was home [when I had the abortion]. He told her his lie—that I slept with one of the workers, and the worker left.” She said, “[I experienced] a lot of pain. They took me to a small clinic in a nearby neighborhood. There they did the cleaning [to remove tissue from the uterus] under anesthesia.” Her father continued raping her afterward, until she got married and left home at age 19. She explained how difficult it was for her to seek help: “The fear. The fear is really difficult. When you’re afraid of someone, it’s very difficult for you to speak.”[160]

A few women interviewed by Human Rights Watch recounted stories of family members or friends who became pregnant from rape or incest and lacked access to safe and legal abortion. Karen, 18, told Human Rights Watch that her sister was raped by an uncle at age 13 and became pregnant. The family tried unsuccessfully to obtain a safe abortion for her. “She didn’t want to have [the baby], but she couldn’t interrupt the pregnancy because it’s illegal…. My aunt took her to the hospital to try to get an abortion, but they said it’s not legal, so it’s not possible.” Karen’s sister gave birth and the child is now 6 years old.[161]

“I know a girl who was raped and got pregnant by her stepfather,” said Madelyn, a 28-year-old woman interviewed for this report. “She was 11 when she was raped. Now she’s 14…. She continued the pregnancy, but she didn’t want that. She would jump down stairs trying to lose it because she didn’t want it.”[162]

Serious Health Risks

Abortion is criminalized in the Dominican Republic, even when a pregnancy threatens the woman’s life or health. Medical providers said that criminal penalties for abortion made it difficult for them to exercise their best judgment and provide the best standard of care when their pregnant patients faced serious health risks. Human Rights Watch asked one provider whether he could use his discretion to end pregnancy in such a circumstance: “In our country, the law doesn’t allow it.” He explained, “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], that pregnancy has to be preserved from conception to delivery…. But it doesn’t work like that. The pregnancy can put a woman’s life at risk.” This doctor admitted that he prioritized his duties as a doctor over the law when his patients were in imminent danger: “My job is to preserve the woman’s life. If I have to violate the law, I will.”[163]

Human Rights Watch documented several cases in which pregnant women and girls faced serious risks to their health or lives because the law did not permit them to access safe abortion. Madelyn, 28, told Human Rights Watch she was seriously injured in a car accident several years ago. As she was receiving emergency medical care, providers discovered that her intestines were perforated, and she had internal bleeding and needed emergency surgery. They also discovered that she was one month pregnant. She underwent surgery, and afterward, the doctor informed Madelyn’s mother that the pregnancy could cause serious problems:

He told my mom the pregnancy could interfere with the surgery. That my belly [growing with pregnancy] could open the surgery [surgical wound] because it was recent. My mom asked, “What can we do?” The doctor said, “I cannot do anything.” But he was very clear that my life was in danger. He said, “There’s nothing I can do because abortion is penalized.”

Madelyn said her mother was deeply distraught and pleaded with the doctor to help them end the pregnancy and protect her daughter’s life. Eventually, doctors discovered that the fetus no longer had a heartbeat, and gave her medicine to remove tissue from the uterus. Looking back, Madelyn questioned the government’s ban on abortion: “If my life is mine, I decide for my life. No one else.”[164]

When Human Rights Watch spoke with Sara, a 22-year-old single mother with two young children, she was two months pregnant. The pregnancy was not planned, and she said she feared for her health, because in her previous pregnancies, she had very high blood pressure and delivered prematurely. She said there was a man in her community who could help her get medication to induce abortion: “He does it privately. He doesn’t want anyone to know.” However, she knew it was a risk because abortion is illegal in the country: “You cannot do that here. If they find out, they can put you in jail.”[165]

Preeclampsia is the leading cause of maternal death in the Dominican Republic.[166] One doctor interviewed for this report explained, “If you interrupt the pregnancy, the blood pressure goes down immediately.”[167] Another doctor further explained how high blood pressure during pregnancy can be life-threatening: “The blood pressure goes up, and it affects the whole system. It can cause convulsions, it can cause the kidneys to shut down, platelets get low, bleeding. The only thing that cures it is delivery.”[168]

Camila, 24, became pregnant for the first time at age 22. The pregnancy was unplanned, and the delivery was complicated because she has a condition that can cause heavy bleeding.

In my family, women suffer myomas [benign tumors], and they have hemorrhages when pregnant. It’s difficult for women in my family to get pregnant. My mom has the same condition.… When my son was born, I had complications, and he did too. I have chronic anemia. I had to have a c-section, and I needed blood.

After she gave birth, the doctor advised her not to get pregnant again, given the risks to her health. When she realized she was pregnant for the second time a year after giving birth, she decided to have an abortion. She paid RD$10,500 [more than US$200] to go to a safe clinic, where a provider counseled her on how to have a medical abortion.

Some treatments for serious and potentially life-threatening illnesses can increase the risk of complications during pregnancy.[169] One doctor interviewed for this report described a case in which a pregnant patient was diagnosed with a serious health condition and wanted to end her pregnancy before beginning treatment for the condition. Because legal abortion was not an option, the provider risked criminal penalties to help the woman clandestinely terminate her pregnancy.[170]

Susi Pola, an advocate with the organization Núcleo de Apoyo a la Mujer (NAM), told Human Rights Watch about a case she was aware of where a 15-year-old girl had recently terminated a pregnancy clandestinely. She had three children already, and her doctor informed her that another pregnancy at such a young age would be dangerous to her health. She terminated the pregnancy by taking pills and a beverage.[171] The girl’s story was published in a recent report by the Coalition for the Rights and Life of Women.[172]

The death of 16-year-old Rosaura Almonte Hernández in 2012 illustrates the impact of the Dominican Republic’s criminal laws that block access to therapeutic abortion. Rosaura, known as “Esperancita,” was diagnosed with leukemia, but she was initially denied access to chemotherapy because she was seven weeks pregnant. Her mother requested access to therapeutic abortion, and her request was denied. Weeks later, under mounting international pressure, doctors provided Esperancita with chemotherapy, but she died in August 2012. In 2017, her mother, Rosa Hernández, with support from the organizations, Women’s Link Worldwide and Colectiva Mujer y Salud, filed a petition with the Inter-American Commission on Human Rights (IACHR) seeking justice for her daughter’s death.[173]

Under the criminal code in the Dominican Republic, women and girls are also denied access to abortion for unviable pregnancies, when the fetus has complications incompatible with life outside the womb. Human Rights Watch did not interview any women or girls who had unviable pregnancies, but a doctor said he had recently treated a patient who was 21 weeks pregnant when she learned that the fetus had anencephaly, a fatal congenital brain disorder. He was unable to offer her access to an abortion:

The only thing I explained is that she has the right [to decide to terminate the pregnancy], but we cannot do it. Legally, there is no way…. I believe it should be a legal option, and each woman should decide for herself what she should do. Because right now, we are violating their rights. We’re telling them, “You can’t do this with your body.”[174]

Stigma, Isolation, and Emotional Distress

Legal restrictions on abortion leave women and girls unable to speak openly about options when they experience unplanned or unwanted pregnancies. Many women and girls interviewed for this report described feelings of isolation and emotional distress when they learned they were pregnant, or when they decided to terminate pregnancies clandestinely. In some cases, those feelings were compounded by treatment by health providers.

Xiomara, 26, had an unplanned and unwanted pregnancy at age 20. Before learning she was pregnant, she had planned to take a job in Europe. “Here in this country, the economic situation is not good at all, so taking a job in Europe, and leaving [the country] was the best option I had.” She had also recently separated from her partner. “When I realized I was pregnant, I felt that my whole future disappeared, vanished,” she said. She was deeply depressed during the first trimester. “My body was rejecting the pregnancy. I started bleeding…. I wouldn’t sleep. I’d cry every day.” She tried to end the pregnancy by neglecting herself. “The doctor told me to stay in bed and raise my feet. I did the opposite.” She also said she took prescription medications that she believed could cause complications in pregnancy. “I took psychiatric medication I had previously used for anxiety. I took sleeping pills. I kept taking them, even though [I knew] they could harm the baby.” She said she never spoke to anyone about her desire to end the pregnancy. “I was ashamed to tell my doctor or my friends…. I felt trapped, with no future.” She remained pregnant, and after giving birth, she continued to struggle with depression for the first six months of the baby’s life.[175]

When Human Rights Watch asked what kind of support she needed when she learned she was pregnant, she said medical providers should offer support and counseling when they inform patients that they are pregnant:

The diagnosis of a pregnancy shouldn’t always be, “Congratulations.” It should be, “Okay, you’re pregnant. This is what happens next.”… [Some women] get overwhelmed when they learn they are pregnant … because they are scared. They should have someone there to tell you that everything you’re feeling now, a lot of women feel. It’s not an obligation to feel happy. When I realized I was pregnant, and the doctor told me, he made a party of it. I looked at him thinking, “Who told you I want to have a son?”[176]

Nicole, a 28-year-old woman who had an unwanted pregnancy, had a similar experience when she had a sonogram at six weeks gestation.

The doctor started pointing at the screen, saying, “Look, it’s a little baby!” and I was shocked…. The doctor is there to give you information in a neutral, professional manner, to provide a service. He should say, “You have this many weeks of pregnancy.” Instead, he says things that are not neutral, and plants ideas in people’s minds.[177]

Lucely, 18, had an unwanted pregnancy at age 16, and said she felt extremely isolated and alone: “The father of the girl [my daughter] had a lot of problems at that time. He didn’t have a job. They did a sonogram, and I realized [I was pregnant]. I wanted to die. Oh my god. I thought about having a child with no house, with no one. I felt alone in that moment…. I was almost in shock.” Lucely wanted to end the pregnancy, but she was already in the second trimester. “I drank tea, a really weird tea,” but she remained pregnant. “Everything ended right there,” she said, describing how the pregnancy changed her life. “I never went back.… I suffered a lot. My mom was far away. I was here alone. My father spoke bad to me. He’d insult me. He didn’t help me. I feel bad to even think about it. It’s like when you feel like no one loves you.”[178]

Maoli, 20, told Human Rights Watch she got pregnant unexpectedly at age 16 and had a clandestine abortion. As an adolescent girl, she said she felt very afraid, and told only her boyfriend and an older friend about the pregnancy. “I told her [my friend] what was going on, and she told me about a tea used for that [abortion], and I took it…. The next day I started bleeding, and I was in a lot of pain,” she said, rubbing her belly. Her friend eventually took her to a medical provider who attended to her, and the pregnancy ended. Four years later, as she recounted the experience to Human Rights Watch, she said it was still difficult to talk about the experience and the fear she felt: “I don’t like to remember it. I haven’t found another person to confide in about it…. I was afraid. Fearful that they [the doctor] would notice, realize [that I had an abortion]. That people would know. I was worried that they’d tell my parents.”[179]

