“We Are Putting Our Reproductive Age at Risk”

“We are Putting our Reproductive Age at Risk” Influencing Factors, Experiences and Reflections on How it is to Manage Cases of Abortions and Obstetric Emergencies with Pregnancy Loss as an Obstetrician-Gynecologist in El Salvador

Emma Stenbacka

Master Thesis, 30 credits Medicine Program, 330 credits

Supervisors: Professor Birgitta Essén & Professor Solveig Jülich Department of Women’s and Children’s Health & Department of History of Science and Ideas

Examinator: Professor Matts Olovsson Department of Women’s and Children’s Health 2019-01-17

Note on the title: “We are putting our reproductive age at risk” is a quote from one informant, when she broadly reflected on how the El Salvadorian health care system fails the patients of reproductive age by sometimes not providing adequate health care.

Table of Contents Abstract ...... 4 Populärvetenskaplig Sammanfattning ...... 5 Abbreviations ...... 6 1. Background ...... 7 1.1. Sexual and Reproductive Health and Rights ...... 7 1.2. The Pregnancy ...... 8 1.2.1. Pregnancy Related Problems and the Loss of a Pregnancy ...... 9 1.2.1.1. In Early Pregnancy: Focusing on Abortions ...... 9 1.2.1.2. In Late Pregnancy: Focusing on Obstetric Emergencies with Pregnancy Loss .. 11 1.3. Maternal Health Problems Globally and in Latin America ...... 12 1.4. The El Salvadorian Context ...... 13 1.4.1. Legal and Ethical Aspects and the Role of the Physician ...... 14 1.4.2. The Patients and Prosecuted Women ...... 16 1.5. Theoretical Framework: Reproductive Governance ...... 17 1.6. Objective and Questions at Issue ...... 18 2. Material and Methods ...... 20 2.1. Medical Humanities ...... 20 2.2. Study Design ...... 20 2.2.1. Selection: Purposive and Snowball Sampling ...... 20 2.2.2. The Informants ...... 21 2.2.3. The Interview Guide and In-Depth Interviews ...... 21 2.3. Transcription ...... 22 2.4. Thematic Analysis ...... 23 2.5. Ethical Considerations ...... 24 2.6. The Researchers Preunderstanding ...... 25 2.7. Concepts ...... 25 3. Results ...... 27 3.1. The Influencing Factors and How They Influence ...... 27 3.1.1. Ethical Principles and Conflicting Laws ...... 27 3.1.2. The Catholic Church ...... 29 3.1.3. Environment of Polarization, Judgmental Attitudes and Hierarchy ...... 30 3.2. Experiences and Reflections… ...... 32 3.2.1. …Concerning Abortions ...... 32 3.2.2. …Concerning Obstetric Emergency With Pregnancy Loss ...... 34 4. Discussion ...... 37 4.1. The Circumstances of Reporting a Patient or Not ...... 37 4.2. Prioritizing of the Religious and Moral Values ...... 39 4.3. Unprofessional Management and The Loss of Rights of the Pregnant Woman ...... 41 4.4. Conclusion ...... 42 4.5. Strengths and Limitations and Potential Sources of Bias ...... 43 4.6. Implications for Future Research ...... 44 5. Acknowledgement ...... 46 6. References ...... 47 7. Appendix ...... 51 7.1. Attachment 1: Information About the Study and Informed Consent ...... 51 7.2. Attachment 2: The Interview Guide ...... 53 7.3. Attachment 3: The Interview Guide for the Case ...... 56

Abstract

In El Salvador, where induced abortion is prohibited on all grounds, women are condemned to aggravated homicide, with the prison sentence up to 40 years, also for other pregnancy outcomes such as spontaneous abortions and other obstetric emergencies with pregnancy loss. The physicians managing the cases have to consider ethical principles and conflicting laws, making it impossible to keep them all and many times the woman goes directly from the hospital to the prison.

The purpose of the report was to gain deeper understanding and knowledge about the influencing factors on the clinical management, and obstetrician-gynecologists’ experiences and reflections on managing cases with abortion and obstetric emergencies with pregnancy loss. More broadly, the goal of the report was to contribute to the field of medical humanities by demonstrating how in these cases non-medical and -biological factors influence on the clinical management. This was done using a qualitative approach, thematically analyzing five semi-structured in-depth interviews with obstetrician-gynecologists in El Salvador with the help of the theoretical framework of reproductive governance.

The results showed that the main influencing factors on the clinical management of abortion and obstetric emergencies with pregnancy loss were the ethical principles and conflicting laws, the Catholic Church and the environment of polarization, judgmental attitudes and hierarchy. Depending on the individual prioritization of the factors, influenced by both the private and work environment and done either deliberately or not, they had all created an individual framework for managing the cases and hence also to weigh the rights between the woman and the unborn in different situations. In practice, there is no consensus on how to clinically manage the cases of abortion and obstetric emergencies with pregnancy loss and the management depends on both the obstetrician-gynecologist’s individual framework and the particular circumstances at hand. From this conclusion one might question the equal right to health care and the patient safety for pregnant women in El Salvador.

Populärvetenskaplig Sammanfattning

I El Salvador är abort totalförbjudet och kvinnor kan bli dömda för mord med fängelsestraff upp till 40 år också för att ha fått ett sent missfall. Idag sitter 26 kvinnor i fängelse dömda för detta.. Läkarna som tar hand om fallen måste överväga etiska principer och motsägande lagar, vilket i många situationer innebär att minst en lag måste brytas. Ofta åker kvinnan dessutom direkt från sjukhuset till fängelset då det är vårdpersonalen som anmäler henne.

Syftet med den här rapporten var att få större förståelse för vilka faktorer som påverkar läkarna då de handlägger sådana fall samt ta reda på deras erfarenheter och reflektioner. Studien var kvalitativ och baserades på fem intervjuer med specialiserade läkare (obstetriker-gynekologer) i El Salvador. Intervjuerna analyserades tematiskt med hjälp av det teoretiska ramverket reproduktiv styrning.

Resultatet visade att de viktigaste faktorerna som påverkar i handläggningen är de etiska principerna och motsägande lagarna, den katolska kyrkan samt en omgivning präglad av polarisering, dömande attityder och hierarki. Dessa faktorer hade läkarna prioriterat på olika sätt och därigenom skapat sig ett individuellt ramverk som gav dem vägledning i hur de ska hantera fallen. Sammanfattningsvis betyder detta att det i praktiken inte finns någon samsyn på hur dessa fall ska hanteras, utan det beror på en kombination av läkarens egna prioriteringar och de yttre omständigheterna. Detta innebär att olika patienter kan få olika vård beroende på vilken läkare som är ansvarig liksom vilka omständigheter som råder. Från denna slutsats är det möjligt att ifrågasätta rätten till lika sjukvård och patientsäkerheten för gravida kvinnor i El Salvador.

Abbreviations

ARENA Alianza Republicana Nacionalista FMLN Frente Farabundo Martí para la Liberación Nacional FWCW Fourth World Conference on Women ICPD International Conference on Population and Development MDG Millenium Development Goals MS 13 Mara Salvatrucha 13 NGO Non-Governmental Organization OOH (Births) Out-of-Hospital (Births) PoA Programme of Action SDG Sustainable Development Goals SRH Sexual and Reproductive Health SRHR Sexual and Reproductive Health and Rights TA Thematic Analysis UN United Nations US United States WHA World Health Assembly WHO World Health Organization

1. Background Everyone has the right to health, including women and mothers. This is stated by the World Health Organization (WHO) and the United Nations (UN). However, 830 women, adolescents and girls die daily from pregnancy and childbirth related causes (UNFPA/Strategic Plan, 2017). The main mortality reasons are severe hemorrhage, sepsis, pre-eclampsia and eclampsia, delivery complications and unsafe abortion (WHO/Maternal Mortality, 2018). In El Salvador, where induced abortion is not allowed under any circumstances, females are targeted not only for illegal abortions but also for spontaneous abortions (miscarriages) and obstetric emergencies. Within the health care system, the regulating laws and ethical codes are contradictory, putting the medically responsible physicians in a challenging situation when treating their female patients searching for pregnancy related problems (Zureick et al., 2018).

1.1. Sexual and Reproductive Health and Rights Within the area of Sexual and Reproductive Health and Rights (SRHR), an International Conference on Population and Development (ICPD) was held in Cairo in 1994. 179 governments approved on a Programme of Action (PoA) representing a paradigm shift from the established macro- demographic viewpoint to an individual-based-viewpoint, declaring Sexual and Reproductive Health (SRH) an essential human right:

Reproductive health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions and system at all stages of life. Reproductive health, therefore, implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth […]. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases. (UN/A/CONF.171/13, 1994)

In 1995, the Fourth World Conference on Women (FWCW) was held in Beijing, reaffirming the Cairo agenda with 189 countries coming to consensus about a Platform for Action including multiple actions in areas where women were discriminated (UN/A/CONF.177/20, 1996). These have since had follow-up conferences and are still given mandate to be valid as basis for action plans within SRHR (RFSU, 2017).

Although these declarations are considered important mile stones, the work for SRHR has not been without controversies. For instance, the Cairo PoA stated that reproductive health includes abortion and underscored the importance of providing safe abortion services – but only in countries where it is legal (UNFPA, 2014). At first, the El Salvadorian government opposed itself to paragraphs regarding induced abortion, but later made official withdrawals when they in fact did not disagree with the government’s believes (UN General Assembly/A/64/894, 2010). Despite differences in induced abortion legislation, all governments agreed on improving the quality and access to postabortion care, a corner stone in obstetric emergency care (UNFPA, 2014).

In year 2000, the UN constituted the Millenium Development Goals (MDG), putting the framework for 2015. The MDGs was compounded of eight main goals, of which three were directly related to SRH. In 2004, on the 57th World Health Assembly (WHA), the WHO adopted its first global strategy on reproductive health. It emphasized the actions needed for obtaining the MDGs in relation to SRH, pointing out improving pregnancy care and eliminating unsafe abortion (but, as stated in the Cairo PoA, only providing safe abortion services where it is allowed by law) among its five priority aspects (WHO/RHR/04.8, 2004). In year 2015, the MDGs were replaced by 17 Sustainable Development Goals (SDG), setting the agenda for 2030. SDG 3 “Good health and well-being” includes reduce maternal mortality (UN Woman, 2015) and SDG 5 “Gender Equality” includes a target to assure global access to SRHR as agreed on in the Cairo PoA, the Beijing Platform for Action and their follow-up conferences (UN Development Programme, 2015). Moreover, the UN Reproductive Health Policies 2017 stated that SRH is crucial for achieving the SDGs (UN Department of Economic and Social Affairs, Population Division, 2017).

In summary, the UN member states have agreed on that postabortion care and obstetric emergency care is crucial in maternal health, however the right to safe induced abortion care is limited to the countries where it is legally allowed.

