In Brief Series 2013, No. 2 Unintended Pregnancy and Abortion in Uganda
Unintended pregnancy is common in Uganda, leading to high Key Points levels of unplanned births, unsafe abortions, and maternal • Abortion is permitted in Uganda under injury and death. Because most pregnancies that end in some circumstances, but the relevant laws and policies are unclear and are often abortion are unwanted, nearly all ill health and mortality interpreted inconsistently, making it difficult for both women and the medical resulting from unsafe abortion is preventable. This report community to understand their options. summarizes evidence on the context and consequences of • While maternal mortality has declined in unintended pregnancy and unsafe abortion in Uganda, points Uganda in the last decade, levels remain very high: An estimated 310–438 women out gaps in knowledge, and highlights steps that can be die of pregnancy-related causes per 100,000 live births. Furthermore, many taken to reduce levels of unintended pregnancy and unsafe Ugandan women suffer severe morbidity, abortion, and, in turn, the high level of maternal mortality. often as a result of unsafe abortion. • Unintended pregnancy is common in Uganda, leading to high levels of un- Uganda, a country of nearly 35 million Unintended pregnancy is very planned births. In 2011, more than four (including 8 million women of reproduc- common in Uganda in 10 births were unplanned—either tive age), has one of the highest rates In 2008, an estimated 1.2 million unin- mistimed or unwanted. On average, women of population growth in the world.1–3 tended pregnancies occurred in Uganda, in Uganda have 6.2 children but only Although the economy has improved representing more than half of the intend to have 4.5 children. steadily in the last two decades, poverty country’s 2.2 million pregnancies (Figure • Adolescents and young adults are particu- remains pervasive; the gross national 1, page 3). Such unintended pregnancies larly at risk for unintended pregnancy. income per capita (US$510) is less than result in two main outcomes—unplanned Premarital sex is common in Uganda: 1 6 half the average for Sub-Saharan Africa. births and abortion. According to the More than one in three never-married While Uganda’s population remains mostly 2011 Uganda Demographic and Health women aged 15–24 have had sex. rural, women are increasingly moving to Survey, more than four in 10 births (43%) • Contraceptive use remains very low in urban areas, in many cases to seek work are unplanned (Table 2, page 3).7 The Uganda. Only 26% of married women and or education and to find opportunities proportion of births that are unplanned 43% of sexually active unmarried women 4 is higher among rural, poor and less to help their families live a better life. use a modern method. Furthermore, one In 2011, about 28% of Ugandan women educated women than among their urban, in three married women are not using of reproductive age had at least some wealthier and better educated counter- contraceptives even though they do not secondary education, compared with 18% parts. Additionally, women in the Eastern want to become pregnant. a decade earlier (Table 1, page 2). As and North regions had the highest propor- • Treating complications of unsafe abortion women’s opportunities have increased, so tions of unplanned births (50–54%), poses significant costs to the Ugandan have their desires to have fewer children while the proportions among women liv- health system. On average, postabortion and plan their fertility. However, resource ing in Karamoja, Kampala and the Central care costs nearly US$130 per patient; the 1 and Southwest regions were lower constraints, such as the shortage of annual costs total nearly US$14 million. providers, limit access to health care and (12–37%) than the national average. make it difficult for women to meet their reproductive health needs.5 Table 1 Fertility, Sex And Contraceptive Use urban counterparts (0.6 chil- young people are reluctant to dren). There may be several fac- openly seek the family planning Selected characteristics and behaviors of Ugandan women aged 15–49, by year, 2000–2011 tors that explain the disparity services and counseling they in fertility outcomes, including need. According to the 2011 Characteristic/behavior % or mean disparities in access to contra- Demographic and Health Survey,
