22 February 2013

Kenya: The Scarlet 'A' for Abortion (part 1)

Abortion is a hard topic for any nation, but in Kenya it's done, not spoken of. Hundreds of thousands of women have them each year, but they rarely speak of it. Worse still, many seriously harm themselves with unsafe methods, all in an effort to keep the secret.

Abortion in Kenya is a tricky thing to pin down. No one knows for sure how many go on - the only national figures come from a three-month study of women hospitalised for abortion related complications that happened in 2002. According to that, somewhere around 300,000 abortions occur annually. But it's hard to stand by 10-year-old reports.

Asking Kenyans, many people will animatedly talk about a friend of theirs who's had one, or at least a friend of a friend. They were asked to go with her, or she got pills off a website or she had one at seven months pregnant. But it's extremely rare that someone will come out and say they personally have had an abortion.

Part of this is due to the procedure's still dubious legality - yes, the new constitution has expanded the parameters for having one, but few women feel confident interpreting the laws. However, an even bigger reason to keep the silence is the general stigma attached to abortions. Because of this, women are finding the most secretive methods they can to have it carried out, and telling as few people as possible. They deal with the guilt alone, and if there are complications they try to hide them, leading to a staggering amount of serious injuries and deaths when unsafe methods are used. All to keep the silence.

The Scarlet "A":

Abortion is any termination of a pregnancy. That means even naturally occurring miscarriages fall under the word's definition, they're just referred to as spontaneous. But when most speak of abortion, they're referring to the induced termination of a pregnancy.

Induced abortions are brought on by a variety of methods, ranging from clinical to gruesome. The most famous is probably the manual vacuum aspiration, or MVA. As the name suggests, MVA is a procedure whereby the embryo is removed from the uterus with a suction device. This is considered a surgical option, but a less invasive method is available as well - the abortion pills, typically mifepristone and misoprostol. The combination of drugs causes the uterus to shed its lining and lose the embryo. The pills, however, are only recommended to terminate pregnancies up to nine weeks.

These are the safe versions - typically conducted at a certified health facility and by a trained medical professional. The technical descriptions may sound horrible, but the other side of the coin is far worse. Unsafe abortions, which the World Health Organisation (WHO) defines as an abortion conducted outside of health facilities or any other place recognised by law or provided by an unskilled person, are far more common. Some of them are done by ingestion - swallowing litres of concentrated black tea or swigs of caustic material like bleach. Others are invasive, with all manner of tools being forcefully pushed into the uterus.

In Kenya, unsafe abortions are far and away the more common choice. They are cheaper - legal abortions require multiple visits to a hospital - and quieter.

Fix the Problem before It Starts:

Regardless of where they stand on the moral implications of abortion, most people agree that avoiding unwanted pregnancies is the best option. Some advocate abstinence, while others push natural methods or modern contraceptives, but the idea behind all of this is that women who don't want to be pregnant have options to avoid it. Despite these options, the Guttmacher Institute released a report on abortion and unintended pregnancy in Kenya in May 2012 that found 45 percent of sexually active unmarried women, who want to prevent pregnancy, do not use any family planning method.

Paul Mugambi is a lawyer with the Kenyan Chapter of Human Life International, a prolife organisation, based in Nyeri. Mugambi believes there is a link between abortion and contraception use in society. "The culture that entertains and propagates the contraception mentality [does not] want to have children. And [we] take it in our hands to use artificial methods," Mugambi says. Essentially, artificial contraception creates a cultural disinterest in child bearing, making abortion the next step when prevention methods fail.

Instead, Human Life International promotes the use of natural family planning. "It is a matter of understanding the way the body operates. You learn to know when your body is or is not fertile, and when to or when not to engage in sex," explains Mugambi. He further states that there are four methods around these principles that the organisation teaches married couples to use.

Muchira Muraguri is the Programme Director at Family Health Options Kenya (FHOK). While he doesn't completely disagree with Human Life International - he believes that increased education and use of family planning will reduce the current rate of unwanted pregnancies and subsequent unsafe abortions - he is certainly a proponent of modern contraceptive methods.

Muraguri gestures to a word document printed out and stuck on his office wall. It reads, "Family Planning reduces 71 percent of unwanted pregnancies." These are statistics from the WHO. Yet the Guttmacher Institute found that only 12 to 17 percent of Kenya's poorest and uneducated married women use modern contraceptives. This is compared to 48 to 52 percent of the wealthiest and most educated. All the barriers, pills, patches, devices and methods in the world won't prevent pregnancies if they aren't used.

Margaret* is 30 years old. She has three children from separate fathers who are all either dead or unsupportive. After her first child was born, Margaret started using contraception, but it immediately had adverse symptoms. "I felt dizzy and I would bleed from the first to the 30th of every month. The doctor told me to stop using the contraceptives because of this," she recalls. Margaret eventually conceived again. Her two elder children now live with her mother. She lives with her third child.

