Rwanda: Conditioned Legalization of Abortion Divides Society
Until 1977, abortion was generally illegal in Rwanda. The Criminal Code (Ordinance 43/Just.of 18 May 1970), which was based on the 1940 Penal Code of the Belgian Congo, contained no stated exceptions to the prohibition on the performance of abortions, and an abortion could be carried out only under general criminal law principles of necessity to save the life of the pregnant woman.
In 1977, Rwanda enacted a new Penal Code (Law 21-77 of 18 August 1977) that liberalized to some degree the performance of abortions. The law prohibits abortion except when the continuance of the pregnancy seriously endangers the health of the pregnant woman. In such cases, a second medical opinion is required, and the intervention must be performed by a State physician or physician approved by the State in a public hospital or a private hospital approved by the State.
Rwandan legislature recently (2012) approved a bill legalizing abortion in cases of rape, forced marriage or incest. According to the draft penal code, article 165 stipulates that there is no criminal liability for a woman who causes her own abortion and a medical doctor who helps a woman to abort provided that the four conditions are met.
The conditions include; when a woman is pregnant as a result of rape, forced marriage, incest in the second degree and when continuation of pregnancy jeopardizes the health of the unborn baby or that of the pregnant woman.
The penalty for abortion without being under the above exceptions is imprisonment and paying fines. The years of imprisonment however vary depending on a number of circumstances.
The government hails the move as the promotion of women's rights. Churches see it as a violation of the fundamental right to life. Abortion remains a sensitive issue in a country still recovering from the 1994 genocide. Rwandan religious authorities also oppose the partial legalization of abortion.
On 19 April 2012, President Paul Kagame received a delegation of Christian church representatives. "Serious and profound discussions" took place, according to a press release by the Rwandan bishops group Conférence Episcopale du Rwanda (CEPR). "We choose the child's life and, understanding the pain of the mother whose dignity was damaged, we are committed to supporting and helping her keep the child," said CEPR president Smaragde Mbonyintege.
Parliament spokesperson Augustin Habimana, on the other hand invited the churches to be more realistic. He urged them to have the courage to see both sides of the coin. "Let us consider a woman who is forced to have a child that she might not love. Also imagine the disgrace of a child learning it was born from rape or incest. Women should at least have the right to choose whether or not to end such pregnancies." He said.
Members of the Chamber of Deputies passed the draft Penal Code, with the majority voting in favor of an article that permits abortion under special circumstances. The abortion law reform continues to stir up a heated debate among the public and different organizations.
Ethiopia like any other country is also struggling with issues concerning abortion. Abortion is illegal in Ethiopia except in cases where the mother's life is in danger, but illegal abortions are easy to obtain and widespread. According to the World Health Organization (WHO), complications arising from illegal abortions are now the second leading causes of death after tuberculosis for young women in Ethiopia.
The death rate from illegal abortions is a staggering 1,209 per 100,000 abortions and estimates show that some 70% of women, who are brought to hospital suffering from serious problems after back street abortions, will die.
A number of factors contribute to the high death rate, including a lack of access to contraception, a very low literacy rate among women (only about 14% of women are literate), and Ethiopia's poverty level. These problems caused by unsafe abortions are also having an impact on overstrained health services in the country, where health expenditure per person is just about US $1.50 on health care resources annually
Despite all efforts to promote modern family planning services, Ethiopia demonstrates a particularly alarming increase in the incidence of unwanted pregnancies and incomplete and unsafe/septic abortions, particularly among adolescents. It is estimated that unsafe/illegal abortions accounted for 54% of all direct obstetric deaths.
Studies have shown that unsafe illegal abortion is rampant among single women, teenagers, students, and factory workers. This trend clearly demonstrates that the country still lags behind in delivering family planning services due to infrastructural and policy constraints that impede effective service delivery.
WHO does not advocate the legalization of abortion, but calls for better family planning to help avoid the need for abortion. Given the political commitment and support of the government, focus on improving the status of women through education, employment, and health becomes the most serious undertaking. The outcome of such action will be the key solution to the empowerment of women and in reducing the high abortion rates. In addition, improving availability and accessibility of family planning services in working areas and institutions and ensuring availability of trained manpower to render essential services is necessary.
Abortion is illegal in Uganda except to save the life of the woman. Nevertheless, many women obtain abortions, often under unhygienic conditions, and the practice is quite common: about 300,000 induced abortions occur annually among Ugandan women aged 15-49 and a large proportion of these women require treatment for post-abortion complications.
The Ugandan Ministry of Health is considering the recommendations of a report it commissioned into the safety and legality of abortion. The report proposes legalizing abortion in specific cases such as rape. Illegal abortion in Uganda contributes to a high ratio of maternal mortality
In the male-dominant culture of Uganda, where men control most of the financial resources, men play a critical part in determining whether women receive a safe abortion or appropriate treatment if they experience abortion complications.
