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.