1.2. The Pregnancy Within the female reproductive period, the pregnancy refers to the period from conception to birth (or the loss of a pregnancy). A pregnancy carried to term is between 37+0 and 41+6 weeks of gestation, with a mean of 40 weeks. During this time, the pregnancy evolves from a zygote to an embryo to a fetus through millions of cell divisions. When the healthy baby is born, it has developed its organ systems and is ready for the extrauterine environment. For the pregnancy to develop, the mother is undergoing vast physiological adaptations. Most of these changes are regulated from

stimuli by the placenta and the fetus and involve practically all maternal organ systems (Cunningham et al., 2018).

Furthermore, the pregnancy is usually divided into three successive approximate three-months periods, trimesters; the first reaching until week 14+6, the second from week 15+0 until 28+6 and the third from week 29+0 until 42+6. Moreover, the pregnancy is divided into early and late; the early referring to the first half, mostly focusing on the first trimester, and the late referring to the second half. Sometimes, the term midtrimester is also used, and refers to the first half of the second trimester (Cunningham et al., 2018).

1.2.1. Pregnancy Related Problems and the Loss of a Pregnancy As understood in 1.2. the pregnancy is a time of great changes, both for the developing pregnancy and the woman carrying it. This period is not free of risks and specific pregnancy related problems are related to the different time periods within the pregnancy (Cunningham et al., 2018). Below, the most relevant for this report are presented.

1.2.1.1. In Early Pregnancy: Focusing on Abortions According to Cunningham et al. (2018) early pregnancy related problems include ectopic pregnancies and abortions. An ectopic pregnancy is the pregnancy implanted anywhere else than in the endometrial lining of the uterine cavity, with 95% being in the fallopian tube. They correspond to 1.5% of all pregnancies and thanks to modern medicine, nowadays only 3% of all maternal deaths. When an ectopic pregnancy is diagnosed, it is urgent to treat it either medically with methotrexate or surgically with laparoscopy and salpingectomy, due to that the pregnancy is not able to develop and the potentially life-threatening situation of a hemorrhage which could follow a rupture of the ectopic pregnancy.

Abortion is defined as the termination of a pregnancy before the fetus is viable, and according to the WHO, that is before 22 weeks of gestation, or <500 g if reliable dating criteria is absent (Rouse et al., 2017). Cunningham et al. (2018) and Hoffman et al. (2016) argue that the terms abortion and miscarriage should be used interchangeably. However, more commonly is that “miscarriage” is used for a spontaneous loss and “abortion” implies the intended interruption.

Spontaneous abortion (miscarriage) includes complete, incomplete, threatened, inevitable, and missed abortion, and are together the most common complication of a pregnancy. Septic abortion is more common in countries where induced abortion is illegal. They all result in the ending of a

pregnancy. Of the spontaneous abortions, over 80% occur within the first 12 weeks and are referred to as early (Hoffman et al., 2016). Tsur et al. (2016) estimates that up to 50% of all conceptions may be lost, but only 15% result in a clinical spontaneous abortion. Fetal causes, such as chromosomal abnormality, correspond to 60% of these. Hoffman et al. (2016) state that if the fetus is chromosomally euoploid, maternal factors and medical disorders (diabetes mellitus, systemic lupus erythematosus, obesity, thyroid disease and infections amongst others), developmental anomalies and environmental aspects play a bigger role, and these abortions usually occur later. Midtrimester abortion corresponds to 1.5% to 3% of all abortions, and after week 16 only 1%. These pregnancy losses could be caused due to multiple reasons, such as fetal anomalies, placental origins, uterine deformities, maternal disorders, or medically induced with the vast majority being because of fetal anomalies detected by prenatal screening (Cunningham et al., 2018).

Symptoms of abortions, both spontaneous and induced, are vaginal bleeding and tissue discharge, uterine cramps, discomfort or pain in the suprapubic and lower back area. In diagnosing the abortion, the medical history, together with gynecological exam and ultrasonography are corner stones. The management of spontaneous abortion is based on expectant, medical or surgical treatment and can be individualized due to the type and the gestational length. The medical regime is usually misoprostol (prostaglandin E2, causes uterine cramps and ripening of the cervix) and the surgical is usually curettage or vacuum aspiration (Cunningham et al., 2018).

Regarding induced abortion, the term “therapeutic” abortion refers to the ending of a pregnancy due to maternal medical indications. The terms “elective” or “voluntary” abortions refer to the ending of a pregnancy as a request of the woman and are to be proceeded before the fetus is viable. Due to the gestational length, medical or surgical management are the options (Cunningham et al., 2018). The recommended medical regime is based on the combination of mifepristone (antagonist of progesterone, a hormone necessary for maintaining the pregnancy) followed by misoprostol – but in settings where mifepristone is not accessible, the single regime of misoprostol is used (Zamberlin et al., 2012) and the surgical methods are the same as described under spontaneous abortion (Cunningham et al., 2018).

Moreover, the WHO uses three categories when describing the safety regarding an abortion: safe, less safe and least safe. The categorization takes in factors such as abortion method, the provider’s skill and gestational age. A safe abortion is provided by a health-care worker and with methods recommended by the WHO. A less-safe abortion is performed by a trained provider using non-

recommended methods. A least-safe abortion is performed by an untrained person using invasive, dangerous methods (Ganatra et al., 2017).

1.2.1.2. In Late Pregnancy: Focusing on Obstetric Emergencies with Pregnancy Loss Obstetrical complications could be grouped up as hypertensive disorders, obstetrical hemorrhage, preterm birth, postterm pregnancy, fetal-growth disorders and multifetal pregnancy. All of these correspond to a higher both fetal and maternal mortality and morbidity. An obstetric emergency could be defined as when the life of both or either of the fetus and mother is at risk (Cunningham et al., 2018). According to the Citizens Coalition for the Decriminalization of Abortion (la Agrupación Ciudadana de la Despenalización del Aborto) (2014) the majority of women prosecuted and condemned in El Salvador for late pregnancy outcomes have had out-of-hospital (OOH) births, many of them preterm and therefore focus will be on these in this chapter.

OOH births could be classified as planned or unplanned and are to consider obstetric emergencies if they are unplanned, especially if not managed or inadequately managed by health care professionals (trained nurse, midwife or physician). Risk factors are living in rural areas with poor communications to health centers, low socioeconomical level and multipara (Fernández Domínguez et al., 2015). Socioeconomical factors associated are single motherhood, maternal unemployment and low education (Lima et al., 2018). Unplanned OOH births are by international study reports considered associated with increased both maternal and neonatal mortality and morbidity (Flanagan et al., 2017). Lima et al. (2018) states examples of neonatal complications which include asphyxia, hypothermia, problems related to the umbilical cord or placenta, higher admission rates to neonatal intensive care unit and, as already described, higher mortality rates.

A preterm or premature birth is defined as a neonate being born before gestational week 37+0 and could also further be subdivided according to gestational age. Being born preterm is associated with higher mortality and morbidity, mostly because of organ system immaturity. Over the last decades premature neonatal survival has increased drastically if access to the new technology and health care (Cunningham et al., 2018).

Globally, 99% of all neonatal deaths occur in low- or middle-income countries and the main causes for these are preterm births (28%), severe infections (26%) or asphyxia (23%), with the highest risk of death being on the first day in life (Lawn et al., 2005). WHO estimated that year 2015 approximately 2,7 million newborns died and also that 2,6 million were stillborn. Neonatal and maternal health is closely linked (WHO/Maternal Mortality, 2018).

1.3. Maternal Health Problems Globally and in Latin America WHO estimates that around 830 women die daily due to pregnancy or childbirth related causes and that 99% of these occur in developing countries. Further on, the most vulnerable are women living in rural and poor communities as they are at most risk for not be given the needed health and prenatal care, and especially adolescents under 15 years are at the highest risk for maternal mortality. The major reasons for maternal death globally are severe bleeding (usually post-partum), sepsis (ditto), hypertensive disorders, obstructed labor and unsafe abortion. Most of these deaths are preventable if the woman would be given adequate health care. WHO states that to prevent maternal deaths, it is of great importance for women to have access to the health care and to prevent too early and unwanted pregnancies and for all women to have access to safe abortion and post-abortion care (WHO/Maternal Mortality, 2018).

In the majority of countries in Latin America, maternal health is still a matter. Maternal death has declined by 40% on an average since 1990 to 2013 (compare to in El Salvador the decline was 39% and globally the decline was 45%). In Latin America the maternal mortality ratio is 85 deaths of 100 000 live births, and this average is considered to be low among developing countries globally. However, in the region year 2013 still over 9000 women lost their lives due to pregnancy related reasons. Considering the developments made since 1990, little progress has been made preventing maternal deaths, abortions and adolescent pregnancies (which many are results of non-consensual sex) (PAHO, 2014).

Globally, it is estimated that it is as frequent to undergo an induced abortion in a country with the most restrictive laws as in one with the most liberal laws, the only difference being the access and safety level of it. In Latin America, only 1 of 4 induced abortions are categorized as safe, though the majority are categorized as less safe (because it nowadays is more common to obtain misoprostol outside the health care system, rather than as earlier using invasive methods) (Ganatra et al., 2017). However, all unsafe abortions are associated with higher mortality and morbidity (Calvert et al., 2018) and since the Cairo ICPD 1994, they have been recognized as such. Postabortion and obstetric emergency care are considered to save women’s lives. According to the Guttmacher Institute, 26 countries worldwide prohibit induced abortion altogether. Six of these are in Latin America and the Caribbean; the Dominican Republic, Haiti, Honduras, Nicaragua, Suriname and El Salvador (Singh et al., 2018). In 2014, at least 10% of the deaths in the region were related to unsafe abortion and approximately 760 000 were treated for abortion complications (Guttmacher Institute, 2018). A recently published systematic review concluded that in settings where induced abortion is limited,

at least 9% of the abortion-related hospital admissions are of near-miss character and that 1,5% ends with death. The morbidities include hemorrhage, sepsis, injuries and anemia (Calvert et al., 2018).

In El Salvador, between 2011 and 2015, 63 women died because they were not given treatment because of the risk of the fetus, 13 died from ectopic pregnancies and 14 died from complications of abortion (Sperber, 2018).

1.4. The El Salvadorian Context El Salvador is the smallest but most densely populated country in Central America with its 6,3 million people. Approximately 65% live in urban areas (of which around a third live in slum areas) and 40% are under 18 years old. Spanish is the official language and almost 90% know how to read and write (the majority of these live in urban settings). 50% belong to the Catholic belief, a third belong to Evangelical or other protestant fraternities and the rest are non-believers. As many other Latin American countries, El Salvador was colonized by the Spanish Crown and after the liberation 1821 the economy was dominated by a few oligarchs which created big tensions. The tensions finally resulted in a state coup 1979 which became the start of the civil war that lasted until 1992. On one side there was the military supported by the United States (US) and on the other the Frente Farabundo Martí para la Liberación Nacional (the National Liberation Front Farabundo Martí; FMLN) guerrillas (after the civil war it transitioned to a political party). 75 000 people died and one million fled. Afterwards the emigrations continued, and the El Salvadorian diaspora is estimated to almost 3 million people, with the vast majority living in the US. It was during the 1980s in Los Angeles, the US, that the gangs arose and in the 1990s when the immigrants got deported back, they also brought the gang structures. Today around 600 000 form part of the rivaling gangs Mara Salvatrucha 13 (MS 13) and Barrio 18 and deadly violence and criminality is part of today’s society, especially for the poor people. Today 70% have informal jobs and the economical gaps are wide, poverty is widespread especially in rural settings where 60% are estimated poor. These factors contribute to the gang recruitment (Lindahl, 2014).

