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Stigma is the main cause of unsafe abortions

Unsafe abortion practices remain the major contributor to maternal death in Uganda. PHOTO/PROMISE TWINAMUKYE

What you need to know:

  • An abortion is considered unsafe when it is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.

Abortion in Uganda is still illegal unless performed by a licensed medical doctor and in a situation where the woman’s life is deemed to be at risk.
As the world marks  the international Safe Abortion Day slated for Tuesday, September 28, health activists admit the continuous existence  of the problem, calling for the urgent need to fight the vice especially among young girls and vulnerable women.

“We want to ensure that we reduce the rates of unsafe abortion procured especially at the community  levels where women and young girls  are using rudimentary methods to terminate unwanted pregnancies,” Yiga Musah, the team leader of Community Health Rights Network (Cohorinet), says. 
Cohorinet is non-government organisation working that deals with sexual reproductive health services and rights. 
Yiga adds that as health activists they want to ensure that restrictions on access, provision and uptake of safe abortion services are removed. Clearer policies on abortion should then be put in place.

“We have launched a community-based advocacy agenda through which we want the government not only to stop on post abortion care but also ensure that it comes out with clear policies so that when one needs safe abortion can easily access the service without strings attached,” he says. 
The number of abortion cases in areas in which Cohorinet has conducted community outreach stood at 2,200 before the Covid-19 pandemic.

The number, according to Yiga as now hit 4,328 since the first lockdown in 2020 with the majority being young girls below 23 years  or about 60 per cent. 
“Guidelines are not clear to make it easy for the women of reproductive age to access safe abortion services. Cultural and religious leaders have distanced themselves on such issues yet they are aware that unsafe abortions are happening. Also, there is still a gap on provision of post abortion care services and women have resorted to local methods which are very dangerous to their lives ,” he says.  

The World Health Organanisation recommends two safe options; using pills or surgical option. 
In Uganda, misoprostol is recommended specifically the postpartum haemorrhage (PPH) usage.
Procedures used in PPH management include manual removal of the placenta, manual removal of clots, uterine balloon tamponade, and uterine artery embolisation. Laceration repair is indicated when PPH is a result of genital tract trauma.

Dr Fatumah Nakalembe,  a community engagement officer says hard-to- reach areas are the most affected because vulnerable women and girls fail to get access to family planning services which lead to unwanted pregnancies.
 “We have encountered several challenges while carrying out outreach services, especially since victims rarely openly come out and talk about it in their community,” she says.
“Illegal termination  leads to loss of lives because of too much bleeding  , attaining permanent injuries due to equipment used and loss of reproductive systems for women in case they use dangerous methods of unsafe abortion.”

About post abortion care
The government introduced post abortion care  services in referral hospitals but the number of women seeking the  services is still very low.
“Majority of women and girls are not aware that post abortion care is available in hospitals because they are not sensitised on how they can approach the service providers and where to find them yet it’s free,’”he says.

About abortions policy
Ugandan law clearly allows abortion to save a woman’s life. However, the 2006 National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights go even further—permitting abortion under additional circumstances, including in cases of fetal anomaly, rape and incest, or if the woman is HIV-positive.
The existing laws and policies on abortion are interpreted inconsistently by law enforcement and the judicial system, which makes it difficult for women and the medical community to understand when abortion is permitted. 

Unsafe abortion practices remain the major contributor to maternal death in Uganda, impeding the achievement of universal health coverage and quality of maternal health care.
Despite the fact that the uncertainty of the legal position risks misapplication of the law, abortion laws are actively enforced. 
Women and girls, and health workers are left vulnerable to law enforcement personnel and face arrest, prosecution and imprisonment.

Women and girls are also denied legal abortions and resort to unsafe means of terminating unwanted pregnancies. As a result, unsafe abortions contribute to an already high rate of maternal mortality in Uganda.

What’s needed to improve safety and quality of abortion care? 
A multi-country research study led by the World Health Organisation (WHO), the United Nations Special Research Programme HRP, and partners in 17 countries is shedding light on the severity and clinical management of abortion-related complications.
Published in The BMJ Global Health Journal, the facility-based study across 11 sub-Saharan African countries and six Latin American and Caribbean countries also explores women’s experience of post-abortion care.

Researchers collected data from more than 20,000 women presenting at over 200 participating health facilities with an abortion-related complication. Their signs and symptoms were classified into one of five categories, based on severity: deaths, near miss, potentially life-threatening complications, moderate complications and mild complications.
The majority of women in the study suffered a mild to moderate complication. However, twice as many women in the African sites than in the Latin America and Caribbean sites had a potentially life-threatening complication, or nearly died.

Social and economic factors are a major risk factor for mortality and morbidity
Abortion remains a stigmatised issue. This can hinder access to safe abortion, particularly for women living in poverty or places where access to effective contraception and safe abortion is limited or unavailable. 
Women in the study who were single, pregnant for 13 weeks or more, or presenting with an incomplete abortion were significantly more likely to suffer a severe outcome. 
“Abortion represents a field where inequality is such a big issue,” explained Mariana Romero, who led the study in Argentina. “A woman with material resources has different opportunities to access safe and informed care than a woman with less economic advantage.”  

Listening to women’s experiences
High-quality abortion care is about much more than clinical management. Respect and dignity are integral.
By asking women about their personal experience of post-abortion care, the study shows how much more work is needed to ensure effective communication and emotional support. This includes efforts to reduce anxiety during examinations, answering women’s questions and giving explanations at the time of care.

“As healthcare providers, if we are talking about care, we have to include not only the physical wellbeing of a person but also autonomy and empowerment. When a woman puts herself in the hands of the health system we need to build trust, confidence, and ensure this person feels comfortable coming back to us,” continued Mariana Romero. 

Learning from data to improve access to safe abortion and contraceptive counselling
In both regions, the study found that dilation and curettage was still used in the management of abortion-related complications – despite longstanding global efforts to replace this method with safer uterine evacuation methods, as recommended by WHO.
“The study shows us we still have a long way to go to move away from the older methods such as curettage and provide better care with safer medical methods,” said Zahida Qureshi, Associate Professor at the University of Nairobi, who led the study in Kenya and was the regional coordinator for Anglophone countries in Africa.

“These data will help pick up things we need to improve at each level: from a good referral system that can direct women to facilities with the right supplies, equipment and availability of essential staff, to contraceptive counselling to prevent a pregnancy women do not desire to have, and access to quality of care at every stage.”