Fabiana, a 26-year-old woman who helped a friend terminate an unwanted pregnancy, described how some women experience stigma around abortion:

Women don’t perceive abortion as something illegal. They don’t internalize the legal aspect of it. What they internalize is the idea that they could go to hell for it. What affects them most is the religious and moral aspect of it. That you’re a bad woman, a bad mother who killed your baby, that God would not allow you in heaven. That is really internalized and that causes a lot of pain and suffering.[180]

Mayerlin, 38, attempted to terminate an unwanted pregnancy at age 20. She tried various clandestine and unsafe methods, but she remained pregnant. She told Human Rights Watch that she felt that she could not speak to anyone about her desire to end the pregnancy. “I was afraid and ashamed…. As a mother, if I had had an abortion, society would have condemned and judged me.”[181]

Eridania, 28, had an unplanned pregnancy as a young woman. When she became pregnant, her partner disclosed that he was already married to another woman, and he abandoned her. “My parents also turned their backs on me,” she said, explaining how her family reacted when they learned she was pregnant as an unmarried woman. She said, “[I felt] very depressed in every sense, knowing that everyone had turned their backs on me. I couldn’t count on anyone. I had no economic security. No job.” She considered ending the pregnancy, but a psychologist at a public health facility dissuaded her from making that choice: “She talked to me about abortion, the harms, that it’s a murder because the first day of pregnancy is a life. That you cannot interrupt it because it’s part of you.”[182]

Vulnerability to Undue Pressure, Abuse, and Coercion

When abortion is legal and accessible, women and girls facing unplanned pregnancies can freely seek confidential, factual, and unbiased information from qualified professionals about a full range of options. Pre-abortion counseling can reveal whether women or girls are facing undue pressure, or coercion, from partners, parents, or other sources, around their decisions.[183] Because abortion is illegal in the Dominican Republic, pregnant patients are not provided with information about a full range of reproductive health options, including abortion. In the absence of a standard of care that includes information about safe and legal abortion, women and girls may be more susceptible to undue pressure fr0m partners or others who want to control their reproductive health.

Human Rights Watch interviewed some women and girls who said they were pressured, abused, or misled by others, often their partners, to terminate unplanned pregnancies they wanted to continue. In extreme cases, as two cases in recent media reports show, women and girls may face abuse or coercion to have abortions against their wishes. While women and girls may face coercion or abuse around pregnancy decisions even in settings where abortion is legal and accessible, criminalization forces discussions of abortion to happen clandestinely, and often informally, denying women standardized, reliable, and confidential reproductive health counseling to make pregnancy decisions without undue influence from anyone else.

A young woman interviewed by Human Rights Watch said a neighbor gave her a substance to induce an abortion without informing her, even though she did not want to terminate her pregnancy. Maria Fernanda told Human Rights Watch that her father began raping her when she was 11 or 12. At 13, she became pregnant as a result. She was already entering the third trimester when she found out. “I didn’t know what was going on. I had a fever. I was sick. The doctor gave me a [pregnancy] test, and it was positive.” She said she never wanted to end the pregnancy, but other people urged her and tried to coerce her to do so. “There were people who wanted to give me things without me knowing. I didn’t understand. I was a girl.… I drank a very sour tea, but thank god, it didn’t harm me or the pregnancy. A neighbor prepared it. They said it was for the pain. I was too innocent [to understand what was happening].” Though the pregnancy was difficult, she was happy with her decision: “I felt sad and depressed for what had happened, but I endured the pregnancy, and at nine months, I had my boy.”[184]

Alicia, 17, said her partner hurt her to try to induce a miscarriage when he learned she was pregnant. She said that at age 14 she believed she was pregnant, though she was in the early stages of a pregnancy and had not confirmed with a test. When her partner found out, he hit her in the abdomen to try to induce a miscarriage: “My friend told him I was pregnant. And when he learned, he beat me really hard on the belly. When I went to the bathroom after he beat me, some liquid came out, with blood in it.”[185] She miscarried.

Paola, 31, was 22 years old when she said she was pressured to have an abortion against her wishes by her partner, who impregnated her, and who she later learned had another partner. “I did a blood test at the hospital, and I was three months along. I felt excited. I was going to have it [continue the pregnancy], but then that person [who got me pregnant] didn’t want it, so he bought pills for me—Cytotec. I took the pills and I lost the pregnancy.” She described how she took the pills at home, alone, and went to the hospital the next day for medical attention: “I got dizzy, and I started bleeding. I had high blood pressure. My blood pressure went up a lot. They did the cleaning [of the uterus].” She found it hard to talk about and said at the time she felt unable to speak to anyone else about her options: “Had I had his support, if he told me to have the baby, and he’d provide for us—even if he kept his other partner—I wouldn’t have done this. I didn’t have any support from my family.”[186] Paola said the interview with Human Rights Watch was the first time she had ever spoken about the experience with anyone other than her former partner.

Two recent cases widely reported by the media in the Dominican Republic also illustrate how the criminalization of abortion can lead to coercion and abuse. In early 2018, a 20-year-old woman in the city of San José de Ocoa was detained on abortion-related charges. She sought medical attention at a hospital for a miscarriage, and her medical provider reported her to authorities for inducing an abortion. The woman said that her partner gave her misoprostol without her knowledge, claiming it was a medication to help with pain she experienced after a fall in the second trimester of her pregnancy.[187]

The brutal murder of 16-year-old Emely Peguero in 2017, who was five months pregnant at the time of her death, also illustrates how women and girls can be subjected to abuse and coercion. The preliminary forensic report on her death detailed signs of unsafe abortion, as well as injuries to the head, that led to hemorrhage. The BBC quoted the forensic report as stating: “Remains of the fetus were found in her womb, contusion of the cervix and vaginal canal, perforation of the uterus with indications that great force was applied in that area and scattered organs of an induced abortion.”[188] Peguero’s father said she did not want to have an abortion. Her partner, Marlon Martínez, pled guilty to her murder, and his mother was arrested on charges of complicity in the murder.[189] In June 2018, Martínez and his mother were instructed to go to trial.

 

III. The Dominican Republic’s Human Rights Obligations

The criminalization of abortion is incompatible with the Dominican Republic’s international human rights obligations. Authoritative interpretations of international human rights law establish that denying women and girls access to abortion is a form of discrimination and jeopardizes a range of human rights, including the rights to life; health; freedom from cruel, inhuman, and degrading treatment; nondiscrimination and equality; privacy; information; and freedom to decide the number and spacing of children.

The Dominican Republic is obligated to respect, protect, and fulfil the rights guaranteed under the international and regional human rights treaties to which it is a party, including the International Covenant on Civil and Political Rights (ICCPR),[190] the International Covenant on Economic, Social and Cultural Rights (ICESCR),[191] the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT),[192] the Convention on the Elimination of Discrimination Against Women (CEDAW),[193] the Convention on the Rights of the Child (CRC),[194] and the American Convention on Human Rights.[195] Fulfilment of the Dominican Republic’s obligations under these and other relevant treaties includes ensuring that abortion is safe, legal, and accessible.

Right to Life

Denial of access to safe, legal abortion puts the lives of women and girls at risk. International human rights bodies and experts have repeatedly stated that restrictive abortion laws contribute to maternal deaths from unsafe abortion and jeopardize the right to life. For instance, the UN Human Rights Committee (HRC), which monitors states’ compliance with the ICCPR, has noted the relationship between restrictive abortion laws and threats to women’s and girls’ lives. It has frequently expressed concern about criminalization of abortion and has called for expanded access.[196]

In 2017, the HRC called on the Dominican Republic to:

Amend its legislation to guarantee safe, legal and effective access to voluntary termination of pregnancy where the life or health of the pregnant woman or girl is in danger or where carrying the pregnancy to term could cause the pregnant woman or girl substantial harm or suffering, especially in cases where the pregnancy is the result of rape or incest or when it is non-viable.[197]

The UN CEDAW Committee, which monitors state compliance with the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), has repeatedly called for states to “legalize abortion not only in cases in which the life of the pregnant woman is threatened, but also in cases of threats to her health, pregnancies resulting from rape or incest, and cases of severe fetal impairment, and to decriminalize abortion in all cases.”[198]

Similarly, the UN Committee on the Rights of the Child, which monitors the implementation of the CRC, has noted that “the risk of death and disease during the adolescent years is real, including from preventable causes such as … unsafe abortions” and urged states to “decriminalize abortion to ensure that girls have access to safe abortion and post-abortion services, review legislation with a view to guaranteeing the best interests of pregnant adolescents and ensure that their views are always heard and respected in abortion-related decisions.”[199]

Moreover, the UN Committee on Economic, Social and Cultural Rights (CESCR), which monitors compliance with the ICESCR, has called on states to amend restrictive abortion laws and to increase access to legal abortion in order to decrease maternal deaths.[200]

In its 2016 review of the Dominican Republic, CESCR noted with concern “the large number of unsafe abortions that are performed and the high maternal mortality rate,” and urged the government to “[f]ast-track the discussion and adoption by Congress of the bill that would decriminalize abortion in cases where the procedure is necessary (rape, danger to the mother’s life or physical or mental health, fetal non-viability) in order to safeguard women’s fundamental rights.”[201]

Regional human rights experts have also raised concerns about restrictive abortion laws. The Inter-American Commission on Human Rights (IACHR) in a 2018 statement urged states, “to adopt legislation designed to ensure that women can effectively exercise their sexual and reproductive rights, with the understanding that denying the voluntary interruption of pregnancy in certain circumstances constitutes a violation of the fundamental rights of women, girls, and female adolescents.”[202]

In 2017 the IACHR stated:

Denying access by women and girls to legal and safe abortion services or post-abortion care can cause prolonged and excessive physical and psychological suffering to many women, especially in cases involving risks to their health, unviability of the fetus, or pregnancies resulting from incest or rape. Without being able to effectively exercise their sexual and reproductive rights, women cannot realize their right to live free from violence and discrimination.[203]

While most international human rights instruments are silent concerning the starting point for the right to life, the American Convention on Human Rights is the only international human rights instrument that contemplates the right to life from the moment of conception. Under article 4, “[e]very person has the right to have his life respected. This right shall be protected by law and, in general, from the moment of conception. No one shall be arbitrarily deprived of his life.”[204]

However, this provision is not unqualified and has been interpreted by the bodies that monitor the human rights provisions in the American regional system as not providing an absolute right to life before birth. In 1981, the Inter-American Commission on Human Rights was asked to establish whether or not the right-to-life provisions provided by the American Convention on Human Rights and the American Declaration on the Rights and Duties of Man were compatible with a woman’s right to access safe and legal abortions. The commission concluded that they are. In the case of the Declaration, the commission noted that the conferees in Bogotá in 1948 rejected language that would have extended the right to the unborn and “thus it would appear incorrect to read the Declaration as incorporating the notion that the right of life exists from the moment of conception.”[205]

