In Brief 2009 Series, No.3 Unsafe Abortion in Zambia

In Zambia, because safe, legal abortion is inaccessible to complications (including complications from spontaneous abortion) increased many women, an unknown number of women each year from about 5,600 in 2003 to more than resort to illegal abortions, many of which are performed 10,000 in 2008—and totaled 52,791 over the six years. In other words, under unsanitary and unsafe conditions. The death toll about 85 times as many women were from these procedures is likely high, and almost all such treated for abortion complications as underwent safe, legal abortion in these deaths could be avoided if access to safe abortion were five key hospitals. At least half of reported complications were attributable improved and unintended pregnancies were prevented. to unsafe abortion. Increasing access to safe abortion would likely decrease the rate of complications and mortality Zambia’s abortion law permits pregnancy Determining the scope of unsafe abor- attributable to abortion, a trend that termination on health and socioeconomic tions and the unintended pregnancies has been noted in South Africa.8 grounds (see box, page 2).1 However that precede them is an important step few women who need an abortion can toward achieving effective policies to Health Care Providers’ Attitudes meet requirements that it be performed reduce maternal deaths and improve the About Abortion by a physician, in a hospital and with reproductive health of Zambian women. Ministry of Health guidelines stipulate the consent of three registered medical that health workers treat women who practitioners, one of whom must be a The Level of Abortion have undergone induced abortion in a In Eastern Africa as a whole, an esti- specialist with expertise relating to the sensitive and humane manner and inform mated 14% of all pregnancies end case. (In emergency situations, consent women about the possibility of legal in abortion; in 2003, there were an from only one physician is needed.) That abortion.9 Yet a recent study found that estimated 2.3 million induced abortions there are fewer than two physicians for many health care providers (including in the region (Table 1, page 2).5 That every 10,000 people in Zambia is just doctors) were not aware of the require- translates to 39 abortions per 1,000 one of the hurdles women face when ments for legal abortion.10 When the 2 women of reproductive age, or about seeking a legal abortion. Others include law was explained, many thought that 20 abortions per 100 live births. The the cost of the procedure and the strong requiring three doctors’ consent was majority of these abortions were illegal social and religious sanctions against unacceptable because of the shortage and were likely performed under unsafe abortion. Women who cannot overcome of doctors in most parts of the country; conditions. As a result, for every 100,000 the considerable logistical, financial or some expressed interest in being live births occurring in Eastern Africa, an social obstacles to obtaining a legal trained to provide legal abortions. procedure may resort to illegal abortion, average of 160 women die from causes risking their well-being and seven years’ related to unsafe abortion—more than Some health care providers are 3 6 imprisonment. in any other region of the world. uncomfortable with the issue of abortion or hold judgmental attitudes toward No national data on abortion are avail- Experts in Zambia have suggested abortion patients.10–12 Interviews with able for Zambia, but hospital records increasing access to safe abortion by providers revealed that those with offer some clues to the incidence of safe reducing the number of doctors’ signatures negative and discriminatory attitudes and unsafe abortion. According to data required and allowing midlevel providers about women trying to terminate their 4 from five major hospitals across Zambia, to perform abortions. However, inaction pregnancies gave those women lower a total of 616 women obtained safe by policymakers, persistent stigmatiza- quality care.11 Providers’ negative tion of abortion, lack of awareness of induced abortions between 2003 and attitudes toward abortion and other 7 In contrast, abortion laws and a shortage of health 2008 (Figure 1, page 3). types of sexual and reproductive the number of women admitted to care personnel and resources continue health care may affect adolescents the hospitals with abortion-related to act as barriers to safe services. disproportionately. In 2001, 94% of Termination of Pregnancy Act of 1972 medical professionals, who had likely due to unsafe abortion. used IUDs or plastic cannulas Data from four districts in In Zambia, abortions are allowed under the following circumstances: “(a) continuation of the pregnancy would involve risk to the life of the to induce abortion. A recent Western Province suggest that pregnant woman; risk of injury to the physical or mental health of the study of unsafe abortion in in 1994­­–1995, about 120 pregnant woman; or risk of injury to the physical or mental health of any Zambia found that one form of deaths occurred as a result existing children of the pregnant woman; greater than if the pregnancy medication abortion, misopros- of induced abortion for every were terminated; or (b)…there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be tol,* was widely available in 100,000 live births.15 More severely handicapped. In determining whether the continuance of a preg- pharmacies and prescribed by than half of these deaths were nancy would involve such risk[s]…account may be taken of the pregnant some doctors, but there were among schoolgirls. Another woman’s actual or reasonably foreseeable environment or of her age.” also reports of use without study estimated that in 1993, 10 Source: reference 1. proper instruction. 