Thirty first of every August is ‘African Traditional Medicine Day’ but how many know about it?

Over a span of about 150 years three members of my family have practiced medicine. My grandfather, my brother and I have all at one time or another provided medical care to the needy, all of us receiving acknowledgements from our patients and society. However, that is about where the similarities cease, for with the coming of the colonial power to our lands my grandfather’s practice became severely restricted and despised. Generally, he practiced in secrecy from then on. On the other hand, in the case of my brother and I who were trained in ‘scientific medicine’ by the colonials, our practices were legitimised by stints in the ‘motherland’ as well as being registered by professional regulatory authorities.

 African traditional medicine

In all countries of the world there exists traditional knowledge related to the health of humans and animals. The World Health Organization (WHO) defines traditional medicine as “the sum total of all the knowledge, skills and practice, based on the theories, beliefs, and experiences indigenous to different cultures,whether explicable or not, used in the maintenance of health as well as in the diagnosis, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing”[i].

This definition applies to all traditional systems of medicine whether in Europe, India, China or Africa. Yet whereas European missionaries and colonial administrators left alone, sometimes even encouraged, traditional medicine in India and China, they almost violently discouraged African traditional medicine. In particular, the intricate relationship between African medicine and African religion[ii] made traditional medical practices key targets of attack by early European Christian missionaries, who considered many African traditional religious rites and rituals to be against Christian teachings and morals. Traditional healers were regarded as heathens because of their participation in African Traditional Religion.

The medicine my brother and I practice derives from the germ theory of disease (see below) while my grandfather’s traditional African medicine is based on concepts that are much broader and holistic. In traditional African societies it is believed that good health, disease, success or misfortune are not chance occurrences but arise from the actions of individuals and ancestral spirits according to the balance or imbalance between the individual and the social environment. African traditional understanding was that sickness was a kind of punishment by the spirits of the ancestors to those who do not observe the rules of good social behaviour, from whom the ancestors withdraw their protection leaving them exposed to the whims of evil spirits who cause physical and mental dysfunctions. Traditional healers use plants in a variety of ways, depending on the illness to be cured. Parts of plants can be applied directly to wounds and cuts or, if necessary, prepared as powders, infusions, or even used in the form of smoke or fumes. African herbal medicine is often associated with magic[iii], for example the prescription of amulets and charms as prevention or treatment of diseases.

Today, many Africans including some self proclaimed Christians, and especially politicians, consult a traditional healers for advice on various issues, including health-problems. The African traditional ‘doctors’ have skills in both herbal remedies as well as in spiritual healing, the latter involving various traditional religious rites and rituals. In this regard, African medical practice is holistic- it takes into account all of patient’s physical, mental, and social conditions in the treatment of illness.

The Germ Theory of disease

The Germ Theory of disease is the foundation of modern (western) medicine and was an important basis for innovations such as antibiotics and hygienic practices. Germ theory was validated in the late 19th century, thanks to the works of Louis Pasteur (1822-1895) and Robert Koch (1843-1910). It proposes that microorganisms are the cause of many diseases. Hence management of the disease is focused on establishing which microorganisms are responsible and applying specific drugs (antibiotic) for their elimination. Modern medicine is also referred to as Allopathy, which is defined as the treatment of a disease by using remedies whose effects differ from those produced by that disease. This is the principle of mainstream medical practice, as opposed to that of homeopathy– a complementary disease-treatment system in which a patient is given minute doses of natural substances that in larger doses would produce symptoms of the disease itself.

There is no doubt that introduction of antibiotics (e.g. Penicillin), revolutionised medicine and remains one of the most important milestones in the history of medicine. However, as observed by some critics, the concentration in modern medicine on fighting germs using antibiotics has tended to ignore the “soil upon which the bacteria flourish[iv]” In other words modern medicine tends to focus on the disease not the whole person, as is the case in traditional systems of medicine. “Modern medicine seems too grounded in the study of disease [pathology] and in its eradication and not enough in studying health and how to create and sustain it”. This in fact, is where the great divide exists between modern medicine and African traditional medicine.

 

Preparing and drying out freshly picked mutis

Bridging the divide- Integration of traditional medicine in national health systems

The World Health Organization estimates that 80% of the populations of Asia, Africa and Latin America use traditional medicine to meet their primary health care needs. For many people in these countries, particularly those living in rural areas, this is the only available, accessible and affordable source of health care. In scenarios such as these African governments should have no option but to ensure there is collaboration between conventional and traditional health practitioners. To this end, Ministries of Health need to set up mechanisms for the regulation and integration of traditional medical practice in national health systems.

The 50th Session of the WHO Regional Committee for Africa which took place in Ouagadougou, Burkina Faso, 28 August to 2 September 2000 recognized the importance and potential of traditional medicine for the achievement of health for all, and set 31st August of every year as African Traditional Medicine Day[i]^{, [ii]}. The Regional Committee adopted a regional strategy for the promotion of the role of Traditional Medicine in national health systems, including establishing structures, programmes and offices in Ministries of Health to institutionalize traditional medicine. Currently 39 countries (including Kenya) have set up such offices, and a few training institutions have established departments of Herbal Medicine[iii]. Other examples of collaboration between traditional medical practitioners and modern medical practitioners are to be found in Uganda and South Africa. In Uganda the Traditional and Modern Health Practitioners against HIV /AIDS (THETA[iv] ) have demonstrated the positive impact traditional medical practitioners can make on health care delivery. In South Africa research conducted by AMREF shows that traditional practitioners can play important roles in integrated HIV/AIDS/STI/tuberculosis programs[v].