With regard to the Convention, the commission found that the wording of the right to life in article 4 was very deliberate and that the Convention’s founders intended the “in general” clause to allow for non-restrictive domestic abortion legislation. As the commission phrased it: “It was recognized in the drafting session in San José that this phrase left open the possibility that states parties to a future Convention could include in their domestic legislation ‘the most diverse cases of abortion,’” allowing for legal abortion under this article.[206]

Furthermore, the Inter-American Court of Human Rights, which issues binding decisions on state parties to the American Convention, has concluded that embryos cannot be understood to be a person for the purposes of article 4(1) of the Convention.[207] The Court noted that “it can be concluded from the words ‘in general’ that the protection of the right to life under this provision is not absolute, but rather gradual and incremental according to its development, since it is not an absolute and unconditional obligation, but entails understanding that exceptions to the general rule are admissible.”[208]

Right to Health

The right to health is protected in numerous human rights treaties.[209] International bodies have repeatedly stated that criminalization of or unreasonable restrictions on access to abortion violate the right to health. CESCR has stated that, “States must reform laws that impede the exercise of the right to sexual and reproductive health. Examples include laws criminalizing abortion…”[210] In country-specific concluding observations, CESCR has recommended that states advance women’s health by providing for exceptions to criminalization of abortion and removing barriers to access.[211]

The CEDAW Committee has affirmed states’ obligations to “take appropriate legislative, judicial, administrative, budgetary, economic and other measures to the maximum extent of their available resources to ensure that women realize their rights to health care.”[212] It explained that “barriers to women’s access to appropriate health care include laws that criminalize medical procedures only needed by women and that punish women who undergo those procedures.”[213]

The Committee on the Rights of the Child has warned of the danger of unsafe abortion to adolescent girls’ health. It has often urged states to decriminalize abortion in all circumstances, and to ensure that adolescent girls have access to safe abortions.[214]

In its 2015 review of the Dominican Republic, the Committee expressed concern regarding “[p]regnant girls resorting to unsafe abortions, because abortion is criminalized,” and urged the Dominican Republic to “[e]xpedite the adoption of the proposal to decriminalize abortion and ensure access to safe abortion and post-abortion care services, irrespective of whether abortion is legal or not.”[215]

Right to be Free from Torture and Other Cruel, Inhuman, or Degrading Treatment

Criminalization and inaccessibility of abortion is incompatible with the right to freedom from torture and other cruel, inhuman, or degrading treatment or punishment. The UN Committee against Torture has said that criminalization of abortion with few exceptions may result in women experiencing severe pain and suffering if they are compelled to continue pregnancy. It has expressed concern at the severe physical and mental anguish and distress experienced by women and girls due to abortion restrictions. The Committee has called on governments to “allow for legal exception to the prohibition of abortion in specific circumstances in which the continuation of pregnancy is likely to result in severe pain and suffering, such as when the pregnancy is the result of rape or incest or in cases of fatal fetal impairment.”[216]

Similarly, the Human Rights Committee has ruled in individual cases against Ireland, Peru, and Argentina that the governments violated the right to freedom from torture or other cruel, inhuman or degrading treatment by failing to ensure access to abortion services in these cases.[217] It pointed out that this right relates not only to physical pain, but also to mental suffering.[218]

The CEDAW Committee and the Committee on Economic, Social and Cultural Rights have also said that denial or delay of access to legal abortion may amount to torture or cruel, inhuman, or degrading treatment.[219] The UN special rapporteur on torture has said that “[h]ighly restrictive abortion laws that prohibit abortions even in cases of incest, rape or fetal impairment or to safeguard the life or health of the woman violate women’s right to be free from torture and ill-treatment.”[220]

Furthermore, the Committee of Experts of the Follow-up Mechanism to the Inter-American Convention on the Prevention, Punishment and Eradication of Violence against Women, noted that laws that establish an absolute prohibition of abortion “perpetuate the exercise of violence against women, girls and adolescents … and violate the prohibition of torture and mistreatment.”[221] The committee concluded that states should establish “laws and policies that enable the termination of pregnancy at the very least in the following cases: i) risk to the life or health of the woman; ii) inability of the fetus to survive; and iii) sexual violence, incest and forced insemination.”[222]

Rights to Nondiscrimination and Equality

The rights to nondiscrimination and equality are set forth in all major international human rights treaties,[223] as well as the American Convention on Human Rights.[224] CEDAW prohibits discrimination against women in all spheres, including in the field of health care.

In a 2014 statement, the CEDAW Committee observed that “failure of a State party to provide services and the criminalization of some services that only women require is a violation of women's reproductive rights and constitutes discrimination against them.”[225] In country-specific concluding observations, the CEDAW Committee has often stated that restrictive abortion laws constitute discrimination against women.[226]

Moreover, the Human Rights Committee has held that lack of availability of reproductive health information and services, including abortion, undermines women’s right to nondiscrimination.[227]

Similarly, the Committee on the Rights of the Child has also said that punitive abortion laws constitute a violation of children’s right to freedom from discrimination.[228] The Committee on Economic, Social and Cultural Rights has said, “A wide range of laws, policies, and practices undermine the autonomy and right to equality and non-discrimination in the full enjoyment of the right to sexual and reproductive health, for example, criminalization of abortion or restrictive abortion laws.”[229]

The Inter-American Commission on Human Rights has expressed that limitations on accessing health services that are required only by women, including therapeutic abortion, generate inequalities between men and women with respect to the enjoyment of their rights.[230]

Right to Privacy

The ICCPR provides that “[n]o one shall be subjected to arbitrary or unlawful interference with his privacy, family, home or correspondence, nor to unlawful attacks on his honor and reputation,”[231] and other treaties and authoritative interpretations reinforce the right to privacy and medical confidentiality. Similarly, article 11(2) of the American Convention on Human Rights states that “[n]o one may be the object of arbitrary or abusive interference with his private life, his family, his home, or his correspondence, or of unlawful attacks on his honor or reputation.”[232]

In several individual cases, the HRC has found that criminalization of abortion, or a state’s refusal to act in accordance with a woman’s decision to undergo a legal abortion, constituted a violation of the right to privacy.[233] It has also called for respect for professional secrecy of health providers and confidentiality for patients who undergo abortion.[234]

The Committee on the Rights of the Child has emphasized, “All adolescents must have access to confidential adolescent-responsive and non-discriminatory reproductive and sexual health information and services, available both on and off-line, including … safe abortion services.”[235] It has recommended that governments ensure that children have access to confidential medical counsel and assistance without parental consent, including for reproductive health services.[236] It has specifically called for confidential access for adolescent girls to legal abortions.[237]

The CESCR has recommended that states ensure that the personal data of patients undergoing abortion remain confidential and has commented on the problem of women seeking health care for complications from unsafe abortions being reported to authorities.[238] Likewise, the Committee against Torture has called for protection of privacy for women seeking medical care for complications related to abortion.[239]

Right to Information

The right to information is set forth in numerous human rights treaties.[240] For example, CEDAW provides that states should provide women “[t]he same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights.”[241]

The right to information includes both a negative obligation for states to refrain from interference with the provision of information by private parties and a positive responsibility to provide complete and accurate information necessary for the protection and promotion of rights, including the right to health.[242]

The CESCR has stated that the right to health includes the right to health-related education and information.[243] It has said:

Information accessibility includes the right to seek, receive, and disseminate information and ideas concerning sexual and reproductive health issues…. All individuals and groups, including adolescents and youth, have the right to evidence-based information on all aspects of sexual and reproductive health, including … safe abortion and post abortion care.[244]

 The Committee has called on the Dominican Republic to “ensure access to and availability of sexual and reproductive health services and information for all women and teenage girls, particularly in rural areas.”[245]

The CEDAW Committee and the CRC have called on the Dominican Republic and other states to ensure that children have access to reproductive and sexual health education and information, including in schools.[246] The CRC has recommended that states “adopt or integrate a comprehensive gender-sensitive sexual and reproductive health policy for adolescents, emphasizing that unequal access by adolescents to such information and services amounts to discrimination.”[247]

The Inter-American Commission on Human Rights has noted that women cannot fully enjoy their human rights without information and education on health care services.[248] It has specifically asserted that states’ obligation to provide information on sexuality and reproduction is “particularly relevant” since it “helps people be prepared to make free and informed decisions concerning these aspects that are so intimate to their lives.”[249] For this reason, the commission has called on states to provide timely, complete, accessible, and reliable information on reproductive health, in a proactive manner.[250]

Right to Decide the Number and Spacing of Children

CEDAW provides that “States Parties shall ... ensure, on a basis of equality of men and women…. The same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education, and means to enable them to exercise these rights.”[251]

Freedom from Gender-Based Violence

The Dominican Republic has clear obligations under international and regional human rights treaties to protect women and girls from sexual and domestic violence, including by private actors. The CEDAW Committee stated in General Recommendations 28 and 19 that violence against women constitutes a form of discrimination and states have a due diligence obligation to prevent, investigate, prosecute, and punish acts of gender-based violence.[252] In its General Recommendation 19, the CEDAW Committee stated, “States may also be responsible for private acts if they fail to act with due diligence to prevent violations of rights or to investigate and punish acts of violence.”[253]

The Dominican Republic has similar obligations under the Inter-American Convention on the Prevention, Punishment, and Eradication of Violence Against Women, known as the Convention of Belém do Pará, to “apply due diligence to prevent, investigate, and impose penalties for violence against women.”[254] In addition, the Convention on the Rights of the Child (CRC) states that children must be protected from “all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation—including sexual abuse—and ensure that victims of such acts receive legal and psycho-social redress.”[255]

The full criminalization of abortion in the Dominican Republic undermines the government’s efforts to prevent, investigate, prosecute, and punish acts of violence. Women and girls pregnant from rape or in the context of abusive relationships who seek to terminate pregnancies must do so clandestinely, without the support of authorities who could take steps to end the violence.

 

Acknowledgments

This report was researched and written by Margaret Wurth, senior researcher in the Children’s Rights Division at Human Rights Watch.

Heather Barr, senior researcher in the Women’s Rights Division, edited the report.

Michael Garcia Bochenek, senior counsel to the Children’s Rights Division; Amanda Klasing, senior researcher in the Women’s Rights Division; and Tamara Taraciuk Broner, Americas senior researcher, reviewed and commented on the report. Chris Albin-Lackey, senior legal advisor, provided legal review, and Tom Porteous, deputy program director, provided program review.