From a research carried out in the country, respondents' descriptions of men's involvement in women's abortion care agreed that men's stated attitudes about abortion often prevented women from involving them in either the abortion or post-abortion care.
Most men believe that if a woman is having an abortion, it must be because she is pregnant with another man's child, although this does not correspond with women's reasons for having an abortion. If the woman does experience post-abortion complications, the prevailing attitude among men in the sample was that they cannot support a woman in such a situation seeking care because if it had been his child, she would not have had a covert abortion.
Since money is critical to accessing appropriate care, without men's support, women seeking an abortion may not be able to access safer abortion options and if they experience complications, they may delay care-seeking or may not obtain care at all. Barriers to involving men in abortion decision-making endanger women's health and possibly their lives.
In Uganda, induced abortion is permitted only when continuation of a pregnancy would endanger a woman's life. The country's major religions too, outlaw the practice. Because of this, it is often practiced in secret, with many women having to rely on practitioners who use dangerous methods under unsanitary conditions. An estimated illegal 300,000 abortions are said to occur annually in the country. And the consequences have been deadly for many women.
The state of affairs surrounding abortion makes it difficult to get facts on the practice. However, a new study by the Guttmacher Institute "Abortion Worldwide: A Decade of Uneven Progress" offers some new data, which could have policy implications. "Surveys of knowledgeable health professionals suggest that in Uganda, 23% of women seeking abortions go to traditional practitioners, many of whom employ unsafe techniques, and 56% go to doctors or nurses, who generally provide safer services" says the study. "Some women (15%), try to self-induce using highly dangerous, crude methods which may include; drinking of turpentine, bleach, detergents or tea made with livestock manure, inserting herbal preparations into the vagina or cervix, placing foreign bodies such as sticks, coat hangers or chicken bones into the uterus and jumping from roof tops, while (7%) others purchase abortion-inducing drugs from pharmacists or other vendors.
These are said to result into complications like damage of the bladder or bowel, damage of the cervix, secondary infertility, tubal blockage, fistula, severe bleeding and sometimes death. As a solution, Ibembe says provision of high quality safe abortion services by trained service providers is crucial in reducing maternal mortality that currently stands at 435 per 100,000 live births.
The study further shows that urban women in Uganda are much more likely than rural women to use the services of doctors (42% vs. 16%). Similar results were reported in Burkina Faso and Côte d'Ivoire for this multi country study. In Uganda, just like in Cameroon, Ghana and Zambia, women cited fear of legal consequences, social stigma, high cost and lack of access to trained health professionals as important factors preventing them from obtaining safe abortions.
Further data on Uganda, the study shows, experts estimate that 50% of all women having clandestine abortions experience health complications requiring treatment. "Such complications are thought to be more common among poor women than better-off women (55 % vs. 38 %)."
The study also indicates that an estimated 45% of all women who experience complications requiring treatment do not receive medical care at a facility, and the proportion is even higher among poorer women. Data from the reproductive health division at the Ministry of Health show that abortion related complications are among the top five direct causes of maternal deaths.
However, when they make it, many women with untreated complications suffer long lasting health effects, such as anaemia, chronic pain, chronic inflammation of the reproductive tract and infertility.
With the urge to curb maternal complications and possible deaths, Ntungamo district woman MP, Beatrice Rwakimari, says much as it might be a right for a woman to abort, the right of the unborn baby should not be overlooked. She states that the right of the mother and the baby should not be compromised and emphasizes that as policy makers, focus on unwanted pregnancies should be the first step in fighting unsafe abortion.
The suggestion made is that Uganda should work on ensuring that the unmet need for contraceptive intake that stands at 41% be reduced by ensuring that more women use family planning methods to avoid unwanted pregnancies.
'Unmet need' refers to the percentage of women who would like to be able to either space their children or stop having children but are not using contraception.
Besides reducing unsafe abortions, Reproductive Health Uganda (RHU) says Uganda would save $112m (sh257.6b) by investing in contraceptive commodities and services to fill the entire unmet need.
The issue of abortion is widespread all over the world. However the level of its effect is varied in different parts of the world.
In Africa pregnancy and childbirth are among the greatest dangers that women face; which is also the continent that has the world's highest rates of maternal mortality— at least 100 times, those in developed countries. Abortion accounts for a significant part of the death toll.
Focusing on Tanzania, the following research explains; maternal mortality is very high; for every 100,000 births, 950 women die. In the United States, the figure is 11, and it is even lower in other developed countries. But Tanzania's record is neither the best nor the worst in Africa. Many other countries have similar statistics; quite a few do better and a handful do markedly worse.
