In April, nurse Julia Pineda was making her rounds at the hospital in Suchitoto, a lakeside town in El Salvador, when she developed a rash. As her symptoms multiplied—high fever, red eyes—the petite 32-year-old consulted a colleague, who offered a preliminary diagnosis: Zika. Pineda was 10 weeks pregnant with her third child, and terrified.

The baby still growing inside Pineda is battling the same virus that scientists say caused thousands across Latin America to be born with microcephaly, a birth defect in which babies’ undersize heads hide severe brain abnormalities. Another chilling thought crossed her mind: prison. Pineda feared that if she miscarried the baby, she might be accused of having had an abortion—a crime in El Salvador that could put her behind bars for up to 50 years.

El Salvador is one of six countries with the most extreme abortion law in the world. Abortion is criminalized in all circumstances, regardless of rape, incest, the viability of the fetus, or whether the pregnancy poses a risk to the mother’s life. This law went into effect in 1998, changing from a partial to an absolute ban, due in large part to lobbying by the country’s archbishop. The next year Congress reinforced the law by adding a clause to the constitution defining life as beginning at conception.

View Images Pregnant women line up at a maternal waiting house to receive bug repellent and mosquito nets. Photograph by Nadia Shira Cohen

Since then, at least 150 women have been prosecuted under the abortion ban. According to data pulled by the Salvadoran Citizens’ Association for the Decriminalization of Abortion, 49 women have been convicted, and 26 charged with homicide. By law, doctors must contact police if they suspect a woman of having an abortion, which carries a charge of two to eight years.

Sometimes, women who say they lost their babies to miscarriages late in the pregnancy are also accused of aborting. If convicted, they face up to 50 years in prison for homicide. Activists brought this issue to light with a group of women known as Las 17, who insist that they were imprisoned for abortions they did not commit. Their numbers are climbing: Today at least 21 women are in prison for violating the ban, despite claiming to have suffered late-term miscarriages.

During their trials, most of these women, almost entirely uneducated and low-income, were represented by public defenders. In at least two cases they were represented by lawyers from the prosecution. Their sentences are based on evidence such as a “float test,” which measures a fetus’s lung buoyancy to determine whether it was alive at birth—a test that has been widely discredited by the scientific community. It is not uncommon for a prosecutor or a judge to deride the women for not having maternal instinct.

View Images A pro-life mural condemns abortion on a side street off the main highway to San Salvador. In 1998, a law banned abortion even in cases of rape, incest, threat to the mother’s life, or the fetus’s viability. Photograph by Nadia Shira Cohen

“We haven’t found another country where criminalization of obstetric emergencies is at such a systematic level as in El Salvador,” says Charles Abbott, a legal adviser for the Center for Reproductive Rights, who consults with local lawyers on the country’s court cases. In July, a conservative party submitted a proposal to the legislature that would raise the minimum sentence for abortion to 30 years.

El Salvador, already the world’s most dangerous country outside of a war zone, is particularly so for women, where an eighth report experiencing physical and sexual violence. Rape is institutionalized by warring drug gangs, which control large swathes of the country.

If the proposed increase in prison time passes, Abbott says, “it would be most drastic sentence in the world. If a man raped a teenager and she aborted, his criminal sentence would be six to 10 years, and hers would be 30 to 50.” That amendment awaits a vote, but last week, the liberal ruling party submitted a rebuttal: a bill that would allow abortion in the case of rape, or if the fetus endangers the mother or is unviable.

Meanwhile, a blood test sent to the capital of San Salvador still hadn’t come back with Pineda’s Zika results by August, nearly four months later. When her nine-year-old son came home from school with a brochure about Zika featuring a frighteningly inaccurate drawing of a fetus with two heads in a pregnant belly, she comforted him. But still, she worries about the baby inside her.

Scientists have linked Zika with an increased risk of miscarriage in pregnant women, but the evidence so far is limited and anecdotal. Dr. Nelson Menjivar, a private-practice gynecologist in San Salvador who spoke to the Guardian in February, said, for example, that in the course of one month he had treated 11 otherwise healthy women who miscarried after contracting Zika. A perfect storm of circumstances could catapult a case like this onto the list of 27 court battles currently being fought by activists in El Salvador against women who are being prosecuted under the abortion law, but claim to have miscarried.

