The abortion dilemma

By Caroline Ariba

Make no mistake; every 60 minutes, slightly over 33 women will have had an abortion. By the end of the day, a whopping 800 abortions will be carried in Uganda, translating to 292,000 abortions annually. And of these, 1,500 will die!

Well, this is according to a 2013 report by the Centre for Reproductive Health Uganda titled; A Technical Guide to Understanding the Legal and Policy Framework on Termination of Pregnancy in Uganda.

Annually, the report also revealed that 900,000 of the country's 2.2million pregnancies are unplanned. Even worse, an alarming 400,000 of these end up in abortion, most of which are largely unsafe!
 
Note however, the Ugandan law agrees to abortion for health purposes only. Specifically, Article 22(2) states that; "No person has the right to terminate the life of an unborn child except as may be authorised by law."

To expound on this the 2006 National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights states that; pregnancy termination is Uganda is permissible in cases of fetal anomaly, rape and incest, or if the woman has HIV.
 
Mulago Hospital's senior gynecologist Dr. Charles Kigundu argues that almost rarely do abortions in the country occur on the grounds listed above.

"Yes, they are very vital grounds, but how many times do you see women or actually teenagers get abortion on these grounds. Not quite often, yet there are all sorts of shady abortions going on!"
 
He then said that the law which should be bringing to a halt the number of abortions has instead pushed them further into the dark. "Remember that just because they are in the dark does not mean that they are not happening. Oh yes, they are and more unsafe than ever, claiming lives like never before," Dr. Kigundu said.
 
Like Uganda, the Nigerian law only allows for abortion to preserve the mother's life but she too has had large numbers of procedures performed despite its stand.

In fact, back in 2008, the Society of Gynecology and Obstetrics of Nigeria reported that 11% of maternal deaths in Nigeria are caused by unsafe abortions. Despite this similarity, Uganda hurts more from unsafe abortions.

As a matter of fact, in its 2008 annual report, the health ministry estimated that 26% of all maternal mortality which stands at 438 per 100.000 live births, in the country was as a result of abortion-related conditions.
 
Nigeria and Uganda are not the only ones wallowing in unsafe abortions. See, a 2011 World Health Organisation (WHO) annual report stated that the African region as a whole is too.

"Its regional incidence has hardly declined, remaining close to 13 percent. More tellingly, close to 62% of the women who die from unsafe abortion or 29 000 (out of the 47000) are from the African region," it further revealed.

WHO further revealed that deaths from unsafe abortion worldwide have dropped from 69,000 in 1990 to 47,000 in 2008.  A one-third decline in maternal mortality from 546,000 deaths in 1990 to 358,000 2008 was seen.

Do not celebrate yet, because despite the decline in the number of deaths due to unsafe abortion, WHO reported that the proportion of women dying from unsafe abortion has remained the same at approximately 13% of all maternal deaths.
 
Abortion WHO further stated had increased from 19.7 million in 2003 to 21.6 million in 2008, with up to 14 women per 1000 women having carried out one.  The reduction in percentage however at the time had a lot to do with a vast number of children below the reproductive age.
 

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  Cost of unsafe abortion

The health ministry recently revealed that 40% of admissions for emergency obstetric care in Uganda are a result abortion related cases.

Professor Joseph Babugumira of the University of Washington goes further ahead to expound on these costs. So in his report, he stated that such complications need complex tertiary care, which is only available at referral hospitals.

"But also, these complications defiantly need 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."
 
Using computer projections and data estimates, he found that the annual cost of induced abortions in Uganda amounted to US$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, he stated if saved, could be better deployed.
 
What could help?

A 2013 brief by the Guttmacher Institute states that Uganda's abortion rates are higher than East Africa's as a whole which stands at 18%.

Then the United Nations Population Fund (UNFPA) 2012 annual report also stated that of the 292.000 unsafe abortions, 140.000 of them occur amongst girls aged between 15 and 24 years of age. Note also, that the very report places the country's teenage pregnancy at 24%, thus explaining the 140.000 figure.
 
Esperance Fundira, the UNFPA country director argues that behavioral change and prevention of pregnancy through preparedness should be promoted.

"We need to ensure access to contraceptives at all times to prevent any unwanted pregnancies. For example if these 140.000 girls had access to condoms at all times, chances are low that they would get pregnant."
 

  However the country's unmet need for contraception, which according to the 2012 State of Uganda Population report stands at, 41%, would make this a bit tricky to achieve.

The un-met contraceptive rate is defined by UNFPA as the percentage of those that want some form of contraceptive but cannot access it. And yes, this is worse than Kenya and Tanzania's which stand at 25% and 22% respectively. Oh, then there is Rwanda whose rate is at 38%.
 
A 2011, Guttmacher Institute report also revealed that only 13–15% of Uganda's poorest and least educated married women used modern contraceptives, compared to the 37–39% of the wealthiest and most educated women. "39% of the urban married women used modern contraceptives compared to their rural counterparts a mere 23% in the village.
 
In Uganda, the Guttmacher Institute brief quotes a study among rural Ugandan secondary students that found that 43% of them said they had been very unwilling to have their first sexual encounter when it did.

The report further revealed that because of the stigma associated with premarital sex, many young people are reluctant to openly seek the family planning services and counseling they need.
 
Indeed the 2011 Demographic and Health Survey, one of the most commonly cited reasons that unmarried, sexually active young women do not use a contraceptive method is that they are not married, underscoring the impact of the general taboo against sex outside of marriage.
 
It is on these grounds that, several individuals and civil society organizations under the umbrella body, the Coalition to Stop Maternal Mortality due to Unsafe Abortion, believe having a pro-choice abortion policy would help.
 
Would fully legalizing help?

Those against abortion, however safe have out rightly called it murder, and a fast rout to encouraging promiscuity. A quite vocal Reverend, Steven Gelenga of St. John's Church in Kamokya, a Kampala suburb couldn't stress how bad legalizing abortion would make the situation.

"Why go for sex if you are not prepared for the consequences. Sex is sacred; we need to treat it as such!" He argued that legalizing abortion will lead to more abortions and even worse the spread of HIV.

"I mean, since they know it is easy to run and remove, they will keep doing it."
 
During a university dialogue on sexual rights organised by reproductive health earlier this month, the minister for Primary Healthcare, Sarah Opendi, said that before anyone talks abortion, they should put emphasis on family planning.

"Yes, this will prevent the consequences of any unwanted pregnancies. However, what happens when a woman is faced with no option after the pregnancy happens anyway, what happens?" she wondered. "Also, abortion is not a pleasant thing that you go around doing, it is not at all!"
 
Legalizing abortion researchers have found does not necessarily increase the number of abortions carried out per say.

The Executive Director Reproductive Health gives an example of the decision in 1973 by the Supreme Court ruled that women, in consultation with their physician, have a constitutionally protected right to have an abortion in the early stages of pregnancy.

"Yes, at first the number of safe abortions, with the key word being 'safe' increased. But the deaths from abortion related situations were going down," he said.