ABORTION IN AFRICA AND SOUTHERN AFRICA Background Note An abortion is the medical procedure for ending a pregnancy. It is also sometimes known as a 'termination' or a 'termination of pregnancy'. Abortion is a safe medical procedure if performed by qualified medical personnel in a conducive environment. Unsafe abortion is one of the leading causes of maternal mortality and morbidity globally. A principal cause of unsafe abortion is restrictive abortion laws. The legal restrictions lead many girls and women to seek services in other countries, from unskilled providers or under unhygienic conditions thereby exposing them to a significant risk of death or disability. Unsafe Abortion Unsafe abortion is the third leading cause of maternal mortality and morbidity globally and is one of the four leading causes of pregnancy-related death. The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating an unintended pregnancy, either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both. The persons, skills and medical standards considered safe in the provision of abortion are different for medical and surgical abortion and also depend on the duration of the pregnancy. http://www.who.int/reproductivehealth/publications/unsafe_abortion/induced_abortion_20 12.pdf Nearly half of all abortions worldwide are unsafe—that’s roughly 21 million annually—and nearly all unsafe abortions (98%) occur in developing countries. In the developing world, 56% of all abortions are unsafe, compared with just 6% in developed regions. https://www.guttmacher.org/fact-sheet/facts-induced-abortion-worldwide More than 6 million women in developing countries are treated every year for complications from unsafe abortion with at least 9% of maternal deaths (16,000) annually being due to unsafe abortions. In the poorest countries, women have the fewest resources to pay for safe procedures. They are also the most likely to experience complications related to unsafe abortions. https://www.guttmacher.org/sites/default/files/factsheet/ib_aww-africa.pdf While abortion is a safe procedure when performed by skilled health care providers in sanitary condtions, illegal abortions are generally unsafe and lead to high rates of complications and to maternal deaths and morbidity, http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf?ua=1)

Where legislation allows abortion under broad indications, the incidence of and complications from unsafe abortion are generally lower than where abortion is legally more restricted. Across the world, 40% of women of childbearing age live in countries that have highly restrictive laws, and/or where abortion, even when lawful, is neither available nor accessible. Unsafe abortion and associated morbidity and mortality in women are avoidable. Safe abortion services therefore should be available and accessible for all women, to the full extent of the law. http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf?ua=1 Nearly 14% of all unsafe abortions in developing countries are among women aged under 20 years. In Africa, young women below the age of 25 years account for nearly two thirds of all unsafe abortions on the continent. (p.24, WHO Safe Abortion Guidance). Young women are especially vulnerable in cases where effective contraceptive methods are only available to married women, where the incidence of non-consensual sexual intercourse is high or because they face barriers in accessing and negotiating the use of contraceptives. The most common complications from an unsafe abortion are incomplete abortion, excessive blood loss and infection. Less common but very serious complications include septic shock, perforation of internal organs and inflammation of the peritoneum. Many women who face complications are unable to access the treatment they need with some facing long-lasting health effects, such as chronic pain, inflammation of the reproductive tract and infertility. Beyond its immediate effects on a woman’s health, unsafe abortion has negative consequences on a women’s family as well as society at large. Complications from unsafe abortion may reduce women’s productivity, increasing the economic burden on poor families. It can also result in significant costs to overburdened public health systems. The Situation of Abortion In Africa Source: https://www.guttmacher.org/sites/default/files/factsheet/ib_aww-africa.pdf During 2010–2014, an estimated 8.3 million induced abortions occurred each year in Africa. The number has increased from 4.6 million annually during 1990–1994 and is principally linked to an increase in the number of women of child-bearing age. The annual rate of abortion varies slightly by region, ranging from 38 per 1,000 women of childbearing age in Northern Africa to 31 per 1,000 in Western Africa. In Eastern, Middle and Southern Africa, rates are 34 per 1,000. The highest number of abortion-related deaths worldwide occur in Africa representing more than half of the abortion-related deaths occurring globally. About 1.6 million women in Africa are treated annually for complications from unsafe abortions. Young women are disproportionately affected with 60 percent of unsafe abortions performed on women under the age of 25. Unsafe Abortions in Southern Africa Source: Unsafe abortion incidence and mortality, Global and regional levels in 2008 and trends during 1990 –2008 WHO. Abortion facts and findings 2011- Population reference Bureau • • •

58% of abortions performed in the region are unsafe amounting to 120 000 unsafe abortions per year. 370 deaths per 100 000 are linked to unsafe abortions. 61% of maternal deaths are due to unsafe abortions.

