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SITUATIONAL ANALYSIS OF UNSAFE ABORTION IN ZAMBIA Dr. Sweebby Macha

1.1. Country profile Zambia is a landlocked country covering a total of 752 614 square meters and a total estimated population of 10.3 million people in 2002 with an annual growth rate of 2.9% in the year 2000.1 Although there are differentials in rural and urban percentages in male and female population, the differences are not very significant. Copper belt province has the highest population followed by Lusaka, Northern; Southern and Eastern provinces. Sparsely populated, the population density stands at 10.4 people per kilometre. The rural- urban disparity continues with 60 % of the population residing in the rural areas.

1.2. Status of women Despite women being in the majority and the society being predominantly matrilineal, there are gender disparities which do not favour women in the country’s socio-economic, cultural and political spheres. These imbalances prevent women from effectively contributing to and benefiting from the development process. Women are generally less educated than men in Zambia and 4 out of every 10 women are illiterate.2 Information on decision making indicates that women’s powerlessness in decision-making extends to the personal health care issues. The Zambia Demographic and Health Surveys 2001-2002 indicate that husbands dominate decision making so that about 47% of husbands decide alone on the health care of their wives as compared to only 30% of women who decide alone3. 50% of husbands also decide alone about the timing and number of children as compared to 10% of women deciding alone4. This raises questions of its implications on access to safe abortion by married women. This fact has implications on women’s access to health care and services including safe abortion.

1 National AIDS Council, 2002 2 National Gender Policy.12-16 3 ZDHS 4 2

1.3. Knowledge and use of contraceptives Contraceptive knowledge is almost universal in Zambia with 98% of women and men knowing at least one method. Knowledge among the youth is also widespread5. The ZDHS 2001/2 shows that 34% of women report using one method. Common methods among single women 15% is male condom and pill 10%, female condoms, IUD, implant diaphragm and jelly or foam less than 1%. Urban women (46%) are more likely to use contraception than rural women (28%). Traditional methods are twice as high in rural areas than urban areas. Literate women are more likely to use family planning than illiterate women. There is high teenage pregnancy6 Most women found at antenatal clinics were teenagers.7 Despite this knowledge, only 34 percent of married women in Zambia are currently using a contraceptive method, and of this number 23 percent of married women are using modern methods while the remaining 11 percent are using traditional methods. Some of the reasons for the low utilization of family planning are misconceptions and myths and preference for larger families.8

The “Unmet need for family planning” can essentially be divided into issues to do with; (a) client factors- which include women’s fear of the supposed side effects associated with modern methods especially the pill and injectables (b) service factors-which include providers, method mix equipment and other logistics and during one study where two clinics and rural health centers were visited in five provinces no IUDS, female condoms, long term implants, diaphragms and jellies were found in stock in any of the rural health centers and in most urban clinics 9. Available contraceptives in public health clinics are predominantly male condoms, short term injectables and microgynon.

5 WLSA-Zambia, Girls Empowerment Project Report 6 ZDHS-2001-2002, (2003). Central Statistics Office, Central Board of Health, ORC Macro. 7 WLSA, Gender, Sexual and Reproductive Rights and HIV/AIDS, 2006 Unpublished. 8 Mtonga, 2000. 9 Assessment of Contraceptive……… 3

(c) cultural /environmental factors-which include women who would like to either delay the next pregnancy by three or more years (spacing) or want to stop child bearing (limiting), but are not using any contraception.10

The 2001/02 DHS reports unmet need of 27 percent, the same proportion as in1996. Of this number, 17 percent have unmet need for spacing their next birth and 10 percent for limiting birth or stopping child bearing. With the met need at 34 percent, the total demand for family planning is at 62 percent. Another group, where unmet need for family planning is, is among adolescents. This group is not well covered in terms of both information and services for family planning.11 The Contraceptive Needs Assessment of 1995 showed that provider bias was evident towards clients and affected their method choices and there was inadequacy of skills in performing certain screening procedures and poor client - provider interaction. In addition, there is poor motivation on the part of providers due to the fact that most of those assigned to family planning duties have little or no training in family planning and those that are trained have no extra financial incentives. The low interest for family planning in comparison with other reproductive health areas is another factor of major importance.12

1.4. Health services In 1991 the Zambian government embarked on extensive reforms in the health sector. The National Health Policies and Strategies was made in 1992 with the goal of achieving equity in health opportunities; increase the life expectancy; create an environment and encourage lifestyles which support health; provide quality assured health services and improve individual and family health through efficiency administered population control activities. The health reforms took a primary health care approach which saw the establishment of the Central Board of Health (CBoH) in 1996. The CBoH was meant to act as a technical unit responsible for the delivery and implementation of health reforms and the development of the primary health care program.

10 Assessment of Contraceptive…………. 11 Reproductive Health Policy 12 Assessment 4

The reforms provide for the decentralization of the health care system with district health boards and three teaching, central and specialist hospitals in Lusaka, Kitwe and Ndola. Provincial hospitals (also known as General Hospitals) were established in provincial centers with specific responsibilities for training. These hospitals are also expected to provide provincial level specialist services as well as act as sources of references and expertise to other agencies. Below this were district hospitals offering district level health package, clinics, health centers and health posts were at the bottom of the ladder. A referral system from clinics to district hospitals, general hospital and then to the specialist and central hospitals was put in place. Other health services were to be provided by the Zambia Flying Doctor Services and the Churches Medical Association of Zambia.13 The reforms also introduced a cost sharing program where users were expected to pay user fees.