Abortion is illegal in Tanzania (except to save the mother's life or health), so women and girls turn to amateurs, who may dose them with herbs or other concoctions, punch their bellies or insert objects vaginally. Infections, bleeding and punctures of the uterus or bowel can result, and can be fatal. Doctors treating women after these bungled attempts sometimes have no choice but to remove the uterus.
80% of Tanzanians live in rural areas and the hospital in Berega — miles from paved roads and electric poles — is a typical rural hospital, struggling to deal with the same problems faced by hospitals and clinics in much of the country. Abortion is a constant worry.
Worldwide, there are 19 million unsafe abortions a year, and they kill 70,000 women (accounting for 13 percent of maternal deaths), mostly in poor countries like Tanzania where abortion is illegal, according to the World Health Organization. More than two million women a year suffer serious complications. According to Unicef, unsafe abortions cause 4% of deaths among pregnant women in Africa, 6% in Asia and 12% in Latin America and the Caribbean.
Reliable figures on abortion in Tanzania are hard to come by, but the World Health Organization reports that its region, Eastern Africa, has the world's second-highest rate of unsafe abortions (only South America is higher). And Africa as a whole has the highest proportion of teenagers — 25 percent — among women having unsafe abortions.
The medical director, Dr. Paschal Mdoe, 30, said many patients who had had the unsafe abortions were 16 to 20 years old, and four months pregnant. He said there was a steady stream of cases, much as he had seen in hospitals in other parts of the country. "It's the same everywhere," he said.
On a Friday in January, 6 of 20 patients in the women's ward were recovering from attempted abortions. One, a 25-year-old schoolteacher, lay in bed moaning and writhing. She had been treated at the hospital a week earlier for an incomplete abortion and now was back, bleeding and in severe pain. She was taken to the operating room once again and anesthetized, and Emmanuel Makanza, who had treated her the first time, discovered that he had failed to remove all the membranes formed during the pregnancy. Once again, he scraped the inside of her womb with a curette, a metal instrument. It was a vigorous, bloody procedure. This time, he said, it was complete.
Mr. Makanza is an assistant medical officer, not a fully trained physician. Assistant medical officers have education similar to that of physician assistants in the United States, but with additional training in surgery. They are Tanzania's solution to a severe shortage of doctors, and they perform many basic operations, like Caesareans and appendectomies.
Abortions in Berega come in seasonal waves — March and April, August and September — in sync with planting and harvests, when a lot of socializing goes on, Dr. Mdoe said. He said rumor had it that many abortions were done by a man in Gairo, a town west of Berega. In some cases, he said, the abortionist only started the procedure, knowing that doctors would have to finish the job.
Dr. Mdoe said he suspected that some of the other illegal abortionists were hospital workers with delusions of surgical skill.
"They just poke, poke, poke," he said. "And then the woman has to come here." Sometimes the doctors find fragments of sticks left inside the uterus, an invitation to sepsis.
In the past some hospitals threatened to withhold care until a woman identified the abortionist (performing abortions can bring a 14-year prison term), but that practice was abandoned in favor of simply providing post-abortal treatment. Still, women do not want to discuss what happened or even admit that they had anything other than a miscarriage, because in theory they can be prosecuted for having abortions. The law calls for seven years in prison for the woman. So doctors generally do not ask questions.
"They are supposed to be arrested," Dr. Mdoe said. "Our work as physicians is just to help and make sure they get healed."
He went on, "We as medical personnel think abortion should be legal so a qualified person can do it and you can have safe abortion." There are no plans in Tanzania to change the law.
The steady stream of cases reflects widespread ignorance about contraception. Young people in the region do not seem to know much or care much about birth control or safe sex, Dr. Mdoe said.
In most countries the rates of abortion, whether legal or illegal — and abortion-related deaths — tend to decrease when the use of birth control increases. But only about a quarter of Tanzanians use contraception. In South Africa, the rate of contraception use is 60 percent, and in Kenya 39 percent. Both have lower rates of maternal mortality than does Tanzania. South Africa also allows abortion on request.
But in other African nations like Sierra Leone and Nigeria, abortion is not available on request, and the figures on contraceptive use are even lower than Tanzania's and maternal mortality is higher. Nonprofit groups are working with the Tanzanian government to provide family planning, but the country is vast, and the widely distributed rural populations makes many people extremely hard to reach.
Geography is not the only obstacle. An assistant medical officer, Telesphory Kaneno, said: "Talking about sexuality and the sex organs is still a taboo in our community. For a woman, if it is known that she is taking contraceptives, there is a fear of being called promiscuous."
In interviews, some young women from the area who had given birth as teenagers said they had not used birth control because they did not know about it or thought it was unsafe: they had heard that condoms were unsanitary and that birth control pills and other hormonal contraceptives could cause cancer.
Mr. Kaneno said the doctors were trying to dispel those taboos and convince women that it was a good thing to be able to choose whether and when to get pregnant.