Category Archives: Unsafe Abortion

Selected case studies of women who were denied enjoyment of ‘right to health’ in Kenya

 

A review of ‘Human Rights Issues in maternal health care in Kenya: Do Kenyan women enjoy the right to maternal health?’ and ‘Barriers to enjoyment of health as a human right in Africa’ provides a useful background to the case studies.

The recently launched report by the Kenya National Commission on Human Rights[i] highlights several incidents and situations where women were denied their right to health care services both because of non-availability of resources and non-affordability of services, as well as misdeeds on the part of health care providers. People living with disabilities (PWDs), in particular, complained of mistreatment, especially delays in getting attended to in health facilities. Most health institutions were not disabled-friendly in terms of infrastructure and means of communication, for example, facilities for sign language or Braille.

A Level 2 Health Facility at Mtwapa, Mombasa County (Picture: J Mati)

Witnesses raised several complaints related to the inefficient referral systems in several health facilities that caused considerable delays in obtaining higher level care, not infrequently resulting in fatal consequences for the women and their babies. This was particularly a serious problem when it came to referral of patients from levels 1 and 2 to appropriate higher level facilities.

In some cases, women in rural areas had to be transported on wheel barrows by family members or on donkey carts. Where hospitals had ambulances, the patients or the relatives were required to pay amounts ranging from KSHs. 500 to KSHs. 3,000 supposedly to fuel the vehicles. In situations where people were unable to pay, patients were denied treatment. In other instances, blood was not readily available in hospital blood banks, or the facilities lacked adequate infrastructure to obtain blood for emergency transfusions.

In Tana River, for example, a woman who developed complications after delivering at a dispensary (level 2) died while waiting to raise funds, through harambee, to fuel a government ambulance to take her to Hola District Hospital. A similar report is given in connection with a maternal death due to lack of transport between Magarini Dispensary and Malindi District Hospital, both in Kilifi County.

In Lamu County, patients who needed to be referred to Coast Provincial Hospital in Mombasa were reportedly required to pay between KSHs. 8,000 and KSHs. 10,000 to fuel the hospital’s ambulance. Where there are no ambulances, as in Wajir and Marsabit District Hospitals families had either to hire expensive taxis or resort to donkeys and camels to transport their sick members.

Witnesses testified that the high cost of hospital delivery, especially the fees charged at level 4 and 5 facilities, was a key hindrance to accessing skilled attendance at delivery. A witness during the inquiry stated thus: ‘Many women deliver at home because they do not have enough money to go to the hospital’.

 Corruption, especially among hospital management staff, was also cited as a barrier to accessing maternal health services. According to witness accounts from Kitale, corruption in health facilities meant that patients ended up paying for drugs and other items that ought to be provided for free. Similarly, bribes were solicited to facilitate earlier scheduling of surgical treatment, as stated by a witness at the Coast: “For one to get an operation done quickly at Coast General Hospital one has to pay bribes or know someone because there are long queues, so I left”.

Mistreatment in health facilities by unkind, cruel, sometimes inebriated hospital staff, who scolded, abused and even beat patients also features prominently in the report. So are delays in getting attended to in health institutions, particularly in the labour ward, where witnesses complained of being neglected during labour, in some cases ending in delivering unattended within the hospital. An example is the case of a woman who waited at the out-patients from 5am to 4pm before being admitted to the labour ward, ending up with a stillborn child. Women complained of being admitted in overcrowded wards and sharing of beds; up to three women with their babies sharing one bed, even when some of them were still bleeding, which exposed them to potential risk of infection, including HIV and Hepatitis B. Detaining of women for non-payment of hospital charges obviously contributes to congestion in hospital wards.

There were complaints of frequent lack of essential medicines, equipment, commodities and supplies in public health facilities resulting in denial of services to the needy. It was common in most public facilities for patients to be asked to purchase medicines, gloves and dressings, besides being referred to private institutions for specialised radiological and ultrasound diagnostic examinations. Essential resources for effective provision of sexual and reproductive health services were lacking in many health facilities. For example, many lacked the drugs needed for post-exposure prophylaxis (PEP) following sexual abuse including rape. The Inquiry established that non-availability of family planning commodities was a fundamental barrier to accessing comprehensive family planning in Kenya, this being illustrated by the frequent stock outs of commodities. There were complaints of frequent shortages of various contraceptives which denied clients a wide choice of family planning methods.