As a nurse, it is Pineda’s responsibility to report suspected abortions to the authorities. Though she didn’t consider abortion to be an option for herself, she believes the ban should be eased and took the possibility of miscarriage seriously. “It was emotional to think I could lose the baby and face the possibility of prosecution,” she says.

(See photographs of parents living with babies with microcephaly in “Here's What We Know Now About Zika and Birth Defects.”)

View Images Sanitation workers fumigate houses, streets, sewers, and schools against mosquitos that carry Zika, dengue fever, and chikungunya. Photograph by Nadia Shira Cohen

A Scramble at the Outbreak

In November, when the first Zika cases were reported in El Salvador, activists thought the government might relax its abortion law. As the virus spread, the United Nations urged affected countries to make an exception in cases of pregnant women contracting Zika. Instead, the Salvadoran Ministry of Health fumigated neighborhoods, distributed bug spray and mosquito larvae-eating chemicals, and offered a piece of advice for women: Wait two years to get pregnant.

In June, the country confirmed its first case of Zika-linked microcephaly, and three more have followed. Of the 11,000 confirmed Zika cases, 334 are pregnant women. At the Ministry of Health in San Salvador, brochures identifying Zika symptoms spill out of boxes in the cramped waiting room. Mirian Gonzalez, the coordinator for women and children, admits that birth control methods are not working. “We also need sexual education, because there’s no family planning method.”

During an earlier visit to Mexico, Pope Francis seemed to suggest contraception could be used during the Zika crisis, but stayed firm on the church’s abortion stance. "Abortion is not a lesser evil. It is a crime," he said, and then added that “avoiding a pregnancy is not an absolute evil."

View Images Pigeons flock into the square in front of the Metropolitan Cathedral in San Salvador. Photograph by Nadia Shira Cohen

But contraception is inaccessible and unpopular in El Salvador, which has one of Latin America’s highest rates of teenage pregnancy. A third of mothers giving birth in the country’s hospitals are between the ages of nine and 18. And the results have been deadly for those with unwanted pregnancies. The leading cause of death for pregnant teens is suicide, and thousands undergo dangerous illegal abortions each year, with estimates ranging from 6,000 to 35,000. According to a 2011 World Health Organization study, 11 percent of these illegal abortions result in the mother’s death.

Though the health ministry’s official stance is pro-abortion, it claims to have little power to change the law. “Abortion is a broader issue; we can’t justify it because of Zika,” says Gonzalez. “A woman can die if she doesn’t have this access. But Congress decides. Our hands are tied.”

As Zika cases rose, an online facilitator of abortions called Women on Web offered an alternative: misoprostol, an abortion-inducing ulcer drug, mailed to women with the virus for free. In Brazil, the crisis’s epicenter, requests more than doubled, but the organization had to suspend operations after the postal service confiscated the packages. Between November and March, Women on Web’s requests from El Salvador jumped 30 percent, though lack of Internet access meant the actual number was still low.

Infected While Pregnant

Meanwhile, the health ministry’s Zika response was widely criticized. "The government is warning about a risk and proposing that women don't get pregnant so they don't run the risk of having children with physical problems, but are they doing enough about the Zika-carrying mosquito?" Father Luis Ayala of the Catholic Church asked the BBC in February.

Elizabeth Torres is wondering the same thing. She’s the only person in El Salvador studying the mosquito that transmits Zika. In the vector’s lab at the National University in San Salvador, the 26-year-old biology major sounds awed by Aedes aegypti, which carries dengue fever, chikungunya, and Zika in its three-millimeter body. With funds from a California university, she discovered three different kinds of DNA variations within the species. This research, she says, is a step toward pinpointing how to wipe out the mosquito.