Concerning the health care system, it is divided into public, private and seguro social. The public health care is free of charge for the patient and includes both prenatal controls and contraceptive methods. The private health care is payed for by the patient (Política Nacional de Salud 2015-2019, 2016). A third form of health care is the seguro social, meaning that the employee receives a health insurance from work (Instituto Salvadoreño del Seguro Social, 2010).

1.4.1. Legal and Ethical Aspects and the Role of the Physician Until 1998 induced abortion in El Salvador was allowed on the grounds of that the woman’s life was at risk, if the pregnancy was result of rape or if the fetus had a non-viable anomaly. Induced abortion became totally prohibited after the organization Si a la Vida (Yes to Life) sent in a formal request to the legislative assembly, being dominated by the conservative party Alianza Republicana Nacionalista (the Republic Nationalist Alliance; ARENA), that voted in favor of it. The prison sentence was decided for the woman to be 2-8 years and 6-12 years for the physician performing it. The same year the general assembly also amended the constitution so that it states that human life begins with conception, after that an archbishop sent a letter urging it (Viterna and Bautista, 2017). Although induced abortion is totally prohibited, some health care providers do perform them clandestinely either medically or surgically. To access one, one must know who to ask and in some cases have the economical possibility to pay for one (Sperber, 2018).

El Salvador is not the only country prosecuting against women undergoing induced abortions, however the country is extreme in the sense that it also prosecutes against other pregnancy outcomes such as spontaneous abortions and other later obstetric emergencies with pregnancy loss and that the women for this can be prosecuted for aggravated homicide, with the prison sentence of 40 years (Zureick et al., 2018). In 2016, the congresswoman Lorena Peña from the leftist party FMLN declared the necessity of decriminalizing induced abortion on four grounds: 1) if the pregnancy is life threatening for the woman 2) if the fetus has a non-viable malformation 3) if the pregnancy is the result of a sexual violation or incest and 4) on socioeconomical grounds (El Diario de Hoy, 2018). As a response to this, the congressman Velásquez Parker of the conservative party ARENA made a proposition of changing the prison sentence for induced abortion as to a maximum of 50 years (ARENA, 2016).

Furthermore, the criminal law requires health care professionals to report suspected crimes or might otherwise be subject of prosecution themselves. However, this goes against the medical ethics about protecting the patients’ confidentiality sprung out of the Hippocratic oath. In El Salvador this is known as the Professional Secret (el Secreto Profesional) that is regulated in both the penal and health code, and if violated implies the sentence of fine, suspension of medical license or imprisonment with a maximum of two years. Concerning reporting suspected crimes, the penal code actually values the maintaining of the patient’s confidentiality and states that information received through the breaking of confidentiality is invalid for legal purposes. But due to that induced abortion is prohibited and that information about the law change was sent out to public hospitals after the voting 1998, many may be more aware of that side (Zureick et al., 2018).

From a survey McNaughton et al. (2006) sent out to obstetrician-gynecologists in El Salvador, 80% reported that they thought they legally had to report suspected induced abortions and 56% reported that they had been taken part in announcing patients (results indicating that it was more likely in public setting), whereas only 23% were aware of that the Professional Secret means the obligation of protecting confidential patient information. The main reasons for reporting patients were fear of being accused themselves, moral and religious believes or believed legal or ethical responsibilities. Almost 90% of the respondents believed that women delayed in seeking health care due these circumstances. Between 1998 and 2003 the number of women needing blood transfusion as postabortion care doubled, indicating that the abortion-related morbidity increased after the law change. Sperber (2018) reports in The Lancet about obstetrician-gynecologists in El Salvador announcing that pregnant women could be undertreated due to their underprioritizing of the unborn and give the example of cancer treatment that sometimes is not provided for the woman.

Since before 1998 it was by far not as common to be prosecuted for either illegal induced abortion nor aggravated homicide of newborn. Viterna and Bautista (2017) aims to explain the factors leading up to today’s circumstances claiming that there are four key parts for understanding why women were and are faced with the sentence of aggravated homicide even when losing a pregnancy they wished to keep. First, the mighty movement against induced abortion benefited from the turbulent post-civil war time, providing the space for new groups to advocate their ideologies. It also piggybacked on the already established political and Catholic structures and believes making it a rapid mobilization. Second, the coherent decision of the induced abortion rights movements to disengage in the political scene and debate between 1999-2007 due to the political climate (later, in 2009 the Citizens Coalition for the Decriminalization of Abortion was founded). Third, the language used in the discourse was possible to influence towards increased prosecutions. For example, the sliding from using terms describing obstetric emergencies such as OOH pit latrine births towards ”aggravated homicide”. Media, including the biggest newspaper el Diario de Hoy (Today’s News), began to cover the theme with this new language. Fourth, the extreme rate of criminal violence from gangs that put great pressure on the legal system combined with both that the attorneys face quotas on how much they must proceed monthly and that the gang members could make serious threats of violence. This situation could create an incentive for the attorneys to rather pursue cases against women accused of undergoing abortions, as they are not connected to powerful gang members. What is more, these women often lack the resources to pay for a defense attorney, which makes the conviction more likely.

1.4.2. The Patients and Prosecuted Women When the Citizens Coalition for the Decriminalization of Abortion got engaged, they found 17 women imprisoned for aggravated homicide and 2014 decided to launch the campaign Las 17 (The 17). These women have in common that they come from poor socioeconomical conditions, are poorly educated and with deficient access to health care. The organization is also working for the decriminalization of induced abortion on the four grounds presented in 1.4.1. (La Agrupación Ciudadana de la Despenalización del Aborto, 2014). CID-Gallup and the Non-Governmental Organization (NGO) la Colectiva Feminista (the Feminist Collective) (2017) made a survey investigating the public opinion and found that a majority was in favor of a law-change in the first two induced abortion grounds (if the pregnancy is life threatening for the woman or if the fetus has a non-viable malformation) and that the health care should offer the necessary treatment to save women’s lives. Also, two out of three considered it unfair to investigate an obstetric emergency criminally.

From 1998 to 2014, 74 women were prosecuted for induced abortions and 23 were found guilty. From 1998 to 2016, 75 women were prosecuted for aggravated homicide of their newborn, and 34 were convicted. Some of the women convicted for the latter were in the first place prosecuted for induced abortion. In comparison to the prison sentences gang members usually face, these women were generally given two to three times longer prison sentences because they were convicted for aggravated homicide due to the parental relationship (Viterna and Bautista, 2017). When this report is written, 26 women are incarcerated due to obstetric emergencies (La Agrupación Ciudadana de la Despenalización del Aborto, 2018).

One of the women who has been convicted for aggravated homicide of her newborn is María Teresa Rivera, whose case is presented in Attachment 2. After having spent more than four years in prison, she got help from the Citizens Coalition for the Decriminalization of Abortion with defense attorneys who could prove that the proof used in trial was inadequate, after which she was granted an asylum in Sweden – a unique decision claiming she was discriminated by the state of El Salvador (Halkjaer, 2017). For example, the judge had stated that the baby had died from perinatal asphyxia and that it means “[…]la agresión producida al recién nacido […]” (“an aggression produced against the newly born”) which could be claimed a definition of unknown origin and therefore not valid (Lic Muñoz Rosa, 2014).

When this report is written, 20 years old Imelda Isabel Cortez Palacios just got released from prison, having been charged with aggravated homicide to a tentative degree with the prison sentence of 20

years (Redacción BBC News Mundo, 2018). She comes from a rural district in east El Salvador, lives under poor circumstances and has a mild mental retardation. Since the age of 12 she has been sexually violated by her now 70 years old stepfather and as a result of this got pregnant at the age of 18 years. Not fully aware of the pregnancy, in April 2017 she gave birth in the pit latrine outside the house, after which she became unconscious. Her daughter survived, which is the reason for that she got accused of aggravated homicide to a tentative degree (La Agrupación Ciudadana de la Despenalización del Aborto, 2018). Her conviction was postponed eight times due to similar reasons – the last time in November 2018, when 1,5 hours after the trial was supposed to start it was announced that the attorney had a cold and therefore could not attend (The Court Hearing of Imelda Isabel Cortez Palacios, 2018). In December 2018, after having spent more than 1,5 years in prison awaiting her sentence, while her daughter have been under custody of her grandmother, the prosecutors retracted and requested to change the classification of the crime to “causing damage trough abandonment and distress to a person minor of age” with the prison sentence of one year, which she had already served (Redacción BBC News Mundo, 2018). Although the paternity of the stepfather is proven with DNA the attorneys had him arrested first about a year after Cortez Palacios got arrested, and this after that organizations working with her urged it (La Agrupación Ciudadana de la Despenalización del Aborto, 2018).

1.5. Theoretical Framework: Reproductive Governance As theoretical framework for this report I will use Morgan and Robert’s (2012) concept of reproductive governance which was developed with Latin America as reference. It could be understood as a theory deciphering the mechanisms through which actors – for example the state, religious, and economical institutions, NGOs and social and activist movements – use different sorts of tools to control, monitor and guide the population in regard of reproductive behavior. The tools could be for example using legislative controls, punishments of different kinds, economic incentives, lobbying, moral injunctions and ethical motives. The actors do not seldom collaborate, for example the Catholic Church – and especially the organization Opus Dei – are pointed out by Morgan and Roberts as influential politically.

The discourse is usually set around the concept of moral beliefs versus different “rights” that all sorts of actors could claim. Moral regimes are often described in contrast of what the actor claims being immoral, irrational and wrong. The rights do not rarely oppose each other – for example the woman’s right to her own body and the unborn’s right to life. “Human rights” are in Latin America understood as a more collective concept, and not only to individuals, especially in countries having suffered traumatic civil wars. Moreover, the concept of “natural rights” is common in Latin

America, and implies divinely given rights – trumping all other sorts of rights, laws, ethical principles etc. The unborn’s right to life could be considered a such.

Moreover, Morgan and Roberts discuss the aspect of when an actor could consider different groups have different rights. They present the example of Nicaraguan migrants giving birth in Costa Rica, as they are more likely to become candidates to sterilization at the same time as the Costa Rican nationalists make worrying statements of the fertility decline. The sterilizations have been reported as reasonable by newspapers. Worth noting is the Catholic Church’s strong influence over the nation and its position of being against sterilization. Also, the migrant woman is often portrayed having an exploiting character of her refugee home state at the same time as the unborn is considered to have the rights as a full citizen (however, not on paper).