Several witnesses complained of negligent actions by doctors and midwives, for example, forgetting items such as surgical instruments or swabs in a patient’s abdomen; performing procedures such as hysterectomy without prior informed consent; poorly managed labour leading to ruptured uterus, maternal morbidities such as VVF and RVF, intra-uterine foetal death or a mentally handicapped child,. Other examples of negligent actions or omissions were performing episiotomy and failing to repair it, and failure to recognise accidental injury during surgery and failing to repair it immediately. There were women who complained that not enough information was given to them about the various diagnostic and treatment modalities they had been subjected to by health providers. In particular, there was inadequate information given to the patients before and after surgical procedures.

 The Report cites an article published in The Daily Nation Newspaper of 18th January 2011 on a case of maternal death associated with abortion:

“A woman aged 40 years who was held at Murang’a police station for allegedly procuring an abortion died after she developed complications while in the police cells. The Police said the woman was reported to have terminated the pregnancy by swallowing some chemical, and locked her up in a cell at the police station. They said she later developed complications and was being rushed to hospital when she died en route.”

 It can be argued that had the police taken the woman to a health care professional, instead of holding her in remand at the police station, she most likely would have survived. In other words this was a case of preventable death associated with denial of enjoyment of right to health. Yet this was after the promulgation of the Constitution of Kenya 2010 which has relaxed the rigidity on termination of pregnancy that existed previously. Article 26 (4) permits safe abortion if 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.

What can be learned from the above case studies?

Clearly, they demonstrate that Kenya has yet to address the well known factors and barriers that have over the years sustained the prevailing high rates of maternal and newborn mortality and morbidity. Maternal health services that are inaccessible, non-affordable and of poor quality, have been perpetuated by several serious weaknesses in the health systems- inadequate capacity in terms of human resources and health infrastructure, negligence and malpractices especially among over-worked de-motivated health service providers, and various socio-cultural barriers, among others. Addressing these barriers is a prerequisite to meeting local and international goals and targets including the Vision 2030 and Millennium Development Goals.


[i] A Report of the Public Inquiry into Violations of Sexual and Reproductive Health Rights in Kenya

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Access to legalised abortion is a key ingredient to improvement of maternal health in Africa

It is worrying to note that while most advocates of improved maternal health are greatly disturbed by the WHO report that rates of induced abortion worldwide remain high worldwide, and especially the finding that in the Africa region almost all (97%) abortions are unsafe, there are others who belittle the significance of these findings, stating: “Ireland, where abortion is banned, has one of the world’s best maternal health records. Legalised abortion does nothing to improve medical care.”

Whilst it may be possible that Ireland has one of the world’s best maternal health records, it is unrealistic to make that the yardstick, and to conclude that African countries, for example, should stick to their strict anti-abortion laws, and by some grace the high rates of unsafe abortion and maternal deaths will reduce. There is a world of difference between the circumstances under which an average Irish woman lives and that of the average African woman. The Irish woman is today enjoying a living standard above the average woman in the British Isles, and can with ease slip across the channel to obtain safe abortion if need be. All these benefits are beyond the reach of the African woman. The truth of the matter is that the high mortality is concentrated among the poor and marginalised. The wealthy women in Africa have easy access to very safe abortion in their countries or abroad, as necessary. To the rich African woman as it is for the Irish, perhaps “legalised abortion does nothing to improve medical care”; to the average woman in Africa, it can be a matter of life and death. Restrictive abortion laws do not translate to lower abortion rates, but unsafe abortion can be effectively minimized by ensuring women have easy access to contraceptive services, backed up by a positive legal framework that facilitates safe abortion.

The Status of Maternal Health and Unsafe Abortion in Kenya

Unsafe abortion is a public health concern;

  • In order to achieve MDG 5 on Improving Maternal Health, it is imperative that the issue of unsafe abortions is addressed.
  • Unsafe abortion is an important contributor to the high maternal mortality rates in Kenya
  • Granted unsafe abortion is simply one of several contributors to MMR, BUT it is one we know how to prevent- an important public health principle
  • Incidence of unsafe abortion generally reflects the magnitude of unwanted pregnancies in any particular community.
  • Unsafe abortion can be effectively minimized by ensuring women have easy access to contraceptive services, backed up by a positive legal framework that facilitates safe abortion.

