Kenya: “It was worth the sacrifice”: Kenya’s Dr. John Nyamu on why he spent a year in prison

http://www.ipas.org/~/media/Files/Ipas%20Publications/MAMattersNov2012.ashx

 

PERSPECTIVES: ‘It was worth the sacrifice’: Kenya’s Dr. John Nyamu on why he spent a year in prison

 

From: Ipas, Medical Abortion Matters (November 2012)

 

Until 2011, abortion was illegal in Kenya except to save a woman’s life. For years the climate of fear and secrecy surrounding abortion hurt women, their families, and health-care providers. Unsafe abortion in Kenya still causes an estimated 30 percent of maternal deaths and countless other injuries.

 

Now, a newly ratified Kenyan constitution allows for legal abortion on much broader terms-and, when the new law is fully implemented, it stands to dramatically increase women’s ability to exercise their reproductive rights.

 

Ipas’s senior clinical advisor Mary Fjerstad recently sat down with Kenya’s much-respected Dr. John Nyamu to discuss the long and difficult path he and so many other Kenyans have traveled to get where they are today.

 

Mary Fjerstad: Doctor Nyamu, would you tell me what the situation was like in Kenya when abortion was considered a criminal act? [Editor’s note: Before constitutional reform, abortion in Kenya was highly restricted with few legal indications for having the procedure.]

 

Dr. John Nyamu: Most health-care workers were afraid of talking about it openly. Abortion was never performed in government hospitals unless the life of the woman was in real danger. Even then it was very bureaucratic as one doctor could only do the procedure with permission in writing from two other doctors; one doctor had to be a psychiatrist and the other doctor had to be a senior doctor in the hospital. Abortions were performed by D&C or induction. In reality, these legal abortions were provided almost exclusively at Kenyatta National Hospital, provincial hospitals and very rarely in district hospitals. (Kenyatta National Hospital is the major teaching hospital in Nairobi).

T

here were wards in hospitals where women who had unsafe abortions were treated for uterine and bowel damage due to perforations and developed sepsis, brain damage and many women died.

T

here was tremendous secrecy about abortion, women were aborting late. The penalty for a doctor who performed an [illegal] abortion was 14 years [in prison]; pharmacists could be imprisoned for three years for giving abortifacient medicines and women themselves could be imprisoned for seven years for having an abortion.

 

Some private clinics were providing safe abortion. They were harassed regularly by local police, usually by extortion. They were used virtually as the personal ATMs of the police [ATM = Automatic Teller Machine, a banking machine from which you can withdraw cash using a bank card]. A policeman would say, “I’m short of cash, give me your cash or I’ll arrest you.” The entire staff, including nurses, doctors and women seeking abortion could be arrested. Due to the fear, the providers kept servicing [the police] to buy their freedom.

 

Your case was profiled by The Center for Reproductive Rights’ paper in 2010, “In Harm’s Way: the Impact of Keny’s Restrictive Abortion Law.” Can you briefly describe what happened to you that led to this paper?

 

In 2004, [data were shared] which showed worrying trends and consequences of unsafe abortion in Kenya. This was followed by a major crackdown on clinics, hunts for women who had abortions, some clinics were closed and I was targeted. There were 15 fetuses found along a major road with some documents from a hospital I had worked at previously but had since closed. My clinic was raided and two nurses and I were arrested. This appeared to have been very well organized with all the media including print, radio and TV present to report on the matter.  When we were asked to pay bribes, we refused-because we knew the fetuses were not from our clinic and the documents were planted on the road-and we were locked up. [Editor’s note: subsequent pathology examinations found that the fetuses were still-born fetuses, not aborted fetuses.]

 

The three of us were ultimately charged with two counts of murder, rather than an abortion-specific offense. Since murder is a non-bailable offense in Kenya, we had to stay in remand prison pending our trial. We all spent a year in prison. One of the nurses was six months pregnant and delivered while she was in prison. One of the nurses still works for me and the other got her green card and has since immigrated to the United States.

 

A senior doctor, a gynaecologist, was instructed by the Director of Medical Services of the Ministry of Health to accompany the police and inspect the two clinics operated by Reproductive Health Services. The purpose of the inspection was to verify if there was any abortifacient equipment. He gave witness in court that the two facilities had legal equipment normally found in a gynecologist’s clinic and he would be surprised if he did not find it as he uses the same equipment for his work. The police forensic department was asked to look for DNA on the equipment from the clinic. DNA was taken from any instruments or equipment with blood on them-even the couches and lab coats were confiscated. The results from the government chemist found that there was no DNA linkage between the fetuses found on the road and any blood specimens from the clinic. The doctor also found that the clinic was duly registered and all staff had proper and up-to-date licenses.

 

The case was eventually ruled as improper [Editor’s note: They were acquitted of all charges]. With that ruling, the attorney general decided not to pursue prosecution due to lack of evidence.

 

Was it horrible being in prison for a year?