Susan Raqib, senior coordinator, and Lily Acton, former intern, in the Children’s Rights Division conducted background research for this report. Design and production assistance were provided by Tabashshum Islam, associate in the Women’s Rights Division; Fitzroy Hepkins, administrative manager; and Jose Martinez, senior administration coordinator. Gabriela Haymes translated this report into Spanish, and Claudia Núñez, Spanish web editor at Human Rights Watch, vetted the Spanish translation.

We are deeply grateful to Yaneris González Gómez, who showed extraordinary compassion and dedication while working with Human Rights Watch as an interpreter and fixer for this project.

Human Rights Watch benefitted from the time and insights offered by many Dominican and international nongovernmental organizations, activists, and experts. In particular, we would like to thank the following individuals and groups for their support and collaboration: Colectiva Mujer y Salud; CE-MUJER; Centro de Investigación para La Acción Femenina (CIPAF); Centro de Estudios de Género (CEG-INTEC); Círculo de Mujeres con Discapacidad, Inc. (CIMUDIS); Comunidad de Lesbianas Inclusivas Dominicanas (COLESDOM); Comité de América Latina y el Caribe para la Defensa de los Derechos de las Mujeres – República Dominicana (CLADEM-RD); Confederación Nacional de Mujeres Campesinas (CONAMUCA); Coalición por los Derechos y la Vida de las Mujeres; Carmela Cordero; Foro Feminista; Instituto de Género y Familia de la Universidad Autónoma de Santo Domingo (UASD); Junta de Mujeres Mamá Tingó (JMMT); Movimiento de Mujeres Dominico Haitianas (MUDHA); Movimiento de Mujeres Unidas (MODEMU); Núcleo de Apoyo a la Mujer (NAM); Paola Pelletier; Sergia Galván; and TÚ, MUJER.

We also wish to thank American Jewish World Service (AJWS); Center for Reproductive Rights (CRR); Planned Parenthood Federation of America (PPFA); Oxfam – Dominican Republic; Plan International República Dominicana; Women’s Equality Center (WEC); and Women’s Link Worldwide for input and guidance on our project design.

Most importantly, we are deeply grateful to the courageous and resilient women and girls who shared their stories with us.

 

 

[1] Convention on the Rights of the Child (CRC), adopted November 20, 1989, G.A. Res. 44/25, annex, 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/44/49 (1989), entered into force September 2, 1990, art. 1.

[2] World Health Organization (WHO), “Health for the World’s Adolescents: A second chance in the second decade,” ch. 2 (2014), http://www.who.int/maternal_child_adolescent/documents/second-decade/en/ (accessed August 9, 2018).

[3] Center for Reproductive Rights, “The World’s Abortion Laws 2018,” http://worldabortionlaws.com/ (accessed June 25, 2018).

[4] Penal Code of the Dominican Republic, 1884, art. 317, modified by laws 1690 of April 8, 1948, 224 of June 26, 1984, and 46-99 of May 20, 1999. “El que por medio de alimentos, brevajes, medicamentos, sondeos, tratamientos o de otro modo cualquiera, causare o cooperare directamente a causar el aborto de una mujer embarazada, aun cuando ésta consienta en él, será castigado con la pena de reclusión menor.”

[5] Penal Code of the Dominican Republic, 1884, art. 317. “Los médicos, cirujanos, parteras, enfermeras, farmacéuticos y otros profesionales médicos, que, abusando de su profesión, causaren el aborto o cooperaren a él, incurrirán en la pena de cinco a veinte años de reclusión mayor, si el aborto se efectuare.”

[6] Penal Code of the Dominican Republic, 1884, art. 317. “Se impondrá la pena de prisión de seis meses a dos años a las personas que hayan puesto en relación o comunicación una mujer embarazada con otra persona para que le produzca el aborto, siempre que el aborto se haya efectuado, aun cuando no hayan cooperado directamente al aborto. La misma pena se impondrá a la mujer que causare un aborto o que consintiere en hacer uso de las substancias que con ese objeto se le indiquen o administren o en someterse a los medios abortivos, siempre que el aborto se haya efectuado.”

[7] Center for Reproductive Rights, “The World’s Abortion Laws 2018,” http://worldabortionlaws.com/.

[8] Human Rights Watch interview with Katherine Jaime and Orlidy Inoa, Comité de América Latina y el Caribe para la Defensa de los Derechos de las Mujeres – República Dominicana (CLADEM-RD), Santo Domingo, Dominican Republic, February 12, 2018.

[9] Constitution of the Dominican Republic, art. 37.

[10] For example, Human Rights Watch interviews with Katherine Jaime and Orlidy Inoa, Comité de América Latina y el Caribe para la Defensa de los Derechos de las Mujeres – República Dominicana (CLADEM-RD), Santo Domingo, Dominican Republic, February 12, 2018; Zobeyda Cepeda, Oxfam, Santo Domingo, February 14, 2018; Myrna Flores Chang, manager of the Gender and Rights Program, Fernando de la Rosa, head of education, and Leopoldina Cairo, manager of programming and evaluation, Profamilia, Santo Domingo, Dominican Republic, February 20, 2018; Dr. José De Lancer, obstetrician-gynecologist, Santo Domingo, Dominican Republic, April 13, 2018.

[11] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[12] Human Rights Watch interview with Dr. José De Lancer, obstetrician-gynecologist, Santo Domingo, Dominican Republic, April 13, 2018.

[13] “Imponen tres meses de prisión a mujer se habría provocado aborto,” Listin Diario, February 18, 2018, https://www.listindiario.com/la-republica/2018/02/18/503212/imponen-tres-meses-de-prision-a-mujer-se-habria-provocado-aborto (accessed June 25, 2018); “Video: Joven que guarda prisión tras aborto ofrece su versión de los hechos,” Ocoa en Red, February 12, 2018, http://ocoaenred.com/index.php/noticias/policia-y-justicia/7261-video-joven-que-guarda-prision-tras-aborto-ofrece-su-version-de-los-hechos (accessed July 5, 2018).

[14] Human Rights Watch interviews with Cinthya Velasco, executive director, Colectiva Mujer y Salud, Santo Domingo, Dominican Republic, April 12, 2018; Myrna Flores Chang, manager of the Gender and Rights Program, Fernando de la Rosa, head of education, and Leopoldina Cairo, manager of programming and evaluation, Profamilia, Santo Domingo, Dominican Republic, February 20, 2018.

[15] Human Rights Watch interview with Fátima Lorenzo, executive director, Ciudad Alternativa, Santo Domingo, Dominican Republic, February 20, 2018.

[16] Human Rights Watch interview with doctor, date and location withheld for security reasons; Cinthya Velasco, executive director, Colectiva Mujer y Salud, Santo Domingo, Dominican Republic, April 12, 2018; Myrna Flores Chang, manager of the Gender and Rights Program, Fernando de la Rosa, head of education, and Leopoldina Cairo, manager of programming and evaluation, Profamilia, Santo Domingo, Dominican Republic, February 20, 2018.

[17] Guttmacher Institute, “Abortion Worldwide 2017: Uneven Progress and Unequal Access,” March 2018, https://www.guttmacher.org/report/abortion-worldwide-2017 (accessed June 27, 2018), p. 8.

[18] Guttmacher Institute, “Abortion in Latin America and the Caribbean,” March 2018, https://www.guttmacher.org/fact-sheet/abortion-latin-america-and-caribbean (accessed June 27, 2018).

[19] Guttmacher Institute, “Abortion Worldwide 2017: Uneven Progress and Unequal Access,” March 2018, https://www.guttmacher.org/report/abortion-worldwide-2017 (accessed June 27, 2018), p. 51.

[20] The Guttmacher Institute estimated there were 82,000 abortions in the Dominican Republic in 1990. Stanley K. Henshaw, Susheela Singh, and Taylor Haas, “The Incidence of Abortion Worldwide,” International Family Planning Perspectives, vol. 25, suppl. (1999), p. S35.

[21] Profamilia, “Situación del aborto en República Dominicana,” November 2016, http://profamilia.org.do/wp-content/uploads/2017/08/Situación-del-aborto-en-RD-min.pdf (accessed June 28, 2018), pp. 58, 63.

[22] Bela Ganatra, Caitlin Gerdts, Clémentine Rossier, et al., “Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model,” The Lancet, vol. 390 (2017), p. 2374.

[23] Bela Ganatra, Caitlin Gerdts, Clémentine Rossier, et al., “Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model,” The Lancet, vol. 390 (2017), p. 2376.

[24] World Health Organization (WHO), “Preventing Unsafe Abortion,” February 2018, http://www.who.int/en/news-room/fact-sheets/detail/preventing-unsafe-abortion (accessed June 27, 2018).

[25] Guttmacher Institute, “Abortion in Latin America and the Caribbean,” https://www.guttmacher.org/fact-sheet/abortion-latin-america-and-caribbean.

[26] Pan American Health Organization (PAHO), Health Information Platform for the Americas (PLISA) Database, “Health Situation in the Americas: Basic Indicators 2017,” http://www.paho.org/data/index.php/en/indicators.html (accessed October 1, 2018).

[27] Ministry of Public Health, Pan American Health Organization (PAHO), and World Health Organization (WHO), “Basic Health Indicators: Dominican Republic,” 2015, http://www.msp.gob.do/oai/documentos/Estadisticas/2017/IndicadoresSalud/Indicadores%20basicos%20de%20salud%202015.pdf (accessed June 26, 2018).

[28] Email from Dr. José Mordán, head of the Department of Family Health at the Ministry of Public Health, to Human Rights Watch, November 3, 2018.

[29] Ministerio de Economía, Planificación y Desarrollo, Unidad Asesora de Análisis Económico y Social, “Sistema de Indicadores Sociales de la República Dominicana (SISDOM),” vol. II (2016), http://economia.gob.do/wp-content/uploads/drive/UAAES/SISDOM/2016/Datos%20estadisticos/SISDOM%202016.%20Volumen%20II%20Serie%20de%20Datos.pdf (accessed October 1, 2018), p. 153.

[30] Email from Dr. José Mordán, head of the Department of Family Health at the Ministry of Public Health, to Human Rights Watch, November 3, 2018.

[31] See, for example, A. Faúndes, L. C. Santos, M. Carvalho, C. Gras, “Post-abortion complications after interruption of pregnancy with misoprostol,” Advances in Contraception, vol. 12, no. 1 (1996), pp. 1-9.

[32] World Health Organization (WHO), “Safe abortion: technical and policy guidance for health systems: second edition,” 2012, http://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf;jsessionid=0D219EEF61F9037071CAB70E52841EB1?sequence=1 (accessed July 12, 2018).

[33] See, for example, “N.L. Moreno‐Ruiz, L. Borgatta, S. Yanow, N. Kapp, E.R. Wiebe, B. Winikoff, “Alternatives to mifepristone for early medical abortion,” International Journal of Gynecology and Obstetrics, vol. 96, no. 3 (2007), pp. 212-218.