In conclusion, the concept allows for the exploration and understanding of reproduction as something not merely private and biological, but the opposite, as a phenomenon directly intertwined with structural, systemic and societal (including economical) factors which openly or occultly govern it. Moreover, it allows for the investigation of different groups’ perceptions of rights and when the rights sometimes are clashing.

1.6. Objective and Questions at Issue Understood by previous research are the mechanisms leading up to today’s legislation and context, including the precarious role of the physicians working within this field in El Salvador, having to consider contradictory laws and ethical principles while providing (or not) sometimes life-saving health care to their patients who could be prosecuted for their pregnancy related problems. Naturally, the obstetrician-gynecologists are the physicians most often seeing these cases. The circumstances regarding abortion and obstetric emergencies in El Salvador are extraordinary, which makes investigating this field suitable for understanding how non-medical and -biological factors influence on the clinical management.

The objective of this report was to gain deeper understanding and knowledge about the influencing factors and the obstetrician-gynecologists’ experiences and reflections on clinically managing cases with abortion and obstetric emergency with pregnancy loss, from two specific questions at issue:

1. What structural, systemic or societal factors influence on the clinical management of women, adolescents and girls with abortion or obstetric emergency with pregnancy loss? How do the factors influence on the management?

2. What are the obstetrician-gynecologists’ experiences and reflections on the clinical management of women, adolescents and girls with abortion or obstetric emergency with pregnancy loss? How do they weigh the influencing factors and the different rights against each other?

2. Material and Methods 2.1. Medical Humanities The study is interdisciplinary and lies within the field of medical humanities. According to Cole et al. (2014) medical humanities is a field that explores human experiences, contexts and critical and conceptual issues in medicine and health care. Since medicine and health care always involve humans and therefore the stated factors, it is of great importance to understand them. Clinical medicine, health and illness, cannot be fully understood by biomedical means – it needs to be addressed also by its context made up of historical, social, cultural, political, psychological and economic characteristics. Hence, medical humanities can be understood as a bridge between these subjects.

I consider this being of great importance especially for the medical responsible physician when treating cases of delicate character, such as abortion and obstetric emergencies. And maybe even more so when the cultural context, such as in El Salvador, have these cases in the target line for diverse opinions by different actors. Since these cases, apart from their medical and biological character, are affected by the mentioned characteristics (i.e. regulated by laws and ethics which in themselves are products of a these factors, and are dependent on the physician’s perceptions, believes and conceptions) it is essential for the responsible physician to be aware of these non- medical and -biological factors in order to fully understand both the patient and the case at the time when providing health care.

2.2. Study Design Since the objective of the study was to gain deeper understanding of a complex and interdisciplinary topic a qualitative approach was chosen. This approach is focused on human experiences with a holistic approach (Kvale and Brinkmann, 2014). The aim with the study design was to obtain detailed and deep perspectives on the questions at issue and how it was done is presented below.

2.2.1. Selection: Purposive and Snowball Sampling The study was based on interviews with five specialized obstetrician-gynecologists working in San Salvador, who were selected based on purposive and snowball sampling, which have the aim to give the data with both width and depth, so that the questions at issue can be answered. Purposive sampling focuses on specific attributes of the chosen informants, for example that they have knowledge about the inquired topic (Malterud, 1998). Snowball sampling (sometimes referred to as chain or referral sampling) aims to find more informants within the same field of interest through

recommendation from an initial informant, which is useful when studying a limited (sub)group (Beins, 2017).

The participants of the study were recruited through e-mail, WhatsApp or personal encounter. Three of the informants were found based on purposive sampling and two from snowball sampling. Initially an information sheet (see Attachment 1) was sent to the participants, in order for them to make an informed consent on participating in the study or not.

2.2.2. The Informants All of the informants had been educated in San Salvador. The medicine program lasts eight years, of which the last consists of working in a rural hospital (servicio social) (UES, 1992). After graduation, the specialization consists of working in a public hospital under supervision for three years (UES, 2015). They had been serving as specialized obstetrician-gynecologists between 5 to 23 years, with a mean of 13,5 years. As specialized, one had most experience from working in private setting, two from both public and private, one from private and seguro social and one from public and seguro social. They were of the ages between 38 to 53 years old. Four were women and one was a man. All reported themselves to belong to the Catholic belief.

2.2.3. The Interview Guide and In-Depth Interviews Since the questions at issue focused on narrowly defined but complex topics, the method of in-depth interviews was chosen (Kvale and Brinkmann, 2014). The data was collected with the help of a semi-structured interview guide (see Attachment 2) inspired by Brounéus (2011). It includes a prepared set of questions that the informants will be asked but depending on the answers of each informant the interview will take different paths. After following a such, the researcher will lead the interview back to the prepared questions. Thus, this method provides both a core and a flexibility. It is built up by several steps in order to develop both the themes and the trust between the researcher and the informant. The questions were put together after having considered the previous research and the theoretical framework, for example with the aim to try to decipher what values (such as legal perceptions, moral beliefs and different rights) were prioritized by the informants in different situations and cases of abortions and obstetric emergencies. It became clear when reading background literature and previous research, that the interview guide would benefit from including a wide range of questions, as it is a complex topic needed to be understood in its context. Due to the sensitive topics, the questions were explorative and asked as open-ended as possible, with the aim of making the informant able to choose how thoroughly to answer.

For the case presented in the interview guide, the researcher had interviewed María Teresa Rivera (who got convicted for aggravated homicide of her newborn), also using an interview guide (see Attachment 3) and in-depth interview technique. The interview was conducted in Sweden, where she now resides, before the other interviews. María Teresa Rivera chose the location on beforehand.

The role of the researcher is to be an active listener, using interview techniques such as follow-up questions and reflective listening when wanting to investigate further and deeper, and not, when it is time to close the spoken topic (Brounéus, 2011). The interviews were recorded with the program Röstmemon on the researchers iPhone SE and notes were taken when considered to be helpful.

In order to internally validate the questions in the interview guide, the researcher first confirmed them with the supervisors, then consulted the postdoctoral researcher Hanna Mühlrad at the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet who has been conducting research within the same field in Mexico, after which three Salvadorians who have been working with SRHR were asked to give feedback on the questions. Lastly, a pilot interview was conducted with two Spanish speaking students. In this procedure, the questions were continuously reshaped in order for them to give more complete answers to the research questions.

Further on, the interviews were conducted after time and place had been decided on beforehand. Important was that the informants would feel safe to speak freely about these topics that could be considered sensitive, and therefore each informant was free to choose (Brounéus, 2011). Four of the interviews were held in the informants’ respective private clinic and one in an organization house. Before starting each interview, the informants received both written and spoken information about the study after which a written informed consent was obtained (see Attachment 1). Spanish was the used language for the interviews. The length of the interviews lasted between 1 hour and 5 minutes to 1 hour and 52 minutes, with a mean of 1 hour and 22 minutes. One interview was conducted over two days due to the informant’s work load. One interview exceeded 1 and a half hours, but this was commented on during by the researcher and the informant decided to continue with the interview. All informants were after each interview given a typical Swedish gift, of which they did not know of on beforehand.

2.3. Transcription All interviews were transcribed word for word, three of them with the program ExpressScribe and two with the program Transcribe!. Wordless communication, such as gestures and reactions, was transcribed within parenthesis when considered to contribute to the understanding. Emphasized

words or phrases were also pointed out with the help of parenthesis. During the transcription all identifying material was excluded. The transcription was made directly after each interview in order for the researcher to remember also the wordless communication and the emphasized words or phrases. In the case of when a spoken word was blurred, the researcher asked a Spanish speaking friend to identify only this word. This was the case with two words. In the case of that the researcher did not know the word, it was looked up in the dictionary. This was the case with thirty words. Totally, 43 779 words were transcribed. After each transcription the audio file was deleted.

2.4. Thematic Analysis The transcribed data was analyzed by the researcher with the help of thematic analysis (TA) according to Braun and Clarke (Rohleder and Lyons, 2014). This method was chosen because it was considered to enable the researcher to answer the questions at issue; to find themes (patterns) in both the influencing factors and the informants’ experiences and reflections on clinically managing abortions and obstetric emergencies with pregnancy loss. Furthermore, it was considered a suitable method according to the deductive approach chosen for the research as it enabled for analyzing with the guidance of the theoretical preunderstanding and theoretical framework of reproductive governance. The guide line for Braun and Clarke’s TA includes a six-phase process for systematically identifying themes across the transcribed material: 1) Familiarization with the data 2) coding the data 3) searching the themes 4) reviewing themes 5) defining and naming themes 6) producing the report.

The analysis process was initiated after all the interviews were conducted and transcribed. The familiarization with the data was made reading through the transcribed material several times in order to both get the general picture but also to notice the details. The data was coded semantically (overt) to perceive meaningful content. Despite the sensitive research topics, the researcher found that the informants could talk openly (which is necessary for the semantic coding); in each interview the informants honestly and spontaneously brought up that they despite the sensitive research topics felt that they could speak completely free. The analysis was made with the help of MAXQDA, a software package for coding. All data was coded (even the data that in the beginning was uncertain to contribute to answer the questions at issue) and it was made by labeling the data by descriptive or interpreted keywords or phrases. After all the data was coded, the process of searching for themes was initiated; the codes that seemed to suit well together were put into the same theme. This process generated themes to the questions at issue. In the next step all themes were reviewed to confirm that the material was congruent to the theme and that they were balanced. When the material was not congruent, it was either moved to a better fitting theme or excluded. All transcribed interviews were

re-read to make sure that the themes fitted the overall content told in the interviews. The review led to that the final themes took form, which then were defined and given names to represent its content. Finally, the result was presented with descriptions of each theme. The whole analytical process was made in Spanish. In the cases quotes were used in order to illustrate the content of the theme they were translated to English by the researcher.

2.5. Ethical Considerations The study was conducted according to the Swedish Research Council’s Good Research Practice (2017) and its eight general rules were followed at all time. As this is a student project, no ethical approval was applied for (Svenska Vetenskapsrådet/Humanistisk och samhällsvetenskaplig forskning, 2018). This does by no means imply that ethical considerations have not been taken seriously. When conducting research involving humans it is of outmost importance to consider ethical issues actively and throughout the whole process, and risk/benefit analysis must be carried out as to consider the value of the obtained new knowledge contra the risk of the informants participating. In this study this was especially important due to the sensitive character of the research topic and the illegality of induced abortions in El Salvador, which also could make the informants targets of suspicion and maybe even legal announcement if some of the information obtained were to be connected to the informant. Therefore the following important principles were followed: informed consent, de-identifying and confidentiality (Swedish Research Council, 2017). The informed consent was obtained through letting the informants get both spoken and written information (the information sheet, see Attachment 1) both before deciding on participating or not, and before the interview. The information sheet was put together based on the Swedish Research Council’s guide lines of what an information sheet should include (Svenska Vetenskapsrådet/Informerat samtycke, 2018). A written consent was obtained before the interview and stored at a safe place at the researcher’s home. De-identifying was obtained through eliminating all personal identifying information when transcribing, which was made directly after each interview. After the transcription, the audio file was deleted immediately due to that the informants should not be traceable. Confidentiality was obtained through that only the researcher handled the data. In the case of when a spoken word was blurred, the researcher asked a Spanish speaking friend to identify only this word (which was the case with two words).