Read more on the  Status of Maternal Health and Unsafe Abortion in Kenya

Is it time for a comprehensive Reproductive Health Act for Kenya?

A Presentation made at the Kenya Medical Association State of Maternal Mortality in Kenya Conference held at the Kenyatta International Conference Centre, Thursday 15th September, 2011

Evolution of Modern Obstetrics and Gynaecology Practice in Kenya

In a previous post it was opined that although Kenya has the capacity to train the nurse workforce it needs, the prevailing challenge is ensuring all trained nurses and midwives are employed and efficiently deployed. The State of World’s Midwifery[i] 2011 observes that appropriate employment and deployment of skilled midwives is essential for Kenya to make meaningful progress towards achieving MDG 5. The current post seeks to highlight some of the milestones in the evolution of modern practice of midwifery and midwifery training in Kenya.

In colonial Kenya and before the mid-1960s, obstetrics and gynaecology were practiced as separate services located in different facilities. Whereas gynaecology services were availed as sub-specialty within the department of Surgery at the King George VI Hospital (later renamed Kenyatta National Hospital), midwifery services were considered a separate service altogether, provided in maternity homes that were usually sited some distance away from the main hospital. The tradition of building maternity wards some distance away from the main hospital arose as a long-practised measure to prevent cross infection especially from surgical patients. It also reflected the colonial policy that whereas the Government undertook to provide Africans with what was described as ‘complete medical care’, this service did not extend to obstetric care, which was regarded as a responsibility of the local authorities, the Municipal Councils or in the reserves, the African District Councils[ii].

The initiative to develop midwifery services in urban areas of Kenya is credited to the East African Women’s League (EAWL)[iii] which, “out of concern for the lack of a maternity ward for African women”, and with the encouragement of Lady Grigg (Governor‘s wife), founded the Lady Grigg Child Welfare and Maternity League in 1926. By 1928 the Lady Grigg Maternity Home at Pumwani (now the Pumwani Maternity Hospital) had been built. Other maternity hospitals followed, in Mombasa- Lady Grigg Maternity Hospital Mombasa (now part of the Coast Provincial General Hospital), and in Nairobi- the Social Service League Ngara Maternity Home (sadly, this has since ceased to be a hospital).

The EAWL also advocated for the training of African nurses and midwives, and all three maternity hospitals mentioned above undertook the training of the early midwives in Kenya (to enrolled midwife level). Later on, in pursuit of primary health care following the Alma Ata Declaration of 1978, midwifery training was incorporated into nursing training to produce the Enrolled Community Health Nurse. Training at registered midwife level had to wait until registered nurse training had started in Kenya. Training at para-medical level in Kenya can be traced back to 1927 when the first group of students was recruited for training as Medical Assistants at the Native Civil Hospital, (later re-named King George VI Hospital and Kenyatta National Hospital). This cadre was trained to provide both Nursing and Clinical services. These are the forerunner of the Clinical Officer of today. In 1952 the first batch of Kenya Registered Nurses commenced training at the King George VI Hospital and the Medical Training Centre (now Medical Training College)[iv]. Registered nurses could then undertake a further year’s training in midwifery to qualify for registration as Registered Midwife.

By 1954 of the 12 full time specialists at the King George VI Hospital, only one, Dr Peter L Candler specialised in gynaecology[v]. According to Peter Candler, the most common gynaecological condition he dealt with at that time was vaginal fistula resulting from lacerations during childbirth. This was followed by complications of generalised pelvic sepsis and infertility. However, he reported that ‘attempted’ abortion was unlikely among Africans because of the strong desire to bear children! Nearly two decades later when we came into the scene, the pattern of gynaecology had changed little, except in the case of abortion which had since become a prominent gynaecological problem.