Reproductive health services were integrated to provide for a one stop shopping approach that includes antenatal, contraceptive services, STD/HIV (preventive), adolescent health services, cervical cancer screening and abortion services.14 Legal, surgical and medically managed abortion is offered only at tertiary centers i.e. UTH and Ndola Central Hospital.15 Post exposure prophylaxis is only availed to child victims of sexual assault on a pilot basis at UTH and emergency contraception is only available at UTH and Ndola Central Hospital.16

With a high ANC coverage rate of 93%17 most women rely on a medically trained provider (doctor, clinical officer and nurse/midwife) for antenatal care. The high ANC coverage provides a window of opportunity of delivery of PMTCT services. Nine in ten women receive antenatal health care from a health professional and 72% of mothers’ visit the antenatal clinic at least 4 or more times during pregnancy18. Maternal mortality rates stand at 729 per 100 000 live births in Zambia with the five major causes being

13 Mtonga 14 analysis of health sector reforms in Zambia 15 Mtonga, Kaseba 16 Mtonga 17ZDHS 2001/2 18 ZDHS 5 haemorrhage (34%), sepsis (12%), enclampsia (5%), obstructed labour (8%) and unsafe abortions (4%).19 These causes occur as a result of early pregnancy (75% of maternal deaths occur among teenage mothers20), short spacing between pregnancies, home deliveries, illegal abortions and long distances to clinics.

Cervical cancer is the most common cancer among women in most developing countries, and one of the major causes of mortality.21 There are inadequate facilities for periodic cytological screening (pap smear) in order to detect early pre-invasive cancer, especially in health centres. So far only the major hospitals in Zambia are able to provide cervical cancer screening.22 There were 290 and 33 women admitted at University Teaching Hospital (UTH) suffering from cervical and breast cancer respectively in 1999.23

Treatment of abortion-related complications remains inadequate despite some recent improvements. A 1988 study at UTH’s gynecological emergency ward indicated that one-third of women seeking treatment for abortion-related complications completed their abortions on the floor or on their way to a toilet. Nurses reported that the average patient waited 12 hours in crowded conditions for treatment. Staff members did not give patients food, water, or medications because of expected administration of general anesthesia. There were no sanitary supplies or blankets. Patients with illegally induced abortions were placed at the end of the roster after scheduled cases. Because of blood supply shortages, very few women received transfusions.24 Progress has been made in the provision of Post Abortion Care (PAC) through the PAC

Task Force. PAC comprises three elements of treatment which include: 1) Emergency care (treatment of bleeding, infection is present and the removal of retained products of conception. 2) Provision of counselling and Family Planning Services on discharge of the

19 Nsemukila et al, Situational Analysis of Maternal Mortality in Zambia, 1998 20 Committee on Elimination of Discrimination Against Women 27th Session, Government of the Republic of Zambia Country Report Juneof 2002 21 Reproductive Health Policy;19 22 Reproductive Health Policy;19 23 Reproductive Health Policy; 20 24 Castle, 1989 6

patient. 3) Linkage to other reproductive health services. So far, eight out of the nine

provinces have been oriented and training sites have been established in provincial

hospitals. The expectation is to have one hundred District hospitals providing PAC

services in the very near future.27

1.5. Magnitude of the problem of unsafe abortion in Zambia

YEAR 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 NUMBE 1570 1661 840 212 138 1,164 R OF TOP Table 1: Elective abortion at UTH

According to the World Health Organization an unsafe abortion is “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.”25 Unsafe and poorly performed abortions are a major cause of maternal mortality in Zambia.26 In a study of 288 maternal deaths in Zambian hospitals between 1990 and 1993, approximately 30 percent were associated with poorly performed abortions.27 Hospital records alone, however, do not reflect the full extent of mortality and morbidity caused by abortion because many abortions related maternal deaths occur outside health facilities and never appear in formal records. For some unexplained reason, the number of elective TOP’s dropped drastically between 1998 and 2000. There is however substantial differences between the recorded legal abortions and implicit evidence of illegal abortions. In 1993, MOH reported that doctors in Zambia's hospitals performed 1,164 legal abortions in 1993 but the same source shows that 17,977 women were treated in hospitals for complications

25 World Health Organization, 1992. 26 Castle et al., 1990 27 Likwa, 1994 7 of illegal abortion during the same year.28 There is under reporting of abortion incidences due to the fact that not all TOP is done at hospitals. Hospitals are often only used when complications arise. Contribution of abortion to maternal deaths has invariably been pegged at 15%29; 30% 30and 4% 31and 4%.32

Some 80 percent of the women who were admitted to hospitals with induced abortion related complications were younger than 19.33 Young women are more likely than older women to undergo illegal unsafe abortion. A study conducted to determine socio demographic differences between 199 women who obtained legal abortions and 65 who were hospitalized with complications after illegal abortions revealed that women who succeeded in obtaining legal abortions tended to be between ages 20 and 29 (55 percent), had some secondary education (60 percent), and had children (71 percent). Most women undergoing illegal abortions were between ages 15 and 19 (60 percent), had some secondary education (55 percent), were unmarried (80 percent), and had had no prior pregnancies (63 percent). Of those who resorted to illegal abortions, 81 percent were students who wanted to continue their education.34 Despite the relatively lower risk of abortion early in pregnancy, many adolescents and women of lower socioeconomic status delayed abortion procedures until the second trimester. This may be a result of lack of information, fear, or hesitation on religious grounds. For young girls, this could also be failure to recognize signs of pregnancy, refusal to face the situation, or hope for spontaneous abortion.35

