Background
Liberia's amended Public Health Law (Title 33 of the Liberian Code of Law Revised) which includes a provision on abortion currently being debated before the Liberian Senate for passage into law, would ban abortions after 18 weeks of gestation. The current penal law (Title 26 - Liberian Code of Laws Revised, chapter 16), however, allows abortions up to 24 weeks gestation (about 6 months of pregnancy). Although it is a step in the right direction, more could be done. We disagree with the proposed legislation and believe that there is a better solution to this divisive issue. Therefore, we propose that 12 weeks gestation, the first trimester of pregnancy, as the cut off point for elective abortions. This gives a woman sufficient time to confirm that she is indeed pregnant and address all issues relating to her pregnancy... whether impregnated through incest (human sexual activity between family members or close relatives), rape, or other criminal acts ...that would legally support her desire to safely obtain an abortion.
Only seven nations including the U.S. permit nontherapeutic or elective abortion-on-demand after the twentieth week of gestation. According to the March 19, 2018, Mississippi, United States, Gestational Age Act, Bill 1510, seventy-five percent (75%) of all nations do not permit abortion after twelve (12) weeks gestation, except (in most instances) to save the life and to preserve the physical health of the mother.
Trend analyses conducted by a team of researchers at the National Public Health Institute of Liberia, on maternal and other major causes of death in Liberia, between 2018 to 2022, indicated that, the leading causes of maternal mortality in the country are, post-partum hemorrhage (PPH) at 38% of all maternal deaths; eclampsia/pre-eclampsia at 14%; followed by sepsis; obstructed labor; and, abortion, the fifth most common cause of maternal death. Globally, unsafe abortions cause 8-11% of maternal deaths, predominantly in low and middle-income countries, where the most restrictive access policies are concentrated, and socioeconomic factors further affect access to care (Lancet Global Health, 2018). Consequently, abortion is a subject that attracts substantial attention and is widely deliberated around the world (Liberia included) in all spectrums: public health, medical, political, social, religious, and legal.
Our proposal to restrict abortions to 12 weeks of pregnancy in Liberia is based on statistical data in the Liberia Demographic and Health Survey of 2019/2020 (DHS 2019/20) which indicates that Liberia is among countries with the highest maternal and newborn mortality rates (MNMR) in Sub-Saharan Africa. The DHS also indicates a decline of maternal mortality rates (MMR) in 2013, from 1072 maternal deaths per 100,000 live births to 742 maternal deaths per 100,000 live births. That is, for every 1,000 births in Liberia, about seven women die during pregnancy, during childbirth, or within 42 days postpartum, from causes other than accidents or violence. With such a disproportionally high MNMR, affecting primarily women in households with substantial socioeconomic inequalities, catastrophic health expenditures remain pervasive. Therefore, if access to abortion education and nontherapeutic abortion or, abortion-on demand is readily available and affordable, we believe that more women would choose abortion in the first trimester (12 weeks) when it is safer, as opposed to later in the second trimester (13-16, or 16- 24 weeks), when the risks of complications or even death, is much greater.
Legal
Liberia is swamped with controversies on abortion rights aimed at legislating an amended public health law (Title 33 of the Liberian Code of Law Revised). Public health authorities believe this is an effort to make the law fully compatible with contemporary public health issues and norms. The old Title 33 has been in effect since 1976, over four decades, without any revision, rendering it obsolete.
The current penal code of Liberia, Title 26 - Liberian Code of Laws Revised chapter 16 - legalizes abortion up to 24 weeks gestation. However, the proposed revised public health law would only allow legal abortions up to 18 weeks gestation, thereby reducing the period a woman can choose to legally have an abortion from 24 to 18 weeks. Although this amendment is somewhat welcoming, we disagree with legislating abortion at 18 weeks, proposing instead, 12 weeks as a reasonable option. At 12 weeks gestation, a woman is in her first trimester and can recognize and address all the pertinent issues of her pregnancy... whether through incest, rape, or other criminal acts ...that would legally support her desire to safely obtain an abortion and avert the possible risks, even death, of an elective abortion at 18 to 24 weeks gestation. The revised Title 33 has been passed in the House of Representatives. It is now before the Senate for concurrence, where public hearings are being held, involving stakeholders consisting of public health experts, medical and legal experts, religious leaders, pro-life advocacy groups and reproductive rights advocates.