 

Yes, it was horrible, but it was worth the sacrifice. I was held at the Kamiti Maximum Prison, which is where the hard-core criminals are remanded. I was confined in a small cell for a whole year. I really felt persecuted, but as I said, it was worth the sacrifice.

 

Why do you say it was worth the sacrifice?

 

My arrest and imprisonment was in the media virtually every day. The publicity was an opening for people to realize the magnitude and consequences of unsafe abortion in Kenya; women were dying in great numbers. Before that, abortion was never spoken of in public. There are only about 250 OB/GYNs in Kenya; some districts have none. The media sensation from this case galvanized the Kenya Obstetrical and Gynaecological Society (KOGS), the National Nurses Association of Kenya, the Federation of Women Lawyers, human rights advocates, women’s rights organizations and many others to form an alliance of reproductive health rights advocates.

 

This alliance exists to date and is known as the Reproductive Health and Rights Alliance (RHRA). The RHRA is an advocacy platform to agitate for the reduction of maternal mortality and morbidity due to unsafe abortion. This alliance also offers technical support to abortion service providers through Reproductive Health Network (RHN). The public became aware of abortion and the toll of unsafe abortion. The window was open to the public to realize the terrible toll of unsafe abortion in Kenya.

 

This debate extended to the drafting of a new Constitution in 2010. The Constitution says that “every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care.” My arrest, imprisonment and [the resulting] publicity generated a public awareness that led to a transformation in the understanding that safe abortion is essential to preventing maternal morbidity and mortality.

 

Is there any further action in your own case?

 

Yes, I have since sued the government for malicious prosecution and subsequent confinement for one year in remand prison. The case has been in court for the last six years without yet being assigned a hearing.

 

What does the expansive definition of health in the new constitution mean in terms of when an abortion is considered legal?

 

Abortion is legal if the pregnancy endangers the life of the woman; as an emergency treatment; or when it endangers health, with health defined broadly: physical, social and mental. If in the opinion of a trained health professional an abortion is provided in good faith (in other words, where the pregnancy jeopardizes the woman’s physical, social or mental health), it is legal. [Editor’s note:Under the new law, a woman can make her abortion decision with one health-care provider; others are not required to be involved or sign off on the decision.]

 

What categories of health-care providers can perform legal abortion?

 

Physicians, nurses, midwives and clinical officers [who have completed training to perform abortion services] can now perform legal abortions.

 

What are the next steps in transforming the policies to establish safe, legal abortion in Kenya?

 

Ipas and other organizations took the lead in writing a document called, “Standards and guidelines for reducing morbidity and mortality from unsafe abortion.” The title is taken from a similar document from Zimbabwe and is brilliant. Kenya, like other countries, wants to achieve the Millennium Development Goal of 75-percent reduction in maternal mortality; this can’t be achieved if safe abortion isn’t available.

 

The other milestone on transformation is the revision of codes of ethics and scope of practice for all the professional associations in Kenya. These have been done and are waiting to be launched.

 

This transformation to legal abortion access in Kenya is a testament to very brave, inspired people dedicated to the common good who have sacrificed a lot. How have all the changes we’ve discussed affected providers of safe abortion and women?

 

Providers are now aware of the enhanced protections that have been offered by the constitution. This in turn has increased access to safe abortion services and thereby enabled women to realize their reproductive health rights. In addition, incidences of provider harassment are now on the decrease.

 

Kenya: Grim statistics of unsafe abortions

www.capitalfm.co.ke/news/2012/07/grim-statistics-of-unsafe-abortions-in-kenya/

Posted by CATHERINE KARONGO on July 25, 2012

NAIROBI, Kenya, Jul 25 – Young girls in Kenya continue to procure unsafe abortions with 16 percent of them involving women below 20 years of age, according to the Reproductive Health and Rights Alliance.

A member of the alliance, Joseph Karanja who is an Associate Professor of Obstetrics and Gynaecology at the University of Nairobi said on Wednesday that women between the ages of 20 and 34 accounted for another 73 percent of abortions in Kenya.

“Low access to contraceptives and contraceptive choices (among the older age group) is leading to many unplanned pregnancies that are resulting in unsafe abortions,” he noted.

In Suba district alone, he said, 80 percent of all unsafe abortions involve girls below the age of 20.

According to the World Health Organisation, unsafe abortion is a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both.

Professor Karanja also said studies had shown that young girls in Kenya were more afraid of carrying a pregnancy to term than contracting sexually transmitted infections like HIV/AIDS.

“When we talk to some of these girls they say with pregnancy, most people disown you including parents and it is seen as shameful but with HIV you get all the support, counselling and even sometimes get advocacy jobs. So they see that with HIV your life goes on but with pregnancy everything stops, including schooling,” he explained.

Statistics indicate that in Kenya 300,000 abortions occur annually and 20,000 of these women end up being hospitalised.

“Most women cite wrong timing as the reason for terminating the pregnancy,” he said.

Karanja added that unsafe abortions contribute to 35 percent of all maternal deaths in Kenya which translates to 2,450 deaths out of the 7,000 that occur annually.

