In my years of experience working in sexual reproductive health (SRH), the most topical debates include the topics of unintended pregnancies, teenage pregnancies, sexual gender based violence (SGBV), and abortion among others. Termination of Pregnancy (abortion) is one of the most controversial and emotive issues across the social realm in a conservative society like Zimbabwe. The main thrust of social-cultural discussions in sexual reproductive health is around prevention of unintended pregnancies thus avoiding the topic of abortion completely. However, the dilemma is when prevention fails, what happens next? The Zimbabwe Demographic Health Survey indicates that 14% of women aged 15-49 have ever experienced sexual violence, and thus are at risk of unintended pregnancy which may subsequently result in abortion.
By Dr M Murwira
Globally the World Health Organisation (WHO) estimates that each year, almost half of all pregnancies are unintended. Interestingly 6 out of 10 unintended pregnancies end in induced abortions. Although, Zimbabwe has one of the most successful family planning programmes in Africa with one of the highest contraceptive prevalence rates in sub-Saharan Africa there is still a high rate of unintended pregnancies. According to the 2016 Guttmacher report on Zimbabwe, the estimated national unintended pregnancy rate is 70 per 1 000 women of reproductive age. Overall, 40 percent of pregnancies were unintended and one-quarter of all unintended pregnancies ended in abortion. An estimated 66 847 abortions were performed in 2016, translating to 18 abortions per 1 000 women of reproductive age and most of these abortions are unsafe.
The Magnitude of Abortion in Zimbabwe
The country has one of the highest maternal mortality ratios in the world (525 per 100 000 live births) as per the 2017 Inter Census Demographic Survey. A 2016 study by Madziyire et al indicated that abortion accounted for nine percent of maternal deaths in Zimbabwe. WHO estimates that almost 45% of all abortions are unsafe with high risk of complications? The most recent source of data in Zimbabwe on the contribution of abortion to maternal mortality is from 2007; at that time, abortion complications were one of the top five causes of maternal mortality. It is extremely difficult to accurately capture maternal deaths associated with unsafe abortion, especially in contexts where abortion is highly restrictive and stigmatized. A 2013 report compiled by NGOs in Zimbabwe revealed that more than 20 000 women die each year because of unsafe abortions. National Health and ZIMSTAT reports show that abortion is one of the top ten in-patient causes of illness in Zimbabwean hospitals.
A Lancet report by Grimes in 2006 indicated that although unsafe abortion is a significant contributor to morbidity and mortality among women of reproductive age, the evidence base on the consequences of unsafe abortion is limited. The annual cost to health systems of providing post abortion care (PAC) is higher than the preventive costs of safe abortion. Costs of treating unsafe abortions and their complications consume significant resources of women, their families, and the nation. It costs more to treat someone who has had an unsafe abortion than to provide a safe abortion. The cost of hospital admission, antibiotics, uterus cleaning, blood transfusion and recurrent cost for seeking treatment are astronomical. The socio-economic impact of abortion to girls and women is immense. The woman, who would be a source of support for her children and family, suddenly faces an endangered future. Productivity is reduced due to illness and recurrent hospital visits. A number of other lives could be saved if fewer medical resources were applied to provide safe abortion rather than to redressing the complications of unsafe abortion that are costly.
Termination of Pregnancy in Zimbabwe
The Termination of Pregnancy (ToP) Act of Zimbabwe was enacted in 1977 by the Parliament of Rhodesia and was retained after Zimbabwe’s independence in 1980. The ToP Act has not been reviewed since then. The ToP Act clearly spells out 3 circumstances in which pregnancy can be terminated; (1) Unlawful intercourse – rape or incest, (2) To save the woman’s life, and (3) In the case of serious fetal anomaly up to 22 weeks of gestation.
Access to abortion services in Zimbabwe is difficult with women are facing a myriad of challenges. Legal and administrative barriers coupled with stigma among both women and health service providers and fear of legal and social repercussions as well as risking imprisonment are deterrent factors for safe abortion. The duration of the process for legal termination of the pregnancy, the costs associated with legal abortion are so deterrent that some women cannot afford it; others give up while still in the process of obtaining the legal authorisation to terminate the pregnancy. The process for granting termination of pregnancy takes long leaving the women with the impossibility to abort due to late gestational age. Due to the restrictive abortion laws and high cost in the private sector, most of the unsafe abortions are done clandestinely by herbalists, community members, and at times by medical cadres with high risk of complications. Studies indicate that rather than reduce abortion incidence, restrictive abortion laws result in women pursuing clandestine and unsafe abortions.
In a study conducted in 2019 by Concept Foundation, only 19 percent of health care providers knew the main conditions under which abortion is legal in Zimbabwe. This massive gap in knowledge shows the importance of ensuring that health care providers and the public are made aware of the provisions under which they can currently perform as well as access legal abortion.
WHO defines health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity? Making health for all a reality, and moving towards the progressive realization of human rights, requires that all individuals have access to quality health care, including comprehensive abortion care services. Lack of access to safe, timely, affordable and respectful abortion care poses a risk to not only the physical, but also the mental and social, well-being of women and girls.
Post Abortion Care Services & Access to Safe Abortion
Universal Health Coverage (UHC) means that all people have access to the health services they need, when and where they need them, without financial hardship. To make health for all a reality, we need: individuals and communities who have access to high quality health services so that they take care of their own health and the health of their families; skilled health workers providing quality, people-centred care; and policy-makers committed to investing in universal health coverage. Universal health coverage is based on strong, people-centred Primary Health Care (PHC). Health systems that achieve UHC and the health-related Sustainable Development Goals rely heavily on a solid foundation of PHC. The WHO supports the integration of sexual reproductive health (SRH) services within national Primary Health Care (PHC) strategies to advance progress towards Universal Health Coverage (UHC). To achieve Universal Health Coverage (UHC) the country needs to include PAC as an integral component of Primary Health Care (PHC).
As study conducted on post abortion care in Zimbabwe showed that 85% of cases are treated in the Public Health system with a total of 25,245 PAC patients being recorded in 2016. The study also showed that only 20 percent of Public Health facilities had the basic capability to provide PAC. A Guttmacher report on clandestine abortions in Zimbabwe showed that women seeking PAC reported experiencing substantial delays between being seen at a health facility and receiving complete treatment, often due to lack of money, waiting delays, staffing shortages or staff attitudes, or medicine shortages or inability to get complete treatment at a single facility. The report also indicated that 50% of Public Health facilities faced stock out challenges of drugs and equipment for PAC, thereby severely impacting efficient delivery of PAC. Private sector do provide PAC services but are very expensive costing up to US$400.
Ensuring that women and girls have access to abortion care that is evidence-based, which includes being safe, respectful and non-discriminatory, is fundamental to meeting the Sustainable Development Goals (SDGs) relating to good health and well-being (SDG3) and gender equality (SDG5). Integrating SRH within PHC for UHC requires both political commitment as well as coherent strategies. The Ministry of Health & Child care has made efforts to reduce maternal mortality through improving PAC services; this includes having the Post Abortion Care guidelines, supplying drugs, and providing training for service providers.
There is an urgent need to promulgate a Statutory Instrument (SI) to streamline ToP processes (removing Legal and Administrative barriers). Capacity building of service providers on ToP is key to improve access to PAC. The current PAC guidelines should be reviewed to incorporate current WHO best practices. Advocacy for increased awareness on the provision of the ToP Act and for the possible review of the Act is required.
About the Author: Dr M. Murwira is a Public Health Specialist with expertise in Sexual Reproductive Health and Population & Development.