The expansion of obstetrics and gynaecology services in Kenya is largely attributable to the University of Nairobi’s Department of Obstetrics and Gynaecology. The medical school in Nairobi was established through a presidential directive shortly after 1963, the year of Kenya’s independence. To implement the directive, the Ministry of Health with British Government financing, invited the University of Glasgow to assist in preparing the KNH as a teaching hospital ahead of the launch of the University of Nairobi Medical School in 1967. Thus, a team from Glasgow arrived, and in September 1965, oversaw the opening of the Obstetric Unit at the KNH. Initially, patients were ‘borrowed’ from the Pumwani Maternity Hospital through a process whereby one of the consultants would select a couple of women in early labour and transport them to the Obstetric Unit at KNH for their management. In addition, the Department ran, on behalf of the Nairobi City Council, four antenatal clinics at the health centres in Riruta, Waithaka, Woodley, and Langata. This way it was possible to have enough clinical material for the medical students and student midwives from the School of Nursing. It should also be mentioned that the first medical students taught at KNH were actually ‘borrowed’ from Makerere Medical School! Initially these were Kenyan students who chose to spend an elective term at the KNH, but later the hospital provided refuge to students who fled Idi Amin’s tyranny in Uganda, including some students from other countries.

Establishment of gynaecology (gynae) as a specialty at KNH, separate from Surgery, was not without resistance and intrigues. There were those surgeons that felt there was absolutely nothing new to be gained by creating a department of gynaecology- after all, hadn’t they treated gynae cases all those years? A thorny area concerned the allocation of operating theatre space for a regular gynaecology list. We needed a theatre for emergencies such as ruptured ectopic pregnancy and incomplete abortion; as well as another theatre for elective (‘cold’) cases. I remember one senior surgeon openly saying incomplete abortion never required an evacuation- after all many occurred in the ‘bush’ where there were no doctors! He had always sent them away without any evacuation.


[i] The State of World’s Midwifery 2011, was launched in June 2011 by the United Nations Population Fund (UNFPA)

[ii] Letter written on October 20, 1954 by Robert F Gray to Mr Walter Rogers of Institute of Current World Affairs, 522 Fifth Avenue, New York 36, New York. http://www.icwa.org

[iii] The East Africa Women’s League is an organisation for white women who were born in, lived or worked in East Africa. It was founded in Nairobi in 1917, its main concern being the welfare of women and children of all races in the country then known as ‘British East Africa’. http://www.eawl.org

[iv] http://www.kmtc.ac.ke/public_site/webroot/cache/article/file/Nursing_log1.pdf

[v] Note: Dr Peter Lawrence Candler was admitted to the Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) in 1962.

 

Implementing the Reproductive Health Provisions of the Kenya Constitution

Implementation of RH provisions of Kenya Constitution- KMA conf

Women have the right to safe abortion services within the law

Kenya’s constitution confers to all citizens the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care (Article 43 (1a)). Further, Article 26(4) specifies grounds upon which abortion may be legally provided; specifically, “if 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”. Safe abortion services, as provided by law, therefore need to be available, provided by well-trained health personnel supported by policies, regulations and a health systems infrastructure, including equipment and supplies, so that women can have rapid access to these services (WHO).

It is more efficient to provide legal safe abortion services within the context of Comprehensive Abortion Care (CAC) system that aims to reduce the risk of unwanted (unplanned) pregnancy. Morbidity and mortality related to abortion can be prevented at the following three levels: (a) Primary level- Prevent unwanted pregnancy by providing contraceptive information and counselling, and increasing access to contraceptive services. (b) Secondary level- Prevent unsafe abortion through provision of counselling in early pregnancy, respecting women’s informed choice, and ensuring access to safe medical termination of pregnancy for those who so choose. (c) Tertiary level- Provide post-abortion care (PAC) services: clinical management of complications of unsafe abortion, and prevention of future unsafe abortion through contraceptive counselling and services.
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How Kenya’s New Constitution is likely to impact on access to safe abortion services

Background:

