The demand for abortion in Uganda is high, despite legal and moral proscription. John Semakula explores how a mere policy can bring great cost and pain to citizens.
Abortion is illegal in Uganda. According to the Penal Code, a doctor who thinks that an abortion is justified to save the life of the mother, must write to the director general of medical services in the health ministry, seeking approval to terminate the pregnancy. Upon receipt of the letter, the director general is supposed to convene a medical board, composed of experts, to scrutinise the case and, if satisfied, appoint a specialist to carry out the procedure.
But this is absurd, because there is never time for this red tape in times of emergencies. And, according to an official of the Uganda Medical and Dental Practitioners’ Council, there is no recorded case that has ever followed this procedure.
The code prescribes a prison sentence, ranging from three to 14 years, for procuring, assisting or supplying drugs to aid abortion.
All religions and cultures in Uganda preach against abortion and anyone associated with it is considered a social outcast. But, instead of purging it from Ugandan society, it is swept underground, where it sprouts into tremendous cost to society.
Abortion seekers usually go to illegal clinics, where procedures are performed under unhygienic conditions by under-trained practitioners. Such procedures usually lead to a high rate of death and severe complications, leading to diversion of substantial, scarce healthcare resources.
Research by the Guttmacher Institute, a US-based non-governmental organisation which promotes reproductive health including abortion rights, released at Grand Imperial Hotel in Kampala recently, shows that over 5% of Ugandan women aged 15 to 49, perform unsafe abortions every year. Almost half of these abortions are administered by non-professionals like pharmacists, traditional healers and women themselves, which poses a great risk to their lives.
According to Prof. Joseph Babugumira of the University of Washington, who carried out research on induced abortions in Uganda, the problem is the fact that abortion is illegal.
Illegally performed abortions are unsafe, he said, and pose a large health risk to women because of inadequate skills of the providers, unhygienic conditions and hazardous techniques. “These increase the rate of immediate complications, such as severe bleeding, abdominal and genital injury or death,” he wrote in his 2011 report.
“If women survive the procedure, they may develop complications, most commonly haemorrhage, sepsis and genital perforation. Such complications need complex tertiary care, which is only available at referral hospitals with the capacity to perform extensive surgical operations, blood transfusion and intensive care. Patients with such complications tend to have long hospital stays, with 57% staying for more than 13 days.”
He adds: “This results into consumption of large amounts of healthcare resources, such as personnel, theatre space, medications and hospital beds. Some of the women who survive their hospital stay also suffer long-term complications such as pelvic infection, ectopic pregnancy, vesico-vaginal fistulae, urinary incontinence, utero-vaginal prolapse, infertility, and mental health problems.
“These complications usually require specialist care and are associated with increased health resource utilisation.”
Babugumira adds that because abortion is illegal, the majority of trained and untrained providers choose surgical techniques such as evacuation and manual vacuum aspiration to terminate pregnancies.
“Drugs like misoprostol and mifepristone, are the safest form of medical abortion. But they cannot be openly imported and have to be smuggled into the country at a higher cost,” he says.
Cost of abortions
Babugumira used computer projection to estimate the annual cost of induced abortions in Uganda and came up with about $64m (sh160b).
He divided this into societal and healthcare costs. Societal costs include productivity costs (52%) — death of young mothers, loss of labour to sick hours and attendants. Healthcare costs (48%) include direct medical and direct non-medical.
The average societal cost per induced abortion was at $177 (sh442,500). Of this, the average direct medical cost was $65 (sh162,500), while the average direct non-medical cost was $19 (sh47,500).
The average indirect cost was $92 (sh230,000). Patients incurred $62 (sh155,000) on average, while government incurred $14 (sh35,000).
In a country where total per capital health expenditure is only $44 (sh110,000), these costs represent a substantial diversion of public healthcare resources, which, if saved, could be better deployed.
Yet, Government, which should be responsible for providing healthcare, incurs only 17% of the total costs, with the bulk of the total healthcare costs (83%) incurred by patients and their families. That, he concluded, may be the reason for the policy-maker apathy that characterises efforts to reduce unsafe abortions in Uganda.
Last month, the Association of Uganda Women Medical Doctors (AUWMD) organised a three-day workshop at Makerere, where they discussed abortions vis-a-vis the present legal framework.
Stephen Sserumaga, a coordinator with the Uganda Youth Empowerment Scheme, Kawempe, explained how the youth resort to abortion for fear of financial implications, stigma, expulsion from school and health problems like HIV.
Prof. Florence Mirembe of Mulago Hospital said abortion-related complications were some of the leading causes of admissions to the gynaecological wards in hospitals countrywide.
Mirembe, who is also an associate professor at Makerere University, said Uganda spends about sh7.5b a year treating complications resulting from unsafe abortion.
