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.

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).

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. 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. 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. 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.

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. 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.

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.”

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. “Even though abortion is illegal under the framework, there are not prosecutions,” one doctor explained. 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.”

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. 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. “We’ve never seen them put someone in jail for an abortion,” said Fátima Lorenzo, director of the nongovernmental organization Ciudad Alternativa. Some advocates said they feared the 2018 case could signal a move toward greater enforcement of criminal penalties for abortion.

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).

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. 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.

Human Rights Watch could not locate any recent, comprehensive, country-specific estimates of the abortion rate in the Dominican Republic. 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.

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.”

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.

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.”

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. The Pan American Health Organization estimates an average of 68 maternal deaths per 100,000 live births in Latin America and the Caribbean.

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. At least eight percent of maternal deaths in the country are attributed to complications from miscarriage or abortion. 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. 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.

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. The WHO recommends the use of misoprostol in combination with mifepristone, another drug used in medical abortion. 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.

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. 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.

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.

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. In a letter to the president of the Chamber of Deputies explaining his veto (“observation”), 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.” 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).

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. 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.

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. 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.” 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. 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). 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. 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.

Despite this, survey data suggest that nearly half of pregnancies in the Dominican Republic are either unplanned or unwanted. 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. 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. 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.

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.

A few interviewees said they got pregnant when they missed doses of their daily oral contraceptive pills. Others became pregnant while switching from one contraceptive method to another. Some women and girls said their methods failed to prevent pregnancy for reasons they did not understand. 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.”

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.

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.

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. While there is evidence that younger women have a higher risk of a failed tubal ligation (that is, a pregnancy occurs), 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. “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?’”

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.” “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. 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.”

“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.”

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.” One 22-year-old woman interviewed for this report explained it simply: “When you don’t want to have a baby, you feel bad.”

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.” 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.” 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.

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.”

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.

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.”

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.

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.

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.”

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?’”

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.

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. 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.” 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.”

Human Rights Watch interviewed two women who had safe—though clandestine and illegal—abortions. Both women had medical abortions under the care and supervision of trained providers. 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.”

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.”

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. 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.”

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].”

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.

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.

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].” 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.

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.

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. 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. 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, 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.

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.

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].”

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.”

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.

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.

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.”

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.

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.”

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.

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.”

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).

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.

Delaying treatment following a miscarriage or an abortion can significantly increase the risk of serious and life-threatening complications. 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.

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.”

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.

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.

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.

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.

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].”

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. “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.”

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.

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.”

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.

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.

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.” 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. In the Dominican Republic, at least eight percent of maternal deaths are attributed to complications from miscarriage or abortion. 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.”

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. 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. In the other case, it was unclear whether the woman induced an abortion or had a miscarriage.

In a 2017 report, Women’s Link Worldwide documented seven maternal deaths in the Dominican Republic. 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. 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.

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.”

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.

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.” Raquel, 38, said a 19-year-old woman in her neighborhood died four years earlier due to hemorrhaging after she had an unsafe abortion.

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. Research has shown that expanding legal access to abortion can lead to significant reductions in maternal mortality. 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. One in ten women and girls in the Dominican Republic reported surviving sexual violence in her lifetime. Of women who reported sexual violence, 61 percent said their partner or ex-partner was the perpetrator. 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. 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. 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.” Although the Dominican Republic is taking steps to address gender-based violence, 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. 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.”

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.”

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.”

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.

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.

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].”

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. 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.

Several women interviewed for this re