[34] Ministerio de Salud Pública (MSP), Dirección General de Medicamentos, Alimentos y Productos Sanitarios (DIGEMAPS), “Cuadro Básico de Medicamentos Esenciales 2018,” June 2018, http://sns.gob.do/descarga-documentos/atencion-primaria/ (accessed July 10, 2018).

[35] Suellen Miller, Tara Lehman, Martha Campbell, et al., “Misoprostol and declining abortion-related morbidity in

Santo Domingo, Dominican Republic: a temporal association,” International Journal of Obstetrics and Gynaecology, vol. 112 (2005), pp. 1291-1296.

[36] Mónica Sánchez and Kate Vasilof, Untold Research, “Encuesta de Opinión Pública sobre el aborto en la República Dominicana,” June 2018, http://www.mujeresdelsur-afm.org.uy/sites/default/files/Resultados%20Desagregados.pdf  (accessed October 1, 2018).

[37] See, for example, “Danilo observó Código Penal porque viola la Constitución y los derechos de la mujer,” Acento, November 28, 2014, https://acento.com.do/2014/actualidad/8199658-danilo-observo-codigo-penal-porque-viola-la-constitucion-y-los-derechos-de-la-mujer/ (accessed June 25, 2018); “Danilo observa artículos sobre el aborto en CP,” Listin Diario, November 29, 2014, https://www.listindiario.com/la-republica/2014/11/28/347211/Danilo-observa-articulos-sobre-el-aborto-en-CP (accessed June 25, 2018).

[38] In the Dominican Republic, the term “observation” refers to changes the president recommends to a piece of legislation. A presidential “observation” functions as a veto.

[39] Letter from Danilo Medina, president of the Dominican Republic, to Abel Martínez Durán, president of the Chamber of Deputies, November 28, 2014, http://acento.com.do/wp-content/uploads/Observaci%C3%B3n-del-Presidente-Danilo-Medina-al-C%C3%B3digo-Penal-28-de-noviembre-2014.pdf (accessed June 25, 2018).

[40] Human Rights Watch interview with Jeanette Abreu, Lorena Valera, and Mildred Suero, Centro de Investigación para La Acción Femenina (CIPAF), Santo Domingo, Dominican Republic, February 12, 2018. See also, Harolyn Gavilán, “Coalición pide despenalización del aborto en las tres causales,” Listin Diario, https://www.listindiario.com/la-republica/2018/07/16/524349/coalicion-pide-despenalizacion-del-aborto-en-las-tres-causales (accessed August 1, 2018).

[41] Tribunal Constitucional, República Dominicana, Sentencia TC/0599/15, 2015.

[42] Ibid.

[43] See, for example, “Presidente Danilo Medina observa el Código Penal,” El Dia, December 19, 2016, http://eldia.com.do/presidente-danilo-medina-observa-el-codigo-penal/ (accessed June 26, 2018).

[44] Letter from Danilo Medina, president of the Dominican Republic, to Dr. Reinaldo Pared Perez, president of the Senate, December 19, 2016. On file with Human Rights Watch.

[45] Cámara de diputados, “Proyecto de ley de salud sexual y reproductiva,” 2017. On file with Human Rights Watch.

[46] Ministerio de Salud Pública (MSP), Dirección General de Medicamentos, Alimentos y Productos Sanitarios (DIGEMAPS), “Cuadro Básico de Medicamentos Esenciales 2018,” June 2018, http://sns.gob.do/descarga-documentos/atencion-primaria/ (accessed July 10, 2018).

[47] Ministerio de Salud Pública (MSP), Centro de Estudios Sociales y Demográficos (CESDEM) and ICF International, “Encuesta Demográfica y de Salud (ENDESA) 2013,” October 2014, https://dhsprogram.com/pubs/pdf/FR292/FR292.pdf (accessed July 10, 2018), p. 114.

[48] Ministerio de Salud Pública (MSP), Dirección General de Medicamentos, Alimentos y Productos Sanitarios (DIGEMAPS), “Cuadro Básico de Medicamentos Esenciales 2018,” June 2018, http://sns.gob.do/download/350/atencion-primaria/6968/cuadro-basico-medicamentos-2018.pdf (accessed July 10, 2018); Human Rights Watch interview with Dr. José De Lancer, obstetrician-gynecologist, Santo Domingo, Dominican Republic, April 13, 2018.

[49] According to the Ministry of Public Health’s 2013 Demographic and Health Survey (ENDESA-2013), 52 percent of pregnancies were planned and wanted at the moment they occurred, 35 percent were unplanned at the moment they occurred, and 13 percent were unwanted. Ministerio de Salud Pública (MSP), Centro de Estudios Sociales y Demográficos (CESDEM) and ICF International, “Encuesta Demográfica y de Salud (ENDESA) 2013,” October 2014, https://dhsprogram.com/pubs/pdf/FR292/FR292.pdf (accessed July 10, 2018), p. 108.

[50] Unmet need for contraception is defined by the United Nations as a percentage of married or in-union women of reproductive age who are fertile and wish to delay or prevent pregnancy, yet they are not using any method of contraception. See, for example, United Nations, Department of Economic and Social Affairs, Population Division, “World Contraceptive Use 2018,” http://www.un.org/en/development/desa/population/publications/dataset/contraception/wcu2018.shtml (accessed July 10, 2018); Ministerio de Salud Pública (MSP), Centro de Estudios Sociales y Demográficos (CESDEM) and ICF International, “Encuesta Demográfica y de Salud (ENDESA) 2013,” October 2014, https://dhsprogram.com/pubs/pdf/FR292/FR292.pdf (accessed July 10, 2018), pp. 122-123.

[51] Human Rights Watch interview with Carolina, 30, Santo Domingo, Dominican Republic, April 13, 2018.

[52] Human Rights Watch interview with Madelyn, 28, Santo Domingo, Dominican Republic, April 14, 2018. See, for example, Gerard J. Molloy, Heather Graham, and Hannah McGuinness, “Adherence to the oral contraceptive pill: a cross-sectional survey of modifiable behavioural determinants,” BMC Public Health, vol. 12, no. 828, pp. 1-8.

[53] Human Rights Watch interview with Daralis, 24, Santo Domingo, Dominican Republic, April 15, 2018.

[54] Human Rights Watch interview with Madelyn, 28, Santo Domingo, Dominican Republic, April 14, 2018.

[55] Human Rights Watch interview with Natalie, 22, Santo Domingo, Dominican Republic, April 14, 2018.

[56] For example, Human Rights Watch interviews with Gabriela, 27, Violeta, 26, and Clara, 22, San Cristóbal province, Dominican Republic, February 16, 2018; Tatiana, 27, Santo Domingo, Dominican Republic, April 14, 2018; Aury, 24, Santo Domingo, Dominican Republic, April 14, 2018; Adelyn, 20, Santiago de los Caballeros, Dominican Republic, April 17, 2018.

[57] Human Rights Watch interview with Samantha, 18, Santo Domingo, Dominican Republic, April 14, 2018.

[58] Human Rights Watch interview with Lisbeth, 16, Santo Domingo, Dominican Republic, April 15, 2018.

[59] Human Rights Watch interviews with Larissa, 22, San Cristóbal province, Dominican Republic, February 16, 2018; Rayneli, 15, Santo Domingo, Dominican Republic, April 15, 2018; Paola, 31, Santo Domingo, Dominican Republic, April 13, 2018; Carolina, 30, Santo Domingo, Dominican Republic, April 13, 2018; Eridania, 28, Monte Plata province, Dominican Republic, February 21, 2018; Vanessa, 37, Santiago de los Caballeros, Dominican Republic, April 17, 2018; Xiomara, 26, Santo Domingo, Dominican Republic, February 18, 2018.

[60] Human Rights Watch interviews with Isamar, 31, Santo Domingo, Dominican Republic, February 20, 2018; Eridania, 28, Monte Plata province, Dominican Republic, February 21, 2018.

[61] See, for example, Herbert B. Peterson, Zhisen Xia, Joyce M. Hughes, et al., “The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization,” American Journal of Obstetrics and Gynecology, vol. 174, no. 4 (1996), pp. 1161–1170.

[62] Human Rights Watch interview with Maoli, 20, Santo Domingo, Dominican Republic, April 13, 2018; Karen, 18, Santo Domingo, Dominican Republic, April 20, 2018.

[63] Human Rights Watch interview with Lucely, 18, San Cristóbal province, Dominican Republic, April 16, 2018.

[64] Human Rights Watch interview with Rebeca, 26, San Cristóbal province, Dominican Republic, February 16, 2018; Juliana, 16, Santiago de los Caballeros, Dominican Republic, April 18, 2018; Stephany, 24, Santo Domingo, Dominican Republic, April 13, 2018; Yamaira, 39, Santo Domingo, Dominican Republic, April 13, 2018; Xiomara, 26, Santo Domingo, Dominican Republic, February 18, 2018.

[65] Human Rights Watch interview with Melina, 26, San Cristóbal province, Dominican Republic, February 16, 2018.

[66] Human Rights Watch interview with Nayely, 29, San Cristóbal province, Dominican Republic, April 16, 2018.

[67] Human Rights Watch interview with Camila, 24, Santo Domingo, Dominican Republic, April 14, 2018.

[68] Human Rights Watch interview with Regina, psychologist, Santiago de los Caballeros, Dominican Republic, April 17, 2018.

[69] Human Rights Watch interview with Gabriela, 27, Violeta, 26, and Clara, 22, San Cristóbal province, Dominican Republic, February 16, 2018.

[70] Human Rights Watch interview with Daralis, 24, Santo Domingo, Dominican Republic, April 15, 2018.

[71] Human Rights Watch interview with Adelyn, 20, Santiago de los Caballeros, Dominican Republic, April 17, 2018.

[72] Human Rights Watch interview with Sergia Galván, advocate, Santo Domingo, Dominican Republic, April 19, 2018.

[73] Human Rights Watch interview with Liliana Dolis, general coordinator of the Movimiento de Mujeres Dominico-Haitianas (MUDHA), Santo Domingo, Dominican Republic, February 16, 2018.

[74] Human Rights Watch interview with Dr. José Mordán, head of the Department of Family Health at the Ministry of Public Health, Santo Domingo, Dominican Republic, April 20, 2018.

[75] Human Rights Watch interviews with Camila, 24, Santo Domingo, Dominican Republic, April 14, 2018

[76] Human Rights Watch interview with Juliana, 16, Santiago de los Caballeros, Dominican Republic, April 18, 2018.

[77] Human Rights Watch interview with Gabriela, 27, Violeta, 26, and Clara, 22, San Cristóbal province, Dominican Republic, February 16, 2018.