Conclusion:

As we look forward to this year’s African Traditional Medicine Day it cannot be lost on us that the ongoing WHO-led collaboration appears to focus solely on herbal medicine, yet traditional African medicine is a broader concept than that, incorporating (beside use of herbs) divination and healing of physical, emotional and spiritual illnesses. In any case, a large proportion of herbalists also engage in divining causes of illness and providing various solutions to spiritually or socially-centered complaints, in addition to use of plant and animal products. To this extent herbal medicine and spiritual healing act as mutually reinforcing systems of African traditional medicine. Accommodating the holistic approach in the proposed integrated health systems remains a critical challenge for all involved including WHO.

[i] http://www.afro.who.int/en/fiftieth-session.html

[ii] African Traditional Medicine Day, 31 August, Special issue, African Health Monitor, World Health Organization Regional Office for Africa).2010

[iii] The Kwame Nkrumah University of Science and Technology in Kumasi, Ghana, established a Bachelor of Science Degree in Herbal Medicine in 2001 to train Medical Herbalists.

[iv] Initiated in 1992 through a partnership between The AID S Support

Organization (TA SO) Uganda Ltd and Medicines Sans Frontières (Doctors without Borders), an international humanitarian organization.

[v] Melusi Ndhlalambi:Strengthening the Capacity of Traditional Health Practitioners to Respond to HIV/AIDS and TB in Kwa Zulu Natal, South Africa AMREF Case Studies 2009.

 

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.

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

Barriers to enjoyment of health as a human right in Africa

The full enjoyment of the ‘Right to Health’ in most African countries is constrained by several pervasive barriers that are the subject of the current review, which urges that governments urgently adopt human rights based approaches to all health interventions in order to ensure equitable distribution of health resources throughout all sections of communities.

The Concept of Health as a Human Right: Health is a basic need for human existence and survival and as such, it is a right that must be respected, promoted and protected by government and society. The Universal Declaration of Human Rights states that “Everyone has the right to a standard of living adequate for health and well-being of himself and his family”. The concept of health as human right is stated in the Preamble of the World Health Organization’s Charter (1946), and also in the International Covenant on Economic, Social and Cultural Rights (1966). Art. 12 states of health as a human right: “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The Declaration of Alma Ata (WHO, 1978) stated: “Health, which is the state of complete physical and social well-being, and not merely the absence of infirmity, is a fundamental human right…. the attainment of the highest possible level of health is a most important worldwide social goal.” The right to health is fundamental to the physical and mental well-being of all individuals and is a necessary condition for the exercise of other human rights including the pursuit of an adequate standard of living. Indeed health is fundamental to enjoyment of the right to life, and the right to a healthy life is fundamental to all other constitutional guarantees.

Right to Health is a Constitutional Issue Besides the South African Constitution[i], the Constitution of Kenya (2010), which was promulgated in August 2010, is among the most progressive constitutions in Africa. It provides for the right to health care services. Article 43(1)(a) in the chapter on Bill of Rights states that every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care, and in Article 43(2), that a person shall not be denied emergency medical treatment. Further, Article 27(2) guarantees equality and freedom from discrimination, and the full and equal enjoyment of all rights and fundamental freedoms. The Constitution obligates the government to take legislative, policy and other measures to achieve the progressive realization of the rights as guaranteed in the Constitution, including the right to health. The Right to Equality encompasses within itself the right of a poor patient to quality health care, regardless of their ability to pay.

Right to reproductive health care services: The concept of reproductive rights as a fundamental human right was endorsed at the 1994 International Conference of Population and Development in Cairo, Egypt. The constellation of rights, embracing fundamental human rights established by earlier treaties, was reaffirmed at the 1995 Fourth World Conference on Women in Beijing, China, and in various international and regional agreements since, as well as in many national laws. They include the right to decide the number, timing and spacing of children, the right to voluntarily marry and establish a family, and the right to the highest attainable standard of health, among others.

That reproductive rights are central to meeting international development goals was recognized by the UN World Summit of September 2005, which also endorsed the goal of universal access to reproductive health. Reproductive rights are recognized as valuable ends in themselves, and essential to the enjoyment of other fundamental rights. Attaining the goals of sustainable, equitable development requires that individuals are able to exercise control over their sexual and reproductive lives.

Right to reproductive health care services is explicitly recognised in the Constitution of Kenya (2010), just as it is recognized or implied in several international and regional instruments (see above), including the United Nations Millennium Development Goals (2000); the Maputo Plan of Action on Sexual and Reproductive Health and Rights (2006); and the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) (2009).

