August 11, 2013
NAIROBI, KENYA – When Eunice, 19, discovered she was pregnant three months before taking her final high school exams in 2012, fear consumed her, she says. She knew that her uncle, who paid her tuition, would stop supporting her if he found out, and her mother could not afford to pay for her schooling in Nairobi, Kenya’s capital.
“Besides the fears that my education would be cut short, I feared that my family would reject me if they found out I was pregnant,” she says. “I was depressed for weeks. My head ached daily. But I had no one to talk to.”
Abortion to preserve the health of the mother has been legal in Kenya since 2010. But Eunice, who declined to give her surname because of the stigma surrounding abortion, was unaware of the law. This prevented her from seeking counsel to determine whether her psychological struggle qualified her for a legal abortion, she says.
“I don’t know much about the law,” she says. “I thought I would be arrested if I was found to have had an abortion. That is why I never told anyone.”
Peers had told her horrifying stories of girls and women who had died in the covert clinics near her home, she says. Terrified at the prospect, she sought any alternative.
Classmates told her about the Aunty Jane Hotline. The hotline provides recorded information on sexual and reproductive health in English and Swahili.
Eunice dialed the hotline and listened to a recording that explained how to obtain misoprostol pills to terminate a pregnancy, she says. She bought the pills at a drugstore in downtown Nairobi and then dialed and redialed the hotline to confirm how to use them.
She took the pills to terminate her pregnancy and managed to return to school in the same week, she says. Although the pills did not cause any side effects, her mental health suffered, and she did not do as well on her exams as she had expected.
Representatives from the Aunty Jane Hotline did not respond to repeated requests for interviews via email, and the hotline does not offer additional contact information.
Eunice is glad that she survived the experience, she says.
“It was a difficult situation that I never want to go back to,” she says. “I’m glad I am alive.”
Even though she is now aware of the law, she says she is still skeptical that hospital staff would have granted her a safe and legal abortion if she had sought one.
“Even if I knew hospitals offer abortion services in certain circumstances, I would not have gone there,” she says. “I’m not sure they would have helped me.”
Three years after Kenya’s Constitution expanded the reasons for which women may obtain legal abortions, women continue to seek illegal, unsafe procedures. To prevent maternal deaths from clandestine abortions, organizations are educating women about the circumstances in which abortion is legal. The government released guidelines and a curriculum on safe and legal abortion in 2012 for medical professionals, but doctors still call for more public awareness about the law.
Because of restrictions and stigma surrounding abortion in Kenya, accurate statistics are lacking, and underreporting is common, according to a May 2012 report published by the Guttmacher Institute, a reproductive health and advocacy organization. But a 2008 World Health Organization study found that in East Africa, unsafe abortion causes nearly one in five maternal deaths.
The 2010 Kenya Constitution expanded the guidelines governing abortion. It permits abortion if the life or health of the mother is in danger or if the woman requires emergency treatment.
Before August 2010, the only way to obtain a lawful and safe abortion was when the life of the mother was in danger, writes Dr. Simon Mueke, the acting senior deputy director at the Ministry of Health, in an email interview. The law also required three physicians to confirm this danger in writing.
But the law is less restrictive now, Mueke writes. One trained health provider – such as a nurse, traditional birth attendant, clinical officer or doctor – can approve an abortion. They can also do so if the mother’s health is at risk.
Dangers to the mother’s health include physical and psychological risks.
Women can cite stress as a reason to obtain an abortion, says Dr. John Nyamu, the national chairman of the Reproductive Health Network, an alliance of obstetric and gynecological associations that advocate for women’s reproductive rights.
“Most of the time, women seeking abortion services say they are under stress, meaning they are not well psychologically,” he says. “Some have physical ailments as well. The health practitioner, after assessing the patient’s health condition, decides whether to carry out the procedure or not.”
Public health facilities must now provide comprehensive abortion-related services, according to the Standards and Guidelines for Reducing Maternal Morbidity and Mortality from Unsafe Abortion in Kenya that the Ministry of Medical Services released in October 2012. Abortions must take place in facilities that meet minimum standards of care, employ qualified health personnel, and have all the necessary equipment for safely terminating a pregnancy.
But three years after the government introduced the new constitution and nearly a year after the ministry released these standards and guidelines, many women remain unaware of their expanded reproductive health rights. As a result, women in Kenya continue to die from illegal, unsafe abortions.
“The law is now far less restrictive, and most women still don’t know about the disinhibitive provisions,” says Dr. Joseph Karanja, a private medical practitioner and an associate professor in the Department of Obstetrics and Gynaecology at the University of Nairobi, in a phone interview.
The number of women and girls who die while procuring a crude abortion is still high, he says. Some women drink toxic substances or attempt to break the amniotic sac in the womb with sharp objects.
Jedidah Maina, program manager of the Trust for Indigenous Culture and Health, an organization in Nairobi that aims to end unsafe abortions in Kenya, says that every time she and other community workers go to the slums, they learn that another girl or woman has died because of complications from an illegal abortion.
Advocacy organizations are stepping in to educate women about their constitutional rights.
Representatives of the Trust for Indigenous Culture and Health visit Nairobi’s slums to explain changes to abortion regulations in the 2010 constitution, Maina says. They encourage women to seek counsel at hospitals if they wish to terminate unwanted pregnancies so that they will follow safe and legal procedures.
“The law says abortion is allowed if the life and health of the mother is in danger,” she says. “The World Health Organization defines health as a state of complete physical, mental and social well-being and not merely the absence of disease. A mother may be well physically but not psychologically.”
Doctors should grant a woman an abortion if a pregnancy will cause psychological harm, Maina says. The organization only educates women, though, and does not procure abortions for them.
“We just give women the information on safe abortion,” she says. “What they do with it is up to them.”
The Reproductive Health Network plans to launch countrywide media campaigns to make women aware of their reproductive health rights, Nyamu says.
But the government must also do more to educate citizens about their rights, he and other doctors say.
The government must interpret the law for citizens to save women’s lives, Karanja says.
The Reproductive Health Network is asking the government to rapidly disseminate its guidelines for abortion care, Nyamu says. Medical personnel in some public health facilities still do not have the document.
“Hospitals also need to be equipped with the facilities and drugs necessary for termination-of-pregnancy procedures,” he says. “The government can identify a few hospitals where all women in need of safe abortions can be referred to before the project is rolled out countrywide.”
The Ministry of Medical Services developed the National Training Curriculum for the Management of Unintended, Risky and Unplanned Pregnancies in October 2012 that improves the implementation of the standards and guidelines for safe abortion in hospitals throughout the country, he says. All medical personnel at both public and private health facilities must undergo the curriculum’s basic training for abortion procedures unless they cite conscientious objection.
“Only then can we reduce maternal morbidity and mortality in Kenya,” Nyamu says.