Abortion laws in Africa All African Union member states allow abortion at least to save a woman’s life and many more permit it on broader grounds, including health grounds. However, few countries have taken positive steps towards ensuring women are able to access abortions to which they are entitled to under the law. This has resulted in women having to seek unsafe abortions. World Health Organization standards and United Nations and regional commitments to reducing maternal mortality call upon states to take measures to ensure access to safe abortion, where legal, including by developing strategies and guidelines for providing safe abortion services. • • • • •

As of 2015, an estimated 90% of women of childbearing age in Africa. live in countries with restrictive abortion laws. Abortion is not permitted for any reason in 12 out of 54 African countries. Five countries in Africa have relatively liberal abortion laws: Zambia permits abortion on socio-economic grounds, Mozambique, South Africa, Tunisia and Cape Verde allow pregnancy termination without restriction as to reason, but it must be within the first 12 weeks. Even where the law allows abortion under limited circumstances, women often face challenges in navigating the processes or overcoming barriers required to obtain a safe, legal procedure. https://www.guttmacher.org/sites/default/files/factsheet/ib_aww-africa.pdf Research shows that the criminalization of abortion has very significant health and life risks for women because it drives women to unsafe procedures due to a lack of other options.

Abortion Laws in Southern Africa Source: http://repronetafrica.org/towards-access-to-safe-abortion-ipas-contributions-to-recentadvances-in-africa/ • Swaziland reviewed its abortion law to conform to the Maputo Protocol in 2005 • Mauritius adopted a more enabling law in a Penal Code amendment in 2012 • Mozambique revised its Penal Code that was enacted by the Parliament in August 2014 and which has very progressive improvements in the abortion law. Abortion is allowed at the request of the woman in the first 12 weeks and for a broad range of indications in subsequent trimesters. The new Act is awaiting promulgation by the President of Mozambique. • In Malawi high maternal mortality rates including from unsafe abortion was of concern to the government. Since 2007 the MOH has worked with Ipas and in-country partners to advance advocacy for legal reform that has involved legislators, lawyers associations, women’s rights organizations, religious leaders as well as local opinion leaders and the youth. The previous government had set up an abortion law review commission that is still working on a draft law that has received wide consultation with Malawians of all walks of life. It is expected that a revised abortion Bill at the least in conformity with the Maputo Protocol will soon be enacted. • In 1996, South Africa enacted a new abortion law—the Choice on Termination of Pregnancy (CTOP) Act[4] that is considered to be one of the most liberal worldwide. It allows for safe abortion at the request of the woman up to twelve weeks gestation and to be provided by doctors as well as mid-level providers. A study in 2010 showed that increased access to safe abortion had resulted in over 91% reduction in abortion-related maternal deaths as well as serious morbidity from unsafe abortions

Countries in Southern Africa can be classified in the following categories according to the reason abortion is legally permitted: REASON Prohibited all together or no explicit legal with the exception to save a womans’ life To preserve physical health and mental health Socio-conomic grounds Without restriction to reason

COUNTRIES Madagascar Zimbabwe, Lesotho,Botswana, Namibia,Mauritus, Swaziland Zambia South Africa, Mozambique