Barriers to enjoyment of Right to Health

1. General issues

Enjoyment of right to health in Africa, besides the inadequate financing of the health sector (see below), is indirectly constrained by several factors that operate at the regional and national levels, and mostly outside the mandate of the health sector. These include poverty, food insecurity and hunger, persistent violent conflicts and displacement of persons, heavy disease burden especially due to HIV and AIDS, and the pervasive gender-based negative traditions such as early marriage, female circumcision and lack of women’s empowerment all of which have profound effects on reproductive health outcomes.

2. Inadequate Funding to Health sector

Many governments in Africa have yet to recognise the importance of health in the overall national development, and expenditure on health is not adequately perceived as a critical economic investment alongside spending on education, agriculture or industries. Health is a critical resource for development, without which investment in all other sectors would go to waste. Poor health impacts negatively on economic productivity, through loss of labour, and under-performance due to illness. Poor health creates critical barriers to any measures intended to uplift the social wellbeing of poor and disadvantaged communities.

The levels of health budgets in most African countries do not demonstrate that health is rated as a high priority among other national needs. Despite the fact that in 2001 African countries pledged in Abuja, to increase health sector budgetary allocation to 15% of government expenditure, and although they repeated this pledge in Kampala in July 2010, in most countries national budgetary allocations for health remain far below this target. A 2007 report of the Regional Network for Equity in Health in East and Southern Africa (EQUINET)[ii] which looked into the progress made in various Southern and East African countries towards achieving the Abuja target, showed that with few exceptions most of the countries were still lagging far behind this target seven years since the declaration.

In Kenya, for the fiscal year 2010-11 just about 5.5 percent of the total Government expenditure was allocated to the ministries of Medical Services and Public Health and Sanitation. This translates to less than $1 per capita expenditure, against the recommended figure of $34 which WHO recommends for effective implementation of health interventions.

Figure 1: Real gross expenditure to the health sector, compared to overall gross Kenya Government expenditure (2007/08 – 2011/12)[iii]

A concern of particular relevance to achieving MDG5 is the disproportionate allocation within the health budget to reproductive health care services. Africa Union’s Maputo Plan of Action for Universal Access to Comprehensive Sexual and Reproductive Health Services in Africa (2007-2010) recommended an increase in per capita expenditures to about 18-24% of the $34 per capita recognized by the WHO. However, in many countries the allocation remains much below these figures.

At the international level, global assistance for reproductive health including family planning, financing has fallen in all recipient countries. Figure 2 shows that whereas there has been a steady increase in overall assistance for health, the amount focused on reproductive health and family planning has remained more or less unchanged since the year 2000.

Figure 2: Total international assistance to health and allocation to reproductive health care programmes (2000-2009)

Source: The Millennium Development Goals Report 2011

 

3. Lack of Equity in Planning for health and distribution of resources resulting in inequitable Access to Health Care services:

Physical access to services (distance to nearest Health Facility): Health care utilization is known to be greatly negatively impacted by distance to health care facilities and access to means of transportation. A study[iv] in western Kenya which explored the impact of distance on utilisation of sick child services in rural health facilities established that for every 1 km increase in distance of residence from a clinic, the rate of clinic visits decreased by 34% from the previous kilometer. According to the Kenya National Bureau of Statistics[v], on average only 6.4 percent of people in Kenya can reach a health facility within one kilometre of their residence; nearly a half (47.7%) of the people have to travel 5km or further to reach the nearest health facility, with marked regional variations (Table 1).

 

Figure 3: Proportion of community that has to travel 5km or more to the nearest health facility in Kenya

(Source: The Kenya Integrated Household Budget Survey (KIHBS) 2005/06).

For example, the proportion of people who live 5km or further from the nearest health facility ranges from 20% and 29% respectively in Nairobi and Central regions to 60%, 64% and 86% respectively in Coast, Eastern and North Eastern regions. The geographical dimension must be taken into consideration when planning health care interventions, especially when targeting socio-economically disadvantaged groups.

Affordability of services: Big disparities exist between the poor and the better off with respect to access to health care services which explains the wide gaps in health outcomes not only between rich and poor countries, but also between the wealthy and the poor in most countries. Generally, the poor lack access to health care in terms of: availability, affordability, and acceptability. Poor people are denied access to health care: (a) where public health facilities lack essential drugs, supplies and commodities; (b) where people have to travel long distances to reach health facilities, especially where public transport is scarce; (c) when fees charged for services (cost-sharing) are unaffordable, and even if there is official exemption (e.g. for pregnant women and children under five) or waiver of fees, people still end up paying on top, for drugs and transport (out-of-pocket expenditure); and (d) where people lack confidence in the services provided at local public health facilities and decide not to utilise them (e.g. poor quality services or negative provider attitudes).

The poor bear the heaviest burden of out-of-pocket health expenditures, irrespective of where they seek health care. In Kenya, data from the National Health Accounts (NHA) for fiscal year 2001/2002 showed that Kenyan households were financing over half of all health expenditures[vi], clearly justifying a conclusion that ill-health contributes to, and perpetuates, poverty because health costs deplete people’s meagre resources. In addition, there is considerable evidence to suggest that by and large public spending on health tends to benefit the better off more than the poor. Quite often it is the better off who get the most from public health services, especially hospital care. In other words, government’s investment in health services, far from promoting equity, works against it[vii].