Another important aspect to consider is balances of power. In this case, all informants were already specialized obstetrician-gynecologists with no attachment to the researcher nor in economical need. Since they were all native Spanish speakers and the questions were aimed to be open-ended one can also argue that they had the opportunity to choose how thoroughly to answer. No economical

compensation was carried out and the typical Swedish gift given afterwards was not mentioned on beforehand.

Concerning the use of María Teresa Rivera’s case, a written informed consent (see Attachment 1) was obtained. Further on, she is nowadays a public person and activist who has been telling her story publicly multiple times worldwide. Her name was not used during the interviews.

2.6. The Researchers Preunderstanding The topic was chosen due to the researcher’s interest in the field as being a medical topic as well as it needs to be understood in its sociological context. It was found interesting how established medical phenomenon (spontaneous abortions and obstetric emergencies) in the El Salvadorian context could be viewed as crimes, rather than situations of medical emergencies, and from this how the woman could be seen as a perpetrator rather than a patient suffering from losing her baby. As the researcher wants to specialize in the field of obstetrics-gynecology, and the physician – usually the obstetrician-gynecologist – is the medical responsible in these situations, it was found interesting to understand how obstetrician-gynecologists in El Salvador navigate within the complex context when treating the patient, as well as understanding the influencing factors behind.

Prior to the study, the researcher had theoretical knowledge on obstetrics-gynecology as well as practical experience from medical clinical rotations both in Sweden and Uganda. Clinical rotations within other medical fields in Spain have contributed to the ability to discuss medical topics in Spanish. The researcher had also taken university courses in History of Science and Ideas as well as Latin American studies both in Sweden and in Spain. Prior to the study, time had also been spent in El Salvador and Latin America, which contributed to the societal preunderstanding. Moreover, the researcher had followed the topic through media the last eight years.

2.7. Concepts In the interviews the informants used the terms mujer (woman), adolecente (adolescent) and niña (girl) and according to the context it was possible to understand whether or not it meant female as general, or when being specified as to age. In the report I have chosen to use woman as describing generally a female and when presenting data on minors the terms adolescent or girl depending on the age referred to.

Regarding abortions, if not specified which type, all types are included in the concept.

Concerning the terms obstetrician-gynecologist and physician, since all sorts of physicians could be the responsible medical in the cases the term is used when not specified in regards of specialization.

3. Results The objective of this report was to gain deeper understanding and knowledge about the influencing factors and the obstetrician-gynecologists’ experiences and reflections on clinically managing cases with abortion and obstetric emergency with pregnancy loss, from two specific questions at issue presented at 1.6. The thematic analysis was deductive and guided by the theoretical preunderstanding and Morgan and Roberts (2012) theoretical framework of reproductive governance. The result is presented with the help of describing images of the themes under each of the questions at issue. In some cases, quotes have been used to illustrate the informants’ point of view.

3.1. The Influencing Factors and How They Influence

3.1.1. Ethical Principles and Conflicting Laws The informants reported that the law regulating induced abortion makes no exception as long as there is fetal heart rate, even in therapeutic situations. Further on, they reported that the law regulating that health care professionals have to report suspected crimes goes against the law of the Professional Secret. Two informants claimed that the total ban of induced abortion was made during one night in 1998, after lobbying from a pro-life Christian group. Since the same year, the constitution also established that life begins with the fertilization, and could therefore be understood as the fetus has equal right to life as the mother. The laws and medical ethics are taught at the medicine program, but the informants disagreed on the quality of this.

There is also an ethical committee at the hospitals which is for evaluating difficult cases. But even though it in some cases have come to the conclusion to be in favor of a therapeutic abortion it could not be performed due to the legislation and there are cases when both the woman and fetus have died: ”In this country they prefer to sacrifice the two. Because they prefer that the mother dies, although the baby won’t live without its mother” [Informant 4].

The medical ethics about doing no harm was reported by some informants, and that the role of the physician was to help and not judge. The informants reported different ways to achieve this; all described giving best medical care and four described trying to minimize the risk for the patient to be reported. On the first aspect, one informant brought up the perspective of when a referral to a more advanced hospital was needed (which could be the case after an unsafe abortion or when there is an obstetric emergency), it would be unethical not to refer, and by referring it is necessary to report the patient to Medicina Legal (Legal Medicine Department) – i.e. report the suspected crime.

The informant described such a case, when a girl from a rural department came in septic after had gotten help performing an unsafe abortion with a Folley catheter; ”These are things you cannot let pass because afterwards there will be consequences, and therefore I had to declare it. Why? Because I did the referral. I did the referral to the public hospital, because the girl could not stay in the private hospital.” [Informant 1]. Although, another informant commented on supposedly the same case, saying that the right thing would have been to simply attend her without announcing. A third informant mentioned that the pressure to announce probably is bigger in public setting. Several informants also described how they teach the patients to defend themselves against some of the health care providers that would try to ask questions as if trying to find proof of that the patient actually purposely ended the pregnancy.

Concerning performing voluntary abortions, the informants had different views on it ethically. One was that if the physician were to be reported to have performed an abortion this would be unethical to the other patients as the physician could go to jail and lose the medical license, and therefore not be able to continue to take care his or her other patients. The ethical and moral aspect of not giving the fetus its right to life was brought up as the most valid argument by those more against induced abortion. As contradictory to that, the argument that it would be unethical not to perform an induced abortion was brought up, as the woman otherwise would have to search an unsafe abortion and therefore it would lie within the ethics to perform it (at least in the cases of the therapeutic ones, but also otherwise as the woman would have her reason to ask for one). One informant reported that she prioritized this view on ethics and therefore performed medically induced abortions until around week 18.

Women who have an abortion could be considered to murder their baby, especially if the pregnancy loss is late in the pregnancy. The informants reported various reasons for why an induced or late spontaneous abortion or obstetric emergency with pregnancy loss could be considered a homicide; that the constitution states that the life begins at conception (and therefore all (believed) intentional pregnancy endings are homicides or murders according to the legislative system), that they 28

themselves did not have the legal expertise to understand why, or that it was because of cultural and macho (misogynist) reasons. One informant believed that if the pregnancy would have been something occurring to men, this situation would have been utterly different and reflects on the situations when the woman’s life is at risk; ” I believe that the machismo has turned the women into victims of so many things, and among these: condemned to die just because this is something occurring to them.” [Informant 2]. Another informant reflects on the injustice in comparison to the sentence a violator could get:

They could get condemned, but the prison time for them is 5-8 years, I think, or 8-10 years […]. Meanwhile, for a woman accused and condemned for aggravated homicide it is up to 40 years. Yes. For a pregnancy outcome. These are the things… unfair. Within our law alright. Because of the machinist culture we have. And I believe also because of ignorance. [Informant 3]

Another important aspect is that there is another contradiction between laws in how to manage minors. The law protecting minors (implemented in 2012) concludes that they should be able to search health care without legal guardian, although many physicians still ask for the presence of one. This was reported to create a bigger problem within the field of SRH as it was described as taboo.

Lastly, the illegality of induced abortion was mentioned to affect that the patients in cases of spontaneous and self-induced abortions, and obstetric emergencies did not dare to give a true medical history, which could contribute to that the health care provided could be of less quality.

3.1.2. The Catholic Church All informants reported themselves to belong to the Catholic belief, and in comparison to the Evangelical Church the view on life and abortion was reported to be the same. The El Salvadorian society was described to be extremely religious, with many putting their religious beliefs and morals first. One informant gave the example of how the religion is visible in the monument ”Si a la vida” [Yes to life] in la Colonia Medica (the area where the majority of physicians have their private clinics) which was sponsored by a religious group by the same name as a statement against induced abortion. The religious group Opus Dei was by one informant pointed out to rule the religion in the country and to have a big influence in politics. One informant pointed out the need of religion in a society as violent and misogynist as the El Salvadorian. Another said that even though the country is very religious, it is not like the Vatican, but in fact a secular state.

Moreover, the Catholic Church was described to be 100% pro-life, and to consider that the life begins with the fertilization – to which some informants pointed out the discrepancy to viability. It was also reported, if interpreted radically, to be against contraceptive methods. This was pointed out as double moral by some informants, that many Catholics use and promote contraceptives. All informants emphasized the value of contraceptive methods, and the one informant putting most emphasize on contraceptives at work was one of the ones most against abortion. As for induced abortion, by some it was described that many morally consider it a sin and a murder, but in practice may not follow this. The informants who reported themselves as more wholeheartedly catholic, considered a termination of a pregnancy as generally wrong (with the exceptions of ectopic pregnancy, non-viable malformations and when the mother’s life is at risk):

If there is a pregnancy, and you haven’t received the necessary education, I consider you have to continue. I mean, this is what I think because of my religion, that you have to continue the pregnancy. It might be different when there is a product of a violation, maybe you don’t know how many men, it could cause a trauma, then… but there is always the possibility of continuing with the pregnancy and have the baby adopted. […] About the ectopics […] why wait until there is no fetal heart beat? In these cases, the opposite, you aren’t provoking any damage and the mother could die from hemorrhage or whatever complication. [Informant 1]

The informants in favor of the four induced abortion grounds also reported themselves as being aware of how important it is to keep in mind other aspects than only the religious:

You have to clarify your values. […] If I would have been radically Catholic, I wouldn’t have sterilized and maybe I would have had 8-10 children. But my reality is different. I can’t be blind to reality. I need to make a decision and help as many as possible to make theirs. […] So, if you will have all the children God gives you, how will you maintain them? […] The risky days are the days when we want to have sex the most! Because of the hormones, it’s biochemical! [Informant 4]

3.1.3. Environment of Polarization, Judgmental Attitudes and Hierarchy Besides the total ban of induced abortion, the constitution and the strong influence of the Catholic Church that make a lot of people prioritize its moral and religions believes, some informants also brought up the fact that El Salvador is a post-civil-war country which could contribute to the radicalization: ”Here the people are full of fanaticism. And also as we are a post-war-country everything is extreme. To the left extreme or to the right extreme, in between there is nothing” [Informant 2]. These factors, together with that SRH is taboo, were reported to have created an atmosphere of polarization in the discourse about induced abortion and further on obstetric

emergencies, and also a judgmental attitude toward the patients searching for pregnancy related problems.