In 2005 Margaret met someone, fell in love and got pregnant with a fourth child. After some deliberation however, Margaret decided she was going to have an abortion. "I sat back and thought to myself, if injections didn't work, and neither did the pill, I [already] have three children, why give birth to a fourth?" she asks distraught. She did not want another child to grow up in uncertainty and struggle like her three children were. She searched for a provider and was informed of a lady who conducted abortions. And she had it done.

"To this date I am tired all the time. I have no strength to do anything," she says.

Legal Implications:

It used to be that abortion was only allowed if the mother's life was in danger. While this law could certainly be seen as the root of Kenya's silence on the subject, laws are more often a reflection of society. Internationally, the largest pro-life groups are typically tied to religion, whether officially or by their supporters' beliefs. The majority of Kenya's population is religious, with Christians making up 78 percent of the population and Muslims 10 percent. Both religions vehemently oppose abortion, but in countries like the US, religious views only serve to intensify the conversation. Kenya's silence is in part due to the importance of religion here, but it goes beyond that.

Children are cherished in cultures worldwide, but the "It takes a village" mentality in Kenya makes any child the responsibility of society, and pregnancy is usually seen as a blessing. But roles have changed as the world has. The thousands of street children in the country are evidence enough that society as a whole doesn't rally behind youth anymore, and poverty and hard lives make many women question the joy of bringing a child into the world. When a woman sees pregnancy as a burden and sees her only way out as getting rid of her child, there's a great deal of pressure and shame.

The country's iciness on the subject is cracking, but slightly. Kenya's new constitution makes abortion permissible under various circumstances - if it is recommended by a trained health professional, if emergency treatment is required and if the life or health of the mother is in danger.

But Muraguri is concerned about the legislation's scope and effectiveness. For example, even with the constitutional changes, the Kenya penal code has not been updated, which he says hinders women from access to proper comprehensive abortive care. In the penal code, an abortion is considered a felony with individuals found guilty facing a sentence of up to 14 years. Doctors and other medical personnel guilty of conducting an abortion will have their practicing license revoked.

This fear is echoed by the many doctors who were reluctant to talk about abortion. Some actually hung up rather than be interviewed, and those who did schedule appointments cancelled them at the 11th hour. One person who would talk, however, was Dr. Joseph Karanja, who is a registered Obstetrician/Gynaecologist and a former chairperson of Kenya Obstetrical Gynaecology Society (KOGS). He does not see the penal code as a problem.

"It doesn't matter what any other law says. The constitution is supreme," Dr. Karanja states. "And any law that is inconsistent with the constitution is null and void to the extent of that consistency," he concludes. As he flips to the opening pages of his white, pocket edition constitution, he adds "You don't even have to change the law. It is there but it does not apply."

Despite being adamant on abortion's legality, many women in Kenya are still unaware of or unable to access legal abortion methods.

When it comes to the pills, Dr. Karanja says the medication is recommended for use within 12 weeks of pregnancy, but only under proper professional observation because of the risk of complications such as excessive bleeding. Muraguri is quick to point out the challenge with this. "You need a prescription [for the abortion pill] not from any medical practitioner but a gynaecologist registered by KOGS. And there are only 250 in the whole country," he states.

Dr. Karanja says the other common legal method, the MVA, takes less time and is less harmful to the mother. "This will take 15 to 20 minutes. The patient can rest a bit then go home," he observes. But the women still have to get approval.

Any woman considering a legal abortion is required to consult with a gynaecologist, psychiatrist and physician. But Dr. David Kiragu, an OB/GYN who performs abortions, said that it was easier for women in cleancut situations, for instance a woman with a stillbirth, with a fetus with gross anomalies or taking chemotherapy, which is lethal to an unborn baby. "It is only for contestable situations, e.g maternal mental disease [or] pregnancy following rape that protracted consultations are required. Doctors are not easy to access though, to get all the consultant clinicians to reach agreement is a nightmare."

On top of that, the consultations will run up her costs. For a legal abortion, costs vary incredibly. The further along in a pregnancy the more it will be. After three months the procedure becomes more complicated and requires better facilities. Dr. Kiragu says that these later abortions can be "very expensive comparable in many cases to the cost of a normal delivery," which can be KSH 95,000 or more. Some insurance policies will cover abortion considering it a complication of pregnancy. But the conditions and costs add up to many women opting for illegal procedures.

Janet* is 41 years old and has had a legal abortion. She married her high school sweetheart, and they had two children together, a girl and a boy. But they weren't born healthy; they are both deaf and mute. In 1998, just five years into marriage, Janet got pregnant again. Her husband was not interested in having another child, but she was.

"He told me that if I gave birth to this child, it would be mine; he would not take care of it," she remembers. Janet gave in; she did not have the means to take care of her children. They only had a sole income, which her husband provided. He took her to a private doctor's clinic to have an abortion. "The doctor was there and two nurses assisted me," Janet says. The nurses injected her with an anaesthetic and walked her through the procedure step by step. "I had no clue what was going on. I was just there," she recalls.

....watch out for part 2....

Originally published in the November 2012 issue of Destination Magazine, authored by Rose Odengo.

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