FY 2001/2002 National Health Accounts (NHA) estimation in Kenya

Inadequate financing of the health sector and inequitable distribution of resources explain the major gaps and disparities in health indicators in most African countries, which have featured repeatedly in successive surveys such as the Demographic and Health Survey (DHS). It is important to realise that because of the size of the poorest population, countries cannot hope to achieve health-related MDGs without urgent implementation of inclusive policies in the planning of health interventions.

Addressing barriers to enjoyment of right to health

Governments must strive to address the pervasive barriers to enjoyment of right to health (including sexual and reproductive health) by all citizens by implementing human rights based approach to all interventions aimed at improving the health of the community. This will empower people to participate in decision making and health policy development, as well as strengthening their capacity to hold the health managers and providers accountable. Ministries of Health should work out clear strategies that seek to make health services inclusively available and accessible, of good quality, affordable and culturally acceptable. It is particularly important to adopt evidence-based planning which should ensure equitable distribution of health resources throughout all sections of communities.

Governments in Africa urgently need to recognise the importance of health in the overall national development, and support it by making appropriate budgetary allocation to the health sector along other critical economic investments. In addition, the international community also needs to examine their funding policies over the last decade or so, which have resulted in stagnation of financing of reproductive health especially family planning programmes.

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[i] www.righttohealthcare.org/Intl/SAfr.htm

[ii] Equinet (2007). Reclaiming the Resources for Health: A regional analysis of equity in health in East and Southern Africa. Fountain Publishers Kampala, Uganda.

[iii] Figures based on gross approved expenditure (2007/8 – 2010/11) and gross estimates (2011/12). Figures indexed to inflation at 2007 CPI.

[iv] Feikin DR, Nguyen LM, Adazu K, et al., The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya. Trop Med Int Health. 2009 Jan;14(1):54-61. Epub 2008 Nov 14. http://www.ncbi.nlm.nih.gov/pubmed/19021892

[v] Kenya National Bureau of Statistics (KIHBS) BASIC REPORT – www.knbs.or.ke/pdf/Basic%20Report%20(Revised%20Edition).pdf

[vi] www.who.int/entity/nha/country/Kenya_NHA%202002.pdf; Adam Leive, Ke Xu. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bulletin of the World Health Organization Volume 86, Number 11, November 2008, 849-856

[vii] Davidson R. Gwatkin (2003) Free Government Health Services: Are They the Best Way to Reach the Poor?

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.

Unsafe Abortion on the increase in Africa, a new WHO Report reveals.

Unsafe abortion as a significant contributor to the persistently high maternal mortality rates in Kenya and other sub-Saharan Africa in general, has been highlighted in several earlier posts. Sadly, a WHO report in conjunction with the Guttmacher Institute published today in the Lancet (on 19^th January, 2012), shows that rather than abating, unsafe abortion rates are still rising, this being particularly the case in sub-regions where access to safe abortion is restricted. While worldwide, 49% of all abortions were unsafe in 2008, in Africa, nearly all abortions (97%) were unsafe. The report confirms that restrictive abortion laws do not translate to lower abortion rates, and that 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. These are crucial steps toward achieving the Millennium Development Goal 5 in countries such as Kenya.

 

Read more on unsafe abortion…

•  The Status of Maternal Health and Unsafe Abortion in Kenya
• Women have the right to safe abortion services within the law
• Focus on providing safe abortion services, not post-abortion care.
• Champions are Urgently Needed for Accelerated Reduction of Maternal Mortality in Africa
• How Kenya’s New Constitution is likely to impact on access to safe abortion services
• A commentary on Unsafe Abortion in Africa

Do HIV infected women in Kenya have the guaranteed right to free choice contraception?

Government’s commitment to voluntary and free-choice family planning practices comes to question as Kenyan HIV infected women continue being coerced to use the IUCD. The Citizen TV on November 22, 2011 ran a story[1] about a widow in Mbita who has benefited from a fish farming venture supported by a grant from an American based non-governmental organisation. The sole qualification she needed to qualify for the grant was to be HIV positive and willing to be fitted with an intrauterine contraceptive device (IUCD). It is probable that this poor widow had no choice but to accept the condition- she needed help to support her family and, to that end, would take considerable risk. The question here is whether she had any choice in embarking on this method of family planning? Is it fair to assume she was in fact coerced to accept an IUCD by the grant of much needed cash?  What is the position of the Kenya Government on the matter?

Cash for contraception? Photo: Edgar Mwakaba/IRIN

According to Prof Peter Anyang’ Nyong’o, Minister for Medical Services, family planning practice should be voluntary[1]. Service providers must educate clients on the range of choices available, and let them choose that which suits them best. “But to flash money and say take this – no, that is not how to do it!” he added. However, it is not clear what the Minister has done to arrest the coercive practices.