Some informants reported that they believe that the medical professionals should involve in the abortion and obstetric emergency discussion from a scientific-medical point of view, as it is a topic of medical importance. Although, since the medical profession in itself is very polarized, it would be hard to come to a consensus. They also reported that the polarization made it hard to talk with people with other beliefs on different levels, such as among colleagues or friends and family, which could be a reason why many do not involve:

First of all, among colleagues we are being judged, because they limit themselves to say ’these are the doctors that are in favor of induced abortion, they kill children, they are the aborters’. And they are many with that double moral, many colleagues. So that makes it hard to fight against, against people who put their personal values or their moral or religious principles first, or if they live with their double moral. That is why this is a little complicated. [Informant 3]

Further on, as a result of that the public system involves more health care professionals of different categories, it could be understood to have a more visible hierarchy, whereas in the private it is usually only the physician and the receptionist. In comparison, the public system was reported to offer less discretion and that the patient could have to wait longer before being attended. Some health care professionals were also described to sometimes treat the patients judgmentally and with a desensitized attitude after a pregnancy loss:

Culturally, if a woman comes to the hospital after an OOH birth, either with the baby alive or dead, or if she comes after a [spontaneous] abortion or with a premature birth and the baby is dying, we always judge. We always judge without knowing, we judge on beforehand, we always ask for example ’why did you not come on time? How is it possible that you didn’t know you were pregnant? Don’t tell me that you didn’t feel the baby moving?’. This is the judgmental way to ask. [Informant 3]

The hierarchy also made the most experienced physician in charge the one making the decisions, which made the health care depend on what that physician believed was the right way of treating the situation. The informants also mentioned that it generally could be challenging to be in charge over manly colleagues as a woman.

Finally, concerning to the legislative aspect, one informant claimed that personal judgments also could affect the legislative process; it is possible that as a physician in this field you could be accused

on a placed case and that the verdict in court could be more affected by the judge’s personal believes than the actual juridical proofs.

3.2. Experiences and Reflections… In this section the obstetrician-gynecologists’ experiences and reflections on the clinical management of abortion and obstetric emergency with pregnancy loss will be presented, as well as how the influencing factors and rights are weighed.

3.2.1. … Concerning Abortions The informants reported about the different types of abortion and everyone made an emphasis on the distinction between spontaneous and induced abortion due to its characteristics and the illegality of the latter. All agreed on that there is no controversy in treating the different types of spontaneous abortions, which includes taking a good medical history, doing exams including the gynecological examination with ultrasound and if needed manage with misoprostol or surgical methods. In El Salvador, misoprostol is a highly regulated medication which is accessible at public hospitals but only the private clinics with permission from el Consejo Superior de Salud Pública (the Superior Council of Public Health) or collaborating with NGOs’ promoting it.

Concerning induced abortion, the informants had different approaches on how to manage these cases. The three in favor of the discussed four induced abortion grounds had a stronger focus on the therapeutic and socio-economical perspective – that women with low education and little access were the ones most vulnerable of the total ban. Also, one informant described, many of these have little knowledge about their rights and for example might not even know when their rights are being violated:

We have cases of pregnancies by brothers, by stepdads, by the legal guardians, and the girls have seen this as something normal, something that have happened to them since they were young and a lot of times even under the understanding of the mother or grandma. That is why a lot of these girls have to live with this, because that is the deal… [Informant 3]

The two other informants wanted to see the law change so that there would be possible to end a pregnancy if it is ectopic, has a non-viable malformation or the mother’s life is at risk. In these cases, the woman’s right to life was considered greater the unborn baby’s right to life in the womb.

Otherwise the baby’s right to life was understood to trump all other arguments. They were both pro having the ethical committee individually evaluate each case. In the case of violation or incest, suggestions were having the baby adopted and give the woman therapy, and duality was shown when one informant reflected upon the possibility of an induced abortion:

I’m no-one to take away the life. If it is a violation, it is not the solution, but the solution would be to make the law harder against the violators. It is not the solution killing the baby. I say this because I haven’t lived it myself. Maybe if it was my daughter who was pregnant by a violator… then I don’t know how I would react! […] The Ethical Committee should evaluate each case. At least I… Because I don’t consider myself that open in that sense. I consider myself a little more pro-life. I believe it is because of my religion. [Informant 5]

The informants in favor of the four abortion grounds (presented in 1.4.1.) reported on that they believed that the ones against the abortion grounds would be likely to change their views on them if they would find themselves in a personal situation in need for one.

The informant quoted above also argued that if the law opened up, it would be possible that minor malformations also would get approved and many with an unwanted pregnancy would come forward and say they got raped as a method of getting an induced abortion:

I know that when the law opens up, this is how it will be. It opens up a big window of opportunities! It is how it will be! Also, with the cases of violations, all girls with unwanted pregnancies could say ’They raped me’. They could report it. That is why I don’t know. Maybe because I am a little more against induced abortion. [Informant 5]

Although reporting on the non-controversy on the spontaneous abortions, it became clear that patients could be suspected of having induced the abortion due to circumstances such as from the patient history or if finding traces in the vagina. In these situations the informants chose to handle the situations differently; one kept to the law and reported the more visible cases, whereas the others thought the correct thing to do was to provide the necessary health care, as it could be understood as a right, and simply to help and not judge: ”My mission is to attend and help her, not make her go to prison” [Informant 2].

All informants agreed on that there is a possibility for El Salvadorian women to get an induced abortion, at least if you have the resources to pay for one. Socioeconomically wealthier women were reported to have better access to clinics performing induced abortions either within or outside the country and were also reported to have access to buy misoprostol from the black market. Informant 5, working in private setting and reported more against induced abortion described that if a patient requested an abortion, she would not perform it, but she would orientate the patient as to understand the risks of the different methods there are;

And obviously, finally, they are not stupid, they make the best decision alright. But, maybe I am a little more open in my explanation, there are also physicians who simply say ’Don’t come here and talk about [induced] abortions, you have no right to abort, it is illegal, get out of my clinic!’ [Informant 5]

3.2.2. … Concerning Obstetric Emergency with Pregnancy Loss The informants reported that concerning the obstetric emergency with pregnancy loss, it is important to keep in mind the differential diagnoses and risk factors that can cause it and that in El Salvador unplanned OOH births are rather common, and that they may be premature or at term. There is no specific protocol to be followed and they could cause higher mortality and morbidity. On paper, all women (and citizen in general) have the equal right to adequate health care.

In the case presented, all informants believed it to have been treated non-adequate, and many also pointed out the fact that no one detected the pregnancy during the spring when the woman repeatedly searched the health care for stomach pains. Further on, one informant also reflected in a wider sense on how this impacts the patients in reproductive age searching for pregnancy related problems:

You had the opportunity to talk to a victim. A victim of the system. Imagine why, she went to the hospital and they did not detect the pregnancy? No, because she didn’t go to the place where they handle pregnancies. […] We do harm without meaning to! […] We are putting our reproductive age at risk! [Informant 4]

The informants further commented on the case, that when the labor started and the woman felt the urge to push or defecate, it could be considered normal to go to the bathroom if unaware of the pregnancy. Reflections concerning why the non-adequate treatment after the unplanned OOH birth include that it could be because of the judgmental attitude of the professionals, the excessive work load especially at the public sector and the fear of being accused by the law.

The informants reported that there are cases when the woman does not know that she is pregnant, for example if she is overweight, or has irregular and anovulatory menstrual cycles or due to 34

psychological reasons. One informant showed duality towards the possibility to go through a pregnancy unaware of it:

In [for example] obese people it could occur unnoticed, but at the same time the women should be able to sense the fetal movements. As a woman, I feel this is something you know. But yes, it has happened, I’ve seen nurses in these situations, that understood very late that they were pregnant. [Informant 1]

Another important fact to take into consideration is that the woman might not prioritize herself and her health due to that in the El Salvadorian society the woman is traditionally and still usually the one with the whole responsibility of the household.

The informants reported a constant awareness of the law requiring announcing the patient when managing obstetric emergencies, as if many considered it possible that the woman purposely had caused the pregnancy loss, even if the patient gave the history of it being an emergency. This due to the suspicious and judgmental environment. It was reported to cause a lot of stress both at work and sometimes afterwards, as they both care about their patients and are living with the threat of being reported only by managing an obstetric emergency case. Another element bringing more stress is when working with gang members or theirs partners, who usually require a special attention and if not given that, they could make serious threats. Other colleagues were reported to not care about the patients, as if considering it rightful for them to be announced in these cases.

Other reflective aspects on the theme was that it could be very dual to work as an obstetrician- gynecologist in El Salvador as it is both painful to see these cases and rewarding to work in a field with such a big demand. To always have to have the illegality in mind is frustrating when trying to provide as good health care as possible. Informant 3 has a lot of experience of working at a public hospital and reflected on a recent case:

Recently I attended a girl about 15 years old coming in with labor pains. When I asked her ‘And the baby’s dad, how old is he?’, since it could be the case of a violation. She said she didn’t know, she didn’t know the dad. […] Finally, she told me the history only between the two of us: she was babysitting her little cousin when suddenly a grown-up man of about 22-24 years made her a visit. […] Afterwards, it became clear that this boy was on the run from another gang, but the neighborhood he entered, where he got to know the girl, belonged to this other gang. […] Afterwards, the mum told me crying […] the gang member of their neighborhood had told her ’look how tasty your daughter has become. Your next daughter will be ours’. […] It is a hell for this family. And cases like these, we see them, they are rather common. [Informant 3]

In summary, working as an obstetrician-gynecologist managing obstetric emergencies with pregnancy loss could be understood as very challenging due to different aspects. For example, the fear of the law, the excessive work load and the suspicious and judgmental environment are important factors for the understanding.

4. Discussion The result of the first question at issue showed that the main influencing factors when clinically managing cases of abortion and obstetric emergencies were the ethical principles and conflicting laws, the Catholic Church and the environment of polarization, judgmental attitudes and hierarchy. The result of the second question at issue showed that the informants manage the cases of abortion and obstetric emergencies differently based on their individual framework that is shaped by the influencing factors and their prioritization, as well as the prioritization between the woman’s rights to health care (and what they considered that to include) and the unborn’s right to life. The prioritization was done either deliberately or not and as products of both the private and work environment. Thus, the objective of the report – to gain deeper understanding and knowledge about the influencing factors and the obstetrician-gynecologists’ experiences and reflections on clinically managing cases with abortion and obstetric emergency with pregnancy loss – was succeeded.

4.1. The Circumstances of Reporting a Patient or Not Considering how to manage the patient, including if to report the patient for abortion-suspected crime, depended on the obstetrician-gynecologist’s individual framework combined with the contextual environment. How the different factors influenced became visible through the informants’ reports on their practical management and their resonating around the topics, and from this the individual frameworks could be understood. In order to decipher the individual frameworks, it was necessary to have an interdisciplinary approach, as medical humanities allows for. The clinical management (guided by the individual frameworks) was to be understood through the context of historical, cultural, societal and religious means. When thematically analyzing, the guidance of reproductive governance (Morgan and Roberts, 2012) was helpful as it allows for the understanding of reproduction and reproductive medicine as directly intertwined with structural, systemic and societal (including economical) factors which openly or occultly govern it, as well as perceptions of different groups’ different rights.

