Ugandan women must be able to choose

By Hamza Businge, Ray of Choice Africa

“If only I had a chance to terminate this pregnancy. I never even planned to have a child or to start a family. I was promised a scholarship to complete my A-Levels and enroll in university but at this point, I can’t pursue my goals. I am disappointed in myself and I have disappointed the people who wanted to support me,” says 18-year-old Sumie*. “I didn’t intend to have a child,” says Sumie. “I was always planning for my future studies.”

I met Sumie when I was working in Kawempe-Ttula, a Kampala suburb with high rates of HIV and teenage pregnancy in schools. I was an employee of Youth Rising International, an organisation originally called Youth Rising Kawempe, which is a subsidiary of the Youth at Work Initiative. Sumie shared this with me when I asked how old she was and what technical classes she intended to take.

“I don’t really know, I just want to do a course that can teach me a skill so that I can earn money to care for my child; I am a single parent. Maybe I will be in a position to pay for my child’s school fees some day.”

Sumie and other young girls I talk to in the Ugandan communities where I work, have made me reflect on how we as global health workers think and talk about abortion rights and access to these rights.

Perhaps the law is flawed.  Should it protect the person who is “presumed yet to live” or save the person who is actually living? Maybe we need to focus on the unconditional choices and decisions of women and young girls and what matters to them at that point. They may not be ready to plan for bearing children yet, but they might want to have children when they are ready – by choice and not by chance or the force of law.

Unsafe abortion remains a major problem confronting Ugandan women, despite a significant decline in the overall abortion rates in the country in the past decades. The majority of Ugandan women’s pregnancies are still unplanned. Nearly half of the 1.4 million pregnancies occurring in the country every year are unwanted[1] and this has resulted in unsafe abortions  constituting nearly one third of maternal deaths among our young people.[2] A number of rudimental means have been employed by women, girls, traditional birth attendants and some health care providers in order to eliminate these unwanted pregnancies. These include the administration of strong detergents like NOMI and OMO and the use of wires, hooks and the like.

The Ugandan Ministry of Health estimates in the Annual Health Sector Performance Report of 2017–2018 that, as of 2018, 5.3% of all maternal deaths resulted from abortion complications.

This is an unprecedented time in humanity’s history, with a population including over three billion young people under the age of 25 and over one billion people between the ages of 15 and 24 years. More than three quarters of the global population live in developing countries like Uganda. But does the law take this context into account?

We as reproductive health advocates are engaging young girls and women to make informed choices by giving them a range of options. For example, all of us have a vision of a generation that only experiences planned and wanted pregnancies and child births. We are increasing access to contraception, yet on the other hand, it is denied to the young girls. There is every reason for the move to eradicate child and forced marriages, but the law does not really articulate this, besides providing for a specific age at which a girl is presumed an adult. What about providing for marriage by choice?

On the other hand, under local abortion rights to health, the health risks revolving around an abortion are only physical, excluding the mental risks. Does this fit the recognized international standards and guidelines that Uganda has ratified?

The legal status of abortion in Uganda is unclear because it provides for some exceptions while criminalising the procedure in most cases. The Ugandan Constitution, under Article 22, Clause 2, provides that “No person has the right to terminate the life of an unborn child except as may be authorized by law”. However, what is authorized by law remains unclear and this restriction, therefore, leads to the practice being continued in secrecy and under unsafe circumstances. The Ugandan Penal Code of 1950 stipulates criminal penalties for anyone who obtains an abortion or contributes to the procurement of the procedure, with the only exception being a procedure aimed at saving a woman’s life.

Abortion can only be legally performed in Uganda by a licensed medical doctor who, based on a clinical assessment and expert opinion, believes that pregnancy places the woman’s life at risk. Abortion is permitted in order to save a woman’s life or preserve her physical health. But have we looked at the instances where women give birth and harm or kill their children due to psychological disorders that stem from the pregnancy? An abortion is illegal unless performed by a licensed and registered medical doctor in a situation where the woman’s life is deemed to be at risk.

The Penal Code’s section 141, which covers attempts to procure abortion, states: “Any person who, with intent to procure the miscarriage of a woman whether she is or is not with child, unlawfully administers to her or causes her to take any poison or other noxious thing, or uses any force of any kind, or uses any other means, commits a felony and is liable to imprisonment for fourteen years”. Section 142 of the same Act lays down a punishment of seven years of imprisonment for “any woman who, being with child, with intent to procure her own miscarriage, unlawfully administers to herself any poison or other noxious thing, or uses any force of any kind, or uses any other means, or permits any such things or means to be administered to, or used on her”.

The law, therefore, seems to suggest that unless the mother’s life is at risk, an abortion will not be performed. The Ministry of Health through the 2006 National Policy Guidelines and Service Standards recommended that in some instances the woman or girl should be assisted to terminate the pregnancy. These instances include severe maternal illnesses threatening the health of a pregnant woman e.g. severe cardiac disease, renal disease, severe pre-eclampsia, and eclampsia; severe foetal abnormalities which are not compatible with extra-uterine life e.g. molar pregnancy, anencephaly; cancer cervix; HIV-positive women requesting for termination; rape, incest, and defilement[6]. The 2012 National Policy Guidelines and Service Standards which replaced the 2006 version retained these provisions and the Standards and Guidelines for the Reduction of Maternal Mortality and Morbidity from Abortion which is still being developed similarly retain the same permissions for termination of pregnancy. 

Religion has played a major part in the formulation of abortion policies. The Catholic Church has a prominent position in Ugandan society and its stance on abortion tends to greatly influence the way other actors and their activities are presented in the media and how stakeholders convey or withhold their messages in the public sphere. Religious, human rights, medical and legal perspectives frame the subject of abortion in Uganda, influencing who is portrayed as the victim and who is vilified for the abortions taking place. The Catholic Church takes center stage in the debate against abortion, while medical statements related to abortion are absent due to fear of legal penalties. What is the impact of the Global Gag Rule on the provision of abortion services in Uganda? It infringes upon national independence and government officials feel constrained by the rule – even when it does not directly apply to them. It suppresses the voices of non-governmental organizations (NGOs) and dictates their policies: although USAID has emphasized the importance of supporting local NGO networks, the rule has “gagged” the coalition-building efforts of NGOs that require broad-based support in order to campaign for women’s health and rights. Therefore, the question remains whether the advocacy for these rights is still relevant.

*not her real name