Coerced sterilization of HIV-positive women came to light in 2007 when 13 cases were documented in Namibia^[2]. Shortly afterwards there were reports of HIV-positive women in Kenya being paid money to accept long-term contraceptive methods, particularly IUCD^[3]. These activities in Kenya (which include the case in point) are supported by Project Prevention, an American NGO founded in 1997 which also pays female drug users in the U.S. and UK to be sterilized. Whereas HIV-positive women do have a legitimate need for FP services, like every other woman they are entitled to exercise choice free of coercion or manipulation through incentives. Use of incentives and disincentives to pressure poor people to be sterilized was rejected at both the 1994 International Conference on Population and Development (ICPD) in Cairo, and the 1995 Fourth World Conference on Women in Beijing. In particular, the Beijing Platform for Action states clearly that “The human rights of women include their right to ….decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence”.

Coercion for sterilisation through incentives reached its peak in India during the rule of Prime Minister Indira Gandhi, with her government’s policy of sterilising (vasectomy) millions of Indian men who had fathered two or more children, being compensated with a transistor radio! This policy was ruthlessly and often illegally applied to the extent it came to symbolize the dangers of authoritarian rule[4]. It is notable that payment for sterilisation continues in India to this very day; for example, a medical college was recently reported to pay men that opt for non-scalpel vasectomy 1,100 Indian Rupees[5]. In Uttar Pradesh, to obtain a shotgun licence requires two people being sterilised; for a revolver licence, the price would be five. Wealthy farmers have managed to stock their armory through forcible sterilization of their poor farm hands![6]

Proponents of coerced contraception are usually driven by the wish to create an HIV-free tomorrow by preventing birth of children infected by their mothers. It is known that in Africa before the advent of antiretroviral drugs up to 40 percent of children born to HIV infected mothers were also infected. However, in Kenya, there has been an increasing access to services for prevention of mother-to-child HIV transmission (PMTCT), most often offered at antenatal clinics and at delivery. According to the Kenya Service Provision Assessment Survey of 2010, 58% of all health facilities nationwide offered some component of PMTCT services, with 33% of these facilities providing all four components for the minimum PMTCT package (HIV testing with pre- and post-test counseling, ARV prophylaxis for mother and newborn, counseling on infant feeding, and FP counseling or referral). This is increasingly reducing the incidence of perinatal transmission as well as rates of mortality among infected children. Accumulated evidence to date shows that administration of antiretroviral therapy to the mother during pregnancy, labour and delivery, and then to the newborn, as well as delivery by Caesarean section for women with high viral loads, can reduce the rate of perinatal HIV transmission to well below 10 percent[7]. What this means is that despite the many challenges not addressed here, it is possible to dream of an HIV-free generation without having to resort to cruel acts of forced contraception for HIV infected persons. Indeed this was the view expressed by UNAIDS Executive Director Michel Sidibé, during a visit to a Millennium Villages Projects (MVP) in Kenya: “We have seen that it is possible to virtually eliminate infant HIV infections in high-income countries ….Now we must apply the knowledge and tools to create an AIDS-free generation in Africa and the rest of the world.”[8]

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[1]Brett Davidson and Lydia Guterman. What’s Wrong with Paying Women to Use Long-Term Birth Control? February 21, 2011 http://blog.soros.org/2011/02/whats-wrong-with-paying-women-to-use-long-term-birth-control/ accessed October 22 2011

[2] Mallet J, Kalambi V. HIV AIDS Policy Law Rev. 2008 Dec;13(2-3):77-8. http://www.ncbi.nlm.nih.gov/pubmed/19297769 accessed October 22 2011

[3]Brett Davidson and Lydia Guterman. What’s Wrong with Paying Women to Use Long-Term Birth Control? February 21, 2011 http://blog.soros.org/2011/02/whats-wrong-with-paying-women-to-use-long-term-birth-control/ accessed October 22 2011

[4] “The World: The Issue that Inflamed India” Lawrence Malkin, TIME New Delhi Bureau Chief, Monday, Apr. 04, 1977

[5] Team to probe forced sterilisation charge Express News Service

http://www.indianexpress.com/news/team-to-probe-forced-sterilisation-

[6] Outrage at guns for sterilisation policy, Indian farmers given firearms licences as an incentive to curb population growth. Randeep Ramesh in Lakhimpur The Guardian, Monday 1 November 2004 23.56 GMT http://www.guardian.co.uk/world/2004/nov/01/india.randeepramesh

[7]http://www.cdc.gov/hiv/topics/perinatal/resources/factsheets/perinatal.htm

[8] http://www.avert.org/pmtct-hiv.htm

My considered view on the new Africa based study published in the Lancet linking hormonal contraception for women to increased HIV infection risk

A research report published in the Lancet on 4^th October 2011 has provoked widespread fear throughout the world. This multicentre study involving in seven African countries: Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zimbabwe, has shown increased risk of HIV infection to women who used hormonal contraceptives– particularly injectable methods like Depo Provera, as well as to male partners among discordant couples. The global concern is due to the fact that there are more than 140 million women worldwide using hormonal contraceptive methods. In most African countries, Kenya included, the injectable contraceptive is the most widely preferred method. The Kenya Demographic and Health Survey (2008-9) showed that more than a half (22%) of the 39% of Kenyan married women using a modern contraceptive method relied on Depo provera.

