In Brief Series 2013, No.1 Unsafe in Tanzania: A Review of the Evidence

Although termination is restricted by law in Unsafe abortion is common in Eastern Africa. Tanzania, it is widely practiced and almost always unsafe, Given the legal restrictions associated and contributes to the country’s high maternal morbidity with abortion, it is difficult to obtain reli- able information on its prevalence and to and mortality. Yet the majority of abortion-related deaths are assess the magnitude of the morbidity and preventable, as are the unintended associated mortality associated with it. No national abortion incidence data are available in with abortion. Better access to contraceptives, more Tanzania, however, estimates for regions comprehensive postabortion care and greater availability of of Africa indicate that unsafe abortion is common and represents the majority of in- safe abortion services within the current legal framework are duced .4 In Eastern Africa, which includes Tanzania, the estimated number critical to achieving the Millennium Development Goal 5 of of unsafe induced abortions was 2.4 mil- reducing maternal mortality and ensuring universal access to lion in 2008, or 36 unsafe abortions per 1,000 women of reproductive age care by 2015. (Table 1)5—the highest regional unsafe abortion rate in Africa. This report summarizes the current evi- referred to as the Maputo Protocol), which dence on induced abortion in Tanzania, requires the government to “protect the Unsafe abortion contributes to clarifies existing law on the provision of of women by authoris- high levels of maternal mortality abortion, and identifies key areas where ing in cases of sexual and morbidity. government and program planners can assault, , [and] incest, and where Unsafe abortion represents one of the take action to decrease levels of unin- the continued pregnancy endangers the leading causes of maternal deaths in tended pregnancy and unsafe abortion. mental and physical health of the [preg- Tanzania. According to the Ministry of nant ] or the life of the [pregnant Health and Social Welfare, 16% of ma- Current is restrictive, woman] or the foetus.”3(p. 16) Yet despite ternal deaths are due to complications 6 but its legal interpretation needs ratification, the Tanzanian government from abortion;* this is comparable to to be clarified. has not incorporated this provision into the proportion of maternal deaths from In Tanzania, the penal code explicitly 5 its national laws. unsafe abortion in Eastern Africa (18%). states that termination of pregnancy is A higher proportion was reported in a legally permitted if it is performed to save Contrary to widespread belief, a health small-scale review of 62 maternal deaths a woman’s life.1 However, a recent report care provider is not required to consult at a regional hospital in Tanzania, where indicated that since Tanzania’s legal with other providers before performing an a quarter of those deaths were due to 2 system is based on English common law, abortion. In addition, the law does not abortion.7 Similarly, an analysis of sentinel the English case of Rex v. Bourne could be specify what level of provider may perform surveillance data for 110 maternal deaths applied in the interpretation of Tanza- a legal termination. Given the absence in rural Hai District indicated that in 23% nia’s abortion law to authorize abortion of interpretation by Tanzanian courts of the cases induced abortion was the to preserve a woman’s physical or mental and the contradictory laws and policies, cause of death.8 health.2 Furthermore, in 2007, Tanzania women and health care providers may lack ratified the African Charter’s Protocol a comprehensive understanding of the *The source for this figure is unclear in the Ministry on the Rights of Women in Africa (also content and scope of the law on abortion. report. Table 1 Abortion and Maternal Mortality Abortion methods, providers not surprising that women will and costs vary in Tanzania. attempt to self-induce or seek Abortion incidence and consequences in Eastern Africa and Tanzania For women who cannot access a cheaper alternative, includ- Abortion incidence safe abortion services, many ing procedures from untrained Eastern Africa (2008) will try to abort the pregnancy providers. No. of unsafe induced abortions 2,430,000 themselves or turn to unskilled % of pregnancies ending in abortion 14 Abortion rate (per 1,000 women) 38 providers. In a study of women The cost of unsafe abortion Unsafe abortion rate (per 1,000 women) 36 who were admitted to a hospital for women and the health Unsafe abortion ratio (per 100 live births) 20 system is high. with complications from an Although no recent costing Tanzania induced abortion, 46% of those No. of abortions na studies have been conducted, in rural areas and 60% of those it is clear that the proportion Consequences of unsafe abortion in urban areas reported that the of hospital admissions for Eastern Africa abortion had been performed by No. of maternal deaths due to unsafe abortion complications, 2008 13,000 16 abortion-related complications % of maternal deaths due to unsafe abortion, 2008 18 an unskilled provider. Prelimi- accounts for a disproportionate No. of women hospitalized for induced abortion complications, 2005 612,940 nary results from a qualitative share of hospital expenditures. Tanzania (2010) study in mainland Arusha and Maternal mortality ratio (per 100,000 live births) 454 According to an exploratory Town West, Zanzibar, found No. of maternal deaths 8,500 study in the late 1990s, the cost % of maternal deaths due to abortion 16 that providers in nonclinical of a one-day hospital stay for settings—such as traditional Note: na=not available. Sources: Eastern Africa—no. of abortions, unsafe abortion rate and the treatment of abortion com- ratio, and data: reference 5; pregnancies ending in abortion: Singh S et al., birth attendants and phar- plications was more than seven : worldwide levels, trends, and outcomes, Studies in Family Planning, maceutical retailers—were 2010, 41(4):241–250; abortion rate: reference 4; women hospitalized: reference 13. Tanzania— times the Ministry of Health’s maternal mortality ratio: reference 11; maternal deaths: reference 12; maternal deaths due to preferred because they ensure abortion: reference 6. budget per person per year.21 greater privacy and lower costs than physicians.17 In addition to the immediate The Tanzanian government has Unsafe abortion is also associ- economic and health costs Methods used for self-inducing shown, through various policies ated with high levels of morbid- associated with unsafe abor- an abortion vary and include —including the implementation ity. In Eastern Africa, more than tion, there are also a number of herbs, high doses of chloroquine of the National Road Map Strate- 600,000 women were estimated indirect costs, such as loss of and the detergent “Blue.”16–19 gic Plan to Accelerate Reduction to be hospitalized for induced income and productivity in the Other known methods are wood of Maternal, Newborn and Child abortion complications in 2005, short term and from long-term ashes in solution, cassava Deaths in Tanzania, 2008– corresponding to a rate of 10 morbidity.22 These latter losses stems, twigs and contraceptive 2015—that it is committed to per 1,000 women aged 15–44.13 are more difficult to quantify pills.17–20 Participants in a small reducing maternal mortality. In The prevalence of unsafe abor- and have not been measured. qualitative study mentioned a 2007, was regis- tions in hospital-based settings drug purchased from retail phar- tered by the Tanzanian Food and in both urban and rural areas in Postabortion care is macies and shops, most likely Drugs Authority (TFDA) for use Tanzania has been documented essential for reducing misoprostol.17 in the prevention and treatment in a number of studies,14–16 maternal mortality. Since 2000, the Tanzanian gov- of postpartum hemorrhage, the which have shown that up to Few studies have collected ernment—through its National leading cause of maternal death 60% of women admitted with an information on the cost of the Package of Essential Health worldwide.9,10 In 2011, the TFDA alleged miscarriage had in fact abortion procedure itself. In one Interventions and Postabortion approved the use of misoprostol had an induced abortion. The study, young people aged 15–27 Care Clinical Skills Curriculum— for the treatment of incomplete actual proportion of Tanzanian estimated that an abortion has committed to providing abortion.9 Overall, progress in women who have an unsafe performed at a health facility postabortion care (PAC) as an reducing maternal mortality has abortion and who need medical cost 10,000–15,000 Tanzanian essential service, recognizing been made over the last two care may be even higher given shillings (US$12–18),* while that limited access to such decades; however, the maternal that some women who attempt they thought the cost for herbs services in rural areas has left mortality ratio in Tanzania is an abortion may experience or other reputed abortifa- many women suffering from still one of the highest in the complications for which they cients was only 10–50 shillings the consequences of unsafe world at 454 per 100,000 live do not seek care. Worldwide, (US$0.01–0.06).19 A recent abortion. The provision of PAC births.11 For comparison, the ra- an estimated one-third of the study estimated that the cost services, including contracep- tio for all developing countries is 8.5 million women who have of the procedure in two urban tive counseling, is an important 240 per 100,000 live births, and complications from unsafe abor- areas was US$32–44.17 Given that for all developed countries tion do not seek care in health the generally prohibitive cost of *All amounts reflect the cost at the time of data collection. is 16 per 100,000.12 facilities.13 obtaining a safe abortion, it is

Unsafe Abortion in Tanzania 2 Guttmacher Institute Table 2 strategy for preventing future addressing the unmet need for Fertility, Contraceptive Use and Unmet Need unintended pregnancy and contraception among women Characteristics of Tanzanian women aged 15–49, 2004–2005 and 2010 mitigating the effects of unsafe who have resorted to an unsafe abortion, and can greatly reduce abortion. Studies have shown 2004–2005 2010 Fertility maternal mortality. that women who receive PAC are Total fertility rate 5.7 5.4 likely to accept contraceptive Wanted fertility rate 4.9 4.7 In 2007, EngenderHealth, counseling services and leave Contraceptive use and unmet need through its ACQUIRE Project Married women the facility with a contraceptive Tanzania, began working with % using any method 26.4 34.4 method.23,25,26 % using a modern method 19.5 26.1 the Ministry of Health and % with unmet need for contraception 24.4 25.4 Social Welfare to decentral- High levels of unmet need Sexually active unmarried women* ize PAC services to lower-level for family planning persist. % using any method 40.5 50.6 % using a modern method 35.7 44.0 health facilities in an effort The difference between Tan- % with unmet need for contraception 31.7 31.2 to increase the availability of zanian women’s total fertility services throughout the country. *Among those who had had within 30 days preceding the survey. Source: rate (5.4 children) and their reference 11. An assessment study found that wanted fertility rate (4.7 chil- implementation of the program dren) indicates the difficulty of was weakened by difficulties achieving fertility desires (Table low economic status, were less family planning, intensifying in obtaining essential sup- 2).11 Women with an unintended educated or resided in rural family planning education and plies, such as manual vacuum pregnancy will either have an areas. offering a wide range of meth- aspiration kits, and by lack of unplanned birth or seek an ods and counseling can reduce 23 A report on the benefits of sufficient trained staff. Indeed, abortion.