Abortion in the era of birth control

With deft hands and diligence, 55-year-old Rael Tago plucks weeds from the fresh grave in front of her house.

She is quiet, the expression on her face hard to place.

She has done this regularly, and maybe that ritual has helped her grow a thick skin. It is as if what she is doing is second nature, as if the pain and emotion have been cleansed from her system.

“I have seven children,” she says, almost in a whisper. It is as if the words escaped her, unplanned and unintended. And then, just as I draw closer to connect with her thoughts, her emotions, she bends her back again to continue weeding the grave.

Beneath that fresh mound of earth lays Jane Shemeko, Tago’s daughter who died at the young age of 21.

Jane was a bubbly young girl full of energy and dreaming big, but a relationship with a man got her pregnant.

Because she was not prepared to have a child, she decided to abort the foetus. Things, however, did not go as planned, and the grave her mother is tending to today is stands as a grim monument to all that.

Tago may not know it, but she is not alone in this pain.

TOMBSTONES OF UNSAFE ABORTION VICTIMS

Across the country stand thousands upon thousands of tombstones dedicated to young girls who lost their lives through botched abortions, young lives cut short by the false hope of a fresh, clean slate.

The numbers may not be that much when pitted against the overall rate of maternal morbidity in the country, but they still serve to add to the grim statistics coming from the health sector.

Last year, for instance, maternal deaths stood at 360 for every 100,000 pregnancies, according to data from the World Health Organisation (WHO). One out of seven of these deaths — or at least 51 out of every 360 deaths — is from unsafe abortion.

This is a reality that Tago has been forced to live with, and her daughter’s grave, just a few metres from the door to her house, serves as a constant reminder of a death that need not have occured.

“I was called to hospital on the day it happened,” she remembers, now sitting on a chair outside her house, her eyes still fixed on the fresh mound she has been taking care of.

“I rushed to the hospital to find her in a bad state in one of the back rooms. She had vomited a lot of blood and was in a lot of pain. ‘Mama,’ she called out on seeing me. ‘They have killed me!’”

The sight of her daughter in such pain shook Tago to the bones.

Wasn’t this the same young girl she had watched grow into a loveable free spirit? Wasn’t Jane still, to the mother, still a baby with a long future ahead? What could a mother do to save the life of her daughter?

“She told me she had been asked to pay Sh5,000 if she wanted to get rid of her five-month-old pregnancy. I was shocked because I had no idea that she was pregnant in the first place. The abortionists had inserted a metal rod inside my daughter’s womb and punctured it, leading to a lot of bleeding and discharge. She was in a lot of pain...” she pauses to wipe a tear rolling down her right cheek with the back of her hand, then continues,

“...and there was nothing I could do.”

OVER 1,200 DIE ANUALLY

A 2013 study by the African Population and Health Research Centre (APHRC) shows that more than 1,200 women die annually in Kenya from complications of unsafe abortions.

The study, titled The Incidence and Complications of Unsafe Abortions in Kenya, 2013, also reveals the strong relationship between unsafe abortions and contraceptive use.

Seven out of 10 women who had an unsafe abortion and developed complications in 2012 were not using contraceptives.

Western and Nyanza regions reported high rates of unsafe abortions and low contraceptive use in 2012 compared to other regions.

And choices, the saying goes, have consequences: for every 10 live births in these regions, there were four induced abortions.

Central and Nairobi regions had two induced abortions for every 10 live births while Eastern had one, according to the study.

“Most, if not all, unsafe abortions are mostly as a result of unintended pregnancies,” says Dr John Ong’ech, an obstetrician at Kenyatta National Hospital.

When women like Jane fail to access contraceptives, their first dilemma is whether or not to keep the unplanned pregnancies, but then their choices are limited by a restrictive abortion law that warns them of jail terms should they decide to end the pregnancies.

Their only way out, they decide, is to head to backstreet abortionists, and these are the ilk that cost Jane her life.

QUACK SHOULD NOT BE FIRST POINT OF CONTACT

“Let the quack not be the first point of contact in case of an unwanted pregnancy,” says Dr Joachim Osur, a reproductive health expert whose concerns are informed by the high number of women seeking post-abortion care in major health facilities around the country.

Many of these women suffer the consequences of their actions, including immediate effects like anaemia, infections, and shock, and long-term complications like infertility and ectopic pregnancies, for the rest of their lives.

Others, like Jane, pay the ultimate price.

She was the breadwinner in her family, doing manual work to provide for her three-year-old first born daughter and mother. In June this year she left home and headed for Kampala, Uganda, where she worked as a house girl until mid-August, when she returned home to work at a neighbour’s farm.

It was during this time that she sought to procure the abortion that killed her.

Her story is as tragic as it can get.

