By Memory Pamella Kadau
Zimbabwe has one of the highest maternal mortality ratios in the world. According to the Multiple Indicator Cluster Survey (MICS) of 2019, Zimbabwe has a maternal mortality ratio of 462 deaths per 100,000 live births and a neonatal mortality rate of 32 deaths per 1000 live births. While this is an improvement from the 614/100 000 live births for maternal deaths recorded in 2014, the slow rate of progress indicates that Zimbabwe is unlikely to meet the Sustainable Development Goal (SDG) target for reducing maternal mortality. The article submits the impact of existing gaps in abortion law, which is part of the limited reforms and the still high maternal deaths over the past two decades. It concludes by providing recommendations for policymakers to reach SDG three on Good Health and Well-being, including reducing the global maternal mortality ratio to less than 70 per 100,000 live births.
Limited legal scope for abortion
The Termination of Pregnancy (ToP) Act is the principal law providing grounds for abortion in the country. Provisions of this law only cover limited circumstances, including if the pregnant woman’s life is in danger or cases of rape, incest, or fetal impairment. In practice, it is tough to obtain a legal abortion; as a result, most abortions are clandestine and unsafe. The government of Zimbabwe, through the Ministry of Health and Child Care, has taken several steps and measures to increase access to and improve Post Abortion Care (PAC) to reduce maternal mortality. However, the sad reality is that the health system is overwhelmed to provide resources for PAC adequately. Budgets have consistently been cut; health workers have been at loggerheads with the government over salaries and working conditions while infrastructure has rapidly deteriorated in most health centers nationwide. Resultantly, the health system is incapacitated to provide adequate and quality PAC.
 National abortion statistical analysis
Zimstat reports that in 2016, an estimated 65,300 induced abortions occurred in the country, translating to a rate of 17 abortions for every 1,000 women aged 15–49. A regional comparison shows that Zimbabwe has one of the lowest abortion rates in Sub-Saharan Africa; the regional rate is double that of the country. Within the country, abortion rates differ across regions and economic classes. Harare and Mashonaland provinces have the highest rate at 21 per 1,000 women aged 15-49; the lowest are in Manicaland and Masvingo provinces at 12 per 1,000 women of the same age. Most abortions occur outside official medical facilities because the law still provides for narrow grounds. Yet, statistics show that abortion is a primary sexual and reproductive health need for thousands of women.
Access to Post Abortion Care (PAC)
PAC is an essential component for women who have undergone abortions. According to UN Women research, the vast majority (85%) of PAC in Zimbabwe is provided in public health facilities. About 50% of the cases are attended to at district hospitals and about one-third at larger, central hospitals. The majority of the women who seek treatment at public health facilities often have mild or moderate complications. However, a significant number (19%) have severe complications.
Many women experiencing complications from unsafe abortion or miscarriages often face. Delays in obtaining PAC. Evidence shows that most women, on average, spend about two days between experiencing difficulties and receiving completed treatment at public health facilities. Significant reasons for treatment delays include insufficient money for relevant payments, transportation, and distance to a health facility.
PAC is not offered at most primary health centres, such as village or farm clinics, which are the facilities most accessible to rural women. Additionally, women must seek medical treatment and PAC at multiple facilities to complete treatment.
Furthermore, many public health facilities request payment from patients for PAC. This is a significant cause for delays in accessing this critical service, particularly for poor and vulnerable women. Ordinarily, PAC is part of emergency treatment and should be provided at no cost. Public health facilities also lack adequate medication for effectively treating PAC patients. Years of under-funding and lack of prioritisation of PAC have seen most public health facilities lacking the critical drug for PAC’s misoprostol. In addition, half of the facilities designated under national guidelines to provide manual vacuum aspiration do not have the equipment to do so. Where equipment is available, use is low owing to the perceptions and attitudes of medical care workers. The first step to address these challenges is reforming the abortion law as this would increase access to women, allocate more resources and skills to PAC and enhance the capacity of medical care workers to provide quality treatment and services to women needing them.
Recommendations
Having noted the impact of the existing legal framework, the article makes the following recommendations to policymakers:
- Amend the law to expand the circumstances under which abortion is legally permitted.
- Improve awareness of healthcare professionals and the public about legal provisions to reduce the number of clandestine and unsafe procedures.
- Ensure the availability of safe, legal abortion services and postabortion care to reduce ill health and death from unsafe abortion.
- Increase the availability and use of WHO-recommended postabortion care methods by ensuring facilities have adequate training, supplies and equipment.
- Increase funding to ensure public health facilities have the resources to provide PAC free of charge and fully implement the National Guidelines for Comprehensive Postabortion Care in Zimbabwe.