In the illegal abortion group of 65 women, the most common method (33 percent) used was insertion of a cassava root into the cervix. Four deaths occurred among women in this group. None occurred in the group receiving legal abortions. Only 12 percent of the women resorting to illegal abortions and 27 percent of those who received legal abortions

28 Likwa, 1994 29 Mhango et al 30 Mati et al 31 Nsemukila et al 1998 32 ZDHS 33 Likwa, 1989 34 castle et al 1990 35 castle et al 1990 8

had ever used modern contraceptives.36 Lack of access to safe abortion services is one of the major reasons why so many women suffer abortion complications and end up dying. Aside from being a contributing factor to maternal mortality, unsafe abortion also results in pelvic infection which may either result in chronic pelvic pain or infertility.37

2. The Legal, Policy and Regulatory Framework on Abortion in Zambia The legal framework comprises of international human rights instruments and consensus documents that the Zambian government has signed and ratified as well as the domestic law in operation in the country. The review under this section is thus divided into three subtitles namely, the international commitments; domestic legislation; and the policy and regulatory framework. The international commitments provide the general international human rights standards and the domestic legislation comprises of the laws relating to abortion in Zambia. The state’s policy and regulatory framework is included because these provide the plans, methodology and strategies for implementing human and legal rights, including the right to access to safe abortion services as provided in the law.

2.1. International Commitments International law is a body of law and general principles concerning relations and obligations between states inter se and between states and other entities. By distinction, the body of law of obligations between states, is referred to as public international law. There is a body of law referred to as private international law that deals with conflicts of laws applicable to private sphere activity. Both branches can apply to rights of legal persons, but generally speaking, international human rights and humanitarian law fall under public international law.

Article 38 of the Statute of the International Court of Justice also recognizes as sources of international law conventions that have evolved between states; the jurisprudence of the Court; the recommendations and general comments of relevant treaty bodies that subsidise the treaty and become part of it; and customary international law which denotes norms and principles that have become jus cogens. Decisions of treaty monitoring bodies

36 Likwa et al 1994 37 Reproductive Health Policy, 2004 9 such as the Human Rights committee that have authority to hear complaints from individuals are also viewed as sources of international human rights law. One such important and recent decision was made by the Human Rights Committee in KL vs. Peru38 where the committee held for the applicant who had been forced to carry her pregnancy to full term even though the law provided for medical abortion in case of severe fetal impairment.

These are however soft norms that are merely a part of the whole scope on international law based on hard norms. They include the consensus documents of world conferences such as the Beijing Declaration and Platform for action, the Vienna Declaration, International Conference on Population and Development (ICPD), World summit on children, the millennium Declaration and Goals, the SADC Declaration on Gender and Development and its addendum on the eradication of violence against women and children. The hard norms comprise of international human rights instruments such as the international covenant on economic social and cultural rights (ICESCR), the international covenant on civil and political rights (ICPR), the international covenant on the Elimination of all forms of Racial discrimination (CERD), the convention on the elimination of all forms of Discrimination against women (CEDAW) and the convention on the rights of the child (CRC). They also include regional instruments such as the African Charter on Human and Peoples’ Rights and the African Charter on the welfare of the African Child.

Zambia is a signatory to most of these international instruments. Among those relevant to this subject, Zambia has signed and ratified the CERD, ICESCR, ICPR, CEDAW, International Labor Organization (ILO) conventions and the CRC. Zambia is also a signatory to the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa. This instrument is very important because it is the only international human rights instrument that articulates women’s sexual and reproductive rights. In Article 14 (2) (c) the Protocol provides that state parties shall take appropriate measures to protect the reproductive rights of women by authorizing medical abortion in cases of sexual assault, rape, incest and where the continued pregnancy endangers the

38 ????? 10

mental and physical health of the mother or the life of the mother or the foetus. The state has however not yet ratified it. There is also a corpus of international guidelines by the World Health Organization and the United Nations Population Fund that are relevant to the subject and these provide for minimum standards for the delivery of abortion services.

Domestic legislation39 however requires that ratified international instruments be domesticated to have efficacy at national level. Until this is done they only form part of the large body of norms that can be used to “persuade” the courts in their judgments. Unfortunately, the courts are not easily persuaded in the use of international law. In the case of Sara Hlupikike Longwe vs. Intercontinental Hotels40 the High Court was persuaded to find for the applicant on the basis of the non-discrimination clauses of the CEDAW. In this case the applicant had been denied entrance into the public area of the hotel on grounds that she was an unaccompanied female while there were no similar restrictions on unaccompanied males. The court held that she had been discriminated against.