2000– 2006 2011 ceptive supplies and informa- one of the most commonly cited 2001 tion as well as socioeconomic reasons that unmarried, sexually and cultural differences among active young women do not use Demographic % living in urban area 17 17 20 certain subgroups of women.9 a contraceptive method is that % with ≥secondary education 18 21 28 they are not married, underscor- Young women are Fertility ing the impact of the general Mean total fertility rate 6.9 6.7 6.2 particularly vulnerable to taboo against sex outside of Mean wanted total fertility rate 5.3 5.1 4.5 unintended pregnancy marriage.7 Adolescents and young adults Sexual activity/marriage Among women aged 20–24 are particularly at risk for un- Premarital pregnancy is also Mean age at first sex 16.8 16.9 17.3 intended pregnancy. Premarital a source of shame, and often Mean age at first marriage 17.7 18.3 18.9 Among women aged 15–24 sex is common in Uganda: results in an array of negative % of never-married women who are sexually experienced 37 34 36 More than one in three never- consequences. Some young % of unmarried women who are sexually active 22 19 18 married women aged 15–24 women are abandoned by their
Contraceptive use/unmet need have had sex, and nearly one in partners, others are forced Among married women aged 15–49 five unmarried women in that to leave home and many are % using any method 23 24 30 12 % using a traditional method 9 6 4 age-group is currently sexually expelled from school. Although % using a modern method 14 18 26 active (Table 1). Moreover, the Uganda’s 2004 National Adolescent Health Policy per- % with any unmet need 35 41 33 average age at first sex among % with unmet need for spacing 21 25 20 women aged 20–24 is about a mits girls to return to school % with unmet need for limiting 14 16 13 year and half younger than the after they give birth, resources
Among sexually active unmarried women aged 15–49 average age at first marriage, and support to empower young % using any method 44 44 43 an age gap that has increased women to do so are scarce.13 % using a traditional method 6 5 5 % using a modern method 38 39 38 during the last decade. Coercive % with unmet need for contraception 40 42 39 sexual debut is also common— Abortion is permitted under one study of rural Ugandan some circumstances, but Unplanned fertility policies are unclear % of births unplanned 38 45 43 secondary students found that The laws and policies surround- % of birth mistimed 24 31 32 43% of girls who had ever had % of births unwanted 14 13 12 ing abortion in Uganda are sex had been “very unwilling” to unclear and are often inter- Notes: Total of mistimed and unwanted births may not equal unplanned births because of have their first sexual experi- preted inconsistently, making rounding. Sources: reference 7; Uganda Bureau of Statistics (UBOS) and Macro International, ence.10 In another study, 20% of Uganda Demographic and Health Survey, 2006, Calverton, MD, USA: UBOS and Macro Interna- it difficult for both women tional, 2007; and UBOS and ORC Macro, Uganda Demographic and Health Survey, 2000–2001, women in a rural area of Uganda Entebbe, Uganda: UBOS; and Calverton, MD, USA: ORC Macro, 2001. and the medical community to reported that they had been understand their options.14 The threatened or forced into having Ugandan Constitution allows their first sexual experience.11 In Ugandan women, on average, when one compares the fertil- abortion if the procedure is such situations, women and girls give birth to nearly two children ity rates and desires of women authorized by the law, but does are less likely to be prepared more than they want—they across wealth levels and place not state the exact circum- to negotiate contraceptive use have 6.2 children but would of residence. Among women in stances, leaving room for legal than they are in consensual prefer to have only 4.5 (Figure the highest wealth quintile, the provisions and interpretations. situations, and therefore are 2, page 4). This difference gap between total and wanted A well-documented 1959 British at increased risk for unwanted between Ugandan women’s fertility is 0.7 children; how- legal ruling that was incorpo- pregnancy; indeed, the study total fertility rate and their ever, the difference increases rated into Uganda’s penal code found that women who had wanted fertility rate—one rapidly as wealth decreases, (British law was the basis for been sexually coerced were more of the highest levels of ex- with the largest gap among the Uganda’s original penal code) likely than other women to cess fertility in Sub-Saharan poorest women (2.3 children). addressed the grounds for have ever attempted to have an Africa8—highlights just how Additionally, rural women, on abortion, which were inter- abortion. difficult it is for women to average have 2.0 children more preted to include saving the meet their fertility desires. The than they intended, a fertility Because of the stigma associ- woman’s life and preserving disparity is particularly striking gap far larger than that of their ated with premarital sex, many her physical and mental health.
