At the end of July last year, Jowelia Nankya, a resident of Kyaliwajala, a Kampala suburb, got a 17-year-old maid from Serere district in Eastern Uganda.
She quickly noticed that the maid was sluggish and tended to sleep a lot. Nankya also noticed that their stock of sanitary towels, which she kept in the bathroom cabinet and their toilet roll got used up very fast.
A week later, the maid confided in her that she had severe abdominal pain and on-and-off bleeding.
"At first, I thought she was going through a hormonal imbalance. However, the bleeding seemed too much; I would find the toilet seat stained; and one time, I went to wake her up in the morning and her bedsheets were soiled. Another time, she was washing dishes and blood suddenly poured out of her onto the floor. She even used to mess up the seats. The girl really seemed sick, weak and slept all the time," says Nakya.
Nankya, who works in health promotion, says she rang up a gynaecologist and asked for an appointment, which was set for 2:00 pm the next day.
She explains that owing to her busy schedule, she would leave home in the morning and go back late in the night every day. However, on the day of the gynaecology's appointment, she went back home at mid-day to pick the maid. Nankya says when she looked at the girl, she got shocked. "The girl was pale and her palms were almost white. It was clear that she was severely anaemic.
"When I informed her that I was taking her to see a doctor, she refused and asked me for money to go back home," says Nankya.
She then disclosed to Nankya that a month before she came to Kampala, she had discovered that she was pregnant and her brother had linked her to a clinic where abortion was done. The girl also disclosed that her boyfriend was at teacher at the school where she had been a student.
Nankya approached several clinics seeking to have the girl treated. However, one clinic in Namugongo refused to have the girl treated, explaining that they were a Catholic-founded clinic and so they could not provide post-abortion care. Other clinics she tried asked for a lot of money, between sh400,000 and sh600,000. So, she ended up going to Naguru Hospital (a government facility).
"I was really surprised by the good quality of care given at Naguru Hospital; she was first taken for a scan from which it was concluded that the abortion had been incomplete (part of the foetus had remained in the womb). To make matters worse, her cervix had closed, so the body could not expel what had remained of the pregnancy," notes Nankya.
The doctor explained that that was why the girl was experiencing severe abdominal pain and bleeding. He warned them that if she was not treated immediately, she could suffer heavy bleeding and infections, which could even make her lose her uterus.
The doctor first gave the girl medicine to open up the cervix and let whatever had remained of the pregnancy to come out. She was then given other treatment and kept for observation overnight.
Fortunately, the girl recovered fully and after a week, Nankya sent her back to the village.
Nankya notes that the treatment at Naguru was generally free, although she had to pay for a few sundries and medicines that were out of stock.
Cost of post-abortion care
Young people, like Nankya's maid, contribute over 40% of maternal deaths in Uganda and unsafe abortions account for almost 10% of all maternal deaths in Uganda.
Research by the Guttmacher Institute shows that in 2013, about 314,300 abortions were carried out in Uganda, translating into 14% of all pregnancies. In addition, about, 128,682 women were treated for abortion complications and more than 93,000 women were hospitalized for complications from unsafe abortions.
Apart from the direct cause of unsafe abortions, which is unwanted pregnancies, the law that restricts access to abortion services is a contributing factor to unsafe abortions.
In his professorial inaugural lecture delivered in April 2017, Prof. Ben Kiromba Twinomugisha of Makerere University noted that: "Albeit access to safe legal abortion is a critical element of the continuum of maternal health care, the law in Uganda restricts termination of pregnancy."
The Ugandan Penal Code of 1950 indicates criminal penalties for anyone who obtains an abortion or contributes to the procurement of one. There is one exception permitted - if the procedure is to save the woman's life.
Such a law also discourages those who have undergone abortions from seeking treatment. In addition, health workers fear to provide post-abortion care owing to the fear of criminal liability, explains Joy Asasira, a programme manager at the Centre for Health, Human Rights and Development (CEHURD).