While the abortionist had told her she would not suffer much while ending a pregnancy that was already past the halfway mark, the dead foetus stayed inside her punctured womb for three days.

All this time, Jane suffered at her employer’s home, bleeding and growing weaker by the hour. By the time she was rushed to Mbale District Hospital — where doctors rushed against time to stabilise her and complete the abortion — it was too late.

The girl, visibly traumatised and needing specialised care, was referred to Jaramogi Oginga Odinga Teaching and Referral Hospital in Kisumu, and Sylvester Aluoch, a reproductive health specialist who handled her case, says the girl was severely anaemic by the time she was wheeled in.

She had lost a lot of blood, Aluoch says, and despite efforts to revive her, her vital organs collapsed on August 22. And thus ended the life of yet another Kenyan woman.

COULD THIS LIFE HAVE BEEN SAVED?

But could this life have been saved? Could Jane have lived enough to see her daughter through school?

Health specialists say yes, this is a death that need not have happened, and the answer to this problem lies in Kenya’s family planning initiatives.

“The contraceptive programme in Kenya is on its knees,” says Dr Osur.

“The components of a contraceptive programme should include community education, procuring and distributing the methods and training of health workers and equipping facilities.

“This used to happen very well up to the late 1980s and early 1990s. The government has not been putting enough money into contraceptive services, and donors have diverted most of their funding to HIV programmes at the expense of family planning.”

To understand the effects of this state of affairs, you need not look further than Tago, who says that she and, to the best of her knowledge, her adult daughters have never used any contraceptive.

“The only thing I have been telling them is to avoid men. Many of us parents don’t want to accept that our daughters are sleeping with boys,” she says.

Hers is one of the many cases that explain the high unmet need of family planning in the country. “We don’t have adequate community education programmes, and that’s why we have such myths,” Dr Osur explains.

Also, the small matter of legislation has been blamed for these deaths. Research has shown that countries with the most restrictive abortion legislation register the highest incidence of unsafe abortions and abortion mortality ratios.

In such settings, women often fear legal reprisals or are unable to access necessary post-abortion care.

CHANGING TREND

But the trend is changing, at least in some countries. South Africa and Cape Verde, for instance, have legalised abortion.

In South Africa, The Choice on Termination of Pregnancy Act (CTOP) of 1996 came to effect on February 1, 1997 and gives women the right to abort on request, to protect the health and well-being of the mother or foetus, or for reasons of rape or incest so long as such is done with the approval of one or two physicians.

This major step was followed by notable declines in abortion-related deaths. IPAS, an international reproductive rights organisations, reports that complications from unsafe abortions led to 33 deaths per 1,000 abortions in South Africa in 1994, and that, after the law was passed, only 1 death per 1,000 pregnancies was reported in 1998.

This number remained steady or dropped in subsequent years, IPAS says, resulting in a 91 per cent drop in deaths related to unsafe abortion between 1998 and 2001.

In Kenya, Chapter 26 (4) of the Constitution only allows abortion when the health of the mother is at risk, and only a trained health professional can certify the risk.

That is why 42-year-old Philisters Amakanji of Mumias County never sought the approval of a health specialist when she decided to end her pregnancy.

When she separated with her husband and moved out of her matrimonial home to Mumias town to work as a barmaid, she had never imagined that she could fall pregnant again.

She had already given birth to three children and, despite her high-risk trade, did not think of contraceptives as necessities.

But they were, as she was to learn in a matter of months. A man had promised to marry her when one of her customers got her pregnant.

She knew the other man would run for the hills if she told him that she was pregnant, so she headed to a kiosk and bought 12 anti-malarial tablets.

Back home, she swallowed the 12 tablets, lay in bed and waited for the worst to happen. It did, and she says she nearly bled to death.

et, at 42, sexually active and not wishing to get pregnant, you would expect that she would be using contraceptives. But she wasn’t.

'ONLY CONSIDERED USING CONTRACEPTIVES LAST YEAR'

“I only considered using contraceptives last year after my daughter from the first marriage got pregnant for the fourth time,” she says. The first time the girl got pregnant, her mother took her to a clinic in Bungoma where the pregnancy was terminated.

“She almost died,” Philisters says, “but I just wanted the best for her.”

Then the girl got pregnant again, and again, and again. Philisters’s friends asked her what was happening and advised her to put her daughter on family planning.

She did, opting for a long-term method for both the daughter and herself.

Now, she says, she hopes she will remain ‘safe’, and that she will not blow any chances of marriage again.

For Tago across the ridge, it is too late. No contraceptive can bring back her daughter. But she has a grandchild to take care of, and that grandchild is, to her, a constant reminder of what could have... but never was.

It is a huge price to pay, but here, on these rain-soaked fields of Mumias — as in everywhere else across the country — death from post-abortion complications has become the norm rather than the exception.

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