Such a solution, and much more, remains unknown as Zika continues to spread across Latin America and the Caribbean, and into the United States. Pharmaceutical companies are racing to develop a vaccine, while scientists are still discovering the virus’s impacts. They now suspect that it causes a rare nervous system condition called Guillain-Barré syndrome, microcephaly, and developmental deficits.

(Read about the Zika-carrying mosquito in “This May Be the Deadliest Creature on Earth.”)

Reports predict that the mosquitos will be contained in Latin America by 2019, but the crisis in El Salvador continues to unfold. Though Zika cases have dropped since fumigations earlier this year, pregnancies from the infectious fall and winter are now coming to term.

View Images Twenty-four-year-old Milagro Castro contracted Zika while pregnant with her first child. She originally thought the virus was just a rumor. Photograph by Nadia Shira Cohen

View Images The parents of baby Norma, who is one of four babies born with Zika-linked microcephaly, say they have spent all their money on medical tests. Photograph by Nadia Shira Cohen

Milagro Castro’s pregnancy is one of those. After two years of marriage she and her husband had finished setting up house in a sleepy town across the lake from nurse Julia Pineda’s village, and wanted a baby. “It’s really difficult to say to women, 'You shouldn't get pregnant,'” the 24-year-old says. In March, nine weeks pregnant, she contracted Zika. Castro was shocked: She’d thought Zika was fake after hearing rumors it was just dengue fever. Now her proof is a stack of her ultrasound exams with the words “Zika” scrawled across the bottom and a note that the “fetus is normal.”

Castro isn’t taking chances. Her first name means “miracle,” and she’s praying for one, every day before she goes to sleep and when she wakes up, negotiating with God that her daughter, who she’s already named Joanna Suje, isn’t born with deformations. With competing advice from different doctors and a jumble of information on the internet, she isn’t sure who else to ask.

Her nightmare has been realized by the four families in El Salvador raising babies with microcephaly. Outside a rural one-room house three hours from the capital, Norma Gutierrez sways in a hammock with a two-month-old baby on her lap, as her husband, Hermes Garay, hovers nearby. The young couple reveals that they’d never even heard of Zika until their third daughter, also named Norma, was born with a small head.

Now Gutierrez believes she had Zika twice. During her second spate of rash and fever, she had pains under her ribcage so severe that she couldn’t walk. At six months, the baby felt like it was coming early. Both times, doctors and an ultrasound revealed nothing wrong. Since Norma was born and diagnosed with microcephaly, they’ve been assigned three specialists at three different hospitals and are waiting to hear if surgery can help. “If we have to pay, the baby has to stay like this because I spent all the money I have,” Garay says.

Jailed for Losing a Child

In August, the latest defendant to make headlines in the abortion ban battle was Santos Elizabeth Herrera Gamez, a 22-year-old who delivered a stillborn outside the hospital. Her boyfriend, a gang member, threw it in the trash. The Citizens’ Association for the Decriminalization of Abortion, the only organization devoted to defending these women, had taken her case, and lawyers were nervous: The judge had already sentenced three other women for the same crime to 35 years each.

“I’m a woman of reproductive age,” noted Angelica Rivas, one of the pro bono lawyers working on the organization’s current cases. “It could be me.” But in September, after spending a year behind bars, Gamez was freed for lack of evidence.

(Learn how the country’s murder rate exploded in “El Salvadoran Gang Violence.”)

Gamez is one of the group’s recent wins. In May, a single mother and sweatshop worker named Maria Teresa Rivera was released after serving four years of her 40-year sentence. She’s now participating in workshops and therapy with in-house psychologist Maria Rosa Cruz, who runs a support group for freed women to prepare them for what they’ll face outside: few employment opportunities and continuous harassment.

One of these women, who asked not to be named for fear of retribution, is still shaken when when we meet on the deck of the pro-abortion organization's offices. Though she’s been out of prison for seven years after being convicted of having an abortion, a local news site had recently broadcast her name. When she came home from work, neighbors were on her porch demanding to know why she did it. “Not even the street dogs kill their own babies,” one told her.

