Unsafe abortion is one of the leading causes of maternal mortality and morbidity. Globally, an estimated 47,000 women die from unsafe abortions each year with an additional 5 million injuries occurring as a result of complications due to unsafe procedures (WHO, 2011). These injuries result in short and long term health consequences for women, including infertility and fistula, and have far reaching economic and societal costs. Ninety-eight percent of all unsafe abortions occur in low to middle income countries. It is a particularly pressing health issue for the African region, where unsafe abortion mortality is the highest in the world and legal abortion services are only available in a handful of countries. However, even in countries where abortion has been legalised, women’s access to safe abortion services remains limited.

HEARD has embarked on a new and important initiative within its Sexual and Reproductive Health and Rights research agenda, to investigate unsafe abortion in Eastern and Southern Africa. The first step in this initiative consisted of a scoping literature review, which was performed in June 2015. The review included 98 articles, covering the burden of disease, abortion legislation, abortion practices, abortion (medical) services, and community perspectives on abortion in Eastern and Southern African countries.

We would like to share some of the key findings from the literature review in this newsletter and inform you of our future plans

  • Presence of restrictive abortion laws are attributed to much higher unsafe abortion rates and related maternal mortality. To be more precise, the United Nations reports that the average unsafe abortion rate in countries with restrictive laws was 26,9 per 1,000 women aged 15-44 versus 7,8 per 1,000 women in countries with liberal abortion laws (UN, 2014). Most abortions laws on the African continent stem from colonial occupation (e.g. the British colonial Act (1861), the French Napoleonic code (1810), and the Belgian code (1867)) which only allowed abortion on the grounds of saving a woman’s life. There have been several attempts to call upon countries to reform their abortion laws.
  • In 2003, the African Union adjusted the protocol on the rights of women in Africa. This protocol, called the Maputo protocol, explicitly recognises women’s right to sexual and reproductive health and abortion as a human right.
    In 2006, the African Union adopted the Maputo Plan of Action of the continental policy framework for the operationalisation of sexual and reproductive health and rights (SRHR). This plan of action is the regionalisation of the International Conference on Population and Development’s programme of action and Africa’s plan of action to realise the SRHR-related millennium development goals.
  • More recently, the African Union launched a campaign for the accelerated reduction of maternal mortality in Africa. Despite these different commitments, countries have been slow to reform their abortion laws, with some notable exceptions such as Zambia, South Africa, Seychelles and Ethiopia. South Africa is considered the frontrunner in terms of progressive abortion laws on the continent. Their ‘Choice of Termination of Pregnancy Act’ of 1996 recognises that all women have a right to make reproductive choices in keeping with their right to bodily and psychological integrity.
  • Studies revealed that the majority of women seeking an abortion were young and married. Studies reported strikingly low rates of contraceptive use and a high reliance on less effective birth control measures, such as withdrawal and the calendar method. Common barriers to using hormonal contraceptives were perceived and real side effects, fear for infertility and the partner’s reaction to using modern family planning. Furthermore, studies pointed at the occurrence of unsafe abortion in contexts in which adolescents have limited access to sexual and reproductive health services and in which health workers are generally reluctant to provide contraceptives to young girls.
  • Community perceptions on abortion were generally negative with abortions being considered a sin or immoral.
    A number of studies reported alarmingly high rates of repeat abortions in women. While the issue of repeat abortion has been on the agenda since the ICPD of 1994, countries fail to address it effectively as part of post abortion care. Different studies in the review reported on the haphazard implementation of post-abortion counselling and supply of contraceptive methods at health facilities, hereby missing an important opportunity to prevent new unintended pregnancies. Again adolescents were disproportionately more affected.
The literature review findings formed the basis for a phased multi-country research investigating the occurrence of and perceptions on unsafe abortion in the region. HEARD selected Malawi, Namibia, South Africa and Tanzania for an initial exploration on this topic. Each country was visited by a team of two HEARD researchers, who conducted interviews with key stakeholders and reviewed country documentation. For 2016, HEARD is planning to expand to a full-scale research, using the initial research findings to determine its focus and methodological approaches.

WHO (2011). Unsafe abortion: global and regional estimates of incidence of unsafe abortion and associated mortality in 2008.
UN. (2014). Abortion policies and reproductive health around the world. New York, USA: United Nations, Department of Economic and Social Affairs, Population Division.