Abortion is illegal in general terms, including in the penal code of Liberia, which makes it a crime after twenty-four weeks of pregnancy, however, it can legally be performed under certain medical conditions. Restrictive abortion laws affect women as well as their families, due to the long-term economic and health costs of rearing a child under difficult socioeconomic conditions. Research from the Lancet found that "ensuring women's access to safe abortion services does lower medical costs for health systems" (Lancet Global Health, 2018). Similarly, international law has always viewed abortion rights within a medico-legal paradigm, the notion that legal and medical control would guarantee safe abortions.
Meanwhile, on June 24, 2022, we witnessed the reversal of Roe vs. Wade, a landmark decision of the U.S. Supreme Court, of 1973, which ruled that the Constitution of the United States generally protected a woman's right to choose to have an abortion. However, in its historic and far-reaching decision in June 2022, the U.S. Supreme Court overturned Roe vs. Wade, declaring that the constitutional right to abortion, upheld for half of a century, was no longer in existence. The Supreme Court held "The Constitution does not confer a right to abortion; Roe and Casey are overruled; and the authority to regulate abortion is returned to the people and their elected representatives" (597 U. S. ____ (2022).
In the Liberian situation, the Supreme Court did not rule on the Abortion Law. The legislators, the elected representatives of the people, decided to amend the law based on the recommendations or influence of local public health officials. The Senate should now exert leadership by concurring with the House of Representatives to pass the amended Title 33, The Public Health Law of Liberia. This should include the provision on abortion by reducing the legal cut off point to 12 weeks gestation.
Considering that many low- and middle-income countries derived their abortion laws using Roe vs. Wade, it leaves reproductive health programs vulnerable in these countries, because they are funded by US aid. This aid, comes through critical USG programs including, the U.S. President's Emergency Plan for Aids Relief (PEPFAR), a US flagship program that supports HIV/AIDs programs, mainly in Africa (politico.com/news, 2023). A child, born by a woman affected by HIV and full blown AIDS, is compromised at birth, by having HIV or AIDS. Therefore, these reproductive health and abortion programs are essential. Consequently, conservative republicans who are pro-life, are threatening not to renew the 5 years funding to PEPFAR, accusing the Biden Administration of using PEPFAR dollars to support abortion.
Religion
Over eighty percent of the country is Christian and around fourteen percent is Muslim (DHS 2019/20). In this light, the Liberian legislators invited many stakeholders to the public hearings...bishops, imams, and pastors... who gave their perspectives on abortion. The religious community expressed apprehension over the moral and ethical implications of the abortion law. They vehemently opposed the existing law and any amendment to it ...indicating that every life, from conception to the developing fetus to natural causes of death, is sacred and should be protected. From the vantage point of religious leaders, abortion ends the life of the fetus, undermines the dignity of the unborn and disregards the moral fabric of the society.
Although religious rights are paramount in Liberia, the religious community should assert all efforts to create awareness for sexual and reproductive rights, educate young people on these rights, provide intrinsic leadership and psychosocial counseling in their places of worship.
The Public Health Case for abortion rights
Reproductive Rights:
There is a strong correlation between low education among young women, poverty, unintended pregnancies, unsafe abortion, and maternal deaths. In Liberia, forty-seven percent of young women with no education have begun childbearing, as compared with twenty percent of those with a senior high school education. Similarly, forty-two percent of young women are among the poorest people in the country who have begun childbearing, compared with ten percent of those among the wealthiest, according to DHS 2019/20.