Unintended Pregnancy and Abortion in Uganda 2 Guttmacher Institute Table 2 Furthermore, according to the clandestine environments; while Disparities in Unplanned Births 2006 National Policy Guidelines they offer confidentiality, they Percentage of births that were unplanned, by women’s social and and Service Standards for Sexual generally charge a high premium demographic characteristics, 2011 and Reproductive Health and for their services. Rights, pregnancy termination Characteristic Mistimed Unwanted Total unplanned Poor and rural women, whose is permissible in cases of fetal access to skilled providers is All 32 12 43 anomaly, rape and incest, or if limited by financial constraints the woman has HIV. However, Residence and the geographic remoteness Rural 32 12 44 the laws and policies are not Urban 30 9 38 of services, often must resort to clearly detailed in legislation, obtaining abortions performed Region and because interpretations of by untrained providers using Kampala 24 7 31 the law are ambiguous, medical Central 1 26 11 37 unsafe methods.17,18 In one providers may be reluctant to Central 2 33 12 46 study, Ugandan health profes- East Central 30 17 47 perform abortion for any reason Eastern 39 11 50 sionals estimated that compared for fear of legal consequences, North 42 12 54 to nonpoor urban women, poor Karamoja 11 2 12 even though the penalties do rural women were less likely to West Nile 41 8 49 not apply to the provision of Western 32 12 44 obtain abortion services from Southwest 22 14 36 legal abortions. doctors, and much more likely Wealth Unsafe abortion is common, to self-induce their abortions Poor 33 12 45 but the complication risk or to use traditional, unquali- Nonpoor 29 11 40 varies fied providers. Consequently, Education The only national estimate women who used these unsafe ≤primary 31 13 44 of abortion levels in Uganda methods had the highest levels ≥some secondary 32 7 39 comes from a 2003 study that of complications: An estimated Note: Total of mistimed and unwanted births may not equal unplanned births because of employed indirect estimation 68–75% of poor rural women rounding. Source: reference 7. techniques.15 According to who had had an abortion had that study, there were nearly experienced complications, Figure 1 300,000 abortions in Uganda compared with 17% of nonpoor Unintended Pregnancies in 2003, which is equivalent urban women who went to a More than half of pregnancies in Uganda are unintended, and nearly to a rate of 54 abortions per doctor.17 a third of these end in abortion. 1,000 women of reproductive age, or one abortion for every Attitudes toward abortion fuel stigma 19 such women. This rate is far 44% higher than the average rate for Although desired fertility is Eastern Africa (36 abortions per declining, many Ugandans still Intended 1,000 women).16 want large families and do 56% not approve of abortion.7,8,19 Unintended Women from all socioeconomic Typically, Ugandan men are and demographic backgrounds the head of the household and have abortions in Uganda. Their want more children than their experiences, however, may vary partners do. One qualitative 2.2 million pregnancies considerably. Compared with study found that men generally 14% their poorer counterparts, wom- did not support the practice of en who are well off generally abortion because it prevents have access to a wider range of the birth of a potentially useful Unplanned births providers, and are more likely to member of society.19 Some men be able to visit doctors, nurses said they would not want their 56% Abortions 30% and clinical officers, some of partner to have an abortion be- Miscarriages whom may be trained and able cause they feared the procedure to provide safe procedures.17 would result in health problems However, since abortion is for the woman or legal repercus- legally restricted in most cases, sions for themselves, while 1.2 million unintended pregnancies in 2008 skilled providers must work in others believed that women Source: reference 7.
