It’s a story that repeats itself over and over again in this country: a young girl finds herself pregnant at an untimely moment and is forced to seek an unlawful and dangerous solution to the problem. For Martha (real name held on request), then a high school student in her final year, an abortion was the only avenue to keep open the possibility of pursuing a university degree in human resource management.“Knowing that I couldn’t easily have an abortion here, I desperately went to a neighboring country without my parents’ consent because I was going to do this in hiding,” she says. “I probably went to a quack medic, and the abortion wasn’t done well. In the process, my uterus was damaged after heavy bleeding for days and now I can’t have babies anymore.”
The extent of such unfortunate cases was recently documented in a study published in March entitled, “Abortion Incidence and Postabortion Care in Rwanda.” The study, the first to provide national and province-level estimates of induced abortions and postabortion complications, detailed that there are approximately 60,000 abortions annually in Rwanda for women aged 15-44, of which 40% lead to complications.
Accordingly, says the study, one in every five women in Rwanda can expect to “require treatment for complications of an induced abortion over their reproductive lifetimes.”
The figures have intensified the debate surrounding abortion in Rwanda and threatens to undermine the country’s hopes of achieving the fifth Millennium Development Goal—a 75% reduction in the maternal mortality ratio by 2015—because “the rate of decrease in maternal mortality,” says the study, “is much slower than that needed.”
Abortion has long been an extremely sensitive subject in Rwanda’s culturally conservative environment. According to Jean Claude Rurangwa, a 67-year-old resident of Gasyata, at one time girls who got pregnant outside wedlock could even be thrown over a cliff. Although no such dramatic punishment exists today, women who seek abortions could still be subject to prison sentences of one to five years, while those that facilitate the practice can be sentenced to five to ten years behind bars.
As of now, abortion law, which was put into effect in 1977, maintains that the procedure is permissible to save a woman’s life or protect her physical health, so long as the woman can garner the consent of two separate doctors. However, there is ongoing debate in parliament over potential amendments to Article 165 of the Penal Code, amendments that would make it permissible to have an abortion—or assist in an abortion—if the woman is pregnant because of incest, rape, forced marriage or if the pregnancy threatens the health of the unborn baby or the pregnant woman.
But the article, which was approved by the Chamber of Deputies and is now under consideration by the Senate, will not be easy for all of society to swallow, especially the country’s respective religious communities.
“Rape shouldn’t be a reason for abortion because if you kill the baby and let the rapist live, he will go on raping others, only leading to more abortions,” says Most Reverend Emmanuel Kolini from the Anglican Church. “Incest is also unjustifiable since it has always been here, so a child’s life shouldn’t be terminated simply because the parents are related.”
The Chairman of Bible Society Rwanda Darius Kankiriho, believes there is no justifiable circumstance for an abortion. “No one has the right to decide the fate of the unborn baby,” he says. “If their life or that of the mother’s is in danger, then let God take the course of action instead of man helping the baby to die.”
A delegation of representatives from Christian churches nationwide was recently welcomed by President Kagame to hold a discussion on the subject. The church leaders’ influence on social issues, and on Rwandan society as a whole, might explain the abrupt cancellation of a press conference scheduled to publicise the abortion study in March. According to an email from the Health Communication Centre, the cancellation was a result of stakeholders preferring to have a closed-door meeting.
Stern attitudes and abortion laws could also be contributing to the high number of women—a third of the population according to the study—who fail to seek medical assistance, often out of fear, for postabortion complications. This news comes in spite of the fact that 92 percent of all medical facilities in the country treat postabortion complications, and that “public facilities must provide a comprehensive package of services for the management of postabortion complications if they are a referral or district hospital, or a minimum package of services if they are a health center.”
According to Director of Maternal and Child Health Unit at the Ministry of Health Dr. Fidel Ngabo, who helped author the study, medics are meant to offer postabortion treatment to patients regardless of the circumstance and to maintain the privacy of the patients’ cases.
However, one way to limit the number of women who show up for such critical assistance, says Chantal Umuhoza, coordinator of Safe Abortion Action Fund (SAAF) project, is to actually legalise the practice. Umuhoza adds that the decision to terminate a pregnancy is an inherent human right – one that should not continue to be violated.
How did we get here?
