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Clandestine abortions shoot up as practitioners suspend guidelines

Seventeen-year-old Risper, a Standard Seven pupil in Mpeketoni, Lamu County, got pregnant late last year. Since she wanted to continue with her schooling, she opted for an abortion. She sought counsel from her friends who gave her different options, including using tablets and tealeaves, which did not work because she was still pregnant a month later.

Many teens and even older women around the country procure abortions regularly despite it being illegal unless a medical practitioner deems that the mother’s life is in danger.

The effects of unsafe abortion or attempts to abort can be dire, as was in Risper’s case.

“A friend told me quinine would be effective. I bought the drugs from a chemist and swallowed them,” says Risper.

The failed abortion attempt saw her admitted to the Mpeketoni Sub-District Hospital for post-abortion care. 

Risper says the man responsible for the pregnancy threatened to commit suicide if she did not do away with the foetus, saying it would be a shame to his parents.

To help women such as Risper deal with pregnancy issues and align medical services to the Constitution, the Ministry of Health in 2010 developed national Standards and Guidelines for Reducing Mobility and Mortality from Unsafe Abortions in Kenya for use in all health facilities.

The document, however, generated a lot of hostility among pro-life groups who argued that the guidelines were making it too easy to abort in Kenya, suspending its implementation.

Supporting the church’s stand on the debate, Rev Canon Rosemary Mbogo, chair of the National Churches Council of Kenya says that the church believes in the sanctity of life. “Life begins at conception and there is no way we can allow for the legislation of evil just because people support it, even if we be on the minority; just because many people are doing it does not make it right,” argues Mbogo.

The canon says the church is the conscience of the society and has a duty to teach morality, adding that they were working hard to ensure that they cater to those with unplanned pregnancies.

The Ministry of Health withdrew the guidelines in December, promising to hold more consultations with various groups and re-draft a more acceptable document.

The first part of the document addresses prevention of unintended, risky and unplanned pregnancies while the second part deals with management of such pregnancies.

The guidelines call for access to health information and services as well as availability of youth-friendly services.

The document also calls for provision of contraceptive services. This is where the problem arises because the pro-life group argues that this is opening a window for blanket abortion.

Prof Joseph Karanja of the University of Nairobi – also a council member of the Kenya Obstetrical and Gynaecological Society  — says that the standoff stems from a group that does not want abortion services to be offered under any circumstances.

“Those opposed are mainly made of religious groups who are very vocal and do not want abortion offered regardless of the situation,” says Prof Karanja.

But medical practitioners agree when women cannot access these services, what remains after they get unwanted pregnancies is to abort, and the numbers keep rising.

But whether it is offered legally or not, cases of abortion are still on the rise, putting the country’s conscience between a rock and a hard place.

A report by the Ministry of Health dubbed the Incidence and Complications of Unsafe Abortion in Kenya: Key findings of a National Study, released in August 2013, showed that there were 465,000 abortions carried out in Kenya in 2012.

About only 120,000 women aged between 15 and 49 years received care for unsafe abortions, according to the report; this means just one in five women who aborted received care within the study year.

The study found that about one in every 28 women opt for unsafe and clandestine abortions, which expose them to risks like bleeding, blood poisoning, organ failure and shock. Most of these end up in public facilities for care.

Currently, Kenya has 2,838 health facilities that offer post-abortion care; out of these 1,917 are public facilities, 480 are profit-making private facilities while the remaining 441 are non-profit making health facilities. These hospitals treat complications arising from abortions.

The guidelines further address management of unintended risky and unplanned pregnancies by seeking for provision of psychosocial support for women and girls with such pregnancies.

Among the interventions in the guidelines include provision of social security to persons unable to support themselves and their dependents and adoption services as an option for women who cannot care for the babies.

On termination of pregnancies, the document states that termination of a pregnancy can only be provided in facilities that meet minimum standards while a trained health professional is defined as a registered medical practitioner, registered clinical officer, registered nurse and registered midwife who has acquired the relevant skills for decision making and provision of the service.

Apart from pressure from faith groups, it is still unclear what actually led to the suspension of the document, as senior health officials skirt around the issue without giving any clear answers.

Health Cabinet Secretary James Macharia attributes the suspension of the document not being tight enough to ensure that abortions were safe and when they were necessary.

“If we allow for guidelines that are not tight enough, we will end up exposing women and girls to all manner of complications; if abortion is to be procured, then it has to be safe and there have to be very good reasons for it,” says Macharia.

The secretary also says consultations are ongoing and there will be new guidelines on abortion.

The document covers areas ranging from reasons that might lead to women seeking abortion services like sexual violence to post-abortion care.

Contacted for comment, Director of Medical Services Dr Francis Kimani said further discussion should be put on hold for the time being because “there is a team working on the guidelines and discussions outside the team will only lead to more polarisation”.

The various stakeholders met on Wednesday at a Nairobi hotel on the invitation of Dr Kimani to review the now contentious document.

In the meeting, a team was formed and mandated to come up with new guidelines in two months.

Daniel Yumbya, CEO of the Kenya Medical Practitioners and Dentists Board lauds efforts by the Health ministry to bring together stakeholders to thrash out pertinent issues.

Could lack of guidelines have caused more problems regarding abortion?

Reacting on the suspension of the guidelines, Saoyo Griffith, a reproductive health programme officer at Federation of Women Lawyers said, “Their withdrawal creates a gap that is fuelling questions of how to safely terminate a pregnancy, who qualifies for safe termination, where safe termination should be procured, and when a doctor can lodge objection.”

Even with guidelines, doctors still find themselves in difficult situations as women and girls still seek illegal abortion services. Dr Abdulaziz Dhukifuli, the medical superintendent of the King Fahd Memorial Hospital in Lamu says cases of clandestine abortions continue to rise because women and girls have nowhere to turn and are forced to turn to quacks and other devices.

The doctor narrates a case of one girl who swallowed a coat hanger to do away with her pregnancy and the results were disastrous. Her uterus had to be removed.

The fact that there are different forms of abortions -- threatened abortions, missed abortions, inevitable abortions and clandestine abortions -- further complicates the debate.

A threatened abortion occurs when a woman, usually less than 28 weeks pregnant, shows signs of losing the baby due to various reasons like heavy work. This means that they have to be treated, usually by asking them to rest so that they do not lose the pregnancy. Missed abortion means the woman has lost the baby but without knowing it, and it is only the doctor who finds out. Inevitable abortion occurs when for one reason or another, the woman loses the baby anyway while clandestine abortions are procured illegally.

Dhukifuli says, “We find it difficult to classify clandestine abortions because of the varied nature of procuring. Most of the time these women do not tell you they did it in the backstreet, so a doctor in a public facility just finishes a procedure that they did not start.”

For instance, at the Mpeketoni Sub District Hospital, there was post-abortion care for five incomplete abortions in January this year. February saw ten cases cared for; March eight while in April, ten cases of post abortion care were reported.

One of the most common and safest ways of treating an incomplete abortion is vacuum aspiration, which on average costs Sh1,500. If the complications are heavy, more money will be required.

Lamu County has reported increasing cases of post abortion care over the past four years. In 2010, there were 784 cases, which rose to 858 in 2013.

While he does not call for blanket legalisation, Dhukifuli says the current state of affairs has put practitioners and women in a tight corner.

“As it stands now, practitioners find themselves in a dire state where the question is whether to do or not to do. If a woman walks into a facility and requests for the service, the law forbids outright provision but the same woman will go to a quack who attempt to abort and after a few days, she is back with complications for the same doctor who sent her away to treat her – in short, to complete the work,” says Dhukifuli.

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