[78] Human Rights Watch interview with Isamar, 31, Santo Domingo, Dominican Republic, February 20, 2018.

[79] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[80] Human Rights Watch interview with Stephany, 24, Santo Domingo, Dominican Republic, April 13, 2018.

[81] See, for example, Guttmacher Institute, “Abortion Worldwide 2017: Uneven Progress and Unequal Access,” March 2018, https://www.guttmacher.org/report/abortion-worldwide-2017 (accessed June 27, 2018), pp. 21-23.

[82] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[83] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[84] The World Health Organization (WHO) classifies abortions as safe if they are provided by trained healthcare workers using methods recommended by WHO, such as medical abortion, and appropriate for the duration of the pregnancy. Bela Ganatra, Caitlin Gerdts, Clémentine Rossier, et al., “Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model,” The Lancet, vol. 390 (2017), p. 2374.

[85] Human Rights Watch interviews with Camila, 24, Santo Domingo, Dominican Republic, April 14, 2018; Nicole, 28, Santo Domingo, Dominican Republic, April 12, 2018.

[86] Human Rights Watch interview with Nicole, 28, Santo Domingo, Dominican Republic, April 12, 2018.

[87] Human Rights Watch interview with Camila, 24, Santo Domingo, Dominican Republic, April 14, 2018.

[88] Human Rights Watch interview with Dr. José De Lancer, obstetrician-gynecologist, Santo Domingo, Dominican Republic, April 13, 2018.

[89] Human Rights Watch interview with obstetrician-gynecologist, Santiago de los Caballeros, Dominican Republic, April 18, 2018.

[90] Human Rights Watch interview with obstetrician-gynecologist, date and location withheld for security reasons.

[91] Human Rights Watch interview with Melina, 26, San Cristóbal province, Dominican Republic, February 16, 2018.

[92] Human Rights Watch interview with Alejandro, 24, Santo Domingo, Dominican Republic, February 17, 2018.

[93] Human Rights Watch interview with three health outreach workers, Santo Domingo, Dominican Republic, February 19, 2018.

[94] Human Rights Watch interview with Paola, 31, Santo Domingo, Dominican Republic, April 13, 2018.

[95] Human Rights Watch interview with Alicia, 17, Santo Domingo, Dominican Republic, April 15, 2018.

[96] See, for example, Daniel Grossman, Sarah E. Baum, Denitza Andjelic, et al., “A harm-reduction model of abortion counseling about misoprostol use in Peru with telephone and in-person follow-up: A cohort study,” PLoS One, vol. 13, no. 1 (2018), pp. 1-16.

[97] The term “obstetric violence” refers to negligent, disrespectful, or abusive treatment by health providers when women and girls seek reproductive healthcare during pregnancy, abortion, childbirth, or the post-partum period. See, for example, Virginia Savage and Arachu Castro, “Measuring mistreatment of women during childbirth: a review of terminology and methodological approaches,” Reproductive Health vol. 14, no. 138 (2017), pp. 1-27.

[98] The World Health Organization recommends vacuum aspiration as opposed to dilatation and curettage for incomplete abortion. World Health Organization (WHO), “Safe abortion: technical and policy guidance for health systems: second edition,” 2012, http://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf;jsessionid=0D219EEF61F9037071CAB70E52841EB1?sequence=1 (accessed July 12, 2018), p. 7.

[99] Ministerio de Salud Pública, “Protocolos de Atención para Obstetrícia y Ginecología, Volumen I,” March 2016, http://www.msp.gob.do/oai/Documentos/Publicaciones/ProtocolosAtencion/Protocolos%20de%20Atencion%20para%20Obtetricia%20y%20Ginecologia.pdf (accessed July 13, 2018), pp. 35-70.

[100] Centro de Estudios de Género, Instituto Tecnológico de Santo Domingo (CEG-INTEC) and United Nations Population Fund (UNFPA), “Análisis de Género en la Mortalidad Materna de República Dominicana,” March 2018, http://dominicanrepublic.unfpa.org/es/publications/an%C3%A1lisis-de-g%C3%A9nero-en-la-mortalidad-materna-de-rep%C3%BAblica-dominicana (accessed July 14, 2018); Women’s Link Worldwide, “Maternidad Libre y Segura en República Dominicana: una deuda con los derechos de las mujeres,” 2017, https://www.womenslinkworldwide.org/files/d64ad5156e3c5bb537ccc17bbfe4476c.pdf (accessed July 14, 2018).

[101] Human Rights Watch interview with Juana Ferrer, Lidia Ferrer Paredes, and Vanessa Rodriguez, Confederación Nacional de Mujeres Campesinas (CONAMUCA), Santo Domingo, Dominican Republic, February 19, 2018.

[102] Human Rights Watch interview with Rayneli, 15, Santo Domingo, Dominican Republic, April 15, 2018.

[103] Human Rights Watch interview with Bianca, 30, San Cristóbal province, Dominican Republic, April 16, 2018.

[104] Human Rights Watch interview with Adelyn, 20, Santiago de los Caballeros, Dominican Republic, April 17, 2018.

[105] Human Rights Watch interview with Camila, 24, Santo Domingo, Dominican Republic, April 14, 2018.

[106] Human Rights Watch interview with Madelyn, 28, Santo Domingo, Dominican Republic, April 14, 2018.

[107] Human Rights Watch interview with Aury, 24, Santo Domingo, Dominican Republic, April 14, 2018.

[108] Human Rights Watch interview with Mayerlin, 38, Monte Plata province, Dominican Republic, February 21, 2018.

[109] Human Rights Watch interview with Elizabeth Velez, Catholics for Choice, Santo Domingo, Dominican Republic, February 18, 2018.

[110] Human Rights Watch interview with Dr. José Mordán, head of the Department of Family Health at the Ministry of Public Health, Santo Domingo, Dominican Republic, April 20, 2018.

[111] See, for example, Thália Velho Barreto de Araújo, Estela M. L. Aquino, Greice M. S. Menezes, “Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil,” Cadernos de Saúde Pública, vol. 34, no. 6 (2018), pp. 1-11.

[112] See, for example, Abdhalah Kasiira Ziraba, Chimaraoke Izugbara, Brooke A Levandowski, et al., “Unsafe abortion in Kenya: a cross-sectional study of abortion complication severity and associated factors,” BMC Pregnancy and Childbirth vol. 15, no. 34 (2015), pp. 1-11.

[113] Guttmacher Institute, “Abortion Worldwide 2017: Uneven Progress and Unequal Access,” March 2018, https://www.guttmacher.org/report/abortion-worldwide-2017 (accessed June 27, 2018), p. 42.

[114] Human Rights Watch interview with Carolina, 30, Santo Domingo, Dominican Republic, April 13, 2018.

[115] Human Rights Watch interview with Yamaira, 39, Santo Domingo, Dominican Republic, April 13, 2018.

[116] Mayo Clinic, “Miscarriage,” July 20, 2016, https://www.mayoclinic.org/diseases-conditions/pregnancy-loss-miscarriage/symptoms-causes/syc-20354298 (accessed August 1, 2018).

[117] Human Rights Watch interview with Aury, 24, Santo Domingo, Dominican Republic, April 14, 2018.

[118] Human Rights Watch interviews with Xiomara, 26, Santo Domingo, Dominican Republic, February 18, 2018; Yamaira, 39, Santo Domingo, Dominican Republic, April 13, 2018.

[119] Human Rights Watch interview with Rebeca, 26, San Cristóbal province, Dominican Republic, February 16, 2018.

[120] The Dominican Republic has very high rates of child marriage: 37 percent of women ages 20 to 49 were married before age 18 and 12.5 percent before age 15. Plan International Dominican Republic, “Bride Girls: Portrayal of the forced marriage of young and adolescent girls, in the Provinces of Azua, Barahona, Pedernales, Elias Piña, and San Juan,” March 2017, https://plan-international.org/sites/files/plan/field/field_document/planteamientos_2_arte_final_print.pdf (accessed August 1, 2018), p. 11.

[121] Human Rights Watch interview with Larissa, 22, San Cristóbal province, Dominican Republic, February 16, 2018.

[122] Human Rights Watch interview with Mayerlin, 38, Monte Plata province, Dominican Republic, February 21, 2018.

[123] Human Rights Watch interview with Aury, 24, Santo Domingo, Dominican Republic, April 14, 2018.

[124] Human Rights Watch interview with Ana Paula, 16, Santo Domingo, Dominican Republic, April 15, 2018.

[125] Human Rights Watch interview with Noelia, 33, Santiago de los Caballeros, Dominican Republic, April 17, 2018.

[126] Human Rights Watch interview with Yamaira, 39, Santo Domingo, Dominican Republic, April 13, 2018.

[127] Guttmacher Institute, “Abortion Worldwide 2017: Uneven Progress and Unequal Access,” https://www.guttmacher.org/report/abortion-worldwide-2017; See also, Lale Say, Doris Chou, Alison Gemmill, et al., “Global causes of maternal death: a WHO systematic analysis,” Lancet Global Health vol. 2 (2014), pp. 323–33.

[128] Email from Dr. José Mordán, head of the Department of Family Health at the Ministry of Public Health, to Human Rights Watch, November 3, 2018.

[129] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[130] Centro de Estudios de Género, Instituto Tecnológico de Santo Domingo (CEG-INTEC) and United Nations Population Fund (UNFPA), “Análisis de Género en la Mortalidad Materna de República Dominicana,” March 2018, http://dominicanrepublic.unfpa.org/es/publications/an%C3%A1lisis-de-g%C3%A9nero-en-la-mortalidad-materna-de-rep%C3%BAblica-dominicana (accessed July 14, 2018).

[131] Ibid., See, “Caso 6: Teresa,” pp. 64-67.

[132] Ibid., See, “Caso 1: Miriam,” pp. 47-50.

[133] Women’s Link Worldwide, “Maternidad Libre y Segura en República Dominicana: una deuda con los derechos de las mujeres,” https://www.womenslinkworldwide.org/files/d64ad5156e3c5bb537ccc17bbfe4476c.pdf.

[134] Ibid., See, “Massiel: las consecuencias de la penalización del aborto,” pp. 51-54.

[135] Ibid., See, “Cristina: las falencias en la red de servicios de salud,” pp. 33-38.

[136] Human Rights Watch interview with obstetrician-gynecologist, date and location withheld for security reasons.

[137] Human Rights Watch interview with Catalina, licensed nurse, Santo Domingo, Dominican Republic, February 18, 2018.

[138] Human Rights Watch interview with Melina, 26, San Cristóbal province, Dominican Republic, February 16, 2018.

[139] Human Rights Watch interview with Raquel, 38, Santo Domingo, Dominican Republic, April 14, 2018.