The aim of this presentation is to contribute to the understanding of the provisions in the New Constitution as they relate to access to safe abortion services in Kenya, and to analyse areas of particular concern in the implementation of the Constitution. In order for Kenya to achieve Millennium Development Goal 5 on Improving Maternal Health, it is imperative that the issue of unsafe abortions is addressed, since this is a major contributor to 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 pregnancies in a particular community. Hence, the only sure way of effectively minimizing unsafe abortion is to ensure women have easy access to contraceptive information and services, backed up by positive legislation that decriminalizes abortion. According to UN data[ii], in most so-called developing countries like Kenya, there was a trend towards enactment of more restrictive abortion laws in the period between 1999 and 2007 (Figure 1). Whereas in nearly all countries abortion is permitted to save a mother’s life, only 60 percent and 57 percent respectively of the countries permit abortion to preserve a mother’s physical and mental health. Rape or incest, and fetal abnormalities are respectively considered in 37 percent and 32 percent of the countries; and in only 19 percent are economic or social considerations entertained. Abortion is available on demand in some 15 percent of developing countries.

 

Figure 1: Grounds on which abortion is permitted – percentage of countries

Source: (World Abortion Policies 2007 )

Constitutional provisions that are relevant to abortion services in Kenya

The new Constitution of Kenya, while maintaining the longstanding restrictive stance towards abortion[i], it nevertheless, does provide opportunities for enhancing the reproductive health and rights of Kenyan women, which if adequately implemented can significantly contribute to the reduction of the high maternal mortality rates prevailing in Kenya today, and the achievement of MDG 5. In particular, the Constitution of Kenya:

  • Is committed to nurture and protect the well-being of the individual, the family, communities and the nation[ii].
  • Guarantees reproductive health care as a right for all Kenyans[iii]
  • Commits the government to implement international conventions, and regional commitments that Kenya has pledged to support such as CEDAW[iv] and the Maputo[v] Plan of Action[vi],
  • Guarantees that every person has inherent dignity and the right to have that dignity respected and protected[vii], and
  • Guarantees equality and freedom from discrimination for every Kenyan[viii]

 

The Constitution of Kenya 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. In other words, abortion can be permissible if in the opinion of a trained health professional there is need for emergency treatment (as in cases of severe pre-eclampsia and eclampsia), or the life or health of the mother is in danger (as in the case of severe cardiac disease, or complicated diabetes mellitus that is not adequately responding to treatment).

 

To a certain degree Article 26 (4) has widened access to safe abortion in Kenya through the inclusion of danger to ‘health’ as a ground for abortion in addition to danger to ‘life’, of the mother previously provided in Section 240 of the Penal Code[ix]. As it stands today, the Code of Professional Conduct and Discipline published by the Medical Practitioners and Dentists Board mentions, in addition, the health of the baby: “There is room, however, for carrying out termination when in the opinion of the attending doctors it is necessary in the interest of the health of the mother or baby”.

 

Restrictive medical practices

The Code of Professional Conduct and Discipline (see above) goes on to provide guidance on how medical practitioners should proceed in cases where there is ground for termination of pregnancy (TOP): “In these circumstances, it is strongly advised that the practitioner consults with at least two senior and experienced colleagues, obtains their opinion in writing and performs the operation openly in hospital if he considers himself competent to do so in the absence of a Gynecologist”. This guideline can present a serious access barrier, for example for the solitary medical worker in rural areas, where a second opinion may be a considerable distance away. Similarly restricting performance of abortion procedures to hospitals is not only restrictive but may also be unnecessary, considering that modern techniques for TOP can safely be carried out on an outpatient basis.

 

In addition, quite often in order to establish the risk to the life of the woman, a psychiatric assessment is required. This is not only discriminative to those living far from urban centres where psychiatrists are to be found. In addition, it is a process that gives the woman a label of psychiatric illness, besides being expensive, time consuming, and in many respects completely unnecessary. It is an invasion of the inherent dignity of the woman (see above). In many respects these practices serves to discourage rather than facilitate access to safe abortion services.

 

Provision of Safe abortion services[x]

The World Health Organization defines ‘unsafe abortion’ as “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both”[xi]. ‘Safe abortion’ services, on the other hand, imply the services are provided by well-trained health personnel and supported by policies, regulations and a health systems infrastructure, including equipment and supplies.

 

Almost all the deaths and complications from unsafe abortion are preventable through application of safe abortion practices. Termination of pregnancy (TOP) is a safe medical procedure when performed by trained health care providers using proper equipment, correct technique and ensuring infection prevention standards.