View Images Maria Teresa Rivera cries after hearing that her 40-year sentence for aggravated homicide has been annulled. The prosecutors on her case accused her of purposefully aborting her child, but she says she suffered a natural miscarriage. Photograph by Nadia Shira Cohen

This crime’s stigma is just as strong behind bars. In the women’s prison in Ilopango, a dangerous neighborhood 45 minutes from central San Salvador, the other inmates still call Teodora Vasquez by the fake name she gave them when she arrived nine years ago: Helen. “I was really scared,” she says now. “I heard women who’d come with this crime would get beaten.”

A well-kempt courtyard for visitors conceals the prison’s overcrowding—stuffed to nine times its capacity with up to 250 women sharing a cell. Since arriving nine years ago, Vasquez has progressed from fourth grade to tenth grade, and plans to study law when she’s released.

(Read about what the U.S. is doing to combat Zika in "CDC Director: ‘This Is No Way to Fight an Epidemic’")

In July 2007, Vasquez was nine months pregnant and working late in the high school cafeteria when she started feeling sick. No one came after multiple calls to 911, and she went to the bathroom. On the toilet, she fainted. Police found her bleeding heavily on the floor, having delivered a stillborn. She was handcuffed and taken to a holding cell. Vasquez passed in and out of consciousness, but recalls an officer worrying that she might die on their watch.

The next day she woke up in the hospital, she says, her foot handcuffed to the bed and a crowd of journalists around her. Months later, when her lawyer didn’t show up at her sentencing hearing, the judge pulled a lawyer from the prosecution to represent her. “At the sentencing he just sat next to me,” she recalls. “He didn’t know anything or ask anything, he just waited for the judge to sentence me.” She got 30 years.

View Images Idalia Alverado Sanchez and her husband, Alex, are awaiting their first child at a maternal waiting house, where women can stay to receive prenatal care before giving birth. Photograph by Nadia Shira Cohen

Prosecuted for Seeking Treatment

The women currently in jail for homicide under the abortion law have something in common: they were treated in public hospitals, rather than private clinics, which don’t have to report patient information. Even if doctors in public hospitals try to ignore the law that requires them to call the authorities on suspicious miscarriages or potential abortions, sometimes nurses, neighbors, and family members take the initiative.

“We’d see police come into hospital asking for a patient and knew that somebody notified them about the case even if we tried to keep it secret,” says Guillermo Ortiz, the former head of obstetrics at Hospital de la Mujer, the country’s main maternity center. The cases of miscarriage notwithstanding, those who end up in a public hospital had often tried to self-abort with dangerous methods, he says. “This is the situation of a poor woman. A woman who has at least a few dollars will go to a private clinic or to Guatemala or Mexico and get an abortion. And nothing will happen to them.”

Seeking an abortion in El Salvador is a risky game of cat and mouse through an underground network of doctors, nurses, and pharmacists that help, despite the risk of an eight-to-12-year sentence. And now, with the threats posed by Zika, stakes are higher than ever.

One doctor who performs abortions is hopeful that the international outcry over Zika might sway politicians to loosen the law, at least for emergencies. He has been running a clandestine operation for the past 10 years, passed down to him by a professor when he was a medical student. Now he runs a public clinic, but brings patients to his private practice or the small facility he built in his family’s home. At his busiest, he does five procedures a month and charges between nothing and $1,000, depending on the patient.

“Zika has had a positive impact because it’s exposed the topic,” says the doctor, who jokingly refers to himself as “Dr. Hell” and asks not to be named because of the illegal nature of his work. “It’s a health issue. I have faith for health causes they’d change the law. The first thing they need is a politician willing to take that risk.”

At the moment, the political will is calibrated in the opposite direction. Under the new abortion sentences on the docket in Congress, the repercussions for abortion providers could also increase dramatically, changing punishments from fines to jail time. “Dr. Hell” says he would have to weigh his medical duty against being there to raise his two children. Such a risk may only be worth taking for thousands of dollars per treatment, putting an end to his goodwill. “Then the women who don’t have money, I can’t help them,” he says.

The International Women’s Media Foundation supported writer Nina Strochlic and photographer Nadia Shira Cohen’s reporting from El Salvador.