Advocating for post-abortion care
By Halima Lila
In Tanzania, termination of pregnancy is restricted and only allowed if it is performed to save a woman’s life. Unsafe abortion is one factor contributing to the country’s high maternal morbidity and mortality. Furthermore, unsafe abortion related deaths are preventable, as are the unintended pregnancies associated with abortion.
Hope Centre Tanzania and other Civil Society Organisation’s (CSOs)in Tanzania is advocating for better access to contraceptives, more comprehensive Post-Abortion Care (PAC) and greater availability of safe abortion services within the current legal framework are critical to achieving the Sustainable Development Goal 3 of Good Health and Wellbeing in reducing maternal mortality and ensuring universal access coverage by 2030.
In addition, CSOs are advocating for the government and other stakeholders to offer a wide range of methods and counseling, which can reduce the incidence of unsafe abortion and its consequences by preventing unintended pregnancies. Raising awareness for expansion of PAC services in the country as a whole should be a priority this can be done through training of mid-level providers, offering services at lower-level health facilities and ensuring that facilities are adequately stocked with drugs and supplies.
Moreover, for effective budgeting and service provision, more research on the national-level data on abortion incidence and abortion-related complications is required. Assessments of the cost of unsafe abortion to the Tanzanian health system would help to give policymakers a better understanding of the magnitude of the problem.
In Tanzania, termination of pregnancy is legally permitted if it is performed to save a woman’s life. However, a recent report indicated that since Tanzania’s legal system is based on English common law, the English case of Rex v. Bourne could be applied in the interpretation of Tanzania’s abortion law to authorise abortion to preserve a woman’s physical or mental health.
In 2007, Tanzania ratified the African Charter’s Protocol on the Rights of Women in Africa (also referred to as the Maputo Protocol). The Protocol requires the government to “protect the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, [and] incest, and where the continued pregnancy endangers the mental and physical health of the [pregnant woman] or the life of the [pregnant woman] or the foetus.”Yet despite ratification, the Tanzanian government has not incorporated this provision into its national laws.
Contrary to widespread belief, a health care provider is not required to consult with other providers before performing an abortion. In addition, the law does not specify what level of provider may perform a legal termination. Given the absence of interpretation by Tanzanian courts and the contradictory laws and policies, women and health care providers may lack a comprehensive understanding of the content and scope of the law on abortion.
Unsafe abortion represents one of the leading causes of maternal deaths in Tanzania. According to the Ministry of Health and Social Welfare, 16% of maternal deaths are due to complications from abortion; this is comparable to the proportion of maternal deaths from unsafe abortion in Eastern Africa (18%). A higher proportion was reported in a small-scale review of 62 maternal deaths at a regional hospital in Tanzania, where a quarter of those deaths were due to abortion. Similarly, an analysis of sentinel surveillance data for 110 maternal deaths in rural Hai District indicated that in 23% of the cases induced abortion was the cause of death.
The Tanzanian government has shown, through various policies —including the implementation of the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania, 2008–2015—that it is committed to reducing maternal mortality. In 2007, misoprostol was registered by the Tanzanian Food and Drugs Authority (TFDA) for use in the prevention and treatment of postpartum hemorrhage, the leading cause of maternal death worldwide.
In 2011, the use of misoprostol was approved for the treatment of incomplete abortion. Overall, progress in reducing maternal mortality has been made over the last two decades; however, the maternal mortality ratio in Tanzania is still one of the highest in the world at 454 per 100,000 live births. For comparison, the ratio for all developing countries is 240 per 100,000 live births, and that for all developed countries is 16 per 100,000.
Unsafe abortion is also associated with high levels of morbidity. In Eastern Africa, more than 600,000 women were estimated to be hospitalised for induced abortion complications in 2005, corresponding to a rate of 10 per 1,000 women aged 15–44. The prevalence of unsafe abortions in hospital-based settings in both urban and rural areas in Tanzania has been documented in a number of studies, which have shown that up to 60% of women admitted with an alleged miscarriage had in fact had an induced abortion. The actual proportion of Tanzanian women who have an unsafe abortion and who need medical care may be even higher given that some women who attempt an abortion may experience complications for which they do not seek care. Worldwide, an estimated one-third of the 8.5 million women who have complications from unsafe abortion do not seek care in health facilities.
For women who cannot access safe abortion services, many will try to abort the pregnancy themselves or turn to unskilled providers. In a study of women who were admitted to a hospital with complications from an induced abortion, 46% of those in rural areas and 60% of those in urban areas reported that the abortion had been performed by an unskilled provider. Preliminary results from a qualitative study in mainland Arusha and Town West, Zanzibar, found that providers in nonclinical settings—such as traditional birth attendants and pharmaceutical retailers—were preferred because they ensure greater privacy and lower costs than physicians.
The impact of the Global Gag Rule
Due to a cumulative loss of almost US$500,000 in funds from the U.S. Agency for International Development (USAID), two major family planning organizations in Tanzania have been forced to withdraw critical technical support from the government’s family planning programs. The Global Gag Rule has compounded contraceptive supply problems in the country and hinders the effectiveness of HIV/AIDS programming. Tanzania faces serious reproductive health challenges: women there have an average of 5.6 children, and maternal and infant mortality rates are dangerously high. These challenges are exacerbated by the HIV/AIDS epidemic and the high incidence of illegal abortion, which accounts for significant maternal mortality and morbidity. The gag rule undermines efforts to address these reproductive health issues at a time when the need for comprehensive family planning and reproductive health services is most critical.
In Tanzania, institutions and clients alike are suffering as a result of the gag rule. Public providers have been unable to meet the demand for family planning due to the lack of training and/or necessary supplies, leaving vulnerable women at risk for unplanned pregnancies. The government has also suffered because it lacks adequate capacity to provide family planning services of the same scope or quality as MST or UMATI. Against the backdrop of increasing demand for comprehensive reproductive health services, including HIV/AIDS services, MST and UMATI find themselves struggling financially to sustain their current level of services, especially in hard-to-reach rural areas, and have few alternative funding sources to turn to for assistance. The gag rule has stunted these NGOs’ ability to strengthen and expand access to critical reproductive health services for Tanzania’s women and youth.