However, a similar facts case came up before the same high court in Elizabeth Mwanza vs. Holiday Inn Hotel41 and the court refused to be persuaded to follow its earlier ruling in Longwe vs. Intercontinental Hotel on the grounds that the CEDAW was not part of the domestic legislation and that the act of restraining the applicant from entering a public area of the hotel was not discriminatory as the hotel had right to restrict access to its premises. This illustrates the position taken by the courts in Zambia as regard international human rights law. It also means that an applicant cannot rely on the provisions of an international instrument in a case before the Zambian courts. Such an application will have to be backed by a provision in domestic legislation. International consensus documents such as the ICPD and Beijing Declaration are in the same position and cannot be relied upon in Zambian courts. Citizens can however rely on these provisions before international tribunals such as the Human Rights Commission. 2.2. Domestic legislation

39 Chapter one of the Laws 40 41 11

The grund norm in the Zambian legislative system is the Republican constitution. All other laws draw their validity from the constitution and any laws that are in conflict with it are nullified or held invalid by the court. The key legislation relating to abortion is the constitution itself, the Penal Code, the Termination of Pregnancy Act and the Nurses and Midwives Act.

2.3. The Republican Constitution The Zambian constitution protects the right to life in the Bill of Rights in Article 12(2). It protects the right to life and the only exception to this are the legal execution under the Law. The right to life is in the Bill of rights which is a protected section of the constitution.

2.2.1. Penal Code, Chapter 87 of the Laws Until 1972, when there was a public uproar arising from the death of the daughter of one of Zambia’s prominent families from a botched abortion, performed by a private medical practitioner, Zambia did not really have indigenous legislation on abortion. The country relied on British legislation on the subject. However, abortion was by virtue of the provisions in the Penal Code a criminal act. It is interesting to note that Bwanausi was not charged under the provisions in section 151 of the Penal code. The state proceeded on a charge of manslaughter. Given the evidence produced in court, the state was more likely to succeed on a charge pf attempts to procure abortion. However, this would have ben an admission on the part of the state that the of abortion was unregulated. This is implicit in the hurried manner in which the TOP Act was passed in 1972.The uproar following this death led to the prosecution of the medical practitioner for manslaughter and the bringing before parliament of a bill on termination of pregnancy. The bill was passed into law in 1972. the medical practitioner was charged(the People vs Bwanausi) with manslaughter because the deceased died while the accused was attempting to perform an illegal abortion. In this case the cause of death was said to be reflex vagal inhibition caused by the pumping of dettol into the deceased’s uterus. The accused person was convicted by the High court but the conviction was quashed by the Supreme Court on grounds that the inhibition could have been caused by other factors. 12

The Penal Code is a 1967 piece of legislation adapted from the English legal system. It contains provisions on criminal acts and the nature of crimes they amount to. It also provides for the punishment to be given to convicted persons. Section 151 of the Penal Code provides that any person who with intent to procure the miscarriage of a women or female child 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 whatsoever, commits a felony and is liable upon conviction to imprisonment for a term not exceeding seven years.

It further provides in section 152 that every woman who administers any poison or noxious thing or uses any force of any kind or uses any other means or permits same to be done commits a felony and is liable to imprisonment for fourteen years. The punishment for a female child under subsection 2 of section 152 is community service. Section 153 extends libility to persons who supply to or procures for any person any thing whatever knowing that it is intended to be unlawfully used to procure the miscarriage of a woman or female child and the punishment is imprisonment for fourteen years.

Section 152 was amended in 2005 and now in subsection 2 provides that where a female child is raped or defiled and becomes pregnant the pregnancy may be terminated in accordance with the termination of pregnancy act. It is interesting to note that the word abortion is not used in these three sections although the crimes are refered to as ‘attempts to procure abortion, abortion by pregnant woman or female child and supplying drugs or instruments to procure abortion’. The provision in Section 152 (2) comes very close to that in Article 14 of the Protocol to the African Charter on Human and Peoples right on the rights of women in africa. Unfortunately, this provision does not include the pregnancy arising from incestuous relations. It is worth noting that when a girl is raped by a person within the prohibited rules of conseguinity, that person is charged with incets rather than defilement. Therefore, in Zambian Law defilement excludes incestuous sexual relations. The provision also does not apply to adults. So women victims of rape cannot 13 benefit from the provision in section 152 (2). The punishment for abortion is very stiff and instead of acting as a deterrent it has merely forced the act to go under and be done in a dangerous and secret manner. 2.2.3. Termination of Pregnancy Act, Chapter 304 of the Laws This legislation provides an opportunity for legal abortion. It provides that a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if he and two other registered medical practitioners, one of whom has specialized in the branch of medicine in which the patient is specifically required to be examined before a conclusion could be reached that the abortion should be recommended are of the opinion formed in good faith – a) that the continuance of the pregnancy would involve (i) risk to the life of the pregnant woman or (ii) risk of injury to the physical or mental health of the pregnant women or (iii) risk of injury to the physical or mental health of any existing children of the woman; greater than if the pregnancy were terminated; or b) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

In determining paragraph (a) of subsection (i) account may be taken of the pregnant woman’s actual and reasonably foreseeable environment or her age. The requirement for the opinions to the two medical practitioners do not apply to the termination of pregnancy by a registered medical practitioner in a case where s/he is of the opinion, formed in good faith that the termination is immediately necessary to save the life or to prevent grave permanent injury to the physical or mental health of the pregnant woman (section 3 (4)). Apart from such an emergency case, all terminations must be carried out in a hospital (section 3 (3)).

