The high cost of unsafe abortions

As an orphan, Jane Nankya* lived with her grandmother and everything was okay until an uncle who later joined them sexually abused her and made her pregnant.
At the time she was 12-years-old. She says, “Shortly after the death of my parents, I lived with my grandmother in a two-roomed rented house in Kawempe. We were later joined by my uncle, who had come to the city for treatment.”
As she was adjusting to living with her uncle he defiled her and threatened to chase her away if she told anyone about it.
“Unusual things started happening to me. I used to vomit in the morning and have morning sickness.” She only revealed her condition to a close friend, an agemate. When she told her uncle he was furious.

“He advised me to have an abortion and escorted me to a clinic but abandoned me as soon as he finished talking to the doctor and paying the bill,” she narrates.
The 16-year-old is now a Senior Two student but her life is far from that of a typical teenager.

The aftermath
At the hospital, the doctor gave Nankya two tablets to take in two phases before and after terminating the placenta. She was also tested and found to be HIV positive.
“I knew I had got the disease from my uncle because he was the only person I had ever had sex with,” she says tearfully.
Unfortunately, that is not where her woes ended. That night, when Nankya was sleeping, blood was driping through her clothes. When she dashed to the toilet, something from her vagina with a loud thud and dropped in the pit latrine and she knew it was done.
But this was far from it. Within a few days, Nankya had relentless stomachache. She confined herself to their house to avoid suspicion. “I thought I was going to die. The painkillers could not relieve the pain, it persisted,” she recalls.

Prevalence rates
The Uganda 2003 national abortion incidence study indicates that 15 out of every 1,000 Ugandan women of reproductive age were treated for abortion complications that year.
Such post abortion complications, the study indicated, may require hospital care, blood transfusions and antibiotics.
Nankya’s uncle noticed her deteriorating health and took her back to the clinic. It is there that the doctor revealed that the abortion process was incomplete. He treated her and perhaps saved her life.

Challenges
Denis Kibira, a pharmacist and deputy executive director, health promotion and social development (HEPS-Uganda), says absence of drugs in lower health centres is a major challenge stifling the fight against maternal mortality cases caused by post abortion complications.
“Medicines prescribed for abortions and post abortion care are only available at higher facility centres like referral hospitals but remain missing in lower health centres,” says Kibira.
Health advocates say although there are healthcare guidelines that provide for treatment of abortion complications, as part of emergency obstetric care, the bottlenecks in service delivery remain a challenge.

These are unsustainable procurement and resupply mechanisms for uterine evacuation instruments, contraceptives, and essential drugs and supplies for the many unpreventable maternal deaths.
The essential drugs available for post abortion care according to the National Medical Stores (NMS) are most antibiotics including Misoprostol and Metronidazole pills and injections, Gentamicin, Oxytocin, Ampicillin and Ceftriaxone injections as well as capsules; Amoxicillin, Doxycycline and painkillers including, Ciprofloxacin, Paracetamal, Ibuprofen, Diclofenac.
But also missing are manual vaccine aspiration (MVA kits) which contains accessories used for cleaning up of the foetus remnants.
“The availability of these medicines is affected by budget constraints which result into stockouts,” said Dan Kimosho, the spokesperson National Medical Stores.

Effects
Dr Charles Kiggundu, the former president, Association of Gynaecologists and Obstetricians says apart from the social hitches that come with unsafe abortion, there are severe complications such as infections, severe pain and loss of some of the reproductive body organs like the bladder and uterus.
“Some of these girls use overdose of chloroquine, contraceptives, detergents and others inject themselves using paraffin and sometimes they die before they reach hospital,” he says.
Dr Kiggundu, however, says, “some women use sharp-long instruments, use herbs, and roots.” He explains that when an unsafe abortion happens and the woman cannot have children anymore, it is because the inner lining of the uterus is damaged, which makes it hard for the uterus to hold the baby.
He says with so much damage the outcomes depend on how fast a woman seeks treatment.

The bigger picture
Most abortions are performed under unsafe conditions as abortion is illegal in Uganda and only permissible when preserving a woman’s life. But according to existing data, more than 65 per cent of patients receiving care for post-abortion complications are in the age bracket of 15-19 years like Nankya.
Thus, abortion seekers frequently end up in concealed and illegal clinics where procedures are performed in unhygienic environments by under-trained practitioners leading to a high rate of severe complications.
Kibira says young girls and women also fear to seek for post-abortion care for fear of judgmental treatment. “Abortion-related stigma is very high and a challenge even in cases where it is legalised,” Kibira notes.

What does the law say?
The Penal code Act cap 120, stipulates a seven-year sentence for a woman who commits an abortion and three years for anyone who unlawfully supplies drugs or anything intended to procure a miscarriage.
The Ministry of Health last year unveiled new guidelines aimed at reducing the number of deaths resulting from unsafe abortions, estimated at 1,200 annually.
Anthony Mbonye, the director of health services (community health) at the Ministry of Health said the new guidelines will help reduce the high rates of unsafe abortion, which impose a huge financial burden on the country’s already overstretched health sector.
The guidelines provide health workers with practical information on how they can manage abortion and its complications.

They also offer survivors of rape, defilement, incest and other forms of sexual and gender-based violence access to safe abortion services before reporting the incident to the police.
At a global family-planning summit in July 2012, President Museveni announced that government would increase its annual expenditure on family planning supplies from $3.3 million to $5 million for the next five years.
The Ministry of Health has also laid out a roadmap for providing universal access to family planning, involving the integration of family planning into other health services, and it plans to reduce the ‘unmet need’ for family planning to 10 per cent by 2022.

Boosting contraceptive use

According to the Guttmacher brief, one of the key reasons for the high number of abortions is unplanned pregnancy. Uganda’s unmet need for family planning stands at 34.3 percent, according to the 2011 Demographic and Health Survey (DHS); women are considered to have an unmet need if they wish to space their children’s births or limit childbearing but are not using contraception. Just 30 percent of married women of reproductive age use any form of contraception, according to the 2011 DHS, and only 26 percent of married women and 43 percent of sexually active unmarried women use a modern method.

“Closing the gap in access to contraceptives would save thousands of lives, promote economic development and advance the rights of women, especially in rural areas, among young women, and among women with less formal education,” Peter Ibembe, director of programmes at Reproductive Health Uganda (RHU), told IRIN. “Women and men need appropriate counselling so they understand the facts about modern contraception and are not influenced by myths. They also need a choice of affordable contraceptive methods that meet their needs.”
“Government should also actively promote the use of contraceptives by women and men in Uganda rather than sending conflicting messages about family planning,” he added.

Statistics
Experts say Uganda spends an estimated Shs7.5 billion ($2.28 million) annually on treating complications arising from unsafe abortions alone.
According to the ministry of Health, half of the two million pregnancies that occur every year in Uganda are unwanted. As a result about 400,000 are aborted, with 90,000 of them resulting in severe complications, which most times lead to death.
Because most abortions are unsafe, they contribute to 26 per cent of all maternal-related deaths. This figure that is higher than the World Health Organisation (WHO) average for East Africa of 18 per cent.
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