Three points are worth emphasizing. First, generally, hormonal contraceptives are safe and effective family planning methods that are central to initiatives to reduce unintended pregnancies, empower women, promote economic development, and improve maternal and child health.  Family planning has a key role to play in the attainment of Millennium Development Goals.

Second, there is no such thing as a contraceptive that is 100% safe and, in fact, contraceptive practice is associated with a variety of risks, depending on the method used. This is why family planning service providers have a responsibility to assess the risk to clients of developing method-associated complications (side effects), depending on the health history and the nature of the method chosen. It is important that all clients seeking family planning services should be assessed with regard to their risk of STIs including HIV/AIDS, remembering that all persons at risk of getting infected with an STI are also at risk of getting infected with HIV. It must be realized that HIV/ AIDS is largely a sexually transmitted disease.

The third point to emphasize is that whereas hormonal contraceptive methods are extremely effective in preventing pregnancy they do not prevent infection with STIs including HIV. On the other hand, proper and consistent use of condoms (male and female) is an effective way of preventing most STIs, including HIV. This is why family planning service providers should promote dual protection- the use of condoms for clients who are at risk of acquiring STIs even when they are using other methods of family planning methods.

In Kenya, the above points are emphasized in the Fourth (2009) Revised Edition of Family Planning Guidelines for Service Providers published by the Division of Reproductive Health, Ministry of Health, which is updated from time to time to incorporate evolving research evidence. It is guided by a WHO Scientific Working Group which periodically reviews the latest scientific information on safety of contraceptive methods, and makes recommendations on criteria for their use in different situations (WHO Medical Eligibility Criteria).

What are the prospects of Africa achieving universal access to HIV treatment?

Universal access to HIV treatment is one of the targets of Millennium Development Goal 6 (MDG6), the indicator for which is the proportion of the population with advanced HIV infection with access to antiretroviral drugs (ARVs). For Africa, achievement of this goal is a monumental task considering the sheer magnitude of the problem. In 2008 sub-Saharan Africa was home to just over 22 million of the world’s estimated 33.4 million people infected with HIV[i]. Almost every country in the region has suffered a generalized HIV epidemic, with the highest HIV prevalence rates existing in southern and eastern Africa. South Africa is reputed to harbour the greatest number of people living with HIV in the world (about 5.7 million).

In the past decade there has been a considerable increase in access to HIV treatment in resource-limited settings where antiretroviral medications were previously unavailable, rising 10-fold between 2003 and 2008[ii], thanks to global funding sources, especially the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for AIDS, Tuberculosis and Malaria (GFATM). According to WHO and UNAIDS[iii], the coverage of ARV therapy in the sub-Saharan Africa, rose from 2% in 2003 to an estimated 44% of adults and children by December 2008. However, important access gaps still remain. In Kenya, for example, by 2009 only 290,000 persons that required ARV treatment were receiving it[iv], at a time when more than 1.4 million Kenyans were living with HIV[v]. In the sub-Saharan Africa, by end of 2008 only four countries (Botswana, Namibia, Rwanda and Senegal) had ARV coverage of 50% or more among adults and children who were eligible for the treatment and only six countries had achieved coverage of 50% or more of pregnant women for the prevention of mother-to-child transmission of HIV[vi].

The rapid expansion of treatment access is saving lives, improving quality of life, and contributing to the rejuvenation of households, communities and entire societies. As the number of people receiving ARVs increases, so does improvement in survival among people living with HIV. Evidence suggests that improved access to ARV therapy is helping to drive a decline in HIV related mortality[vii]. In Kenya, AIDS-related deaths have fallen by 29% since 2002[viii]. Paradoxically, this reduction in AIDS-related deaths translates into an increasing population of HIV infected persons at any given time. This implies there is a continuous increase in demand for HIV treatment. However, some data has suggested that ARV therapy may lower HIV transmission rate by as much as 90 percent[ix]. It is believed that improved access to ARVs may help to lower viral load both at the individual and community levels, this resulting in reduced incidence of new infections. Treatment coverage for children have remained lower than for adults[x] due to a number of reasons, among them: diagnosis of HIV in children is more difficult; HIV infection tends to progress faster to AIDS and death in children; and appropriate ARV treatment regimens for children are less accessible.

Challenges for scaling up of ARV treatment

Achievement of the goal of universal access to HIV treatment requires that the scope of coverage of HIV services is rapidly expanded. This in turn demands sustainable financing mechanisms, human resources, quality in service provision and use of services. It will be important to understand and address the key factors that limit the scope of coverage, and impede the demand for and utilization of HIV services, which include a weak, usually under-funded, health system, weak management and governance systems, especially with regard to procurement and distribution of needed resources- for counseling, testing, diagnosis and clinical management and monitoring of treatment, and referral systems. There is need for strengthened logistics systems, including capacity building, in order to enable adequate supply of HIV test kits and drugs at all levels as appropriate.