The Act therefore provides for elective and medical abortion. These provisions make the Zambian TOP Act one of the most liberal on the continent as it allows a woman to obtain an abortion even for social reasons. The act does not however define mental health and it is unclear whether or not the court would use the WHO definition. Further, the act also allows for conscientious objection on the part of staff to provide the treatment. Section 4 14 provides that no person hall be under any duty to participate in any treatment authorized by the Act to he has a conscientious objection. However, such persons still have a duty to participate in any treatment which is necessary to save the life or prevent grave permanent injury to the physical or mental health of a pregnant woman. This means that in a life threatening emergency, the staffs are obligated to carry out the treatment. The conscientious objection is therefore restricted to elective abortion.

In section 5 the Act gives power to the Minister of Health to make regulations for better carrying out of the provisions of the Act. In accordance with this provision, the minister has made regulations requiring the opinion of a medical practitioner given under section 3 to be in the form of a certificate, to be given before the commencement of the treatment for the termination of pregnancy or if this is not reasonably practicable, within 24 hours after such treatment. The regulations also require any medical practitioner who performs a termination anywhere in the Zambia to notify the Permanent Secretary of the Ministry of Health. This information is to be treated with confidence and must not be disclosed except as provided for in the regulations.

2.2.4. The Nurses and Midwives Act, Chapter 300 of the Laws The Termination of Pregnancy Act should be read together with not only the Penal Code but also the Nurses and Midwives Act. Revised in 1997, this Act widens the scope of practice for this cadre of health workers. They can now perform therapeutic, palliative and rehabilitative care and treatment of illness normally carried out in nursing and midwifery practice and in nursing homes. These new responsibilities include a) b) c) d) e) f) h) by virtue of s21 (2) nurses and midwives have the responsibility to counsel clients and therefore have the power to open or shut the door to women’s access to safe abortion. They can also prescribe drugs under s21 (9) from a list defined by the national drug formulary committee. It is not clear from the review whether these would include mifepreston or misoprostol.

The use of vacuum extraction by nurses and midwives however does not extend to elective termination of pregnancy patients as these can only be treated by a registered 15 medical practitioner. This Act also led to the revision of the training curriculum for this cadre of workers. The curriculum now includes trends in maternal and neonatal health, family planning, gender, infection prevention, health management information systems and pre- and post abortion counseling and provision of post abortion care services. The post abortions care component includes, review of all types of abortion; legal statutes regarding abortion; elements of PAC; principles of PAC; history; pelvic examinations; stabilization; referral; types of uterine evacuation didactically; PAC and STIs; post abortion counseling and family planning , and recommendation infection practices.48

4. Challenges and constraints to women’s access to safe abortion in Zambia Although abortion is legal in Zambia, the figure discussed under the heading ‘magnititued of the problem of unsafe abortion’ suggests that access to safe abortion services is severely limited. Therefore, unsafe and poorly performed abortions are a major cause of maternal mortality. There are several factors that constrain women’s access to safe abortion services in the country. Provider biases, limited information among women about the Termination of Pregnancy Act, legal requirements, the limited number of sites that perform the procedure, and social and religious sentiments against abortion, all serve to constrain women’s access to safe procedures. These can be clustered as information and knowledge barriers; inadequate health systems; legal and administrative barriers; social, cultural and religious barriers and lack of political will on the part of the state. These clusters are discussed below.

4.1. Inadequate health services According to the ICPD reproductive health includes at a minimum safe abortion services, where legal, and management of abortion related complications. To deliver this there is need for the country to have an effective and adequate health delivery system. Many health centers have been equipped to provide all maternal and neonatal services except TOPs. To deliver quality abortion services the health delivery system should include adequate and trained staff, adequate and accessible health units, affordable services, clear guidelines, a range of abortion methods, appropriate equipment, pharmaceuticals and 16 supplies, information, education and communication materials for the public and it must be efficiently run.

Service delivery In Zambia, decentralization initiated the formation of district health boards and district health management teams with a focus on primary health care delivery at different levels. It was however characterized by lack of clear guidelines about roles and responsibilities of each of these. This has resulted in tensions between these two levels of decision making thereby affecting the work output. This tension coupled with severe resource constraints feed into inefficiency and corruption that exists in the system (analysis of health sector). Also, as a result of this tension systems of referral between levels of the health care system are weak, especially in rural areas. This has serious implications for abortion services which rely a great deal on referrals as they are not offered at community or health center levels.

Inadequate units and staffing Secondly, there are inadequate health units and staff in the country. Currently, Zambia has 206 urban centers serving a catchment population of 30 000-50 000 in a radius of 30 Kilo Meters and 880 rural centers with a catchment population of 10 000 within a 30 kilo meter radius. In rural areas this means a woman will be referred from a rural health center or post to the district hospital which may in turn refer to the provincial hospital. This means the woman will cover a long distance to access the service. This has implications on time and cost as the woman can only get to the hospital she has been referred to when she can afford to travel there.

Further, in rural areas most health centers have serous staff and equipment shortages and are unable to provide a basic package of primary health services or provide 24 hours coverage.42 Some rural health centers are inadequately staffed with no nurse or midwife and services are delivered by untrained staff. Currently, registration figures indicate that 7051 enrolled nurses, 2901 registered nurses approximately 3,500 nurse-midwives, 531 physicians and 12093 clinical officers exist but it is not clear how many are in practice or

42 RHP; 22-23 17 where they practice. This has implications on access to safe abortion if the untrained staff have negative attitudes towards abortion. There is no safeguard or guidelines requiring the untrained staff to automatically refer such cases. There is therefore potential for these being a hindrance to women’s access to safe abortion services.