15% of all maternal deaths in Lusaka were due to unsafe The same study noted that abortion.17 nurse-midwives in public and Why and How Zambian traditional healers may charge private health facilities in two Women Obtain Abortions as little as ZK5,000 for an For each woman who dies as districts felt that abortion Women’s reasons for terminat- unsafe abortion, whereas a result of unsafe abortion, should not be an option for ing a pregnancy vary widely, a safe abortion typically many more experience compli- adolescents with unintended but small-scale studies of costs ZK10,000­–20,000 (plus cations. In 2000–2008, some 12 pregnancies. patients seeking postabortion ZK50,000 if the woman does 66,579 women were admitted care reveal certain patterns. not have a referral) at a public to five major Zambian hospitals Characteristics of Women Adolescents’ primary motiva- facility and even more at a for abortion-related complica- Having Abortions tions include feeling ashamed private facility.10 tions, accounting for slightly Information on women who because of the stigma attached more than one-third of all obtain abortions in Zambia to unwed motherhood, wanting Consequences of gynecologic admissions.7 How- generally comes from health to continue with school, having Unsafe Abortion ever, seeking postabortion care care facilities. Women who been abandoned by their The most severe consequence from Zambia’s underresourced induce abortion themselves partner, feeling too young to of unsafe abortion is death. health care system is not a or go to a lay provider and do be a mother and being unable The maternal mortality ratio in simple matter. As of 2004, not seek postabortion care at to afford having a baby.3 In a Zambia stands at 591 deaths a hospital are therefore not study of patients of all ages, per 100,000 live births, as *The drugs misoprostol and mifepristone included. A 1993–1994 study participants wanted to avoid 16 safely terminate pregnancy, but neither of 2007, and a significant is currently registered in Zambia for of four facilities found that the being expelled from school, proportion of these deaths are this purpose. average patient seeking care avoid revealing a secret rela- for abortion complications was tionship, protect the health aged 24–26 and the mother of of their existing children and Table 1 13 two children. Another study avoid revealing that they had Abortion, Unplanned Births and Contraceptive Use showed that women presenting violated cultural norms, such as Zambian women experience high levels of unintended pregnancy. at University Teaching Hospital postpartum sexual abstinence.15 in 1990 with complications Abortion from unsafe abortion generally Privacy, secrecy and economic Estimated no. of induced abortions in Eastern Africa 2,300,000 were 15–19 years old (60%), % of pregnancies ending in abortion in Eastern Africa 14 concerns drive many women’s % of maternal deaths that are due to unsafe abortion in Eastern Africa 17 had some secondary education decisions about what type Maternal deaths per 100,000 live births in Zambia 591 (55%), were unmarried (60%), of provider and method to Unplanned births had had no previous pregnan- use—and thus determine the Among women aged 15–49 cies (63%) and were students risks they face.3,9,15 Women in % of births that were unplanned 41.4 who wanted to continue their Unwanted 15.8 several studies reported that Mistimed 25.6 education (81%).14 That study they, or people they knew, found that compared with had attempted to self-induce Contraceptive use and unmet need Among women aged 15–49 women obtaining illegal abor- abortion by ingesting the % of currently married women using contraceptives 40.8 tions, women seeking legal antimalarial drug chloroquine, Any modern method 32.7 procedures were older (55% Any traditional method 8.1 herbal remedies, gasoline or % of currently married women with an unmet need for contraception 26.5 were aged 20­–29) and a higher detergents. Others had gone % of sexually active unmarried women using contraceptives 47.6 proportion were mothers Any modern method 43.5 to traditional healers, who had Any traditional method 4.0 (71% had children). given them herbs or inserted % of unmarried women with an unmet need for contraception 4.4 cassava sticks or roots into Note: Data for Zambia are from 2007; regional data are from 2003. their cervix. A small minority Sources: Regional abortion data—reference 5. Regional maternal mortality had received abortions from data—reference 6. All data for Zambia—reference 16.