* According to the the incidence of unsafe abortion investing in family planning and the problem of inadequate medi- 2010 Tanzania Demographic and and its consequences by pre- maternal health found that, if cal supplies continues to be a Health Survey, 26% of recent venting unintended pregnancies. barrier to services. A study of births were unplanned, and the the need for family planning health facilities in three dis- proportion has increased slightly was fully met in Sub-Saharan • Increase access to compre- tricts of Tanzania found that on since the 2004–2005 survey.11 Africa, the number of women hensive PAC. Abortion-related the day of the survey, only 24% who die from pregnancy- and mortality and the severity of re- of facilities had manual vacuum Although the contraceptive birth-related causes would de- lated morbidity can be reduced aspiration kits in stock, and prevalence rate has risen over crease by 29% and the number by offering comprehensive PAC only one of the five hospitals the past decade, it is still very of unintended pregnancies would services. These must include surveyed had both misoprostol low. However, between 2004 and drop by 78%, from 19 million to use of modern and less invasive and the kits, which can be used 2010, the use of a modern con- 4 million.27 Not only would this technology and ideally a choice for the treatment of incomplete traceptive method has increased kind of investment save money of treatment methods, as well abortion.24 among both married women in overall health care costs, but as postabortion contraceptive (from 20% to 26%) and sexually it would also help achieve eco- counseling and provision of a A small-scale study of 62 cases active unmarried women (from nomic and social development method of the woman’s choice. of maternal death found that 36% to 44%).11 Nonetheless, goals—including the Millennium The expansion of PAC services in the standards of care for those the demand for family planning Development Goals—and more the country as a whole should who died from abortion com- remains high in Tanzania. importantly, it would save lives. also continue, through training 7 plications were alarmingly low. of midlevel providers, offering Notably, substandard care— Women who face an unintended More can be done to address pregnancy represent an impor- services at lower-level health defined as whether death could unsafe abortion. facilities and ensuring that have been prevented without tant group with unmet need for The Tanzanian government contraception; they want to de- facilities are adequately stocked the delay in proper care—was must continue to address the with drugs and supplies. identified in all cases. Staff lay or stop having children, but issue of unsafe abortion to interviews revealed that the are not using contraceptives. prevent maternal deaths and • Improve providers’ ability to causes of substandard care were One in four married women and improve women’s health. Other offer abortion services within the most frequently attributed to a one in three unmarried women key domestic and international current legal context. It is criti- lack of training and limited staff of reproductive age have an stakeholders can take action cal to raise health care provid- availability. unmet need for contraception, now to support the following ers’ awareness of the content and this proportion has changed measures: and scope of the Tanzanian PAC is not only important as little since 1999.11 In 2010, the abortion law and to equip them a means to reduce maternal level of unmet need was even • Reduce unmet need for con- mortality, but is also critical to traception. Increasing access to *A small proportion of women have higher among women who had miscarriages.

Guttmacher Institute 3 Unsafe Abortion in Tanzania with appropriate training to hood in the United Republic of Insights from Mtwara, Dar es Salaam: CREDITS Tanzania, Bulletin of the World Health USAID/Tanzania, 2010. provide safe abortion services This In Brief was written by Vanessa Organization, 2003, 81(2):87–94. within legally permitted 21. Mpangile GS, Leshabari MT and Woog, Guttmacher Institute, and An- circumstances. 9. Venture Strategies Innovations, Kihwele DJ, Induced abortion in drea B. Pembe, Muhimbili University Tanzania fights maternal mortality, Dar es Salaam, Tanzania: the plight of Health and Allied Sciences, Dar es • Conduct more research. registers misoprostol for postabor- of adolescents, in: Mundigo A and Salaam, Tanzania. It was edited by National-level data on abortion tion care services, Jan. 13, 2011, Indriso C, eds., Abortion in the John Thomas. The authors are grate- , accessed Nov. Zed Books, 1999, pp. 387–403. Brown, Marie Stopes Tanzania; Vibeke complications, and assessments 26, 2012. Rasch, University of Copenhagen; 22. Woog V, Bankole A and Singh S, of the cost of unsafe abortion Evert Ketting, Radboud University 10. Prata N et al., Saving maternal A review of the evidence on the cost Nijmegen; and Alice Cartwright and to the Tanzanian health system, lives in resource-poor settings: of post-abortion care in Africa, in: Emmanuel Rwamushaija, both of would help raise awareness of facing reality, Health Policy, 2009, Lule E, Singh S and Chowdhury SA, Venture Strategies Innovations; and 89(2):131–148. eds., Fertility Regulation Behaviors the issue and give policymakers for contributions by the following and Their Costs: Contraception and a better understanding of the 11. 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January 2013