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Abstract Background Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua, from June to July 2014. Case presentation This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria’s experience. Conclusions Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria’s case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria’s experience demonstrates that an individual’s health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion.

OBJETIVO: Determinar cómo perciben las mujeres de Ocotal, Nicaragua, las barreras de acceso a la atención de salud reproductiva; describir sus conocimientos acerca de los derechos reproductivos; y consignar sus opiniones acerca de la prohibición total del aborto en Nicaragua. MÉTODOS: De mayo a junio del 2014, se establecieron tres grupos de discusión en español en los que participaron 17 mujeres de dos barrios diferentes de la ciudad de Ocotal. Se utilizó una guía de discusión semiestructurada que constaba de preguntas de respuesta libre para dilucidar las perspectivas locales con respecto a los temas del grupo de discusión. RESULTADOS: Los obstáculos graves, incluidos 1) la violencia contra la mujer, 2) el machismo, 3) las críticas por parte de otros, y 4) la falta de comunicación y formación, limitan la capacidad de las mujeres para tomar sus propias decisiones de salud reproductiva. Las mujeres mostraron una carencia generalizada de conocimientos acerca de sus derechos reproductivos y los documentos internacionales de derechos humanos que los definen. Además, como consecuencia de sus ideas religiosas y culturales, la mayor parte de las mujeres apoyaron la prohibición total del aborto en el país en la mayor parte de las circunstancias, con la posible excepción de la violación. CONCLUSIONES: Se debe alentar a los hombres y mujeres de Ocotal a participar en los programas comunitarios diseñados para reducir la repercusión de los siguientes obstáculos para obtener atención de salud reproductiva: 1) la violencia contra la mujer y el machismo; 2) la educación sexual no estandarizada y la información acerca de sus derechos reproductivos insuficientes; y 3) la comunicación deficiente dentro de las familias y en la comunidad en general. Con objeto de reducir el estigma en torno a la salud y la actividad sexuales, las futuras campañas de salud pública orientadas a tratar las necesidades de salud reproductiva de las mujeres de Ocotal deben llevar a cabo en los barrios estos tipos de programas.

Background: In 2007, WHO launched a global initiative for the elimination of mother-to-child transmission of syphilis (congenital syphilis). An important aspect of the initiative is strengthening surveillance to monitor progress towards elimination. In 2008, using a health systems model with country data inputs, WHO estimated that 1·4 million maternal syphilis infections caused 520 000 adverse pregnancy outcomes. To assess progress, we updated the 2008 estimates and estimated the 2012 global prevalence and cases of maternal and congenital syphilis. Methods: We used a health systems model approved by the Child Health Epidemiology Reference Group. WHO and UN databases provided inputs on livebirths, antenatal care coverage, and syphilis testing, seropositivity, and treatment in antenatal care. For 2012 estimates, we used data collected between 2009 and 2012. We updated the 2008 estimates using data collected between 2000 and 2008, compared these with 2012 estimates using data collected between 2009 and 2012, and performed subanalyses to validate results. Findings: In 2012, an estimated 930 000 maternal syphilis infections caused 350 000 adverse pregnancy outcomes including 143 000 early fetal deaths and stillbirths, 62 000 neonatal deaths, 44 000 preterm or low weight births, and 102 000 infected infants worldwide. Nearly 80% of adverse outcomes (274 000) occurred in women who received antenatal care at least once. Comparing the updated 2008 estimates with the 2012 estimates, maternal syphilis decreased by 38% (from 1 488 394 cases in 2008 to 927 936 cases in 2012) and congenital syphilis decreased by 39% (from 576 784 to 350 915). India represented 65% of the decrease. Analysis excluding India still showed an 18% decrease in maternal and congenital cases of syphilis worldwide. Interpretation: Maternal and congenital syphilis decreased worldwide from 2008 to 2012, which suggests progress towards the elimination of mother-to-child transmission of syphilis. Nonetheless, maternal syphilis caused substantial adverse pregnancy outcomes, even in women receiving antenatal care. Improved access to quality antenatal care, including syphilis testing and treatment, and robust data are all important for achieving the elimination of mother-to-child transmission of syphilis. Funding: The UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction in WHO, and the US Centers for Disease Control and Prevention.