The situation in other countries
In England, a doctor who refuses to carry out an abortion on the basis of religious convictions is guilty of manslaughter, if the woman dies.
In many African countries, the colonial laws on abortion have been revised in response to the increasing calls for respect of women’s health rights. In Ghana, Ethiopia, South Africa, Benin and Chad, laws regarding abortion have been liberalised.
In 2004, Ethiopia changed the law on abortion to allow termination of pregnancy, resulting from rape or incest, where the foetus has an incurable or serious deformity, or where the pregnant woman, owing to a physical or mental deficiency, is unfit to raise the child.
In South Africa, the Choice of Termination of Pregnancy Act allows a woman to get an abortion on request during the first trimester of a pregnancy (first 12 weeks).
In Ghana and Botswana, the law allows abortion to be carried out if the pregnancy involves risk to the life of the mother, or injury to her physical or mental health.
Abortion illegal in Uganda
While the debate on legalising abortion has lingered on, the proposal is opposed by many Ugandans. Most arguments are based on religious, cultural and moral grounds.
On religious grounds, the right of the unborn child to live is equivalent to that of the mother. Traditionalists favour large families, while moralists refer to abortion as murder.
But women activists are demanding the expansion of grounds upon which abortion can be made legal, to include incest and rape.
The annual abortion expenditure in Uganda is a testament to the economic impact of abortion in countries where it is illegal. Uganda has an obligation to improve maternal health as dictated by the Millennium Development Goal number 5. This must include unsafe abortions by increasing contraceptive coverage or providing safe, legal abortions.
The AUWMD meeting made the following recommendations:
Increase access to reproductive health information with a focus on the youth and adolescents (bodaboda, market vendors, footballers and fans, students and pupils)
Increase access to contraceptive commodities (condoms, morning after pill, hormonal methods, etc)
Build capacity by providing up-to-date legal and medical information to health workers on abortions.
Conduct more formative research on abortion to inform policy-makers at the national and regional levels.
Revising the laws on abortion to ensure safe abortion.
Babugumira appealed to policy-makers like parliamentarians and health planners to find ways of dealing with the high levels of unsafe abortion and low levels of contraceptive use in Uganda to reduce death and diseases associated with unsafe abortions.
He advised the Government and donor agencies to increase resources to programmes which aim at sensitising women and improving post-abortion care.
Real life experiences
Madina died while trying to abort
Madina’s sudden death is something her family will never easily forget. She died while attempting to abort.
She said she was advised to do it by a colleague, whom she told about her pregnancy.
Madina was in high school when she got pregnant. She chose to abort for fear of what her strict parents would do. Her lover also encouraged her to abort because he could not take care of the baby.
On the fateful day, Madina waited for everyone in the house to sleep, before taking a concoction of Jik and black tea. Her parents were awoken by her groaning as she writhed in pain. She died on her way to hospital.
Madina’s mother has never stopped blaming herself for her daughter’s death. She says she should have talked to her about the dangers of early sex, including pregnancy and abortion.
Joan survived, but was sent away from home
Joan was at university when she became pregnant. Her boyfriend accused her of being careless and cut off communication.
Frustrated, Joan resorted to abortion. She feared that if her uncle, a religious leader, found out that she was pregnant, he would be disappointed. She also feared that pregnancy would affect her health, since she was HIV-positive.
At nine weeks, Joan went to a clinic in one of the city suburbs and paid sh70,000 for an abortion. Joan was writhing in pain and bleeding severely, after a clinic attendant had conducted a procedure on her. She ended up in Mulago Hospital, where she was hospitalised.
Her uncle learnt about the incident and sent her away from home.
Amanda dropped out of school after abortion
Amanda was made pregnant by her paternal uncle in 2004, and when she revealed this to her relatives, she was scorned for bringing a curse to her family.
Overwhelmed by shame, Amanda decided to abort. Her uncle provided her with sh30,000, which she paid to a herbalist, who gave her a local herb to take.
Unfortunately, the abortion was not successful and Amanda had to be hospitalised for the foetus to be removed.
Although Amanda had just completed Senior Four, her parents refused to take her back to school.
These are some of the stories women narrated to researchers in a study carried out in July last year. The research, conducted by Associate Professor Christopher Mbazira of Makerere University’s law department, shows how society’s intolerance has worsened women’s pregnancy challenges.
The number of women who get pregnant by accident every year. About 38% of these pregnancies result into abortions
The estimated number of induced abortions in Uganda in 2009. This was up from 297,000 in 2003
The number of maternal deaths caused by unsafe abortions in Uganda, compared to about 13% of all maternal deaths globally
Uganda spends sh160b on unsafe abortions every year — research