Child murderer, bad mother, hussy… Manuela is one of 181 cases identified in El Salvador of women who suffered obstetric emergencies and were prosecuted with harsh prison sentences. In Manuela's case, the court found -without any evidence- that she had thrown her child into a latrine to cover up an alleged infidelity and thereby avoid public criticism. She was sentenced to 30 years' imprisonment for first-degree murder.
A significant number of countries in the world, including in Central and South America, are moving towards the -in most cases partial- decriminalisation of abortion, as seen recently in Chile, Argentina and Haiti. However, on the short but shameful list of countries that continue to criminalise abortion in all circumstances, in flagrant contravention of international human rights law, remain El Salvador, Honduras, Nicaragua and the Dominican Republic (although this situation could soon be reversed in the Dominican Republic where the Criminal Code (Código Penal) is being reformed).
Unsafe abortions, most often performed in countries where abortion is illegal or available only to the wealthy, carry a high risk for the health and lives of mothers. According to the World Health Organisation (WHO), around 7 million women are hospitalised each year as a result of unsafe abortion procedures, and between 4.7% and 13.2% of maternal mortality can be attributed to this cause each year.
90% of pregnancies in girls under the age of 14 are the direct result of sexual violence
This situation particularly affects women living in poverty or belonging to marginalised groups, many of whom are girls. Central America has the highest rates of child pregnancy in the region. In Guatemala, for example, according to the Observatory for Children's Rights, at least 5,133 girls between the ages of 10 and 14 became pregnant in 2019 - an average of 14 a day.
As documented by Guatemalan organisations together with the World Organisation Against Torture (OMCT) in their Alternative Report to the Committee against Torture in 2018 "it is estimated that 90% of pregnancies in girls under the age of 14 are the direct result of sexual violence and, according to data from the Human Rights Ombudsman's Office, in the majority of cases, the aggressors are the girls’ family members”.
Coming back to Manuela's case, together with the Latin America Litigators Group Against Torture (Grupo de Litigantes contra la Tortura de América Latina) we were able to conclude that Manuela's death, at Rosales National Hospital on April 30, 2010, was due to the repressive legal framework and a justice system that is both profoundly sexist -with the social entrenchment of misogynistic and sexist stereotypical concepts related to women- and discriminatory with regard to socio-economic background.
Instead of receiving the emergency obstetric care she needed, Manuela was interrogated by the doctor
Manuela had spent 20 months living in inhumane conditions, being routinely insulted and humiliated and enduring a huge suffering, having not received the curative and palliative treatment she needed for the lymphatic cancer with which she was diagnosed late in February 2009. Manuela left behind two orphaned children and a precarious financial situation for her family.
Manuela's human rights violations and suffering began on 27 February 2008. At the time, she was 31 years old and, after feeling severe pelvic and abdominal pain, had gone to the latrine a few metres from her house, where she had an obstetric emergency, ejected a foetus and fainted. While she was unconscious, her family called for help and took her to the nearest hospital, located two hours away from the rural community where she lived.
Manuela arrived at the National Hospital in San Francisco de Gotera wrapped in a hammock, with severe bleeding and symptoms of pre-eclampsia. In a country where the right to health, dignity and life of its inhabitants was respected and protected, Manuela would have been treated urgently to stem the loss of blood and to be resuscitated. But that did not happen. Instead of receiving the emergency obstetric care she needed, she was interrogated by the doctor who attended to her, who postponed her medical care for more than six hours. In the meantime, she was bleeding to death and her symptoms worsened. Manuela slipped into a coma, so she was catheterised and received a blood transfusion.
The doctor, who assumed that Manuela had induced an abortion, informed the police that she had committed a crime. A few hours later, while Manuela was still suffering from severe pain in her womb and genitals, and without the presence of a defence lawyer, she was handcuffed to the stretcher and, while immobilised, interrogated by two police officers. Without any evidence whatsoever, they accused her of having killed her child and called her “a hussy” for having had sex out of marriage. She was arrested without a warrant and remained shackled to her stretcher for seven days, during which time she was also insulted by medical staff.
She was imprisoned for almost two years, before she was brought to the hospital during the terminal phase of her cancer. Manuela spent more than 100 days handcuffed to a stretcher. She was subjected to intentional physical and psychological pain that went beyond that which was due to the terminal phase of her illness, and was made worse by being handcuffed, in agony, without even being granted the dignity to be able to move into a more comfortable position. Manuela was sentenced to die separated from her family and her two young children, which had a profound impact on her physical and emotional integrity in the final moments of her life.
Together with the Litigators against Torture Group, we decided to submit an amicus curiae brief to the Inter-American Court of Human Rights in the case of Manuela and family members (case 13,069) against El Salvador*. The purpose was to provide evidence to demonstrate that the treatment to which Manuela was subjected from her admission to the hospital, when she was in a most vulnerable situation, until her death in custody two years later, caused severe and continued physical, mental and emotional suffering for her and her family. This was attributable to the Salvadoran State, which violated the absolute prohibition of torture (Article 5, in particular Article 5.2, among others) under the American Convention on Human Rights.
We do not wish to close this article without paying a posthumous tribute to Manuela, whose courage and dignity we admire. We stand in solidarity with her family, and with the thousands of women and girls who are victims of repressive and discriminatory legal and institutional frameworks that violate sexual and reproductive rights in Central America and around the world.
*The Inter-American Court of Human Rights (IACHR) will issue a judgment in the coming months on Manuela's case which, in an unprecedented move, could grant the creation of fundamental standards to protect the rights to life, dignity, health, personal integrity and liberty of women in the context of countries such as El Salvador, where abortion is criminalised in all circumstances and carries very high penalties for pregnant women, as well as penalties for medical staff. The Centre for Reproductive Rights, the Feminist Collective for Local Development and the Citizen's Group for the Decriminalisation of Abortion filed a petition to the IACHR on behalf of Manuela's family in March 2012, which denounced the numerous human rights violations that Manuela suffered as a result of the total ban on abortion in El Salvador.
Helena Solà Martín is a senior human rights adviser for Latin America at the OMCT
 Citizens' group for the decriminalisation of abortion (Agrupación ciudadana por la despenalización del aborto). Del hospital a la cárcel 1998-2019: consecuencias para las mujeres por la penalización sin excepciones de la interrupción del embarazo en El Salvador. El Salvador. 2019.
 For more information, we recommend reading El aborto en América Central: Hacia un debate informado.
 The Inter-American Commission on Human Rights (IACHR) carried out an in loco visit in 2019, coming 32 years after its previous one. Among many of the issues about which it noted serious concern in its preliminary observations, it highlighted the “criminalization of abortion in all circumstances”, as well as "discriminatory patterns [that] affect almost all sectors of Salvadoran society and result in the normalization and tolerance of violence against women and LGBTI people, against a backdrop that facilitates the occurrence of such violence, in which there is widespread impunity in the face of such crimes".