Focus on providing safe abortion services, not post-abortion care.

In order to minimize the problem of unsafe abortion and its impacts there is an urgent need for a paradigm shift in strategic planning, from the present focus on ‘post-abortion care’ to provision of ‘safe abortion services’. The present challenge for Kenya under the new constitutional dispensation ought to be ensuring all women who are legally entitled to legal termination of pregnancy do access the services without unnecessary impediments.

Addressing the problem of unsafe abortion in Kenya should significantly contribute to the achievement of Millennium Development Goal 5 on Improving Maternal Health, considering that unsafe abortion is one of the major factors behind the high maternal mortality rates in the country. In addition, complications resulting from unsafe abortion contribute to serious sequelae for women’s reproductive health such as chronic pelvic inflammatory disease (PID) and infertility. The incidence of unsafe abortion generally reflects the magnitude of unwanted (unplanned) pregnancies in a particular community. Hence, the only sure way of effectively minimizing unsafe abortion is to ensure women have easy access to safe, effective and acceptable contraceptive information and services, backed up by policies that promote social justice and equality, enhanced status of women, as well as legislation that decriminalizes abortion.

The single, greatest challenge to addressing unsafe abortion in Africa is the lukewarm commitment on the part of governments to promote, protect and respect women’s reproductive rights, including the right to access safe and legal abortion services. This lack of political will affects the availability, accessibility, and quality of abortion-related care.

For several years there has been a mistaken notion that post-abortion care (PAC) services provide the solution to morbidity and mortality associated with unsafe abortion[i]. Consequently considerable resources have been expended on expansion of these services. Unfortunately, although PAC services can (and do) save lives, in many respects the intervention comes late, at the tail-end of the train of events that precipitated the tragedy in the first place, and as such they cannot be considered an efficient public health strategy for the prevention of abortion-related morbidity and mortality.

Prevention of unsafe abortion requires a paradigm shift in strategic planning, to a focus on provision of ‘safe abortion, not post-abortion care, services’.

‘Safe abortion’ services are those provided by trained health workers, supported by policies, regulations and a functional health infrastructure, including equipment and supplies[ii]. Performance of abortion outside these conditions constitutes ‘unsafe abortion’.

The new Constitution of Kenya, while maintaining the longstanding restrictive stance towards abortion, it nevertheless, does provide opportunities for enhancing the reproductive health and rights of Kenyan women. The Constitution is explicit in the chapter on Bill of Rights regarding circumstances when abortion may be legal. Article 26 (4) states: Abortion is not permitted unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law. Although several questions arise from this statement, for example: Who is a trained health professional? Is there any emergency that does not threaten life or health of the mother? What definition of ‘health’ is implied here? etc., whatever the answers may be the Constitution has entrenched the right for a woman to have a legal abortion, though under certain conditions.  The present challenge for Kenya then is to ensure women who are legally entitled to legal termination of pregnancy can access the services without hindrance or delay.

Experience in other countries where abortion has been legalized shows that women are often denied safe abortion services to which they are legally entitled[iii]. The reasons for this include the following:

  • Provider related factors: lack of knowledge of the law, or failure to apply the law, by providers, negative provider attitudes, biases and conscientious objection, and lack of awareness (or neglect) among providers of their ethical/legal obligations to provide women in need with appropriate information on where safe abortion services can be obtained.
  • Medical policies and bureaucracy: insistence on unnecessary/outdated medical abortion techniques e.g. requirement for hospitalization, use of general anaesthesia, etc.; opposition to task-shifting, and other regulatory bottlenecks.
  • Other factors: lack of public information about the law; lack of awareness about facilities providing safe abortion services; lack of awareness (among women) of need to report early in pregnancy.

[i] Mati JKG J. Adolescent reproductive health in the era of HIV/AIDS: Challenges and Opportunities. Obstet. Gynecol. East Cent. Afr. (2005); 18: 1-18

[ii] World Health Organisation. (2003) Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva, World Health Organisation

[iii] World Health Organisation. (2003) Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva, World Health Organisation

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Comments

  • Dr. James N. Mwanzia  On February 8, 2011 at 8:01 am

    I would like to commend Prof. Mati for his sustained efforts to sensitize the public in general and health professionals in particular about this important subject of addressing unsafe abortions.

    I would like to add that, in addition to the provisions under the Bill of Rights, the new constitution provides for a devolved structure for governance and services provision. This provides an excellent opportunity for intervening at the county and community level through advocacy, improved access and quality of care and reducing unintended pregnancies through contraception.

    • africahealth  On February 8, 2011 at 8:40 am

      Thanks for this observation Dr Mwanzia. You are absolutely right that the devolved system of government should open opportunities to improve access down to community level. But there is need for change in emphasis of priority strategies as far as prevention of unsafe abortion is concerned. Thanks again.

  • Oluoch Dory  On September 27, 2011 at 8:03 am

    Bravo Dr. Mwanzia. In deed the public and health providers should be aware that the new constitution in dispensation has provision on legal abortion. I worked in rural area – Kuria and within two months I witnessed so many school girls committing unsafe abortion e,g using crude weapons, abusing drugs in the effort of terminating abortion. In fact, one gal approached me for counseling after she had taken overdose of painkillers but abortion was in vain, the end results was that she had twins and gynecologist discovered that one was rotten while one born alive. This clearly shows the result of unsafe abortion.

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