Abortion kills 1,200 women every year

By Els De Temmerman
and Irene Nabusoba

OVER 1,000 Ugandan women die every year as a result of unsafe abortions and an additional 68,000 suffer serious health complications, according to a recently released report from the Ministry of Health.

“As many as 1,200 unsafe abortions result in death each year. Nearly a quarter (23%) of all abortions result in serious complications,” says the report Road map for accelerating the reduction of maternal and neonatal mortality and morbidity in Uganda.

A 2007 study by the US-based Guttmacher Institute estimates that 56% of all abortions are carried out by medically trained personnel and 44% by untrained or traditional providers.

Poor women in rural areas suffer the most as they cannot afford what qualified medical personnel charge for an abortion and instead opt for the cheaper cost of a midwife or herbalists, or do it themselves.

A doctor charges between sh40,000 and sh140,000, a nurse or midwife between sh22,000 and sh50,000, while the fees of a herbalist or pharmacist range from sh8,000 to sh54,000.
The lower the qualification of the provider, the higher the risk of complications, the Guttmacher study found. “The more highly trained the practitioner, the less likely an abortion will place a woman at risk.”

It estimates that serious health consequences, such as excessive bleeding, infection or injury to the reproductive organs, result from a quarter of abortions performed by doctors, about half of those provided by nurses, midwives and pharmacists, two-thirds of those carried out by traditional practitioners, and 70% of those that are self-induced.

Untrained practitioners use a variety of methods, including hormonal drugs or manual vacuum aspiration. Others use more dangerous techniques, such as the insertion of rubber catheters or sharp objects into the uterus, the consumption of vaginal application of caustic substances or powerful herbal remedies.

Traditional methods used also include inhaling steam from cooked herbs, wearing dried herbs, drinking detergents or applying combinations of these techniques. As a result, half of all abortions carried out in Uganda every year result in complications.

But even abortions performed by trained health workers are not always safe. The proportion of abortions performed by doctors that lead to serious health conditions is higher in Uganda than most western countries.
“Many of our doctors have not been well trained to offer safe methods and are working under unsafe conditions,” says Dr. Charles Kiggundu of Makerere University who participated in the study.

Because abortion is illegal in Uganda, and because of the widespread social stigma attached to the practice, many women who experience complications are not seeking or receiving any help. “Roughly one in five of the estimated 297,000 women who have an abortion each year — a total of 65,000 women — suffer complications that require medical care but do not get treatment in a medical facility,” says the report.

Reasons why women don’t go for treatment, the study says, are the inability to pay for care, the fear of revealing that they have had an abortion and concern that they will receive hostile or judgmental treatment from clinic and hospital staff.

“Some residents express the fear that health care workers might challenge women about their decision to end a pregnancy, or call for the women’s arrest and imprisonment. Some practitioners are said to mistreat patients with complications or to question them harshly.”
Veronica Bakayana, a midwife says that women who show up in hospital fear to reveal that they are suffering from complications of abortion.

“Most times we have to employ guesswork. Sometimes, health workers are forced to shun such women because you may be misunderstood,” she says.

In addition, many level III and level IV health centres do not have the medical supplies or sufficiently trained health professionals to provide proper post-abortion care.
“We still have problems with such care especially in up-country facilities where things like blood transfusion are not there,” says Dr. Anthony Mbonye, the assistant Commissioner reproductive health in the Ministry of Health.

“Post-abortion care involves the administration of antibiotics and the removal of retained products but the drugs, equipment and skills are insufficient.”

Unintended pregnancies
The underlying cause of abortion is unintended pregnancies. Each year, about 775,000 women in Uganda are pregnant against their wish. In other words, four in 10 pregnancies in Uganda are unintended. The proportion of births that were unplanned rose from 29% in 1995 to 38% in 2001.

Ugandan women say they want about five children, but they have on average seven children. This means that they have two more children on average than their ideal number.
The desire for a smaller family has not been matched by an increase in the use of contraceptives.

The use of effective contraceptive methods in Uganda is very low. According to the 2006 Uganda demographic and health survey, only 24% of married women use contraceptives – 18% a modern method and 6% a traditional method.

When women who say they want no more children were asked why they were not using contraceptives, a quarter said they feared side effects, 14% said their partners were against it, 13% said they did not know where to obtain them, while 5% said their religion forbids it.

In addition, reports of shortages of contraceptive supplies in many health centres are seen as a factor discouraging women from practicing family planning. The fact that Ugandan men tend to want larger families than their wives could also influence women’s contraceptive use as many women lack the power to negotiate such matters with their husbands.

Sex education for adolescents is another area which is wanting. Although Uganda provides family life education in schools, a recent survey found that only 44% of boys and 50% of girls aged 15-19 had ever attended a sex education class or talk.

The Guttmacher Institute calls for a broader public discussion about unsafe abortion. “More public attention to the issues of unintended pregnancies and unsafe abortion is greatly needed”, says the report.

“The standards of post-abortion care must be raised and the coverage expanded. Access to family planning services and accurate information about contraception must be widely and effectively provided to reduce the incidence of unintended pregnancy.”

The Institute, above all, calls for policies that support girls’ education. “Education can help women understand the dangers of unsafe abortion, improve their status in the community and empower them to play a more active role in their own reproductive health.”