Even though the curriculum for midwives has been expanded in line with the Nurses and Midwives Act with the effect of this cadre of workers providing essential reproductive health services, the acquiring of the skill of termination of pregnancy is optional for doctors at medical school.43 This is in line with the right of staff to conscientious objection. Acquisition of MVA skills for care of abortion complications is mandatory and seventh year medical school students are required to perform at least five MVAs.44 This reflects on elective abortion as a non priority area and strengthens the idea that it is wrong.

Staff attitudes Research has shown that staff attitudes towards abortion have been negative.45 Ndhlovu asserts that attitude of nurses is either judgmental or conservative; that nurses remain unfamiliar with the problems of the aborting woman due to her short stay in the ward. Nurses participating in that study confessed that they were more sympathetic towards the woman with a spontaneous abortion than the one who had induced abortion. Price 46found that one of the psychodynamic sources associated with emotional reactions of nurses was "over-identification with the fetus and lack of identification with the aborting woman on a conscious/unconscious level". The study confirmed that the complexity of the abortion experience in nurses varied in the amount and type of stress it generates for them. The study concluded that the participants’ perception of abortion greatly influenced their attitudes towards the client. The manner in which the nurses responded to the procedure was found to be a joint function of their psychological state and the reason for which abortion was done.47 The study concluded that the participants’ perception of abortion

43 Mtonga, 2000 44 Mtonga, 2000

45 Ndhlovu 1999 46 Price, 1983:154 47 Ndhlovu, 1999: 115 18 greatly influenced their attitudes towards the client. Thus, the attitude of the nurses has implications for women’s desire to utilize safe abortion services at hospitals. The health reforms also introduced a cost sharing mechanism where the clients bear part of the medical services cost. Abortion is charged at K10 000 (about US$2). When clients skip the referral channels and seek services directly from a district or provincial hospital, they pay a fee of K25 000 (aboutUS$5). Private practitioners that offer abortion services are said to be expensive at a fee of not less K450 000 (US$90).48 As a result self induced abortions are done outside the hospital at minimal cost and hospital services are only sought if ‘something’ goes wrong.49 The use of cost sharing in Zambia, as a part of the reform strategy, has to be viewed within the context of a health system which had previously provided free primary health care to all. People’s attitudes are not always supportive of cost sharing mechanisms when previously they have been used to getting free services.50

Further, services are almost inaccessible to most young girls. Staff attitudes, absence of guidelines relating to adolescent’s access to safe abortion, lack of visibility of youth reproductive health corners and therefore lack of information on services available and the cost element all act as hindrances, located within the health delivery system, to access of safe abortion services by adolescents.

Methods In terms or methods MVA was introduced in Zambia by IPAS as far back as 1988. Following a situational analysis in 1998,51 the use of MVA was scaled up. Doctors in central specialist hospitals use MVA and those in district hospitals use sharp curettage under General Anesthesia, as they lack the MVA kits.52 The hospital policy of treating incomplete abortion with curettage and of performing termination of pregnancy with dilation and sharp curettage (D&C) under general anesthesia is also said to have exacerbated barriers to safe, efficient delivery of abortion care.53

48 Webb, 2000 49 Webb 2000 50 Analysis of Health reforms 51 Kaseba, 1998 52 Mtonga, 2000 53 Bradley et al Improving abortion care in Zambia www.jstor.org 19

One survey showed that MVA was used at tertiary and provincial hospitals but not the two district hospitals surveyed.54 Due to the restrictions of the Nurses and Midwives Act, this cadre of workers does not provide MVA for elective abortion.

In terms o f methods such as use of Mifepristol and Misoprostol no literature was available. However, it was noted that the two do not appear on the list of estimated drug needs in the 2000-2006 integrated reproductive health action plan. Research 55has also shown that there is lack of control over methods used by private practitioners. It is said that some private practitioners insert an IUD or a plastic cannula to induce abortion and tell the women to go to the gynecology ward at the hospital when bleeding starts.

Little research seems to have been done on traditional and unconventional methods of abortion.56 This has led to silence around the dangers of these methods thereby sustaining a market for these methods which are unsafe and often have fatal consequences. Considering that the health system recognizes the services of community based deliverers of various reproductive health services, there is need to devise a program to engage with those that offer these unsafe methods.

4.2. Legal and administrative barriers Although the Zambian Termination of Pregnancy Act is a fairly liberal piece of legislation, its implementation is hampered by its stringent legal and administrative requirements and definitional issues. Whereas the WHO defines health as a state of complete physical, mental and social well being and not merely the absence of disease infirmity,’57 the terms physical and mental health and reasonably foreseeable environment are not defined in the Act. It is thus unclear whether mental health includes psychological distress caused by rape or other sexual assault or detrimental socioeconomic circumstances or diagnosis of fetal impairment for example.