According to the study, in 2009, 47% of all pregnancies across the country were unintended. Although some resulted from a number of horrible situations such as rape or defilement, the most common cause was a failure to use contraceptives. Birth control is another hotly contested issue in Rwanda because, as the study points out, “social sanctions often prevent [women] from using contraceptives because the practice of contraception among unmarried women is perceived as being an indication of promiscuity.”
Unlike in Europe or North America where it is common for girls to discuss their birth control methods with their parents, girls in Rwanda often feel uncomfortable discussing their sexuality with elders. Both sides instead pretend that the young woman is not sexually active, and as a result the need for contraception is not an issue. “My parents would kill me if they knew I was having sex,” comments one young woman. “I can’t tell them I want to go on birth control!”
But access to birth control, the study points out, does increase the number of safe pregnancies, and in turn, the number of healthy babies. Between 2005 and 2010, after emergency contraception became legal and available in Rwanda, the report points out, the percentage of women in unions using such protection increased from 9% to 44%. During that time, the proportion of births attended by skilled personnel increased from 39% to 69% and under-five mortality declined from 152 to 76 deaths per 1,000 live births.
In the absence of birth control, condoms provide a dependable alternative, while also protecting the respective partners against STDs and HIV. But even here there has been debate. “People are scared of carrying or possessing condoms,” explains Dr. Aflodis Kagaba, the executive director of the Health Development Initiative (HDI), a local non-profit organization that has toured more than two dozen schools across the country to educate the youth on Sexual Health and Reproductive Education (SHARE). “There’s a perception that it’s immoral to have condoms.”
“When we ask young people they say ‘we’ll have sex when we’re married’, because that is what their parents have taught them, so it’s kept secretive,” adds Kagaba. “Because it deviates from the culture, young people are shy to go the pharmacy and pick them up. But if you put the condoms in a bathroom they’ll be taken.”
HDI has not only worked to educate students about sex but also to increase their accessibility to condoms. According to the 2005 Rwanda Demographic and Health Survey, only 37% of women aged 15-24 reported being able to access condoms on their own, compared with 73% of young men of the same age. It is even more difficult for women in a boarding school, says Kagaba, where condoms are not available and where the need to buy condoms is not a justifiable excuse to leave the school. “Then if a girl has unprotected sex in boarding school, who would she talk to?” he asks. “It’s a sin!”
As Rwanda continues its ambitious development plan and poverty reduction strategy for 2008-2012—which places a strong emphasis on reproductive health and family planning—and maintains its determination to meet all targets set out in the MDG, there are clearly outstanding issues to address.
Nevertheless, the fact that the country has commissioned and published such a report—the only other published research on this topic to date was a 2004 study of four health districts in Rwanda—shows that there is a desire to at least better comprehend the issue of abortion. Debating amendments to article 165 is another important development.
Moreover, the government’s intention to increase access to condoms among women and men aged 15-24 to 60 and 80 percent respectively by this year, and the decision to make the youth the theme of this year’s world AIDS day campaign, shows an acknowledgement that the youth are having sex—whether their parents, teachers and religious leaders want to believe it or not—and as a result all must be done to ensure they practice it safely and responsibly.
Last November, during the 7th Annual Pe¬diatric Conference in Kigali, young Rwandans themselves made an appeal for regular voluntary HIV counseling and testing in schools as a way of increasing awareness. The conference also heard accounts that there is very little information provided to adolescents on how to handle their sexuality. Parents at the conference admitted that in addition to not knowing how to explore the delicate sub¬ject with their children, they were worried that even initiating such discussions could lead their children to start experimenting with sex.
Cultural and religious views opposed to pre-marital sex and abortion is nothing new in Africa. In many countries these traditional views continue to inhibit change, while the number of women having abortions across the continent is not declining. Between 2003-2008, according to Guttmacher Institute, a US-based non-profit organization that seeks to advance sexual and reproductive health through research, policy analysis and public education, the abortion rate in Africa remained at 29 abortions per 1,000 women of childbearing age. Moreover, in 2011, according to the World Health Organization (WHO), unsafe abortion techniques accounted for one in six maternal deaths in East Africa.
These subjects will undoubtedly remain hotly contested and deeply sensitive in this country. Ending a life, even that of a two-week old fetus, should not be a decision that comes lightly. However, if Rwanda does want to meet its development and health targets, and wants to continue being a role model for its regional neighbors—and for all African countries—such debates between all sides must continue; and the evidence from such laudable reports must be deeply analyzed for the benefit of all Rwandan women.