Guttmacher Institute 3 Unintended Pregnancy and Abortion in Uganda have abortions to cover up of modifying the abortion law maternal death, there are six for abortion complications that evidence of extramarital affairs. for any reason.17 Furthermore, Ugandan women who suffer year.15 Such treatment may Men did, however, express some policymakers have acknowledged severe morbidity, often as a require hospital care, blood support for schoolgirls having that abortion restrictions en- result of unsafe abortion.22 A transfusions and antibiotics— abortions. danger women’s lives, but they hospital-based study in Kampala scarce resources in a country believed that liberalizing the in the early 1990s estimated with frequent drug stockouts Other research has revealed that law could increase the number that 21% of maternal deaths and insufficient medical person- negative views about abortion of abortions and have negative were due to unsafe abortion; in nel.25,26 However, the health are pervasive. In another quali- social consequences.20 2008, the Ugandan Ministry of consequences of unsafe abortion tative study, community mem- Health estimated that abortion- cannot be measured entirely bers acknowledged the deep Unsafe abortion causes related causes accounted for by hospitalization rates, as a stigma surrounding abortion and serious injury—and 26% of maternal mortality.23,24 substantial proportion of women expressed the belief that some sometimes death The latter figure is considerably who need postabortion care do healthcare providers mistreat or While maternal mortality has higher than the World Health not receive it.17 abuse women seeking postabor- declined in the last decade, it Organization’s estimates for the tion care. In the health profes- remains very high in Uganda: Eastern Africa subregion (18%) The costs of abortion and sionals study, providers reported Recent estimates suggest and for the world as a whole postabortion care are that they would rather treat that 310–438 women die of substantial (13%).16 complications of spontaneous pregnancy-related causes per The amount women pay for a abortions (miscarriages) than 100,000 live births, and that According to the 2003 national clandestine abortion varies, but those of induced abortions, Ugandan women have a 3% incidence study, 15 out of every much is dependent on what they and 53% of healthcare facility lifetime risk of dying from such 1,000 Ugandan women of can afford or access. According staff said they did not approve causes.8,21 Furthermore, for every reproductive age were treated to estimates based on the 2003 survey of health professionals, Figure 2 a nonpoor urban woman pays Fertility Disparities about seven times as much to Poor and rural Ugandan women struggle to meet their fertility goals. go to a doctor in a private facil- ity as a poor rural woman pays 9 to obtain services from a tradi- tional or lay practitioner.17 An 8 7.9 abortion was estimated to cost a woman US$25–88 if performed 7.1 by a doctor, US$14–31 if per- 7 6.8 6.9 formed by a nurse or midwife, 6.2 6.1 US$12–34 if performed by a 6 5.6 traditional healer and US$4–14 if the woman self-induced or 5.0 5 4.8 4.9 used a pharmacist. 4.5 4.4 4.0 A recent study addressed an- 4 3.8 other aspect of the economic 3.2 3.3 impact of unsafe abortion—the No. of children 3 cost to the health system of treating complications.27 The re-
2 searchers estimated costs in the three major types of treatment facilities—regional hospitals, 1 district hospitals and health centers—and found that, on 0 average, postabortion care costs Total Urban Rural Lowest Second Middle Fourth Highest nearly US$130 per patient; in Residence Wealth quintile total, such care is estimated to
Total fertility rate Wanted total fertility rate cost nearly $14 million annually in Uganda (Figure 3). Two-thirds Source: reference 7. of this amount, or US$9.5 mil-