[140] Ministerio de Salud Pública (MSP), “Instituciones de salud de RD trabajan en la reducción mortalidad materna y neonatal,” May 1, 2018, http://www.msp.gob.do/Instituciones-de-salud-de-RD-trabajan-en-la-reduccion-mortalidad-materna-y-neonatal (accessed July 12, 2018).

[141] See, for example, Anibal Faúndes and Iqbal H. Shah, “Evidence supporting broader access to safe legal abortion,” International Journal of Gynecology and Obstetrics, vol. 131 (2015), pp. S56–S59.

[142] Ministerio de Salud Pública (MSP), Centro de Estudios Sociales y Demográficos (CESDEM) and ICF International, “Encuesta Demográfica y de Salud (ENDESA) 2013,” October 2014, https://dhsprogram.com/pubs/pdf/FR292/FR292.pdf (accessed July 10, 2018), p. 325.

[143] Ibid., pp. 323-324.

[144] Ibid., p. 325.

[145] Ibid., pp. 337-338.

[146] 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 August 22, 2018).

[147] Ibid., p. 3.

[148] See, for example, Ley No. 24-97, 1997; Ministerio de Salud Pública, Ruta de Coordinación y Articulación Interinstitucional para la Atención de Niños, Niñas y Adolescentes Victimas de Violencia en Republica Dominicana, February 2017. On file with Human Rights Watch.

[149] See, for example, CEDAW Committee, General Recommendation 35 on gender-based violence against women (2017), para. 18; CESCR, General Comment 22, para. 10.

[150] Committee against Torture, “Consideration of reports submitted by States parties under article 19 of the Convention. Concluding observations of the Committee against Torture: Paraguay,” U.N. Doc. CAT/C/PRY/CO/4-6, December 14, 2011, para. 22. See also, in similar terms, Committee against Torture, “Consideration of reports submitted by States parties under article 19 of the Convention. Concluding observations of the Committee against Torture: Nicaragua,” U.N. Doc. CAT/C/NIC/CO/1, June 10, 2009, para. 16.

[151] Human Rights Watch interview with Antonella, health educator, Santiago de los Caballeros, April 18, 2018.

[152] Human Rights Watch interview with lawyer and advocate, Monte Plata province, Dominican Republic, February 21, 2018.

[153] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[154] Human Rights Watch interview with Regina, psychologist, Santiago de los Caballeros, Dominican Republic, April 17, 2018.

[155] Human Rights Watch interview with Mary, outreach worker, Monte Plata province, Dominican Republic, February 21, 2018.

[156] Human Rights Watch interview with Susi Pola, founder, Núcleo de Apoyo a la Mujer (NAM), Santiago de los Caballeros, Dominican Republic, April 17, 2018.

[157] Coalición por los Derechos y la Vida de las Mujeres, “Causales de Vida: Estudio de cinco casos de aborto por causales en República Dominicana,” September 2018, https://oxfam.app.box.com/s/bfuu7gdvb1pmg83eichggk30yih07njk (accessed September 6, 2018).

[158] Human Rights Watch interview with Dayelin, 20, Santiago de los Caballeros, Dominican Republic, April 18, 2018.

[159] Human Rights Watch interview with Yesenia, 37, Santo Domingo, Dominican Republic, February 20, 2018.

[160] Human Rights Watch interview with Carmen, 33, Santiago de los Caballeros, Dominican Republic, April 18, 2018.

[161] Human Rights Watch interview with Karen, 18, Santo Domingo, Dominican Republic, April 14, 2018.

[162] Human Rights Watch interview with Madelyn, 28, Santo Domingo, Dominican Republic, April 14, 2018.

[163] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[164] Human Rights Watch interview with Madelyn, 28, Santo Domingo, Dominican Republic, April 14, 2018.

[165] Human Rights Watch interview with Marta, 30, and Sara, 22, San Cristóbal province, Dominican Republic, February 16, 2018.

[166] Ministerio de Economía, Planificación y Desarrollo, Unidad Asesora de Análisis Económico y Social, “Sistema de Indicadores Sociales de la República Dominicana (SISDOM),” vol. II (2016), http://economia.gob.do/wp-content/uploads/drive/UAAES/SISDOM/2016/Datos%20estadisticos/SISDOM%202016.%20Volumen%20II%20Serie%20de%20Datos.pdf (accessed October 1, 2018), p. 154.

[167] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[168] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[169] See, for example, Centers for Disease Control and Prevention, “Treating for Two: Medicine and Pregnancy, Findings by Health Condition,” 2018, https://www.cdc.gov/pregnancy/meds/treatingfortwo/findings-by-condition.html (accessed September 18, 2018).

[170] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[171] Human Rights Watch interview with Susi Pola, founder, Núcleo de Apoyo a la Mujer (NAM), Santiago de los Caballeros, Dominican Republic, April 17, 2018.

[172] Coalición por los Derechos y la Vida de las Mujeres, “Causales de Vida: Estudio de cinco casos de aborto por causales en República Dominicana,” https://oxfam.app.box.com/s/bfuu7gdvb1pmg83eichggk30yih07njk.

[173] Women’s Link Worldwide, “Madre de “Esperancita” exige justicia ante Comisión Interamericana de Derechos Humanos,” August 17, 2017, https://www.womenslinkworldwide.org/informate/sala-de-prensa/madre-de-esperancita-exige-justicia-ante-comision-interamericana-de-derechos-humanos (accessed July 16, 2018).

[174] Human Rights Watch interview with doctor, date and location withheld for security reasons.

[175] Human Rights Watch interview with Xiomara, 26, Santo Domingo, Dominican Republic, February 18, 2018.

[176] Human Rights Watch interview with Xiomara, 26, Santo Domingo, Dominican Republic, February 18, 2018.

[177] Human Rights Watch interview with Nicole, 28, Santo Domingo, Dominican Republic, April 12, 2018.

[178] Human Rights Watch interview with Lucely, 18, San Cristóbal province, Dominican Republic, April 16, 2018.

[179] Human Rights Watch interview with Maoli, 20, Santo Domingo, Dominican Republic, April 13, 2018.

[180] Human Rights Watch interview with Flor de Liz, 26, Santo Domingo, Dominican Republic, February 17, 2018.

[181] Human Rights Watch interview with Mayerlin, 38, Monte Plata province, Dominican Republic, February 21, 2018.

[182] Human Rights Watch interview with Eridania, 28, Monte Plata province, Dominican Republic, February 21, 2018.

[183] See, for example, Lauren Ralph, Heather Gould, Anne Baker, and Diana Greene Foster, “The Role of Parents and Partners in Minors' Decisions to Have an Abortion and Anticipated Coping After Abortion,” Journal of Adolescent Health, vol. 54, no. 4 (2014), pp. 428-434.

[184] Human Rights Watch interview with Maria Fernanda, 23, Santiago de los Caballeros, Dominican Republic, April 18, 2018.

[185] Human Rights Watch interview with Alicia, 17, Santo Domingo, Dominican Republic, April 15, 2018.

[186] Human Rights Watch interview with Paola, 31, Santo Domingo, Dominican Republic, April 13, 2018.

[187] “Imponen tres meses de prisión a mujer se habría provocado aborto,” Listin Diario, February 18, 2018, https://www.listindiario.com/la-republica/2018/02/18/503212/imponen-tres-meses-de-prision-a-mujer-se-habria-provocado-aborto (accessed June 25, 2018); “Video: Joven que guarda prisión tras aborto ofrece su versión de los hechos,” Ocoa en Red, February 12, 2018, http://ocoaenred.com/index.php/noticias/policia-y-justicia/7261-video-joven-que-guarda-prision-tras-aborto-ofrece-su-version-de-los-hechos (accessed July 5, 2018).

[188] Ana Gabriela Rojas, “Emely Peguero: el asesinato de una adolescente embarazada que puso el foco sobre el terrible número de feminicidios en República Dominicana,” BBC World, October 16, 2017, https://www.bbc.com/mundo/noticias-america-latina-41617665 (accessed July 15, 2018).

[189] Ibid.

[190] Ratified by the Dominican Republic on January 4, 1978.

[191] Ratified by the Dominican Republic on January 4, 1978.

[192] Ratified by the Dominican Republic on January 24, 2012.

[193] Ratified by the Dominican Republic on September 2, 1982.

[194] Ratified by the Dominican Republic on June 11, 1991.

[195] Ratified by the Dominican Republic on January 21, 1978.

[196] See, for example, HRC concluding observations on El Salvador, UN Doc. CCPR/C/SLV/CO/7 (2018); Guatemala, UN Doc. CCPR/C/GTM/CO/4 (2018); Lebanon, UN Doc. CCPR/C/LBN/CO/3 (2018); Cameroon, UN Doc. CCPR/C/CMR/CO/5 (2017).

[197] HRC concluding observations on Dominican Republic, UN Doc. CCPR/C/DOM/CO/6 (2017).

[198] See, for example, CEDAW Committee concluding observations on Chile, UN Doc. CEDAW/C/CHL/CO/7 (2018); Fiji, UN Doc. CEDAW/C/FJI/CO/5 (2018); Marshall Islands, UN Doc. CEDAW/C/MHL/CO/1-3 (2018); Republic of Korea, UN Doc. CEDAW/C/KOR/CO/8 (2018); Saudi Arabia, UN Doc. CEDAW/C/SAU/CO/3-4 (2018); Suriname, UN Doc. CEDAW/C/SUR/CO/4-6 (2018); Guatemala, UN Doc. CEDAW/C/GTM/CO/8-9 (2017); Paraguay, UN Doc. CEDAW/C/PRY/CO/7 (2017); Costa Rica, UN Doc. CEDAW/C/CRI/CO/7 (2017); El Salvador, UN Doc. CEDAW/C/SLV/CO/8-9 (2017).

[199] Committee on the Rights of the Child, General Comment No. 20 on the implementation of the rights of the child during adolescence, UN Doc. CRC/C/GC/20 (2016), paras. 13 and 60.

[200] See, for example, concluding observations of the Committee on Economic, Social and Cultural Rights (CESCR) on the Republic of Korea, UN Doc. E/C.12/KOR/CO/4 (2017); The Philippines, UN Doc. E/C.12/PHL/CO/5-6 (2016); Kenya, UN Doc. E/C.12/KEN/CO/2-5 (2016); and Pakistan, UN Doc. E/C.12/PAK/CO/1 (2017).

[201] CESCR concluding observations on the Dominican Republic, UN Doc. E/C.12/DOM/CO/4 (2016), paras. 59-60.

[202] Inter-American Commission on Human Rights, “IACHR Urges El Salvador to End the Total Criminalization of Abortion,” March 7, 2018, http://www.oas.org/en/iachr/media_center/PReleases/2018/042.asp (accessed May 23, 2018).

