By Dr M Murwira
In the early years of my medical career, it was always exciting to start a new role in the various medical specialties at a Central Hospital. As such, I was looking forward to the experience of working in the Obstetrics and Gynecology department. However, my first Gynecology department night shift was a baptism of fire. In the emergency ward, multiple sick women lying on stretcher beds and on the floor awaited me. It was a horrific experience to see both young and mature women crying, writhing in agony, and covered with blood stained garments.
This article explores some of the horrors of unsafe abortion and the realities faced by women and health workers in relation to post abortion care services in Zimbabwe. This opinion piece will also demonstrate the challenges faced by many health personnel dealing with women suffering from complications of unsafe abortion. The dilemma of coming from a Christian background, the conflict of societal values versus the professional calling of providing services to everyone presenting for health care regardless of their social status, race, ethnicity or their health condition. I was astounded by the magnitude of suffering being experienced by women from all walks of life. Back then, we were very fortunate to have experienced medical personnel to provide guidance and mentorship. Senior staff in the department were able to calm me down indicating that this was the norm and there was nothing unusual about the situation. The women were from across the reproductive age group, married and unmarried. These women usually present late at night or in the early hours of the morning seeking post abortion care services at public hospitals.
I did not realize then, that abortion was such a serious public health issue with women resorting to extreme measures to get rid of unwanted pregnancies. The type of items and substances that are used to achieve this goal by the women ranges from chemicals to physical objects (of various forms, shapes and sizes). Believe you me it was a very traumatic experience to deal with very sick women with complications ranging from severe infections to perforated internal organs (uterus, bladder and intestines). The Zimbabwe Termination of Pregnancy Act of 1977 is very restrictive and only allows abortion in few exceptions. Where abortion is permissible, the process has many administrative and legal barriers leading women to seek clandestine and unsafe abortions. Post abortion care services are mainly provided in the public sector and there is limited information about what happens in the private sector. A recent study by Concept Foundation showed that private sector cost for abortion care in Zimbabwe ranges from US$ 180 up to US$ 450, thus is out of reach for many girls and women seeking post abortion care services.
The social stigma and judgmental attitudes associated with the subject of abortion affect both the women and health providers in our context. Individual socio-cultural beliefs and attitude of some medical colleagues regarding provision of post abortion care limits access to essential health services by women. In addition, there is fear of criminal prosecution for both the women and health providers. The dilemma as a health provider is whether you report the women presenting to hospital seeking medical assistance to the police or you provide the service and turn a blind eye. As a health care provider, how do you verify that the abortion has been induced illegally or it is a natural spontaneous abortion? This is almost impossible, especially when there is no obvious evidence available.
According to the Guttmacher – Lancet commission almost 56% of unintended pregnancies end up in induced abortions, and abortions in developing countries are likely to be illegal and unsafe due to restrictive abortion laws. The commission report also indicates that 50% of abortions are unsafe in developing countries with 14 % of abortions being done by untrained persons using dangerous and invasive methods. Abortion contributes almost 10% of maternal mortality, with Africa having the highest number of deaths due to abortion complications (141 abortion related deaths per 100 000 abortions). Globally 6.9 million women seek treatment for abortion complications. In Zimbabwe Ministry of Health & Child Care reports show that over 30 000 women are admitted to hospital annually due to abortion complications. Abortion complications is among the top 10 causes of hospital admissions in Zimbabwe. The proportion of women presenting to hospital with complications is far less than the women who suffer the consequences at community level including dying in their homes.
Investing in quality comprehensive post abortion care services at all levels (including the private sector) is essential to reduce complications of unsafe abortion. This will ultimately contribute to the reduction of maternal mortality in Zimbabwe. More research is required to better understand the full magnitude and impact of abortion in the Zimbabwean context.
Dr M. Murwira is a Public Health Specialist with expertise in Sexual Reproductive Health and Population & Development.
