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Unsafe Abortion in Tanzania: a Review of the Evidence

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Unsafe Abortion in Tanzania: a Review of the Evidence In Brief Series 2013, No.1 Unsafe Abortion in Tanzania: A Review of the Evidence Although pregnancy 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 pregnancies 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 abortions.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 reproductive health 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 reproductive rights of women by authoris- high levels of maternal mortality abortion, and identifies key areas where ing medical abortion in cases of sexual and morbidity. government and program planners can assault, rape, [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 woman] or the life of the [pregnant Health and Social Welfare, 16% of ma- Current abortion law 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 maternal death data: reference 5; pregnancies ending in abortion: Singh S et al., birth attendants and phar- plications was more than seven Unintended pregnancy: 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, misoprostol 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.
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