[203] Inter-American Commission on Human Rights, “IACHR Urges All States to Adopt Comprehensive, Immediate Measures to Respect and Protect Women’s Sexual and Reproductive Rights,” October 23, 2017, https://mailchi.mp/dist/iachr-urges-all-states-to-adopt-comprehensive-immediate-measures-to-respect-and-protect-womens-sexual-and-reproductive-rights?e=07a43d57e2 (accessed May 23, 2018).

[204] American Convention on Human Rights, art. 4(1).

[205] Inter-American Commission on Human Rights, White and Potter (“Baby Boy Case”), Resolution No. 23/81, Case No. 2141, U.S., March 6, 1981, OAS/Ser.L/V/II.54, Doc. 9 Rev. 1, October 16, 1981, para. 14(a).

[206] Ibid., para 14(6).

[207] Inter-American Court, Artavia Murillo and others Case, Judgment of November 28, 2012, Inter-Am Ct.H.R., Series C. No. 257, para. 264.

[208] Ibid.

[209] ICESCR, art. 12(1); CRC art. 24; CEDAW, art. 12.

[210] CESCR, General Comment No. 22 on the right to sexual and reproductive health (2016), para. 40.

[211] See, for example, concluding observations of the CESCR on the Republic of Korea, UN Doc. E/C.12/KOR/CO/4 (2017); Pakistan, UN Doc. E/C.12/PAK/CO/1 (2017); Honduras, UN Doc. E/C.12/HND/CO/2 (2016); Poland, UN Doc. E/C.12/POL/CO/6 (2016); the Philippines, UN Doc. E/C.12/PHL/CO/5-6 (2016); Costa Rica, UN Doc. E/C.12/CRI/CO/5 (2016); Kenya, UN Doc. E/C.12/KEN/CO/2-5 (2016); and Macedonia, UN Doc. E/C.12/MKD/CO/2-4 (2016).

[212] CEDAW Committee, General Recommendation No. 24 on women and health, UN Doc. A/54/38/Rev.1 (1999), para. 17.

[213] Ibid.

[214] See discussions above under “the right to life.”

[215] CRC, Concluding observations on Dominican Republic, UN Doc. CRC/C/DOM/CO/3-5 (2015), paras. 51-52.

[216] See, for example, concluding observations of the Committee against Torture on Timor-Leste, UN Doc. CAT/C/TLS/CO/1 (2017); Ireland, UN Doc. CAT/C/IRL/CO/2 (2017); and Ecuador, UN Doc. CAT/C/ECU/CO/7 (2016).

[217] Whelan v. Ireland, CCPR/C/119/D/2425/2014 (2017); Mellet v. Ireland, CCPR/C/116/D/2324/2013 (2016); K.L. v. Peru, CCPR/C/85/D/1153/2003 (2005); and L.M.R. v. Argentina, CCPR/C/101/D/1608/2007 (2011).

[218] Ibid., See also HRC General Comment No. 20 on the prohibition of torture, or other cruel, inhuman or degrading treatment or punishment, UN Doc. HRI/GEN/1/Rev.1 (1994), para. 5.

[219] CEDAW Committee, General Recommendation 35 on gender-based violence against women (2017), para. 18; CESCR, General Comment 22, para. 10.

[220] Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, UN Doc. A/HRC/31/57 (2016), para. 43.

[221] Follow-up Mechanism to the Convention of Belém Do Pará (Mesecvi) Comittee Of Experts (Cevi), “Declaration on Violence against Women, Girls and Adolescents and their Sexual and Reproductive Rights,”, OEA/Ser.L/II.7.10, September 19, 2014, http://www.oas.org/es/mesecvi/docs/CEVI11-Declaration-EN.pdf (accessed May 23, 2018), pp. 3-4.

[222] Ibid., p. 7.

[223] See, for or example, ICCPR, art. 2 and ICESCR, art. 2.

[224] American Convention on Human Rights, arts. 1(1) and 24.

[225] CEDAW Committee, “Statement of the Committee on the Elimination of Discrimination against Women on sexual and reproductive health and rights: Beyond 2014 ICPD review” (Feb. 2014).

[226] See, for example, the CEDAW Committee concluding observations noted under the analysis of the right to life and right to health above.

[227] See, for example, HRC concluding observations on the Philippines, UN Doc. CCPR/C/PHL/CO/4 (2012); Paraguay, UN Doc. CCPR/C/PRY/CO/3 (2013); Peru, UN Doc. CCPR/C/PER/CO/5 (2013); and Ireland, UN Doc. CCPR/C/IRL/CO/4 (2014). See also L.M.R. v. Argentina, UN Doc. CCPR/C/101/D/1608/2007 (2011).

[228] See, for example, CRC concluding observation on Namibia, UN Doc. CRC/C/NAM/CO/2-3 (2012).

[229] CESCR General Comment No. 22, para. 34.

[230] Inter-American Commission on Human Rights, “Access to Maternal Health Services from a Human Rights Perspective”, OEA/Ser.L/V/II. Doc. 69, http://cidh.org/women/SaludMaterna10Eng/MaternalHealthTOCeng.htm (accessed October 25, 2015), para. 53. See also Inter-American Court, Artavia Murillo and others Case, Judgment of November 28, 2012, Inter-Am Ct.H.R., Series C. No. 257, paras. 294 and 299. And, Inter-American Commission on Human Rights, “Legal Standards related to Gender Equality and Women’s Rights in the InterAmerican Human Rights System: Development and Application Updates from 2011 to 2014” (2015) http://www.oas.org/en/iachr/reports/pdfs/LegalStandards.pdf (accessed May 2, 2016) citing Inter-American Commission on Human Rights, “Annex to the Press Release Issued at the Close of the 147th Session: Human rights and the criminalization of abortion in South America,” held on March 15, 2013.

[231] ICCPR, art. 17(1).

[232] American Convention on Human Rights, art. 11(2).

[233] See Whelan v. Ireland, CCPR/C/119/D/2425/2014 (2017); Mellet v. Ireland, CCPR/C/116/D/2324/2013 (2016); K.L. v. Peru, CCPR/C/85/D/1153/2003 (2005); and L.M.R. v. Argentina, CCPR/C/101/D/1608/2007 (2011).

[234] See, for example, HRC concluding observation on El Salvador, UN Doc. CCPR/C/SLV/CO/7 (2018).

[235] CRC General Comment No. 20 on the implementation of the rights of the child during adolescence (2016), para. 59.

[236] See, for example, CRC concluding observations on Poland, UN Doc. E/C.12/POL/CO/6 (2016); Indonesia, UN Doc. CRC/C/IDN/CO/3-4 (2014); Venezuela, UN Doc. CRC/C/VEN/CO/3-5 (2014); and Morocco, UN Doc. CRC/C/MAR/CO/3-4 (2014).

[237] See, for example, CRC concluding observations on Sri Lanka, UN Doc. CRC/C/LKA/CO/5-6 (2018); and India, UN Doc. CRC/C/IND/CO/3-4 (2014).

[238] See, for example, CESCR concluding observations on El Salvador, UN Doc. E/C.12/SLV/CO/3-5 (2014); and Slovakia, UN Doc. E/C.12/SVK/CO/2 (2012).

[239] See, for example, CAT concluding observations on Paraguay, UN Doc. CAT/C/PRY/CO/4-6 (2011); and Peru, UN Doc. CAT/C/PER/CO/5-6 (2013).

[240] ICCPR, art. 19(2); American Convention on Human Rights, art. 13(1). See also Inter-American Court, Claude-Reyes and others Case, Judgment of September 19, 2006 Inter-Am Ct.H.R., Series C. No. 151, para. 264.

[241] CEDAW, art. 16(e).

[242] See ICESCR, art. 2(2). See also CESCR General Comment No. 14 on the right to the highest attainable standard of health (2000); and CESCR General Comment No. 22 on the right to sexual and reproductive health (2016).

[243] CESCR General Comment No. 14, para. 11.

[244] CESCR General Comment No. 22, para. 18.

[245] CESCR, “Concluding observations on the fourth periodic report of the Dominican Republic,” October 21, 2016, E/C.12/DOM/CO/4, para. 60(c).

[246] CEDAW Committee, “Concluding observations on the combined sixth and seventh periodic reports of the Dominican Republic,” July 30, 2013, CEDAW/C/DOM/CO/6-7, para. 33(d); Committee on the Rights of the Child, “Concluding observations on the combined third to fifth periodic reports of the Dominican Republic,” March 5, 2015, CRC/C/DOM/CO/3-5, para. 52. See also, for example, CEDAW Committee concluding observations on Burkina Faso, UN Doc. CEDAW/C/BFA/CO/7 (2017); Costa Rica, UN Doc. CEDAW/C/CRI/CO/7 (2017); Ireland, UN Doc. CEDAW/C/IRL/CO/6-7 (2017); and Uruguay, UN Doc. CEDAW/C/URY/CO/8-9 (2016); and CRC concluding observations on Guatemala, UN Doc. CRC/C/GTM/CO/5-6 (2018); Panama, UN Doc. CRC/C/PAN/CO/5-6 (2018); and Sri Lanka, UN Doc. CRC/C/LKA/CO/5-6 (2018).

[247] CRC General Comment No. 20, para. 59. See also para. 61, where the Committee notes that “[a]ge-appropriate, comprehensive and inclusive sexual and reproductive health education, based on scientific evidence and human rights standards and developed with adolescents, should be part of the mandatory school curriculum and reach out-of-school adolescents.”

[248] Inter-American Commission on Human Rights, “Access to Information in Reproductive Health from A Human Rights Perspective,” OEA/Ser.L/V/II. Doc. 61, http://www.cidh.oas.org/pdf%20files/womenaccessinformationreproductivehealth.pdf (accessed October 25, 2015), para. 91.

[249] Ibid., para. 25.

[250] Ibid., para. 92.

[251] CEDAW, art. 16(1).

[252] CEDAW Committee, General Recommendation 28, On the core obligations of States parties under article 2 of the Convention on the Elimination of All Forms of Discrimination against Women, U.N. Doc. CEDAW/C/GC/28 (2010), paras. 19 and 34; CEDAW Committee, General Recommendation 19, Violence against Women, (Eleventh session, 1992), Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI\GEN\1\Rev.1 (1994) (hereinafter General Recommendation 19), p. 84, para. 9.

[253] CEDAW Committee, General Recommendation 19, Violence against Women, U.N. Doc.A/47/38 (1992) para. 9.

[254] Inter-American Convention on the Prevention, Punishment and Eradication of Violence Against Women (“Convention of Belém do Pará”), adopted September 6, 1994, by the General Assembly of the OAS, entered into force May 3, 1995, ratified by the Dominican Republic on January 10, 1996 arts. 7(b), 9.

[255] CRC, art. 19.