Unintended Pregnancy and Abortion in Uganda 4 Guttmacher Institute Figure 3 lion, went to nonmedical costs ally active unmarried women, The Costs of Care (overhead and infrastructure), levels of contraceptive use have The total annual cost of postabortion care in is nearly US$14 million. and the remaining third (US$4.4 been stagnant: In both periods, million) was spent on direct 43–44% used any method and US$ 10,000 medical inputs (drugs, supplies, 38% used a modern method. labor, hospitalization and out- 9,000 Disparities in modern method 8,340 patient fees). Most of the costs use among Ugandan subpopula- of postabortion care arise from 8,000 Direct nonmedical cost tions are considerable: In 2011, treating incomplete abortion; 2,693 only 13–15% of Uganda’s poor- 7,000 however a significant propor- est and least educated married Direct medical costs tion can be attributed to more women used modern contracep- 6,000 serious complications, such as tives, compared with 37–39% sepsis, shock, lacerations and 5,000 of the wealthiest and most perforations.27 3,997 educated.7 A greater proportion 4,000 Another study, which used a of urban married women used 1,312 model-based approach, estimat- modern contraceptives than did 3,000 5,737 ed that the average woman pays their rural counterparts (39% vs. 2,000 1,466 US$62 per abortion (including 23%). 2,685 381 any associated postabortion 1,000 The proportion of women with care);28 it also found that each 1,085 an unmet need for contracep- abortion results in US$177 0 tion—that is, those who either Regional hospitals District hospitals Health centers in societal costs—four times did not want a child soon or Total national cost: Direct nonmedical cost Direct medical costs the annual per capita health wanted to stop childbearing al- expenditure in Uganda. Findings Source: reference 27. together, but were not using any from these two studies suggest method of birth control—has that almost half of the health has remained high during the system cost of treating post- cause unmarried women have a Among married women, com- past decade. In 2011, about one abortion complications is borne stronger desire not to become monly cited reasons for unmet in three married women had an by women and their households. pregnant to avoid stigma of need include personal or partner unmet need for contraception In a country where many women pregnancy outside of marriage. opposition to contraceptive use (Table 1).7 Most of the unmet live on less than US$1 per day, (26%), breastfeeding or post- need among married women was Barriers to contraceptive these costs can have long-term partum amenorrhea (26%) and for spacing or delaying births use 7 impact on households’ economic fear of adverse effects (22%). (62%), but a significant propor- There are many reasons why well-being.1 These reasons suggest that tion (38%) was for ceasing women do not use contracep- there is a dearth of clear infor- tives. Access to services and in- Contraceptive use is low, childbearing altogether. Unmet mation about family planning— and unmet need persists need varies considerably among formation can be a barrier: Rural its mechanisms of action, safety, The high level of unintended subgroups of married women women with an unmet need for side effects, efficacy and ease pregnancy and the gap between (Figure 4, page 6): Those who contraception are more than of use. Furthermore, widespread actual and desired fertility are poor, living in rural areas twice as likely as urban women contraceptive stockouts may in Uganda can be attributed or have no secondary educa- to cite lack of access or lack of affect whether a woman receives largely to insufficient contracep- tion have much higher levels a source as a reason for not us- her preferred method, or any 7 tive use. In 2011, only 30% of of unmet need (35–40%) than ing contraceptives. In addition, method at all.26 married women used a method do their urban, wealthier and male partners may discourage of family planning, a modest better educated counterparts or forbid women from practicing Improvements in contra- increase from 23% a decade (21–28%). contraception. In the qualitative ception and postabortion care are needed before (Table 1).7 Married study mentioned earlier, some Additionally, despite their The demand for postabor- women’s use of modern (rather Ugandan men said they believed higher levels of contraceptive tion care will exist as long as than any) methods increased contraceptives can cause health use, sexually active unmarried women are unable to meet their more dramatically, from 14% to problems, such as permanent women have even greater levels childbearing goals and, as a 26%, but levels are still too low infertility and cancer, while of unmet need than do married result, resort to unsafe abor- to reduce the high rates of unin- others felt that contraceptive women—43% versus 33% use might cause women to have tion. Unfortunately, many health tended pregnancy. Among sexu- 7 (Table 1). This may be be- extramarital affairs.12 facilities in Uganda are not