54 Commonwealth regional Health Community secretariat for East, Central and Southern Africa Monograph: Magnitude of unsafe abortion: Zambia Information Digest 4:1 see also www.medguide.org.zm/zhid/zhid13.htm last viewed November 11 2006 55 Abortion in Zambia in Silent Voices-Abortion around the World, www.silentvoices.org/abortion.html) 56 Webb, 2000 57 WHO 2001 20

The requirement that three medical practitioners must authorize the abortion also creates serious legal barriers to women’s access to safe abortion. Given the state of affairs in rural areas where clinics are far away and may not even have three medical practitioners stationed at the same place; this is a virtually impossible requirement to comply with. That one of these must be a specialist in the branch of medicine in which the patient is specifically required to be examined is also another serious barrier. It is not clear how many mental health specialists are available in the country and where they are located. It is however noted that mental health specialists are included in the minimum staffing requirements for primary health care delivery.58

The law also restricts the cadre of workers allowed to perform abortions to registered medical practitioners. It also gives medical practitioners the right to conscientious objections. It further restricts the kinds of facilities where abortion can be done to government run and approved hospitals. In a country with so few registered medical practitioners and medical facilities are available, these restrictions mean that only few women can access safe abortion services. The Nurses and Midwives Act should have widened the scope of providers of termination of pregnancy. In addition to low numbers of available medical practitioners few centers perform elective abortion on social grounds because specialists are not obliged to perform or allow termination of pregnancy in their centres if it impinges on their religious or moral grounds and have to refer.59

As noted above the Convention on the Rights of a child has not been domesticated for local use in Zambia. Therefore, Article 3 of the convention which is very relevant to issues of access to safe abortion for young girls is not implemented. Young girls shun asking for safe abortion in hospitals because of fear that parents will be informed and requested for consent for abortion 60and when this is requested for by medical practitioners young girls are unlikely to return and may opt for available alternatives which are not safe. This also raises questions of lack of autonomy for young girls choosing abortion.

58 National Health Policies and Strategies, 1991; 66 59 Mtonga, 2000 60 Webb, 2000 21

4.3. Social, cultural and religious factors Societal norms define the acceptability or rejection of abortion and influence the outcomes of unwanted pregnancy.61 Research suggests that abortion is considered as a silent problem in the country.62 In our traditions and customs, abortion is viewed as a taboo and when done must be done in secret. This means a woman cannot go to hospital where she can be seen as wanting to procure the abortion. Women who have abortions are required to undergo sexual cleansing. (WLSA Zambia, 2006 report Chiefs). They would therefore rather do it secretly to avoid being forced to undergo sexual cleansing. Adherence to religion and its views also affects fertility and abortion behaviour. The Roman Catholic Church opposes abortion for all reasons, even to save the pregnant woman’s life or in case of rape, and therefore, Catholic women are subjected to heavy moral and psychological pressures if they admit to having an abortion. Catholic women who opt for abortion are hence forced to do it in secret for fear of stigmatization should the church find out about it.

4.4. Lack of political will Abortion and post abortion care do not appear to have been a government priority. Following the ICPD in 1994, Zambia made an Integrated Reproductive Health (IRH) package. Although the focus was on safe motherhood the IRH plan of action included the production of IEC materials on unsafe abortion. Post abortion care and abortion services were not among the services envisaged for the community, health post and health center packages. Post abortion care services were planned only for the district and provincial health packages. In the 2000-2005 IRH action plan, though one of the specific objectives was the provision of quality reproductive services, the only activity in the work plan relating to safe abortion was the implementation of the Nurses and Midwives Act. There is also lack of research into traditional methods.

4.5. Information and knowledge barriers

61 Warriner IK and Shah IH, eds., 2006

62 Macwangi, 1993 22

Even though the IRH plan of action indicated that the IEC materials to be produced would include ones on unsafe abortion such information is not available in either English or local languages. Therefore few women and girls are aware of the dangers of unsafe abortion or the provisions of the TOP Act.

5. Opportunities for pushing the debate forward Considering that abortion is legal in Zambia and that the law is fairly liberal, pushing the debate on women’s right to access safe abortion services is not altogether as daunting a task as it would be had law been excessively limiting. There exist therefore a number of opportunities that have been noted in the course of this review which can be utilised to take this debate forward. 1. The state is currently considering the domestication of international instruments relating to women’s human rights and this creates an opportunity to lobby for the ratification and domestication of the Protocol on the Rights of Women in Africa. The ratification and domestication of this instrument would pave way for significant changes to the Termination of Pregnancy Act and would be a platform to argue that some of the stringent requirements of the Act be done away with. 2. The Ministry of Health has introduced the Post Abortion Care initiative in hospitals and is currently scaling up operations. The expansion of this unit creates an opportunity to produce information, education and communication materials on the dangers of unsafe abortion and therein include information on access to safe abortion services. It is important that information, education and communication materials are not expressed in ‘negative’ terms or in a pro-choice language but in neutral terms of fact sheets. This is important to avoid retrogressive action from the church which in Zambia is a very powerful pressure group and one of the most influential movements in the country. In the units where MVA procedure was introduced for uterine evacuation it has been reported that congestion on the ward has decreased significantly, that women receive safer and more timely treatment for abortion complications and that increases efficiency of service delivery has enhanced the staffs 23