Barriers to Safe Abortion Access to abortion is commonly restricted, not only by the law, but also by other barriers. Stigma surrounding abortion is a fundamental barrier to accessing abortion services and is often driven by religious and cultural forces. Other barriers include lack of awareness of the law, financial and geographic obstacles to obtaining services as well as health systems that are unable or unwilling to provide safe abortions. In countries where abortions are legal, barriers can include a lack of guidelines for conscientious objections, the need for third party authorizations and a lack of trained medical staff. Lack of budgetary prioritization for reproductive health and maternal health services is also a significant barrier, especially for poor women. Recommendations to Prevent and Respond to Unsafe Abortions • Governments need to take a number of key steps to prevent unsafe abortions. This includes decriminalization of abortion, removing all economic, geographic, social, and cultural barriers to accessing abortion services including third party authorization and addressing stigma. • In cases where access to safe abortions should be provided by law, governments should be required to provide safe and effective abortion services as integral to a package of comprehensive sexual and reproductive health services. Steps should be taken to develop and disseminate guidelines as well as to train health care workers on safe abortion and to provide values clarification training aimed at enabling health care providers to provide good quality services free of judgment. • Civil society can play a key role in raising awareness about women and girls’ rights to access safe abortions including providing information on where to access them and what are the correct procedures and dosages they should expect to receive. • Governments should be encouraged to adhere to the 3A-Q model for health services as a means of responding to the offering of abortion services which calls for high quality services that are available and accessible, are provided without discrimination, ensure respect for human rights and adhere to the principles of patient confidentiality. • Post-abortion services should be offered regardless of the legality of abortion in order to reduce the morbidity and mortality rates caused by complications due to unsafe abortion. • Efforts should be made to calculate and disseminate the costs of abortions including postabortion care, disability, infertility and other burdens on families and society as a whole. • A root cause of abortion is unintended pregnancy, particularly in the case of young girls. There is therefore a need to scale up comprehensive sexuality educational programs that inform people about safe sex and contraceptives, teach young people life skills including how to claim their SRH rights as well as ensuring the availability of a diversity of modern contraceptive options including condoms. This will provide dual protection against both unintended pregnancy and sexually transmitted infections (STIs).

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Steps should be taken to support and amplify the campaign launched by the African Commission on Human and Peoples’ Rights (ACHPR) to Decriminalize Abortions which has the goal of preventing the practice of unsafe abortions. This could include advocating governments to follow the lead of the ACHPR, engaging in dialogues at the community level aimed at overcoming some of the barriers such as stigma and showcasing countries that have decriminalized abortion and implemented appropriate programming. The adoption in 2003 by the African Union Heads of State and Governments of the Protocol to the African Charter on Human and Peoples Rights on the Rights of Women in Africa, the Maputo Protocol[6], are all significant steps forward for abortion rights in the region. Article 14 (2) (c) of the Protocol calls on member states to “authorize medical abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the unborn child.” Civil society organizations need to organize collective advocacy campaigns in order to hold governments to account to the commitments they have made. Conscientious objections need to be regulated so that they do not interfere with a women’s right to access safe and legal abortions.

INTERNATIONAL AND REGIONAL HUMAN RIGHTS TREATIES AND OTHER AGREEMENTS SUPPORTING ABORTION • 1966 International Covenant on Economic, Social and Cultural Rights (ICESCR). • 1976 International Covenant on Civil and Political Rights (ICCPR) • 1979 Convention on the Elimination of all Forms of Discrimination • Against Women (CEDAW). • 1994 International Conference on Population and Development (Cairo). • 1995 Beijing Platform for Actionhttps://www.womenonweb.org/en/page/619/abortionlaws-worldwide • 2003 Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa (Maputo Protocol). • 2005 Continental Policy on Sexual and Reproductive Health and Rights. • 2006 The Maputo Plan of Action REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Abortion facts and figures, www.prb.org/pdf11/abortion-facts-and-figures-2011 Africa Abortion laws compendium from the African Union December 2013. www.guttmacher.org https://www.guttmacher.org/sites/default/files/factsheet/ib_aww-africa.pdf National Catholic Reporter- unsafe abortions on the rise in Africa, http://ncronline.org http://www.worldometers.info/abortions/ https://femnet.wordpress.com/ http://www.ijrcenter.org/2016/02/02/african-human-rights-commission-launchescampaign-to-decriminalize-abortion/ http://www.ipas.org/en/What-We-Do/Community-Engagement/Abortion-Stigma.aspx http://www.iol.co.za/news/africa/mozambiquelegalisesabortion1797600#.VJRMDJCcA WHO Technical and Policy Guidance for Health Systems, 2nd Edition, 2012. http://repronetafrica.org/towards-access-to-safe-abortion-ipas-contributions-to-recentadvances-in-africa/