Asasira adds that the Ministry of Health National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights specify the number of grounds under which abortion is permitted, including rape, incest and defilement, or if the woman has HIV. These policies also allow access to the service at facilities ranging from Health Center IVs through the referral hospital level.
However, Asasira notes that many providers and women are still unaware of the expansions to the law, which has made legal abortion difficult to obtain and to be provided.
Asasira explains that the restrictive laws drive up stigma, which affects service delivery and subsequently drives the practice underground to quacks who procure unsafe abortions.
WHO defines an unsafe abortion as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking minimal medical standards or both.
Asasira decries the fact that unsafe abortions have put the lives of many women in danger, resulting into injury and complications such as excessive bleeding, injuries to tissues and organs, sepsis, secondary infertility and even death or depression.
WHO notes that these result in the death of 47,000 women every year and leaves millions disabled. Twinomugisha noted that there is a direct correlation between restrictive abortion laws that criminalize women who seek abortions outside of the law, and high rates of unsafe abortion.
According to WHO, between 2010 and 2014, three out of four abortions that occurred in Africa and Latin America were unsafe. In addition, the risk of dying from an unsafe abortion was the highest in Africa.
Because of the stigma attached to the issue, even the people who seek treatment usually do not easily open up to health workers, notes Joyce Aponi, a service provider for Reproductive Health Uganda for Mbale.
She explains that if the medical worker fails to probe and win the trust of the patient, the patient might go back without getting the necessary treatment.
Aponi says the cost of the treatment they offer at her facility ranges from sh25,000 to sh100,000, adding that it includes antibiotics and sometimes an evacuation procedure to remove remaining tissue. However, she notes that they only deal with uncomplicated cases and in case of complications, for example, excessive bleeding, severe sepsis, severe pain, shock or damage to the uterus and other organs, the patient is referred to a bigger facility.
Information from the Guttmacher Institute shows that in 2010, the cost of treating complications from unsafe abortion was about $131 per patient. In total, post-abortion care costs about $14m every year in Uganda.
Aponi says counselling is key in post-abortion care, in addition to sensitizing the clients about contraception. She adds that they usually initiate many of the clients on postpartum family planning.
Challenges to seeking treatment
Asasira notes that health-care providers are obliged to provide medical care to any woman who suffers abortion-related complications, regardless of the legal grounds for abortion. However, in some cases, treatment of abortion complications is administered only on the condition that the woman provides information about the person(s) who performed the illegal abortion.
Asasira decries the practice of extracting confessions from women seeking treatment, noting that it puts the women's lives at risk.
She adds that the legal requirement for doctors and other healthcare personnel to report cases of women who have undergone abortion delays care and increases the risks to women's health and lives.
According to WHO, unsafe abortions are almost entirely preventable since they are majorly a result of the unmet needs for family planning, contraceptive failure, a lack of information about contraception, and restricted access to safe abortion services. Asasira notes that other risk factors to unsafe abortions among Ugandans are poverty, lack of access to proper services and the high prevalence of sexual violence (rape, incest and defilement) among the communities.
Information from CEHURD also shows that the level of abortion in Uganda is expected to remain high. This is mainly due to the fact that many pregnancies are unwanted, unintended and poorly timed. Presenting the Guttmacher research at Hotel African recently, Dr Justine Bukenya of Makerere University noted that: "Nearly half of the 2.3 million pregnancies that occurred in Uganda in 2013 were unintended."
As Aponi notes: "Sometimes we get people asking for abortion services. However, we do not offer such services, so we just counsel them. Although there are some that keep the pregnancies, many still go through with the abortion."
According to WHO, almost every abortion death and disability could be prevented through sexuality education, use of effective contraception, provision of safe, legal induced abortion, and timely care for complications.
Asasira highlights the need to sensitize stakeholders (medical workers, members of the judicial system and women) about the laws and policies, in addition to raising awareness.