The DHS 2019/2020 report indicates further that, sixty percent of pregnancies resulting in live births in a span of 5 years were wanted at the time of conception; thirty-three percent were mistimed, meaning that, women wanted to have children later, and eight percent were not wanted at all. When you combine women who want to get pregnant later, and women who do not want to get pregnant at all, it constitutes a gigantic forty percent. Hence, ensuring general education for all women, providing reproductive health and family planning services, would avert unintended pregnancies and mitigate unsafe abortions.
The Government of Liberia and health authorities need to bolster the activities of the Planned Parenthood Association of Liberia, an organization responsible for providing quality sexual and reproductive health services, including family planning services, across the country. Family planning is hailed as one of the greatest public health achievements of the last century (Amy Tsui et. al, 2010). It lowers the number of unplanned pregnancies and abortions and saves lives. Current contraceptive use in Liberia is twenty-four percent of married women and forty-five percent of sexually active unmarried women, who currently use a modern method of contraception, according to the DHS 2019/20.
Conclusion - in the current discourse, we proffer the following recommendations:
- Any abortion laws in Liberia should consider 12 weeks gestation, the first trimester of pregnancy, as the cut off point for elective abortions. This gives a woman sufficient time to confirm that she is indeed pregnant and address all issues relating to her pregnancy... whether impregnated through incest, rape, or other criminal acts ...that would legally support her desire to safely obtain an abortion. The health risk of an abortion is directly related to how, when, where and by whom the procedure is performed. Therefore, health authorities should setup safe abortion clinics with trained providers, equipment, logistics and supplies. Because of intrusive legal restrictions and stigma, many young teenage girls and women seeking abortions in Liberia, often resort to clandestine procedures, where safety cannot be assured. Even in the case of a justified abortion, providers should be reminded that continuing an unwanted pregnancy could induce considerable mental anguish for the mother, if the pregnancy resulted from rape, incest, or other felonious intercourse, or the fetus was found to have a genetic defect that could result in a child, born with grave physical or mental defects.
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- When a woman is not pregnant, it's improbable that she will die from pregnancy related causes, thus prevention of unwanted pregnancies is essential. When considering abortion, whether justified or unjustified, the Government of Liberia should guarantee women's reproductive rights by ensuring that reproductive health and family planning services are readily available and accessible for women of child-bearing age. Liberian women need to be better able to avoid unintended pregnancies, the root cause of most abortions. Making a wider range of modern contraceptive methods available, strengthening access to emergency contraception, and improving family planning services, would potentially lower the rate of unintended pregnancies, and alleviate unsafe abortions, thereby significantly reducing maternal mortality.
- The general population should be informed and educated on the amended abortion law. This extends to medical professionals, the religious community, the judiciary, and law enforcement officials, who need to know and understand fully the legal criteria for the provision of abortion services. The law should allow abortions up to 12 weeks of pregnancy. Any abortion beyond that period, would be a criminal offence.
Correspondence authors: Tolbert Nyenswah, LLB, MPH, DrPH is an international recognized legal scholar and global public health expert, a faculty member in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. Prior to joining the Bloomberg School, he was Deputy Minister, Assistant Minister, Ministry of Health of Liberia, and Director General of the National Public Health Institute of Liberia. He's credited and decorated as Ebola hero/czar for leading Liberia's successful and unprecedented Ebola response as Incident Manager.
Co-author: Mardia Stone, MD, MPH is a senior consultant and advisor in the Division of Global Psychiatry at the Boston University School of Medicine/Boston Medical Center. A global public health expert, she is formerly a WHO consultant in emergency preparedness and response, an Ebola Response Team Coordinator, senior and technical advisor to the Incident Manager of Liberia's Ebola response and the National Public Health Institute of Liberia. Dr. Stone is also a retired obstetrician/gynecologist.
Disclaimer: This Op-ed is written in our personal capacity and is independent of our affiliation with our institutions, Johns Hopkins University and Boston University School of Medicine/Boston Medical Center.
Data in this Op-ed are the most current available and, unless otherwise noted, are drawn from the Liberia Demographic and Health Survey 2019/2020