Acceptability of voluntary HIV testing is another challenge to the scale-up and effectiveness of HIV treatment. It is also a factor in late diagnosis and entry into ARV treatment programmes. In Kenya, as many as 4 out of 5 HIV-infected persons do not know their HIV status, while 63% that should be on treatment, do not know their status, and are therefore not on ARV therapy[xi]. Stigma and discrimination of HIV infected persons in most African countries remain important reasons for fear to come out for testing and declaring status.

A serious challenge is the sustainability of access to affordable drugs. Scaling up of HIV treatment faces the barriers to be created by the adoption of anti-counterfeits policies and laws[xii] that would block the production and importation of life-saving generic medicines, particularly ARVs.

Sustainability of funding of treatment programmes is a formidable challenge. As mentioned above the rapid increase in access to ARVs has largely been driven by PEPFER and Global Fund funding. However, since the Obama administration, there has been a stagnation of PEPFAR funding which, among other things, has discouraged enrolment of new patients into treatment programmes unless they are replacing others who have left or died. This, in turn, would allow PEPFAR funds to support treatment of an array of health issues, including those not directly related to HIV, and stabilize funding for a variety of health concerns[xiii]. This implies many countries will be forced to treat the very sick patients first, and will be hard put to implement the updated WHO standard which raises the cut-off point for commencing ARV treatment from a CD4 count of 200 to 350.

The lesson is clear: whilst advocacy for enhanced international assistance must continue, at the same time African governments must increase national contribution to the cost of health care including HIV treatment, and increasingly reduce over-reliance on foreign support for critical sectors such as health care. For example, it has been reported that foreign agencies pay for more than 90 percent of Uganda’s AIDS-treatment regimens (Uganda is certainly not alone in this category). As the East African[xiv] has put it “donors hold the power of life and death over people living with HIV in Uganda”. Funding from the Global Fund has also been unpredictable. In the wake of repeated corruption allegations, in 2009 the Fund approved just under 6 percent of Uganda’s request. Kenya also has frequently run into a collision with the Global Fund over accounting issues, which has resulted in delayed release of subsequent allocations[xv]. Only Malawi, dubbed the model of success in the sub-Saharan African fight against AIDS, stands alone in this respect- the country is said to have actually doubled its own health spending. African governments can learn a lesson from the trend in Latin America, Asia, and the Middle East, where most governments double their health budgets while receiving aid[xvi].

Without enhanced international assistance and strong commitment by African governments to immediately increase budgetary allocations to the health sector, including for the purchase of ARVs, achievement of universal access to HIV treatment will remain an illusion. It is the hope that the resolution at the recent African Union Summit in Kampala, 19 to 27 July 2010, committing African leaders to invest more in ‘community health workers’ and to meet the Abuja target of investing up to 15% of government expenditure to health, will not simply gather dust like others in the past decade.

Another challenge, not frequently verbalized in medical circles, is ensuring access to appropriate diets for people entering HIV treatment programmes. Addressing the nutritional needs of such people has not been adequately prioritized within HIV and AIDS prevention, care and mitigation programmes that are currently underway in many sub-Saharan African countries. This is despite the knowledge that HIV infection, food and nutrition are closely linked, and cumulative evidence suggests that bolstering the nutrition of HIV infected persons can sustain them in active productive life, delay the onset of AIDS and permit longer survival. Malnutrition, an endemic problem in many parts of the region, is known to exacerbate the effects of HIV by further weakening the immune system, and contributing to poor tolerance to, as well as effectiveness of ARVs[xvii].

Among the major concerns voiced by groups of people living with HIV in five African countries visited by the writer[xviii], was food shortage, especially balanced diet that they are regularly advised to take while on treatment with ARVs[xix]. For example, one person in Zambia complained that he had been instructed to eat five meals a day while on treatment; this at a time when he could barely get one meal per day! The result is that many simply did not take their drugs.

Adequate nutrition improves the effectiveness of HIV treatment and sustains quality of life. In view of this, nutritional assistance should be an important component of HIV treatment programmes. This may be in the form of nutritional assessment, counseling, and increasing access to food, either provided directly, or through social protection programmes such as cash transfers, or facilitated income generation activities. In the long run, mitigation of the impacts of HIV and AIDS should include interventions that focus on increasing access to food and improved diets for HIV infected persons, for example, through measures that enhance household incomes, and improved agricultural productivity.

Related link

Food insecurity a serious threat to achieving universal access to HIV treatment in Kenya-millennium development goal Target 6B

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[i] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) AIDS epidemic update: November 2009.

[ii] World Health Organization, United Nations Children’s Fund, UNAIDS (2009). Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Geneva, World Health Organization.

[iii] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) AIDS epidemic update: November 2009.

[iv] Dr Ibrahim Mohamed Scale up of access to ART in Kenya National Aids Control Program; Ministry of Medical Services Kenya, November, 2009

[v] National AIDS and STI Control Programme, Ministry of Health, Kenya. July 2008. Kenya AIDS Indicator Survey 2007: Preliminary Report. Nairobi, Kenya.)

[vi] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) AIDS epidemic update: November 2009.

[vii] Jahn A et al. (2008). Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi. Lancet, 371:1603–1611; Mermin J et al. (2008). Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study. Lancet, 371:752–759.