It was reported by the informants that some obstetrician-gynecologists actively go against the law of induced abortion being illegal and even provides it as to reduce maternal morbidity and mortality (WHO/Maternal Mortality, 2018) and also claims the ethical arguments and the Professional Secret to trump the law of reporting a suspected crime. The physician could try to minimize the impact of the patient, both medically and legally, and this was done by the informants claiming to have as their main aim to help and not judge their patients as they understood that she might have tried to choose the best solution for herself in the difficult situation she was in.

Examining the likeliness of a physician to report a patient, the chances were highest in an environment when the physician was scared of him or herself being reported, which usually is in a public setting where hierarchy and social surveillance among colleagues was visible and when the physician was less aware or deprioritizing the Professional Secret. This report by the informants and the examination of the influencing factors and how they affect the clinical management of cases of abortion and obstetric emergencies, confirmed, evolved and gave depth to understanding the survey results McNaughton et al. (2006) reported.

Concerning the greater likeliness of being reported as a patient in public setting, this also confirmed the data provided by the Citizen Coalition for Decriminalization of Abortion reporting on the vulnerable socioeconomical living conditions of the incarcerated women having suffered obstetric emergencies, as this socioeconomical group do not have the resources to pay for private health care (La Agrupación Ciudadana de la Despenalización del Aborto, 2014). The informants also contributed to understand that it was more likely to be reported as a physician in the public setting as well.

The socioeconomical factor could also be discussed in relation to the medical aspect of that unplanned OOH births and preterm births are linked to higher mortality and morbidity for both the baby and the mother. The informants’ report of this affirmed literature and previous research (Cunningham et al., 2018; Flanagan et al., 2017). Connecting this fact with that traditional gender roles makes the woman less likely to prioritize herself and her health in the El Salvadorian society reported in the results, makes the chances of higher mortality and morbidity even bigger as she might not search health care until too late. Further on, it was reported that she could be judged by health care professionals by delaying the search for health care. How the health care professionals treat their patients could also be seen as a subtler way of reproductive governance (Morgan and Roberts, 2012), as it might influence on the patients reasoning of their reproductive behavior. If the health care professional, being in dominant position with authority, morally blames the woman’s reproductive behavior, one might believe that it affects her thoughts and actions.

Another aspect reported by one informant, was the connection between that a woman might not search health care on time and the criminality. The women suffering the most from the criminality in society were reported being the socioeconomical vulnerable living in poor neighborhoods controlled by gangs, also described in literature (Lindahl, 2014). In a situation of that a woman would get pregnant as result of a rape by a gang member, she was reported to maybe not dare to tell about the possible pregnancy and as a consequence not attend prenatal controls. Another more

possible situation reported on by the same informant was that in socioeconomical vulnerable settings, the woman, adolescent or girl might not know about her rights and that sexual violation was reported to sometimes be viewed as something normal. These results contribute to the understanding of why socioeconomically vulnerable women are in greater risk of unwanted pregnancy outcomes and losing the pregnancy, as described in previous research (Fernández Domínguez et al., 2015; Flanagan et al., 2017; Lima et al., 2018). As for the responsible physician, it was reported that it could be very stressful and challenging to manage these cases.

Combining the results above with that Viterna and Bautista (2017) pointed out that attorneys face quotas on monthly procedure of cases, at the same time as if the woman is poor she might not have the resources to pay for a defense attorney, makes the socioeconomically vulnerable, poorly educated woman with deficient access to health care the most likely profile to both suffer an obstetric emergency and to go to jail for it. Moreover, the responsible physician’s individual framework of influencing factors and the contextual environment hold key roles in the management of pregnancy problems. There is no practical consensus within the medical college on how to clinically manage the cases of abortion and obstetric emergencies and from this conclusion one might question the equal right to health care and the patient safety for pregnant women in El Salvador. The environment of polarization could be considered to exacerbate this situation as polarization in general makes people of the same believes more likely to discuss the topic, rather than the discussing between the groups of different opinions.

4.2. Prioritizing of the Religious and Moral Values Many of the informants reported on that it in the El Salvadorian society is common to prioritize the moral and religious believes and that these have been influential in politics, something that could be connected to Viterna and Bautista’s (2017) research about explaining the key factors to understand today’s circumstances. They reported on that the new anti-abortion groups in the 1990s piggy-backed on political and Catholic structures, that how the group Si a la Vida (Yes to Life) proposed the law change in 1998 and that an archbishop urged the constitution to state that life begins at conception. These are examples of how these actors have used different tools to govern SRH as explained by Morgan and Roberts (2012). Also, the Catholic group Opus Dei was emphasized as politically influential by an informant, confirming the fact stated by Morgan and Roberts. The fact that an archbishop was the reason for the constitution to change might question the secularity of the state of El Salvador, and could be seen as an argument of that religious values are prioritized. From the constitution’s definition of life together with the illegality of induced abortion springs this legislative trumping over all other rights, even when medical values interfere,

as being the case when for example the life of the mother (and consequently also the unborn) is at risk. Furthermore, the constitution’s statement of when life begins was believed by some informants to be the reason to why women in El Salvador could be condemned for aggravated homicide if losing their pregnancy.

This study showed that moral and religious beliefs continue to have a great influence also on the everyday working tasks of the obstetrician-gynecologists in the health care sector. As they all have created their own framework on how to take on these cases, I find it interesting to discuss informant 5’s way of doing so. The informant tried to combine the values of helping the patients according to medical ethics, not break the Professional Secret together with personally being more against induced abortion (with the exceptions of ectopic pregnancy, non-viable malformations and when the mother’s life is at risk). The combination and priority of these values created a personal framework with the possibility of the informant to “orientate” (i.e. to give the information to) the patients searching for an elective abortion on how they could get one. In this way, the informant skirted around the laws at the same time as she did not have to directly interfere with her personal values of induced abortion being mostly wrong as she never herself performed one – the responsibility of action would be on the patient. Herself would also have been ethically rightful to the patient – not abandoning her in a difficult situation.

Another interesting fact was how the two most religious informants who were considering induced abortion to be generally wrong (with the exceptions of ectopic pregnancy, non-viable malformations and when the mother’s life is at risk), were the ones having the hardest time trying to imagine themselves or a family member being in the position of needing an induced abortion in the four induced abortion grounds. Since this study is qualitative it is problematic to make a generalized conclusion of this, but still the finding in itself is interesting. One of these informants was dual in how she would react if she would find herself in a personal situation, and the informants in favor of the four induced abortion grounds reported on that they believed that the ones against them might change their opinion if found in a personal situation in need for an induced abortion on the four grounds.

Thus, based on that the informants reported on either that it is common that people put their religious and moral beliefs first, or that they by explaining how they resonated on the cases and situations were understood to prioritize them, it was possible to understand their great weight. This confirms the figures of the religious beliefs in literature (Lindahl, 2014) and once again the reasons behind announcing a patient reported by McNaughton et al. (2006). El Salvador can be understood as

having an overall religious character and this study contributes with another perspective on how religious and moral perceptions could govern the reproduction on different levels in society – not merely personal, but also structurally in both medical and juridical field.

4.3. Unprofessional Management and The Loss of Rights of the Pregnant Woman The role of the woman in El Salvador was reported by the informants to include having the major responsibility of the household and family. This also affects the woman when being pregnant, maybe even more so because of that she then is responsible for another growing life. One informant expressed that as a woman, she should be able to feel the fetal movements and therefore understand that she is pregnant. Another informant pointed out that some health care professionals in the public setting were reported to be desensitized and treating their patients judgmentally after having lost their pregnancy. It is arguable that the personnel with this attitude might not have the woman’s right to health care prioritized, but they consider it rightful for her being treated this way as she was the cause of losing the pregnancy. I consider these to be judgmental attitudes as well as the consequential actions are unprofessional.

Moreover, the El Salvadorian society was by some informants reported on being misogynist which was reflected by its laws and culture. One example of this reported on, was condemning the woman to aggravated homicide after having suffered an obstetric emergency with pregnancy loss. This could be understood as a legislative tool for reproductive governance described by Morgan and Roberts (2012), and interpreted as a de-prioritization of women’s rights.

If the pregnancy loss is spontaneous, this could be an empirical example of how in a health care environment, when not even having to prioritize between the woman and the unborn, the unborn’s right to life is still prioritized. And as for the woman losing her pregnancy and therefore not carrying her baby anymore, she is still de-prioritized in regards of her lost pregnancy. I consider that the role of the woman could be understood as to be always be self-sacrificing. In the case of spontaneously losing the pregnancy, it could be considered an impossible situation in certain contexts described in 4.1.; she is likely to not dare to search for health care due to the circumstances, but also – if she doesn’t – she will be judged for not doing so, and it is likely that it might contribute to her being suspected for having provoked the loss herself. Morgan and Roberts (2012) explain the “natural right” to life to be understood as something in the El Salvadorian society prioritized to the unborn and as for the woman, already living a life which also could be considered a “natural right”, is repressed. This continues also after she loses the pregnancy she wished to carry to term. As for being the medical responsible physician, I see no need for aggravating the pain a pregnancy loss could

cause and I consider having these attitudes to be unprofessional. What also is worth emphasizing – and what some informants also pointed out – is that the law requiring to report suspected crimes, such as induced abortion, goes against the medical ethics about doing no harm described by Zureick et al., (2018).

Considering the informants’ report on that socioeconomically wealthier women have access to induced abortion even though it is illegal and that the profile of women condemned for aggravated homicide are socioeconomically vulnerable, poorly educated women and with deficient access to health care, one could argue that different socioeconomical classes have different rights in practice. As a parallel to this, it is interesting to discuss the scenario of Nicaraguan migrants giving birth in Costa Rica described by Morgan and Roberts (2012). The Nicaraguan women could be understood as considered having less rights than the Costa Rican woman, as well as her unborn is considered having the “natural right” to life. Hence, the “natural right” to life of the unborn is in both in the El Salvadorian context and the example of Nicaraguan women giving birth in Costa Rica always trumping.

Thus, having examined how the cases of abortion and obstetric emergencies are clinically managed through interviewing medical responsible obstetrician-gynecologists, it was possible to understand that in the El Salvadorian context the woman was understood as in many was de-prioritized in comparison to the unborn having the “natural right” to life. Depending on the circumstances, for example if being in the public regime and the responsible physician had a personal framework being judgmental towards women in these situations, these de-prioritizations of women’s rights could be realized in a health care context. This could be considered to be unprofessional, although it is important to also keep in mind the challenging situation of the physicians as they – by either reporting the patient or not – will break either the law on reporting the patient or the Professional Secret (Zureick et al., 2018).