Guttmacher Institute 5 Unintended Pregnancy and Abortion in Uganda adequately equipped to manage the potential financial benefits Action is needed to end themselves, to use methods ef- postabortion cases, as they do of efforts to promote modern unsafe abortion and reduce fectively and to switch methods not have enough supplies or contraceptive use.6 According maternal mortality when desired. their providers have insufficient to the study, the total cost of Updated estimates of the inci- • Expand and improve the qual- training.29 Midlevel providers, pregnancy-related medical care dence of unsafe abortion and ity of postabortion care services. such as nurses and midwives, in 2008 would have been US$81 its consequences are needed Because unsafe abortion con- are legally permitted to provide million lower if half of unmet to assess trends and progress tinues to cause serious health postabortion care, but the need for modern contraception since 2003, the year of the most complications, postabortion care majority lack proper training. had been met, and US$162 mil- recent estimates. The existing will remain a vital part of mater- Furthermore, the 2003 study lion lower if all unmet need had evidence highlights several steps nal healthcare. More providers, found that many women delay been eliminated by modern con- that policymakers can take now. including midlevel ones, must seeking care for postabortion traceptive use. Additionally, the • Reduce unmet need for contra- be trained in comprehensive complications because they fear typical cost of postabortion care ception by eliminating barriers postabortion care (particularly that they will receive judgmen- is five times the average annual to family planning services. The provision of manual vacuum as- tal—and in some cases, abu- cost of a year’s worth of modern government should ensure that piration) to adequately address sive—treatment from providers. contraceptive services. Results free or affordable public-sector the need for services in all parts It is likely that these conditions of other studies support these contraceptive services reach all of the country. Sensitivity train- have changed little in the past findings: Ensuring universal women, especially those who ing of providers is also needed. decade.17,18 access to modern contraceptives are poor and young. Programs would save US$86 per women in • Emphasize the importance Levels of unmet need for should offer comprehensive fam- societal and governmental costs of youth-friendly services that modern contraceptives in ily planning services—that is, and avert 50,000 abortions offer confidential reproductive Uganda are among the highest provide counseling, information annually.31,32 health counseling and infor- in Sub-Saharan Africa.30 A 2009 and a wide range of contracep- mation as well as provision of cost-benefit study highlighted tive methods—to enable women to choose the best methods for family planning methods. Figure 4 • Improve health care providers’ ability to offer abortion services Unmet Need for Contraception within the current legal context. Poor, rural and less-educated women have particularly high levels of unmet need. It is critical to raise providers’
100 awareness of the content and scope of the Ugandan abortion 90 law and to equip them with appropriate training to provide 80 safe abortion services within legally permitted circumstances. 70 Implementation of these and 60 similar measures would help reduce the toll of unintended unmet need 50 pregnancy and unsafe abortion,
40 and provide Ugandan women 40 35 35 with the information they need to make the best decisions for 28 30 their own well-being as well as 23 % of married women with unmet need 21 that of their families. 20
10
0 Rural Urban Poor Nonpoor Primary Secondary or less or higher Residence Wealth Education Source: reference 7.
Unintended Pregnancy and Abortion in Uganda 6 Guttmacher Institute REFERENCES 12. Kaye DK, Community perceptions 23. Mirembe F and Okong P, Risk CREDITS and experiences of domestic violence factors associated with maternal 1. World Bank, Uganda, no date, This In Brief was written by Rubina and induced abortion in Wakiso mortality in three Kampala hospi-
Guttmacher Institute 7 Unintended Pregnancy and Abortion in Uganda Advancing sexual and reproductive health worldwide through research, policy analysis and public education
New York Washington D.C. www.guttmacher.org 125 Maiden Lane, New York, NY 10038 1301 Connecticut Avenue, N.W., Suite 700 Tel: 212.248.1111 Washington, DC 20036 Fax: 212.248.1951 Tel: 202.296.4012 Fax: 202.223.5756 [email protected] [email protected] January/2013