Unsafe Abortion in Zambia 2 Guttmacher Institute Figure 1 there were only 1.3 physicians, Abortion Complications 17.4 nurses and 2.7 midwives In five major hopsitals, women treated for abortion complications far outnumber those who obtain for every 10,000 Zambians.2 safe abortions. It is therefore likely that a large proportion of women No. of women 11,000 10,689 experiencing complications are 10,489 unable to obtain professional 10,000 care. Of the women who were 9,575 9,328 able to obtain treatment in the 2000–2008 study, six in 1,000 9,000 nonetheless died as a result of their abortion complications.7 8,000 7,104 Unmet Need for 7,000 Family Planning In the vast majority of cases, 6,000 5,606 women seek abortion because they are faced with an unin- 5,000 tended pregnancy. In Zambia, 41% of births are unplanned, 4,000 and the average women gives birth to about one child more 3,000 than she wants, indicating that unintended pregnancy is 2,000 very common.16 Many women and couples are at risk for 1,000 unintended pregnancy because 139 152 they have an unmet need for 115 33 54 123 0 contraception; that is, they 2003 2004 2005 2006 2007 2008 want to delay or stop child- Abortion complications Safe abortions bearing, but they are not practicing contraception. Source: reference 7. About one in four married women have an unmet need Needed Evidence and decrease abortion-related to the health of Zambian for contraception, and while on Abortion complications and death. women unless steps are taken this proportion decreases as The following research objec- to prevent them. education and economic status tives have great potential to • Examine ways to offer medi- rise, nearly one in five women support policy changes that cation abortion. Medication • Strengthen family planning in the highest wealth quintile would improve services for abortion, an extremely safe service provision and demand. have an unmet need. However, Zambian women and prevent and relatively low-cost form of Providing family planning progress is being made: Levels maternal deaths: early abortion, is not widely services and information— of contraceptive use increased available in Zambian health including ensuring the avail- between 2001–2002 and 2007 • Measure abortion and its facilities. Operations research ability of contraceptive among both married women consequences. A nationally on how to train providers and supplies and training providers (from 34% to 41%) and sexu- representative study estimating where to offer the procedure to help educate women and ally active unmarried women abortion incidence and the could result in safer abortion. men about methods—could (from 33% to 48%). Yet, severity of related complications reduce the incidence of both demand for family planning would be useful for increasing Going Beyond unsafe abortion and abortion- keeps growing, causing the awareness of the health conse- Research Evidence related complications by pre- level of unmet need to remain quences of unsafe abortion. It Even with new evidence on the venting unintended pregnancy, relatively static.16,18 would also serve as a baseline scope of unsafe abortion in especially among adolescents for measuring how effectively Zambia and ways to make the and people living in rural areas new medical guidelines procedure safer and more (currently in development) accessible, unsafe abortions • Improve availability of and increase access to safe abortion will continue to pose a threat access to safe, comprehensive

