Girl’s abortion regrets reflect health failures

Janet Otieno stared at her doorway, surveying its cracks for the first sign of light. Awake and restless, she was already dressed for the day out as she had to leave early or her parents would find out.

As sunrise finally broke in the horizon, feelings of nausea replaced her anxiety. Quickly and quietly, she slipped out of the house and tiptoed her way through the still, muddy streets.

It was still early when she found the place — an unremarkable, rusty shack in Kibera, Nairobi. An elderly woman ushered her inside, scanning the scene for unwelcome witnesses.

Safely concealed behind tattered curtains, she offered Janet a mysterious drink. Hands trembling, the 17-year-old held it to a flickering torch.

BACK-ALLEY ABORTION

A strange black liquid rippled ominously, beckoning her lips to the rim of the cup. Her stomach churning, she gave the woman Sh500 and swallowed the potion in a single gulp.

Two hours later Janet lay sprawled on her bedroom floor, bleeding uncontrollably. A back-alley abortionist had terminated her pregnancy and left her for dead once she had been paid.

“I was scared at the beginning but I was desperate,” says Janet, five years later at age 22. “We were poor and we could not afford to take care of another child, and my boyfriend had disowned me and the baby.”

It’s a warm afternoon, and Janet sips her glass of water calmly. An upright posture and a brawny physique hide the scars of her physical trauma, but the depth of her gaze tells a different story.

Seated comfortably in her two-room home in Kibera, she recounts the complications of her illicit abortion.

“I had stomach pains and a very severe headache and fever,” she says in a mixture of English and Kiswahili. “They had to wash out my stomach so I would be able to have children again — it was so painful undergoing that.”

DEMAND MORE ACTION

According to the Centre for Reproductive Rights, unsafe abortions kill at least 2,600 women in Kenya every year, making Janet one of the lucky survivors.

In 2013, these illegal practices were recognised as a “preventable cause of maternal morbidity and mortality” by the Ministry of Health, which urged the country to find “lasting solutions.”

But, despite Constitutional change in pursuit of these ends, unsafe abortion accounts for up to 40 per cent of all maternal deaths in Kenya. And now, nearly five years after this legal reform, civil society and medical practitioners are demanding more action to curtail this killer.

“You can have very good laws and policies, but unless there is political will to implement them, they end up just as any other papers on the shelf,” says Dr Joachim Osur, technical director of reproductive and child health at Amref Health Africa in Nairobi.

In 2010, Kenya ratified a new Constitution affirming the right to safe abortion if, in the opinion of a trained health professional, “there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law.”

Internationally, the document was hailed as a major milestone in national reform; a large step forward in government accountability. In 2012, the Overseas Development Institute called it a “new narrative for social justice”, applauding its commitment to the rights of women and children.

“In that sense, Kenya was seen as the star of the region,” Dr Osur explains. “The problem we actually have is that law has not been scaled down to service delivery protocols and standards.”

TURN AWAY WOMEN

Last year, the Ministry of Health withdrew the Standards and Guidelines on Reducing Maternal Mortality and Morbidity from Unsafe Abortion — Kenya’s only framework for implementing the provisions of the Constitution.

For the most part, the legislation is now open to interpretation by healthcare providers and police officers, which has led to inconsistency in its local execution.

“What does it mean to be a trained health provider? Who is to provide the training?” asks Evelyne Opondo, regional director for Africa for the Centre for Reproductive Rights. “Our law, if implemented fully, is not bad, but the challenge has been implementation.”

As a result of the lack of clarification, many women who qualify for abortion are unaware of their rights and will not seek services. On a similar note, many health workers don’t know when to provide them and will turn away women who qualify for fear of repercussions.

“If they go to a provider and the providers are not able to provide the services, research has shown that these women don’t just give up,” says Mrs Opondo. “They resort to whatever means are available and this is how they end up on the back street.”

According to a report by the African Population and Health Research Centre (APHRC), more than 460,000 abortions took place in Kenya in 2012, “virtually all of them clandestine and unsafe procedures”.

Last year, in collaboration with the Ministry of Health, it documented roughly 120,000 women who accessed health services to treat complications from back alley abortions.

PENS IN THE UTERUS

Many of them were treated at Kenyatta National Hospital, says Dr John Ong’ech, assistant director of reproductive health and one of the facility’s lead gynaecologists.

“We see very crude things,” he says, “pens in the uterus, beads, metals, anything — the problem is there, cutting across all women of reproductive age.”

For every three women he treats, Dr Ong’ech removes one uterus through surgery, and for every five women he treats, he estimates that one dies. “It will get worse,” he insists. “It is a silent killer. It’s not going anywhere and it has to be addressed.”

An implementation framework for the Constitution is one part of the “fix”, he explains, but the rest lies in prevention of unwanted pregnancy, the “root cause” of unsafe abortion.

In August 2013, APHRC and the Ministry of Health reported that 70 per cent of women who sought healthcare as a result of unsafe abortion in 2012 had not used any form of contraception prior to becoming pregnant.

More than half of them were under 25 years of age, illustrating a “serious lack of family planning and education services”.

PEOPLE RARELY TALK

“In Kenya, there are people who, until now, oppose sex education,” says Ms Opondo. “We know that our structures and society are such that at the family level, people rarely talk to their children about sex and how to prevent STIs and pregnancy.”

