Abortion banned, but still continues
Last year Franca, a single, unemployed teaching graduate was admitted to a hospital in Nigeria suffering from severe pain, a heavily distended stomach and vaginal bleeding. She had undergone an unsafe abortion, carried out by a chemist who scooped out the foetus with a curette. A week later she died from kidney failure and septic infection. She was 23.
It may be hard to imagine what would drive a woman to risk her life to abort a pregnancy. But nearly 20 million women do it every year, almost all in the world's poorest countries. Around 68,000 of them will die, driven to using people who lack proper medical training or attempted by the women themselves, because abortions are heavily restricted or illegal. One expert calls it the killing fields of women in the developing world and it's a topic some people still don't want to talk about.
Just over half way through the UN's Millennium Development Goal (MDG) to cut the number of maternal deaths in developing countries by 75 per cent and to provide universal access to reproductive services by 2015, there are signs that these targets are not on track. A recent report said maternal death remained high or very high in most of the 68 subject countries. West Africa has some of the worst rates and in countries like Niger, one woman in eight dies in pregnancy.
More worrying still is the knock-on effect of the US-imposed Gag Rule on critical contraceptive and community services. Services crucial to preventing unwanted pregnancies and unsafe abortion. Reintroduced by President Bush in 2001, the policy bars funding to organizations involved in counselling, referring or lobbying on abortion, even when using private funds.
"A clinician sitting with a woman can't advise her of what she can do under their country's law," says Gill Greer, Director-General of the International Planned Parenthood Federation (IPPF). "It goes against their ethics and against the highest standards of medical care and against their human rights. It says women aren't valued."
Greer says organizations are forced to abandon strategies they know save lives or lose crucial funding. Those refusing to sign are seeing integrated services cut or abandoned due to lack of funds. Last year a US congressional vote to exempt contraceptives from the policy was carried, but later dropped, after threats to a larger funding bill. "I regretfully believe right-wing groups will continue to represent contraceptive services as abortion-related," says Greer.
Matilda Owusu-Ansah, former director of resources for the Planned Parenthood Association of Ghana (PPAG), told an October hearing of the US House of Representatives into the impact of the Gag Rule, that "to sign would have been to turn our back on women, consigning them to risk their lives and health. It would have meant breaking with medical standards. The rule was playing politics with women's lives."
Losing around $2m has been debilitating. PPAG is the second biggest distributor of contraceptives in rural Ghana and third biggest nationally. Condom distribution has fallen by 40 per cent, clinical services by more than 50 per cent and free contraception to the poorest in rural areas is no longer available. Owusu-Ansah says their clinics have seen a 50 per cent rise in the number of women coming in for post-abortion care.
Integrated services also make access to other US-funded programmes difficult.
"We hoped we would be able to continue our HIV prevention programs by applying to the President's Emergency Plan for AIDS Relief," says Owusu-Ansah. "Sadly, this was not the case. Any partner that receives integrated funds must comply with the restrictions on both US family planning and HIV/AIDS assistance. This includes the Gag Rule."
The IPPF says that between 2001-2005 it lost around $75m and important contraceptive supplies. In contrast, the UK has boosted funding for schemes, including the Global Safe Abortion Fund, which provides two-year grants to NGOs. It initially pledged £3m but has now provided a further £7.5m.
"The work of many organisations to promote and protect the health and rights of women by providing information or counselling about safe abortion, or awareness of the benefits of legal reform, is compromised," says Gillian Merron, minister for the Department for International Development.
Liberalising abortion laws is a burning political issue. Safe abortion is not directly addressed in the MDG and universal access to contraception was only added last year.
"The UN won't talk about abortion, people are nervous talking about it, even international agencies," says Diana Thomas, a spokesperson for Marie Stopes.
"It's taken seven years just to force through this clarification."
Campaigners say tackling maternal death effectively will not happen unless the issue of unsafe abortion, the elephant in the room, is properly addressed. "When one confuses morality with public health issues the results are often tragic," says Greer.
Details of Franca's death are shocking. Before she died, hospital ultrasounds revealed pelvic abscesses. A significant amount of pus was drained from her peritoneal cavity. Dehydrated, vomiting, unable to urinate and feverish, she later developed fits. Large amounts of blood had collected around her open cervix and tests showed anaemia and kidney damage. Her parents were unable to afford the dialysis that might have saved her.
Studies have indicated a ban on abortion does not reduce its incidence. The Lancet medical journal reported in December that the rate of abortion is the same whether legal or illegal. Rather, when restricted, it's more likely to be unsafe. In countries where the situation is critical, where the social and financial implications of an unwanted pregnancy are crippling and with women risking haemorrhages, perforations, septicaemia and more, organizations feel their right to lobby is imperative.
There are positive signs that regionally the issue is being addressed. The Maputo Plan of Action - an agreement ratified by 48 African Union countries to adopt national and regional frameworks in sexual and reproductive health - listed the prevention of unsafe abortion as one of its objectives in achieving the MDG in Africa. This was despite efforts by the US, the IPPF say, to weaken the language and purpose of the agreement.
Source: The Guardian (UK), 18 July 2008