 

Regrettably, in many circumstances where women are legally entitled to have an abortion, safe services are not available to them due to a range of reasons, which include the following:

  • Provider associated problems and biases: a lack of trained providers (recruitment constraints; poor deployment and distribution); negative provider attitudes; stigmatization and other sanctions; conscientious objection among health workers.
  • Medical policies and practices: insistence on hospitalization; insistence on use of unnecessary or outdated techniques including use of general anaesthesia; opposition to task-shifting, and other regulatory bottlenecks.
  • Lack of knowledge of the law or lack of application of the law by providers; lack of public information about the law and women’s rights under the law.
  • Lack of awareness about facilities providing abortion or the need to obtain abortion services early in pregnancy.
  • Lack of awareness among health workers of their ethical and legal obligations to respect women’s rights, and to provide women in need with adequate information on where and how safe abortion services can be obtained.

 

Prevention of unsafe abortion and its complications

The Africa Union’s Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights (2007-2010) aimed to reduce the incidence of unsafe abortion, through the following strategies:

  • Enacting policies and legal frameworks to reduce incidence of unsafe abortion;
  • Preparing and implementing national plans of action to reduce incidence of unwanted pregnancies and unsafe abortion;
  • Training service providers in the provision of comprehensive safe abortion care services where national law allows;
  • Providing safe abortion services to the fullest extent of the law;
  • Educating communities on available safe abortion services as allowed by national laws;
  • Training health providers in prevention and management of unsafe abortion

 

On the whole, there is consensus that to effectively reduce the incidence of unsafe abortion women must have easy access to contraceptive information and services, backed up by positive legislation that decriminalizes abortion. Table 1 shows a suggested three-tier scheme for the prevention of unsafe abortion and the related morbidity and mortality.

 

Table 1: A three-tier scheme for the prevention of abortion related morbidity and mortality[xii]

Conclusion 

 

This review has shown that the new Constitution of Kenya, despite the restrictive stance on abortion, does at the same time provide opportunities for enhancing the reproductive health and rights of Kenyan women. Hence, to be effective in the provision of safe abortion services, it is imperative that health care providers do familiarise themselves with these provisions in the Constitution. This will avoid the introduction or continuation of unwarranted access barriers to what should be legally availed to women in need.

Unsafe abortion remains an important contributor to the unacceptably high levels of maternal morbidity and mortality that prevail in Kenya; it is a key challenge to the achievement of MDG 5, as well as attaining the health targets set out in Kenya’s Vision 2030. In addressing the issue of unsafe abortion particular focus should be on ensuring equity in access to health care, especially for the poor and marginalised communities. Despite the paucity of supportive data, it is highly possible that considerably more induced abortions occur among the wealthier and more mature women than among the poor young single women that are often reported from public institutions. However, it is the latter that protract Kenya’s high maternal mortality rates, and who create the stiffest challenge to the attainment of national and international goals, if they are left ‘out of the loop’. In any case, the Constitution guarantees equality and freedom from discrimination for everyone.

 

Related Links


[i] Japheth Mati, New abortion law is still bad for women. STAR Thursday 29 April 2010

[ii] Preamble to the Constitution of Kenya

[iii] Article 43 (1) (a) Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care

[iv] CEDAW, the Convention on the Elimination of All Forms of Discrimination against Women, is an international agreement that affirms principles of fundamental human rights and equality for women around the world. It was adopted by the UN General Assembly in 1979 through Resolution 34/180.

[v] Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights 2007-2010

[vi] Art. 2 (6) Any treaty or convention ratified by Kenya shall form part of the law of Kenya

[vii] Article 28 Every person has inherent dignity and the right to have that dignity respected and protected

[viii] Article 27 on Equality and freedom from discrimination

[ix] “A person is not criminally responsible for performing in good faith and with reasonable care and skill a surgical operation upon an unborn child for the preservation of the mother’s life if the performance of the operation is reasonable having regard to the patient’s state at the time, and to all the circumstances of the case” Section 240 of the Penal Code, Laws of Kenya.