[viii] National AIDS Control Council, National AIDS/STI Control Programme. Sentinel surveillance of HIV and AIDS in Kenya 2006. Nairobi, National AIDS Control Council, National AIDS/STI Control Programme, 2007.

[ix] Attia S et al. (2009). Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS, 23:1397–1404.

[x] UNAIDS (2008). Report on the global AIDS epidemic. Geneva, UNAIDS.

[xi] National AIDS and STI Control Programme, Ministry of Health, Kenya. July 2008. Kenya AIDS Indicator Survey 2007: Preliminary Report. Nairobi, Kenya.)

[xii] These include the Anti-Counterfeit Act of 2008 in Kenya, the Counterfeit Goods Bill in Uganda and the EAC Anti-Counterfeits Bill

[xiii] NEWSWEEK Aids Programs Hit Setbacks in Africa

http://www.newsweek.com/2010/04/27/aids-programs-hit-setbacks-in-africa.html

[xiv] Esther Nakkazi Uganda: ARV Shortage Sets in As Aids Funding Falls East African 3 August 2009: http://allafrica.com/stories/200908031372.html

[xv] Gatonye Gathura and David Njagi Kenya: Row With Global Fund on Cards Daily Nation On The Web 5 October 2009: http://allafrica.com/stories/200910051673.html

[xvi] NEWSWEEK Aids Programs Hit Setbacks in Africa

http://www.newsweek.com/2010/04/27/aids-programs-hit-setbacks-in-africa.html

[xvii] ^[xvii] WHO (April 2005), “Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action

[xviii] During 2006/7 the writer had the privilege of interacting with groups of PLWHA in Kenya, Tanzania, Uganda, Zambia and Zimbabwe, whilst a consultant to Heifer International of Little Rock, Arkansas, USA.

[xix] Japheth Mati (2010) Food insecurity a serious threat to achieving universal access to HIV treatment in Kenya (Millennium Development Goal Target 6B) http://blog.marsgroupkenya.org/?tag=africa-health-info

A commentary on population and development in Kenya

The theme of Kenya’s National Leaders’ Conference on Population and Development, November 15-17, 2010 is “managing population to achieve Kenya Vision 2030”. Vision 2030 is the national blueprint for long-term development which aims to transform Kenya into “a newly-industrialising, middle income country providing a high quality of life to all its citizens in a clean and secure environment”. The Vision is anchored on three key pillars: Economic; Social; and Political Governance. This conference comes in the wake of the release of the 2009 Population & Housing Census , in which Kenya’s population is estimated at 39 million, with the population growth rate calculated at 2.5 percent over the period 1999-2009. A lot of concern has been expressed on the revelation that Kenya’s population increased by about a million people annually over that period, and that the population is projected to reach 64 million by 2030.

Kenya’s population growth rate increased steadily from 2.5 percent in 1948, peaking at 3.8 percent in 1979, this being one of the highest growth rates ever recorded. In 1989 the population growth rate began to decline, to 3.4 percent and further down to 2.5 percent in 1999, a level that has been sustained to 2009. The current population growth rate (of 2.5 percent), is still considered to be high, and owing to the past growth rates the population is still youthful with nearly half being aged 18 years or below. This is what has been dubbed demographic momentum– a phenomenon of continued population increase despite reducing fertility rates, which is brought about by waves of large populations of young persons entering reproductive age in successive years. This may in part explain the addition of one million people annually to Kenya’s population, as referred to above.

From the above, it is indeed a disconcerting thought for family planning advocates; to realize that there is a limit as to what birth control per se can do to significantly curtail Kenya’s population increasing trend over several decades! Perhaps the attention should change to finding out how to take advantage of the population momentum to improve our economy, so as to provide a high quality of life to all Kenyans, as envisioned in Vision 2030. Nevertheless, family planning will continue to play a central role in measures taken to improve the economy.

Can Kenya make use of the demographic momentum; make it a source of strength, not a threat? This is exactly what the so-called Asian Tigers did. They were faced with a situation similar to Kenya’s- coming from decades of high fertility that had generated huge population momentum. With better planning and viable economic policies they were able to unleash a healthy and better-educated workforce with fewer children to support and no elderly parents totally dependent on them. It can happen here; with adoption of social, economic, and political policies that allow realisation of the growth potential of our youth across the country, Kenya’s large youthful population can become our boon not our bane. To that end, family planning will remain a key driver of Kenya’s sustainable economic growth now and in the foreseeable future.

The government statement that “critical investment will be required in family planning services, health and other social and economic sectors to improve the welfare of Kenyans” is welcome. However, it needs to be followed by a critical review of the factors that have interfered with the effectiveness of Kenya’s Family Planning Programme; there is need to ask ‘what went wrong? In my view, these factors fall in two broad categories: First, an uncertain environment for effective promotion of birth control measures (political commitment; gender equity; child survival, among others), and second, serious chronic institutional weaknesses that interfere with effectiveness of the family planning programme (coverage of FP services; commodity security; quality of services and care, among others). Hopefully, the Leaders’ Conference may address these issues.

Related link

Kenya’s Rapid Population Increase: Our bane, boon or both

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