ability to provide termination of pregnancy. 63 This is an opportunity to show the benefits of safe abortion. 3. The Ministry of Health also has a consistent television program “Your Health Matters’ that should be taken advantage in providing information on the Termination of Pregnancy Act and the access to safe abortion. Dissemination of the Demographic and Health Surveys which is currently being conducted also pose an opportunity to inform the general public on provisions of the Act and safe abortion. 4. The country has a lot of sensitisation and training programs being run in the communities. WLSA runs one such training program for women’s rights. These can be used to inform the participants on the provisions of the Termination of Pregnancy Act. The Act can be treated as part of the training course on women’s human rights alongside other laws such as the laws on marriage, divorce and maintenance. This would avoid singling out of the Act and the subject of abortion. 5. The introduction of youth reproductive health corners in the clinics by the Ministry of Health is another opportunity. Information on the Termination of Pregnancy Act and how to access safe abortion services can be made available at these corners. The youth peer educators can also be trained in this subject as part of their normal training on sexual and reproductive health issues. 6. Zambia has a lot of community radio stations and all of them have programs on health issues. These radio stations are popular with the community and can be utilised to disseminate information on safe abortion in local languages. 7. The current low statistics of medical practitioners against the number of deaths from illegal abortion and cost of treating incomplete abortion against that of providing legal abortion need to be gathered in a lobbying document that can be used to persuade the state to amend the Termination of Pregnancy Act. A comprehensive study however needs to be done for this and a strategic lobbying plan needs to be thought through.

6. Recommendations From the review done, the following recommendations are being put forward:

63 Bradley, 1991 24

 Abortion prevention campaigns should be implemented. Women and girls who are at reproductive age must be encouraged to use family planning methods when they are not ready to become pregnant. Both natural methods and scientific contraceptives must be explained to these women through antenatal and youth friendly health services to give a wider choice and capture more women and girls.  Better sex education must be offered to teenagers and youths. Parents, teachers and health staff in school, churches and homes must provide their children with more information which would enable them to make a more informed decision. They should be mobilized and discussions among them held in schools, churches, and youth groups in villages. The development of innovative ways of discouraging early pregnancy and induced abortions must be explored.  In cases where prevention has failed, access to safe, confidential and legal abortion services should be made available to women and girls in need to protect them from dangerous, illegal abortions.  Develop IEC materials on unsafe abortion which should be placed in schools and youth friendly corners and other places where youths and teenagers congregate.  Conduct studies of women treated for abortion complications, which are designed to obtain information about the route they followed to terminate the pregnancy, including the type and number of procedures, the fees charged, and other data related to the decision-making process. Information in general terms about the location of the abortion should be obtained.  Conduct studies of hospital costs of treating incomplete abortions, including medicines, personnel time, and related services. For comparison purposes, these studies should also look at the cost of a normal delivery.  Conduct a human rights needs assessment which would involve assessing the scope, causes and consequences of unsafe abortion in the Zambian context and culture, based on available data sources, or on the collection of relevant new data. The assessment should identify laws, including the language of enacted laws and the decisions of courts, and the policies of governments, health care facilities and other influential agencies, which facilitate or obstruct availability of and access to abortion services. The extent to which laws that would facilitate access are actually 25 implemented or how they might be, if they are not adequately implemented, should be determined. Laws and policies that obstruct women’s autonomy and choice in decisions regarding their health generally and abortion specifically, and the availability of and access to services, should also be identified, along with laws that facilitate women’s empowerment, and laws that obstruct such empowerment. 26

BIBLIOGRAPHY

Bradley, J., Sikazwe, N. and Healy, J. Improving abortion care in Zambia. Stud. Family Planning 22, 1991. Faber, J. and Koster-Oyekan, W. Maternal Health, Who Cares? Primary Health Care Programme Western 1994. Koster-Oyekan Winny, Why Resort To Illegal Abortion In Zambia? Findings Of A Community-Based Study In Western Province, Elsevier Science Ltd. 1998. Macwan'gi, M. Abortion in Zambia: a Silent Problem. Working Paper Series, Vol. 1, No. 5. Institute for African Studies, Lusaka. 1993. Ministry of Health, Reproductive Health Policy, Draft, Oct 2004. Nanda,P, Health Sector Reforms in zambia: Implications for reproductive Health and Rights, Center for Health and Gender Equity Working Papers, August 2000. National Commission for Development Planning “National Gender Policy.” Draft. Lusaka, Zambia.1996.

Pillai, V., Achola, P., and Barton, T., “Adolescents and Family Planning. The Case of Zambia,” Population Review, 37(1-2):11-20, 1993. World Health Organisation, Safe Abortion: Technical and Policy Guidance for Health Systems, Geneva, 2003. Warriner IK and Shah IH, eds., Preventing Unsafe Abortion and its Consequences: Priorities for Research and Action, New York: Guttmacher Institute, 2006. Gender in Development Division, National Gender Policy, March 2000 Ministry of Education, FAWEZA, and UNICEF, Guidelines for the Re-entry Policy, Zambia, 2004. GRZ, Act No. 15 of 2005, Supplement to the Republic of zambia Government Gazette dated Friday, 7th October, 2005.

*N.B. SPECIAL THANKS TO IPAS - AFRICA FOR SUPPORT TO THIS REPORT.

SIGNED : DR. SWEBBY MACHA ZAMBIA ASSOCIATION OF GYNAECOLOGISTS AND OBSTETRICIANS (ZAGO) DATED: 10 /06/ 2008 27