4.4. Conclusion The answers to the questions at issue was guided by Morgan and Roberts (2012) theoretical framework of reproductive governance and made the objective of the study – to gain deeper understanding and knowledge about the influencing factors and the obstetrician-gynecologists’ experiences and reflections on clinically managing cases with abortion and obstetric emergency with pregnancy loss – fulfilled. The results of this report showed that the main influencing factors on the management of abortion and obstetric emergencies with pregnancy loss were the ethical principles and conflicting laws, the Catholic Church and the environment of polarization,

judgmental attitudes and hierarchy. Depending on the individual prioritization of the factors, influenced by both the private and work environment and done either deliberately or not, they had all created an individual framework for managing the cases and hence also to weigh the rights between the woman and the unborn. Therefore, in practice, there is no consensus on how to manage the cases and the clinical management depends on both the individual framework and the circumstances. From this conclusion one might question the equal right to health care and the patient safety for pregnant women in El Salvador.

This study is an example of how medicine and health care sometimes are needed to be understood in its societal context through the interdisciplinary endeavor of medical humanities in order to comprehend the whole spectra, especially when focusing on such a complex topic as this is. In regard to previous research, the results of this study confirmed and gave depth to the issue. The precarious role of being the medical responsible obstetrician-gynecologist in such a delicate situation is now better understood.

4.5. Strengths and Limitations and Potential Sources of Bias An often emphasized strength of qualitative research is for the questions at issue to be investigated with detail and depth. Also, the semi-structured in-depth interview as method provides both a core and a flexibility. The flexibility makes it possible to obtain information that even from the beginning was not actively being search for. The main criticism of qualitative research is usually the potential source of bias of the researcher because of its subjective role, and the difficulty to generalize the results. These methodological strengths and limitations are important to be aware of throughout the research process (Malterud, 1998).

Strengths of this study included the wide approach of medical humanities and the thorough and structured method of TA to understand this complex topic. All of the data was analyzed, even the data from the beginning not knowing if it would contribute to answer the questions at issue.

Limitations of this study included the relatively low number of informants and especially that none of the them were of the opinion totally against induced abortion. That no more than five interviews were conducted was motivated by the limitation in time of a master thesis. Although the aim of the purposive and snowball sampling was to include informants covering the whole spectra of perceptions, it was difficult on beforehand to know the perceptions of the informant, and thus the whole spectra of opinions was not covered. A limitation in regards of the interview guide could be that the different obstetric emergencies were not asked about separately, but as a wide concept. It is

possible that if asking more specifically, the answered obtained would possibly have been even richer.

My role as a researcher also included both strengths and limitations. Among the strengths were the preunderstandings of both the medical and societal-cultural aspects of the topic. Also, that I was able to conduct the interviews in Spanish, the mother tongue of the informants, contributed to the trust needed when sharing delicate information. However, the same aspects could also be considered limitations since I am only a medical student and not yet specialized, as well as one may argue that my societal preunderstanding of the El Salvadorian context is limited because of my upbringing in Sweden. The latter could on the other hand have contributed to that I could examine the topic with the distance needed for being more objective, as could be difficult when investigating something of a more familiar character. Although I am able to conduct interviews of this character in Spanish, there were moments when I had to ask the informant to specify what they wanted to say because of my limited vocabulary. This could have contributed to a shallower information. Moreover, this was my first more substantial research project and it being of a complex character also provided some challenges in regards of methodology and terminology.

The subjective role of the researcher is also important to consider as it is possible that it will influence the results. Being a Swede trying to interpret a complex topic in the El Salvadorian context could imply a bias, as well as it might contribute to a distance enabling to facilitate the analyze process. Considering the potential sources of bias, it is important to always obtain a critical attitude and role towards the data and research process and trying to be aware of the potential sources of bias in order to actively consider them. For example, it is important to give all data the same time and attention and to present it balanced in the report (Rohleder and Lyons, 2014).

4.6. Implications for Future Research Considering the complex nature of this topic, there are multiple implications for future research. First, as this report had its mentioned limitations, it would be useful to conduct a vaster study of the same kind, including more informants of the whole spectra also asking more specific questions about obstetric emergencies. In order to understand the medical causes of the obstetric emergency cases ending up in prison, a journal review study would contribute to that. The journal review study could be supplemented by a study of the legal case files of the women charged with aggravated homicide. These studies would be benefitted if done interdisciplinary with expertise in both the medical and juridical field.

Moreover, journal review studies on specific obstetric emergencies such as OOH, premature births and stillbirths would contribute to understand whether or not certain circumstances make it more likely for the patient to be criminally suspected. As for the patients’ perspective, it would contribute to understanding of the supposed suspicious environment if conducting a study with the patients on their experiences.

Lastly, since moral and religious beliefs were understood to have a great impact on the clinical management and also in other spheres such as politically, is would be interesting to carry out a study aiming to better understand how it influences, especially in a country as El Salvador that claims being secular.

5. Acknowledgement I would like to thank all the wonderful and helpful people I have met before and during my time realizing the field work in El Salvador. Thanks to everyone for sharing your kindness, hospitality and information, for listening to me constantly talking about this important and interesting topic and for distracting me by bringing me along to different activities. ¡Muchísimas gracias por todo!

Special acknowledgements to my supervisors Birgitta and Solveig for your support and believing in my thesis.

And finally, a special thanks to Robin and Mathias for always having patience with me during our time away.

The field work was supported by the scholarship Minor Field Studies (MFS), financed by the Swedish International Development Cooperation Agency (SIDA) managed by the Swedish Council for Higher Education (UHR).

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7. Appendix The attachments below have been translated from Spanish to English by the author.

7.1. Attachment 1: Information About the Study and Informed Consent

Information about the Study: This study is interdisciplinary within the area of medical humanities and Sexual and Reproductive Health and Rights, SRHR. The aim of the study is to increase the knowledge about the El Salvadorian obstetrician-gynecologists’ experiences and reflections on clinically managing cases with abortion and obstetric emergency with pregnancy loss, as well as understanding the influencing factors on the management.

This study will be conducted during the second half of 2018 and form part of my master thesis within the Medicine Program at the University of Uppsala, Sweden. The supervisors of the study are Birgitta Essén, Professor of International Maternal & Reproductive Health at the Department of Women’s and Children’s Health ([email protected]) and Solveig Jülich, Professor at the Department of History of Science and Ideas ([email protected]). The realization of the study is made possible thanks to a scholarship financed by the Swedish International Development Cooperation Agency, SIDA, managed by the Swedish Council for Higher Education, UHR.

The study is qualitative and consists of semi-structured interviews with obstetrician-gynecologists in El Salvador. The questions are open-ended and according to what the informant consider informative, interesting and reasonable to bring up, please do so. There are no right or wrong answers, what is important for the study are the experiences and reflections. The duration of an interview is planned to not exceed one and a half hours.

The participation is voluntary and can be ended whenever wanted. The interviews (except the personal information) will be recorded and transcribed. Afterwards they will be analyzed thematically. Taken into consideration the privacy of the informants, all personal information and results will be handled with great care and on my hard drive protected with a password. They will be treated confidentially and presented codified. The informants will not receive any economical compensation. The study will be published on the data base the Digital Scientifically Archive, DiVA (www.diva-portal.org).

San Salvador, September 2018 Emma Stenbacka Medical Student at the University of Uppsala, Sweden [email protected] +503 7394 2620

Informed consent for the informants: I have herby taken part of the information of the study.

I give my consent to participate in an interview and for the data to be handled as described above.

——————————— Name

——————————— Signature

——————————— Date

Informed consent for María Teresa Rivera: I have herby taken part of the information of the study.

I give my consent to participate in an interview and for my case to be used in the interviews with the obstetrician-gynecologists in the study.

——————————— Name

——————————— Signature

——————————— Date

7.2. Attachment 2: The Interview Guide

1. Opening question: - Could you tell me a little bit about yourself?

2. Introductory question: - How come you wanted to become an obstetrician-gynecologist? What motivated you?

3. Transitional questions: - Here in El Salvador, can a woman, adolescent or girl search for health care within SRH independently (without spouse or legal guardian)? - Here in El Salvador, can a woman, adolescent or girl decide and access contraceptives independently (without spouse or legal guardian)? - In what extent do you work with women, adolescents and girls who seek health care for pregnancy related problems? - Which laws regulate these cases? Are there any ethical codes? Informal customs? - Are these topics discussed in the medicine program? Among professionals?

4. Key questions: - Could you tell me about the clinical management of a woman, adolescent or girl who comes in and seek health care for early pregnancy related problem or an obstetric emergency?

If not spontaneously brought up, bring up following questions: - One of the early pregnancy related problems is spontaneous abortion, how is the management of those? - About spontaneous and induced abortions, do you consider that you are able to distinguish them? - How is the suspicion raised that it might be the case of an induced abortion? - What happens if the patient claims that it was a spontaneous? Do the physicians believe her? - In the case of an induced abortion, what would you do in the following cases… … if the patient’s life was at risk and the abortion would save it? … if the fetus has a non-viable malformation? … if the pregnancy is the result of a sexual violation or incest? … if the patient lives in poverty or a socially vulnerable situation? - Is there any possibility for women, adolescents and girls to have an induced abortion? - Concerning reporting to the legal authorities…

… is it something you would do? … is it something you think you are obliged to do? … is it something you think you consider correct to do? - Would you mind giving me a reflection about these topics and cases we have talked about?

Continue: - Is there a difference between the health care in the public and private setting? - What about the documentation of the different types of abortion? Do you for example use the ICD codes?

The case: Woman, 28 years old. From San Salvador. Vulnerable social situation. G1P1. Irregular menstrual cycle. Had been in a brief relationship when condom was used as contraceptive. In January she thought she was pregnant due to that she had not received her menses for two months. Although, in the following months she received it. She had during these months upper stomach pains and searched health care several times for this. The physicians detected an infection in the kidneys and she was given antibiotics. They did not take a pregnancy test.

In late November, she suddenly felt a big urge to defecate. Once at the pit latrine outside, she felt something slipping out very rapidly and she started to blead heavily. She shouted to her mother-in- law to call the police, that was located a few blocks down the street. She syncoped and the police took her to the hospital.

She had had an OOH birth in the pit latrine outside the house and the newborn died. According to the woman, the physicians did not take a medical history by talking to her nor did they examine her, but they called the police to come back to the hospital. The autopsy claimed that the cause of death was perinatal asphyxia. The woman later got convicted to 40 years imprisonment for aggravated homicide of her newborn. - Do you have any reflection on the case?

- Do you have any thoughts about why here in El Salvador they condemn so severely? - Taking in to consideration the other physicians, have you positioned yourself as against or in favor of induced abortion? - Could I also ask you about if you have any personal experience from these questions?

5. Ending questions: - Is there anything you would like to add or clarify? - Have this interview raised any important topics? - Is there anyone else you would recommend me to interview?

7.3. Attachment 3: The Interview Guide for the Case

1. Opening question: - Could you tell me a little bit about yourself?

2. Key questions: - Could you tell me a about your story? - What do you believe are the reasons for this happening to you?

3. Ending question: - Is there anything you would like to add or clarify?