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

[xi] World Health Organization. (1992) The prevention and management of unsafe abortion. Report of a Technical Working Group. Geneva, World Health Organization. (WHO/MSM/92.5)

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


A commentary on Unsafe Abortion in Africa

Unsafe abortion remains a major contributor to the unacceptably high levels of maternal morbidity and mortality rates that prevail in Africa. It also continues to be one of the formidable challenges to the achievement of Millennium Development Goal 5 of improving maternal health by 2015. This is despite the many meetings and conferences that have addressed the issue over the last four decades, one of the earliest being the IPPF Regional Conference on Family Welfare and Development in Africa, Ibadan, Nigeria, August/September, 1976, where I was privileged to present a paper entitled Abortion in Africa[1]. Perhaps the most recent meeting is the Ipas[2] sponsored conference in Ghana (November 8-11, 2010), entitled “Keeping Our Promise: Addressing Unsafe Abortion in Africa”.

The persistence of unsafe abortion in Africa is, ultimately, perpetuated by two key factors: (a) the restrictive laws against termination of pregnancy; and (b) the limited or lack of access to adequate abortion services. Criminalisation of abortion in majority of African countries is something inherited from the colonial laws, despite the fact that the law has since decriminalised the procedure in the colonial “mother countries” (United Kingdom 1967; France 1975; Italy 1978; Spain 1985; Belgium 1990). On the other hand, it can be observed that passing of laws for or against abortion has little effect on the numbers of abortions that take place; in fact, the only difference is that the patterns of morbidity and mortality associated with abortion change. Stringent laws against abortion will not deter women in need from going through with an abortion, the only thing such laws achieve is to push many of them to undergo unsafe procedures with consequent high rates of morbidity and mortality. The procedure of medical termination of pregnancy is simple, short and safe when undertaken in the open, by trained persons; however, carried out in secrecy, usually by unskilled operators, it is expensive, unsafe and life threatening.

Obviously, like many other freedoms- legalisation of abortion may be abused, when abortion becomes a primary method of birth control, as happened in the former USSR. Increased access to contraception since the collapse of the Soviet Union, has led to a reduction in the numbers of abortions in Russia. However, it should be realised that induced abortion may still be the only means of birth control for many women in some parts of Africa, i.e. women who have very limited access to contraception, including adolescents and youths who are denied not only the services but also information on sexuality, on moralistic grounds. For such women, the desire to do away with an unwanted pregnancy can be so intense that they will avail themselves of this last resort despite the law, or the attendant risk to their lives. Sadly, many of these women live in countries where penal codes do sanction abortion under certain conditions but they are unaware of this provision; or, for various reasons, they cannot access safe abortion services in their countries.

Evidence from the Demographic and Health Surveys, over the last three decades, shows that women (and men) in most parts of Africa have increasingly taken to contraceptive practice. For anyone who chooses to practice contraception the hope is that it would not fail her or him. The shock of the discovery that this is not so, though infrequent, can drive the hapless individual seeking termination of the pregnancy. For most people it follows logic that if contraception is acceptable, then consideration for abortion should follow where there is failure- this is why in many countries medical termination of pregnancy is an accepted second line of defence against unwanted pregnancy.

Finally, in addressing the issue of unsafe abortion particular focus is needed on ensuring equity in access to health care, especially for the poor and marginalised communities, who are the main victims of quacks in backstreet clinics. Despite the absence of supportive data at this moment, it is highly possible that in many African countries, considerably more induced abortions occur among the wealthier and more mature women than among the poor young single women, that are often reported from public institutions. It is the latter that sustain Africa’s high abortion-related maternal mortality rates, and who will make it impossible to attain national and international goals, if they are left ‘out of the loop’.

Related Link

On The Abortion Question

[1] Mati JKG. Abortion in Africa. In Family Welfare and Development  in Africa. Proceedings of IPPF Regional Conference, Ibadan, Nigeria, August/September,1976.

[2] http://www.ipas.org/Library/News/News_Items/Keeping_Our_Promise_Addressing_Unsafe_Abortion_in_Africa.aspx Conference co-sponsored by FEMNET, Ghana Ministry of Health, IPPF Africa Regional Office, Marie Stopes International and the United Nations Economic Commission for Africa. A BBC interview on this conference is available on http://www.bbc.co.uk/worldservice/africa/2010/11/101109_ghana_abortion_conference.shtml

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