RUFUNSA, ZAMBIA — The concoction was dark and sludgy, a blend of berries, roots and leaves. The moon serving as a beacon, Chikondi carried the mixture back to her mud-brick hut in a white, 2-liter container and slid it under her bed. She had arranged to be alone that night, sending her two daughters, ages 9 and 12, to their grandmother’s under the pretext of helping with fieldwork. At cockcrow, she would take her first sip.
Chikondi was three months pregnant with a baby she could not afford. The 29-year-old lives in Rufunsa, a small village east of Lusaka, the capital, amid an expanse of maize fields and mud homes with grass-thatched roofs. Her boyfriend of three years was unemployed and not ready to be a father. She had long supported her girls with an assortment of farming jobs, such as preparing fields and planting crops, but the coronavirus pandemic had made even those scarce.
In Zambia, abortion is legal but difficult to obtain. So Chikondi’s friend had mixed her an herbal concoction, a common method of terminating a pregnancy at home. Chikondi didn’t ask what the brew consisted of — more important was that her friend had used it to end her own pregnancy with no major problems.
Morning announced itself with a ray of light jutting through a small hole that served as a window in Chikondi’s hut. Her boyfriend, Banda, arrived around 6 a.m. (She is being identified by her middle name and he by his last name to avoid stigma.) He handed the concoction to Chikondi. She took a sip, frowned, shook her head. “I have never taken anything as bitter as that in my life before,” she says. By midday, the white container was half-empty; Chikondi was doubled over in pain.
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Chikondi’s decision is not uncommon. Although Zambia has among the most liberal abortion laws in sub-Saharan Africa, as many as 70% of the country’s abortions are considered “unsafe,” according to a 2016 study in Social Science & Medicine, an academic journal published in the Netherlands. A woman who ends a pregnancy without the assistance of a trained professional or at a substandard facility risks heavy bleeding or other life-threatening complications. The Zambian government estimates that nearly one-third of pregnancy-related deaths are tied to such abortions.
At the country’s largest hospital, University Teaching Hospital in Lusaka, officials suspect that the pandemic likely worsened the problem by making birth control harder to get and unwanted pregnancies more common. Dr. Mulindi Mwanahamuntu, head of clinical care in the hospital’s obstetrics and gynecology department, says emergency gynecological admissions spiked during the pandemic, and more than half were linked to non-clinical abortions. “I am imagining how many women are out there that have failed to access post-abortion care, those that are silently dying,” he says.
In recent years, the government has tried to make contraceptives more accessible. Even so, in rural Zambia, where the majority of people live, they aren’t easy to acquire. In a survey of rural women who were married or living with a partner, only 43% said they used modern contraceptives, such as birth control pills, according to a study in BMJ Open, which is affiliated with The BMJ, a medical journal based in London. “Our mothers have to go to health facilities to access such services like family planning, and sometimes the health facilities are far,” says Dr. Alex Makupe, director of clinical care at the Ministry of Health.
For Chikondi, the nearest hospital is about 70 kilometers (43 miles) away. Before the pandemic, she would take a day off work and spend hours on a bus to get an injectable contraceptive that would last about three months. Like all contraceptives provided by public hospitals, the injection was free, but the bus ride cost about 100 Zambian kwacha ($5.40) — roughly one-tenth of her earnings during a good month.
Sometimes Chikondi couldn’t afford the trip, and had little choice but to wait for the health care workers who visited her community every six months as part of the government effort to improve contraception access. In the interim, she begged friends traveling to the capital to bring her back birth control pills, which Zambians can buy without a prescription.
As the pandemic encroached on the country, Chikondi’s patchwork system unraveled. Mainly because of the crush of coronavirus patients, health care workers stopped coming to Rufunsa. Because of travel restrictions, her friends stopped going to Lusaka. Chikondi and her boyfriend used a condom when they could spare 3 kwacha (16 cents) for one. “The money was not always available,” she says.
Dr. Goshon Kasanda, an obstetrician-gynecologist at the Ministry of Health, says that, in recent months, health care workers have started distributing birth control in rural Zambia again. “We are trying everything possible to ensure our mothers have access to maternal care that includes contraceptives,” he says. But for some women, it’s too late.
Doreen Mulimba’s life closely mirrors Chikondi’s. The 33-year-old lives in the same village, plows the same fields. Mulimba and her husband already had four children when the pandemic cut off their access to birth control. “We tried the natural method, but it failed us,” she says.
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Mulimba was four months along, her stomach starting to push against her shirt. “At first, I wanted to terminate the pregnancy, but my faith could not let me do it,” she says. “I have seen a lot of women aborting using herbs, and I thought I could do the same because having another child means more problems. But I will let the will of God prevail. He will provide for this child.”
Chikondi’s financial woes led her to a different choice. But a legal abortion never felt like a realistic option. Under Zambian law, to obtain an abortion outside of an emergency, she would need three doctors — one of them a specialist — to sign off. That’s tough. In 2014, Zambia had fewer than 1,000 licensed doctors and 60 obstetrician-gynecologists for 15 million people, according to the Social Science & Medicine study.
Cost is another roadblock. Many legal providers, the study says, prey on abortion stigma and demand a payment beyond the cost of the procedure. “I have heard of some women aborting from hospitals,” Chikondi says, “but I understand that requires a lot of money.”
Instead, over the course of a day, she slowly drained the white container of the herbal concoction. Her friend had expelled her fetus within 24 hours. “I started having stomach cramps and water coming out of my private part,” Chikondi says. Then, blood.
One day went by. Two. Three. Chikondi was still pregnant. She couldn’t think straight. Couldn’t walk. She’d used most of her clothes to sop up blood, but didn’t have the strength to wash them. A foul odor choked her bedroom. Her boyfriend panicked: Was she going to die? Banda ran outside, flagged down a car and asked the driver to rush her to University Teaching Hospital. He had no money, but promised to pay 200 kwacha ($11) later. The driver obliged.
Chikondi was hospitalized for a week. Doctors removed the fetus and cleaned the blood out of her uterus. She also had a blood transfusion. A few weeks later, she sits on a reed mat, baking in the sun, her countenance pale and weak, her eyelids sunken. “Having an abortion is like committing murder — worse, murdering your own child — and after all I went through, it’s traumatizing,” she says. Fighting back tears, she sips liquid made of boiled avocado leaves, a home remedy to help regain lost blood.