According to the study, called Incidence and Complications of Unsafe Abortion in Kenya, the highest rates of abortion were recorded in the Nyanza, Western and Rift Valley regions, where unwanted pregnancy could be attributed to “poor women’s health, higher poverty levels, gender-based violence, and poorer access to family planning services”.

Lack of education is exacerbated by lack of access to contraception, she explains, especially for low-income and rural populations.

“People with money will always get (an abortion), so the ones who suffer most are the poor,” she says. “Imagine women in a rural area — it’s probably one provider that serves an entire region, so where do they go after that? Do they just give up, and maybe die?”

In a 2012 report, the Kenya National Commission on Human Rights (KNCHR) identified high perceived costs, stock-outs, unavailability of emergency contraceptives and injectables, misinformation and propaganda as primary barriers to family planning access.

It also put the spotlight on Kenyan cultural norms, many of which “place decision-making authority regarding number of children on the man” and “equate the use of family planning to immorality”.

FEAR, STIGMA AND RELIGION

In addition to addressing these socio-cultural obstacles, KNHCR called on the Government to promote gender equality, eliminate public and private family planning fees, invest in community health infrastructure, and involve men in family planning initiatives.

“A lot of times a number of women are very incapacitated in terms of making decisions about whether to use contraceptives or not,” Ms Opondo explains.

“We can help build the capacity of women to understand their -rights, to have the information, to know where to seek services and what to do if those services are denied.”

Unfortunately, fear, stigma and religion have hindered discussion of these solutions in Kenya, where resistance to abortion remains widespread.

When the topic was thrust into the political spotlight in March 2010, a number of leaders argued passionately against the Constitutional clause, citing several of these historic motives.

During negotiations, Robinson Njeru Githae, then Minister for Nairobi Metropolitan Development, urged the Government not to upset the Church (one of its major stakeholders) with decisions about a “very emotional” issue.

THINK IT IS 'FOREIGN'

Linah Jebii Kilimo, who was Assistant Minister for Co-operative Development and Marketing at the time, also cautioned the National Assembly, fearing that legal abortion would invite “a curse” into Kenya.

“It is not an issue that is Kenyan,” she stated. “It is not from our country. I think it is foreign.”

The country has made important changes since then, but abortion is still a contentious topic. It hunts in the shadows, says Dr Ong’ech, where women pay up to Sh100,000 for the discretional services of a trained professional.

Even women who are entitled to abortion by law may not claim it openly, preferring to avoid the stigma with a quick, quiet fix.

“Kenyan society is very conservative,” he explains. “We rarely make a radical move. Doctors, off the camera, are performing abortion a lot in Kenya for those who can afford it.”

Those who cannot afford it are women like Janet, who paid Sh500 for a back alley operation that nearly left her infertile for life.

To curb the killer of unsafe abortion, Kenya must adopt a multilateral approach to reproductive health rights that moves the focus from unsafe abortions to unwanted pregnancies.

LASTING SOLUTIONS

According to Dr Osur, this paradigm shift made a brief appearance in 2013 with the Standards and Guidelines on Reducing Maternal Mortality and Morbidity from Unsafe Abortion, but was withdrawn as quickly as the document itself.

“It had all the elements that were needed,” he explains. “They were basically prioritising prevention of unwanted pregnancy, counselling options for those who are pregnant and where they are providing safe abortion services.”

In order for Kenya to take the next step in tackling unsafe abortion, he says, a similar framework must be adopted.

Paired with effective sexual education, greater investment in family planning, trained health workers and female empowerment, the guidelines would lead to the “lasting solutions” the health sector commanded in 2013.

“(The Government) is doing something but a lot more could be done,” says Dr Osur. “It will take time to learn that things have changed and they need to do things differently.”

As it stands, he says, the Ministry of Health must manage translation of the Constitution while the County Governments tackle access to family planning and trained healthcare professionals.

Sexual literacy and female empowerment is everyone’s responsibility, including the Ministry of Education.

“(Abortion) is a bigger agenda than the political class… It is a systematic issue,” he explains. “We can contribute positively, each of us in our own areas to make unwanted pregnancy and unsafe abortion something that does not happen.”

LIFE FOR HER BABY

If Kenya remains stuck in its current approach, women like Janet will continue to pay the price. Five years after her own illicit abortion, she wishes she had known more about family planning and the consequences of the decisions she made in her youth.

Like so many other girls her age, Janet opted for abortion to avoid peer humiliation and the wrath of her parents, and because she knew she couldn’t provide a good life for her baby.

“The guilt of killing someone still lives with me,” she says, shifting uncomfortably on her caved-in couch. “If I had known that previously, I would not have aborted.”

Today, Janet has completed her schooling and is the happy mother of a three-year-old son, who lives with her at home in Kibera. Energised from a full day of preschool, he bounces around the living room as she finishes her cool glass of water.

Pausing from his rowdy routine, he grabs his backpack and climbs onto Janet’s lap. For the first time since beginning her story, the 22-year-old’s face breaks into a smile.

Perhaps with time and a renewed national commitment to tackling this issue, stories like hers will become increasingly rare. In Kenya, there won’t be any more “lucky survivors,” only women who are healthy and happy with their choices.