African Journal of Reproductive Health Women's Health and Action Research Centre ISSN: 1118-4841 Vol. 8, Num. 1, 2004, pp. 7-8

Editorial

Breaking the Silence on Prevention of Unsafe Abortion in Africa

Friday E Okonofua¹

¹ Editor, African Journal of Reproductive Health and Provost, College of Medical Sciences, University of Benin, Benin City, Nigeria.

Code Number: rh04001

It is estimated that nearly 70,000 women die annually from the complications of unsafe abortion around the world. Over 69,000 of these deaths occur in developing countries while 23,000 occur in sub-Saharan African countries alone, representing an estimated 680 deaths per 100,000 abortion procedures^1,2 in Africa. Apart from the sheer numbers of deaths in Africa, many women suffer long-term complications including infertility, chronic pelvic pain and ectopic pregnancies. The consequences of these losses and sufferings to individuals, families and communities are manifold, and are a recurrent decimal in the poor reproductive health statistics coming from many African countries.

Despite the severe effects and consequences of unsafe abortion in Africa, there has remained an unmitigated silence at all levels regarding the need to do something to reduce the scale of the problem. Abortion having for long been regarded as a sensitive issue, many African governments and leaders have simply refused to speak about it for fear of losing political or social support in their communities. The situation has become worse with the recent gag rule imposed by the United States, as it has had the effect of also gagging civil society response to unsafe abortion in Africa. Many African countries, being dependent on donor support from the United States for their reproductive health projects, are fearful of the consequences of withdrawal of such support should they meddle in the terrain of programming on unsafe abortion.

Thus, it was refreshing that despite the difficult times, Ipas was able to convene a regional meeting in Addis Ababa in March 2003 to discuss the prevention of unsafe abortion in sub-Saharan Africa. The conference was attended by policymakers, service providers, reproductive health advocates and academicians from many parts of Africa. Presented in this edition of the African Journal of Reproductive Health are peer-reviewed papers from the proceedings of the conference. The editors of the journal had no difficulty in accepting to publish the papers, as we believe that the silence on unsafe abortion in African countries must be broken to enable concerted efforts to be developed to solve the problem.

The prevention of unsafe abortion anywhere rests on the tripod of primary, secondary and tertiary prevention initiatives. Unfortunately, many of these prevention efforts are not well developed in many parts of Africa. Primary prevention (the prevention of unwanted pregnancies that lead to abortion) is not well developed in many parts of the continent. Contraceptive use continues to be low in many African countries, and there continues to be large unmet needs for contraception especially among vulnerable populations. We believe that as part of finding solution to the problem, efforts must be concentrated on removing barriers that limit women's (and men's) access to effective contraception needed to prevent an unwanted pregnancy. Effective contraception should continue to be an important part of efforts to prevent unsafe abortion, as it has the multiplier effects of preventing recurrent abortion and promoting other indices of reproductive health.

Secondary prevention of unsafe abortion (the safe termination of an unwanted pregnancy) is even less well developed in Africa. Many African countries have restrictive abortion laws that limit women's access to safe abortion practices. Only in a few African countries - South Africa and Tunisia - is abortion available on demand. In some others - examples being Ghana and Zambia - although abortion laws are liberal, women still have limited access to safe abortion as a result of various socio-cultural and health services-related barriers. By contrast, in a preponderant number of African countries, abortion is legally restricted, resulting in underground practices that severely compromise the safety of the procedure. Several papers in this edition of the journal have emphasised the need to increase women's access to safe abortion practices in Africa, drawing upon existing international policy documents and examples from countries across the world. Lithur in her paper³ emphasises the need to destigmatise abortion by creating community awareness on the problem, while Ashenafi⁴ discusses the role of law reform advocacy. Overall, there can be no doubt that increasing access to safe abortion practices is critical to reducing maternal mortality associated with unsafe abortion in Africa.

For years, tertiary prevention of abortion - the proper management of abortion complications - has formed the main plank of efforts to reduce abortion-related mortality in Africa. Also referred to as post-abortion care, the concept consists of the management of abortion complications using inexpensive technology such as manual vacuum aspiration, the proper counselling of women who have had an abortion and their linkage to effective post-abortion contraceptive services. No doubt, post-abortion care has resulted in a significant reduction in morbidity and mortality associated with abortion in many parts of Africa. However, many women still have limited access to post-abortion care and there continues to be poor integration of the method into public health services in many parts of Africa.

In sum, the papers contained in this edition of the journal all point to the fact that abortion is a critical and pressing reproductive health problem in Africa. Without addressing its correlates in a realistic fashion, it will be difficult to reduce the current high levels of maternal morbidity and mortality in Africa. Women are the only direct casualties of unsafe abortion and, therefore, it is a gender-based as well as a rights-based issue. A critical first step in efforts to address the problem is to break the silence by openly discussing the issues in scientific circles as well as within domestic and political contexts. We need to provide the evidence and facts and strike at the conscience of people, who at the moment believe that nothing is happening or that the matter can be trivialised. AJRH is pleased to be part of this discussion and, therefore, we dedicate the issue to women and families who have been hurt by the process of abortion throughout the continent. We salute Ipas for their courage and initiative in organising the conference and urge other organisations to be prepared to join the vanguard.

References

1. Alan Guttmacher Institute (AGI). Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences. New York: AGI, 1995.
2. Bankole and Westoff CF. Childbearing Attitudes and Intentions, DHS Comparative Studies. Calverton: Macro International, 1995, 17.
3. Nana Oye Lithur. Destigmatisation of abortion: expanding community awareness. Afr J Reprod Health 2004; 8(1).
4. Meaza Ashenafi. Law reform advocacy for safe abortion: its scope and relevance, the case of Ethiopia. Afr J Reprod Health 2004; 8(1).

© Women's Health and Action Research Centre 2004