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.