At a clinic in Kampala, a young man is asking about abortion pills. He wants them for his 20-year-old girlfriend, who is 10 weeks pregnant. He has come to a Marie Stopes clinic because they offer a range of services, including family planning, abortion services and post-abortion care. He has just had a meeting with counsellors, but they told him they cannot advise him without his girlfriend present.
“They have told me that I have to come with her, which is very, very impossible because she can’t escape from home,” he says. “Her parents are there, and so she told me to come and get some information about tablets for abortion.” Before he leaves he asks a woman sitting in the waiting room if she knows which kind of pills his girlfriend needs to take.
He is one of the few men to come to a Marie Stopes clinic in Uganda alone. Mostly, women come by themselves, or accompanied by a female friend or female family member.
Stigma surrounds abortion and, as a result, many do not tell their partners they are looking to terminate a pregnancy, or often that they are pregnant at all.
Sarah has come to Marie Stopes for an abortion, but has only told her sister. She says if her husband knew she was pregnant he would make her keep the baby.
After her consultation, like most clients, she has opted for the surgical method, instead of taking pills at home. Sarah will be awake throughout the surgery, but it has fewer side effects than the pills, so it is less likely that her partner or relatives will discover what she has done.
Despite the secrecy, abortion rates are high in Uganda. According to the Centre for Health, Human Rights and Development, a Kampala-based research and advocacy organisation, each day 840 girls and women have abortions in Uganda, and on average five die as a result. Annually, unsafe abortion leads to more than 1,500 deaths.
The centre and Marie Stopes, an international family planning organisation, say a contributing factor to these figures is the fact that Ugandan law on abortion is confusing and ambiguous. Contrary to public belief, abortion is not illegal across the board, but advocates of safe abortion describe the law as “restrictive”.
The Ugandan constitution states, “No person has the right to terminate the life of an unborn child except as may be authorised by law”, without elaborating on what the law may be.
A section of the Penal Code Act says abortion is permitted in order to save a woman’s life, but another section says clients who have abortions, and healthcare providers who perform them, are at risk of up to 14 years in prison.
Legal obscurity
Marie Stopes Uganda says this legal obscurity has influenced how abortion is perceived, and has influenced decisions made by both providers, and girls and women seeking abortion services. In fact, as many healthcare providers do not understand what services they legally can and cannot offer, the majority do not offer any.
Similarly, as many girls and women believe abortion is illegal in all cases, each year thousands seek out abortions in unregulated and unsafe environments, or attempt an abortion themselves.
In 2006 new guidelines were put in place by Uganda’s ministry of health, which theoretically extended legal abortion to cases such as incest or rape, or if the mother suffers from HIV or cervical cancer.
Yet, it is unclear as to whether or not these policies overrule or coincide with the constitution. Joy Asasira, programme manager at the Centre for Health, Human Rights and Development, says the fact that the policy framework and legal framework are removed from each other provides a huge challenge for those trying to interpret what is or is not legal.
Marie Stopes Uganda offers abortions to women who meet a strict list of criteria, in line with local regulations.*
Dr Milton Awudo, quality assurance expert at Marie Stopes, says the organisation’s work has widespread “underground support”, including from police, judges, government figures and activists.
Nevertheless, over the years there have been instances where police have come to Marie Stopes clinics to investigate claims of abortions, which were in many instances reported by patients’ family members.
It say none of its staff have ever been imprisoned as a result of these visits, and Asasira says the rarity of arrests and imprisonments reinforces the fact that the law is ineffective.
However, she recalls two instances where young women were imprisoned for having abortions – one for 10 years after she terminated a pregnancy which was the result of rape.
Vocal opposition
Awudo says the strongest and most vocal opposition to abortion is predominantly from religious and conservative groups. But members of such groups have also availed of Marie Stopes’ abortion services, he says.
“You are seeing nuns coming for safe abortion. We have seen priests who bring their young girls for safe abortion,” he says.
Despite this, quality assurance training officer Norah Tuhaise says even after nuns and priests avail of abortion services, many continue to preach publicly that abortion is immoral.
This religious and social stigma can have a lasting effect on the young women who decide to terminate a pregnancy, activists say.
Gynaecologist and obstetrician Dr Charles Kiggundu has witnessed first-hand the human toll from Uganda’s unsafe abortions.
“I’ve seen women that come wanting to prevent pregnancy, women who come wanting to terminate pregnancy. I’ve also seen women who come when they’ve had complications from safe abortions, and I’ve also written death certificates for women who died from unsafe abortions.”
He has been advocating for safe abortion for more than a decade, although previously he felt differently. Fifteen years ago he advised a young woman who wanted an abortion against the procedure, because of potential health risks, and on moral and legal grounds, he says.
Three days later she was brought to his emergency ward with severe complications after attempting an abortion herself. She had perforated her uterus, which had to be removed.
‘Striking scenario’
He calls that moment a “striking scenario” which changed the way he saw abortion.
“It still hits me that she had to lose her uterus,” Kiggundu says. “She’s there, she’s alive, but I wonder what kind of quality of life she has.”
Kiggundu says the government has begun having more open discussions about abortion, but that with elections approaching it is not a topic that politicians want to deal with. He hopes that within the next five years Uganda can work towards decriminalising abortion.
However, he says this can only be done when the laws in Uganda are interpreted in a new way, “for the support of the women, rather than against”.
* This article was amended on January 15th at 11.45am and at 2.45pm to clarify the circumstances under which Marie Stopes provides abortion services in Uganda
First in a series of three. Tomorrow: Uganda moves to meet contraceptive needs.
This article was supported by a grant from the Simon Cumbers Media Fund