Unsafe Abortion in Zambia 3 Guttmacher Institute abortion care, including post- Care Women International, 2007, Abortion Care, Pilanesberg National 16. Central Statistical Office et al., abortion care. To ensure that 28(7):654–676. Park, South Africa, Dec. 2–6, 2001. Zambia Demographic and Health safe abortion is available to 4. Ipas and Division of Inter- 10. Ministry of Health, Strategic Survey 2007, Lusaka, Zambia: Central Statistical Office; and the extent allowed by law, national Health, Department of assessment of policies, programs Public Health Sciences, Karolinska and research issues related to Calverton, MD, USA: Macro Interna- Zambia should consider the Institutet, Deciding Women’s Lives prevention of unsafe abortion tional, 2009. World Health Organization’s Are Worth Saving: Expanding the in Zambia, unpublished report, 17. Syacumpi MM et al., Country recommendations for safe Role of Midlevel Providers in Safe Lusaka, Zambia: Ministry of Analysis of Family Planning and provision, which include Abortion Care, Chapel Hill, NC, USA: Health, 2008. HIV/AIDS: Zambia, Washington, DC: Ipas, 2002. training providers about safe 11. Kaseba C et al., The Situation Policy Project, 2003. and aseptic abortion practice, 5. Sedgh G et al., Induced of Postabortion Care in Zambia: An 18. Westoff CF, New estimates of ensuring the availability of abortion: estimated rates and Assessment and Recommendations, unmet need and the demand for trends worldwide, Lancet, 2007, Research Triangle Park, NC, USA: family planning, DHS Comparative needed equipment and supplies, 370(9595):1338–1345. Research Triangle Institute, 1998. Reports, Calverton, MD, USA: Macro and promoting the use of 6. WHO, Unsafe Abortion: Global 12. Warenius LU et al., Nurse- International, 2006, No. 14. the safest methods for first- and Regional Estimates of the midwives’ attitudes towards 19. WHO, Safe Abortion: Technical trimester abortions, including Incidence of Unsafe Abortion and adolescent sexual and reproductive and Policy Guidance for Health manual vacuum aspiration Associated Mortality in 2003, fifth health needs in Kenya and Zambia, Systems, Geneva: WHO, 2003. and medication abortion.19 ed., Geneva: WHO, 2007. Reproductive Health Matters, 2006, 14(27):119–128. Progress in Zambia could be 7. Likwa RN, Abortion statistics in CREDITS furthered by programs to Zambia: research in brief, Lusaka, 13. Kinoti SN, Gaffikin L and This In Brief was written by Rose- reduce the stigma surrounding Zambia: Department of Commu- Benson J, How research can affect mary Ndonyo Likwa, University of nity Medicine, School of Medicine, policy and programme advocacy: Zambia, and Ann Biddlecom and abortion and by including University of Zambia, 2009. example from a three-country study Haley Ball, both of the Guttmacher training in safe abortion on abortion complications in Sub- Institute. The authors thank the 8. Jewkes R et al., The impact of Saharan Africa, East African Medical following colleagues for their help- services as a formal component age on the epidemiology of in- Journal, 2004, 81(2):63–70. ful comments and suggestions on of medical curricula. complete abortions in South Africa early drafts: Akinrinola Bankole and after legislative change, British 14. Likwa RN and Whittaker M, Leila Darabi, Guttmacher Insti- REFERENCES Journal of Obstetrics and Gynaecol- Women presenting for abortion and tute; Stephen Mupeta, University 1. Termination of Pregnancy Act, ogy, 2005, 112(3):355–359. complications of illegal abortions Teaching Hospital, Zambia; Amos at the University Teaching Hospital, Laws of Zambia, Ch. 304, 1972. 9. Mtonga V and Ndhlovu M, Mwale, Youth Vision Zambia; and Lusaka, Zambia, African Journal of 2. World Health Organization Midwives’ role in management of Duah Owusu-Sarfo, United Nations Fertility, Sexuality and Reproductive (WHO), The World Health Report elective abortion and post-abortion Population Fund. Health, 1996, 1(1):42–49. 2006: Working Together for Health, care: Zambia country report, Suggested citation: Likwa RN, Geneva: WHO, 2006. paper presented at the confer- 15. Koster-Oyekan W, Why resort to Biddlecom AE and Ball H, Unsafe ence Expanding Access: Advancing illegal abortion in Zambia? findings 3. Dahlback E et al., Unsafe abortion in Zambia, In Brief, New the Roles of Midlevel Providers in of a community-based study in induced abortions among York: Guttmacher Institute, 2009, Menstrual Regulation and Elective Western Province, Social Science & adolescent girls in Lusaka, Health No. 3. Medicine, 1998, 46(10):1303–1312. ©2009 Guttmacher Institute

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Unsafe Abortion in Zambia Guttmacher Institute