More grim statistics indicate that 40 percent of women who die of abortion in the country are below the age of 20.

He said there is need for the country to have a strong social support system for girls to avoid unsafe abortions and also make available family planning services for those who require them to shun unplanned pregnancies.

Mid this month, Kenya failed to make a specific commitment on the use of Family Planning at a London summit that was attended by major international donors and 69 poor countries even as statistics indicate that 25 percent of married women have unmet need for family planning.

According to the Kenyan constitution, abortion is illegal except where 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 written law.

 

Why Kenyan Women Fear Romney

Will the Republican nominee reinstate the global gag rule on abortion?

Kenya 2012

By Irin Carmon

June 20, 2012

Also published at Salon

As much as reproductive rights were catapulted into major campaign issues this cycle – in the Republican primaries and beyond – one political football has remained unaddressed. That would be the global gag rule, which bars international organizations receiving U.S. funding from providing, referring for or even discussing abortion. It’s been implemented by every Republican president since Reagan and promptly lifted by Clinton and Obama. But reproductive health advocates here in Kenya haven’t stopped worrying.

Rosemarie Muganda-Onyando, a longtime women and adolescent health advocate who now works with the group PATH, put it pretty bluntly.

“We’re not sleeping at night.” She added, “If Mitt Romney did win – oh please do not talk about it.”

During the most recent round of the gag rule, lack of clarity even among advocates created a chilling effect. (Abortion is legal in Kenya in cases of risk to health and life, as well as in cases of sexual violence, though the constitutional provision is still poorly understood.)

“I think people just got really scared,” said Muganda-Onyando. “From our understanding, if you had any work on abortion, whether it was just prevention or education, even if that funding came from somebody else, you couldn’t get any funding at all. Even for a project on agriculture.”

An estimated 30 to 40 percent of maternal deaths in Kenya are attributed to unsafe, illegal abortion. At the same time, the decline in the fertility rate flatlined. There was another complication: “As HIV/AIDS money increased by leaps and bounds, you also did see a substantial decline in support for family planning.”

“We know that a Republican win could reverse some of the gains that have been made because since it was listed, “there’s been an increase in the U.S. government’s investment in family planning,” though another advocate told me that not that much has changed and some international staff don’t seem aware the policy has been lifted. Still, she says, “Right now the U.S. government invests more money in health in the region than any other country,” including healthcare projects like PATH’s, which serve an estimated 8 million people.

“I’m not exaggerating,” she said. “This is a real fear for us.”

 

Kenya: backstreet abortions kill thousands every year

http://af.reuters.com/article/worldNews/idAFTRE79O45K20111025?sp=true

Tue Oct 25, 2011 2:07pm GMT 

By Katy Migiro

NAIROBI, Oct 25 (TrustLaw) – “I was bleeding like hell. I knew that I was going to die,” Emily said, recalling how she sat naked on a plastic basin, haemorrhaging blood for two weeks after paying $10 (6.75 pounds) for an abortion in Nairobi’s Mathare slum.

“It is the most painful thing I have ever experienced in my life. Even giving birth is not as painful as doing abortion.”

One reason the world’s population is soaring — to 7 billion, by U.N. calculations, on October 31 — is because many poor women have little control over their bodies or their fertility.

One place where that is most apparent is in Kenya, where high rates of sexual violence, limited access to family planning and poverty mean 43 per cent of pregnancies are unwanted.

The majority of these women and girls have no choice but to give birth because abortion in most cases is technically illegal, although enforcement of laws around abortion are ambiguous, leading to one standard for the rich and another for the poor and uneducated.

As a result, at least 2,600 Kenyan women die in public hospitals each year after having botched backstreet abortions. Many more die at home without seeking medical care. And another 21,000 are admitted for treatment of abortion-related complications.

When Emily, 28, found out she was pregnant in 2009, her boyfriend denied it was his child and left her. She was jobless and already had a seven-year-old daughter, Ashley, to care for. Emily’s friends advised her to terminate the pregnancy.

“I have seen what my girls have gone through with abortion. I was very afraid,” she said, adding how she found a 20-year-old friend dead alongside a note explaining how she had drunk a bottle of bleach hoping to cause a miscarriage.

After two months debating what to do, Emily borrowed $10 from friends — the equivalent of two months’ rent — and sought treatment from a well-known local abortionist.

The elderly woman inserted a plastic tube into Emily’s vagina and told her to sit for several hours on a bucket until she heard a pop.

“I felt something hot from my stomach coming out. She gave me some medicine and I went home,” Emily said, sitting in a friend’s one-room corrugated iron shack off a muddy alley.

After a week of bleeding, Emily’s friends brought her more medicine from the abortionist but it didn’t help. Eventually, they carried her to a nearby clinic where she was given an injection that stopped the haemorrhaging.

Her ex-boyfriend beat her when he found out about the abortion.

“He told me that I am a murderer, that I killed his baby,” Emily said.

WOMEN DIE IN POLICE CUSTODY

Kenya is a deeply religious Christian country and the church is vocal in its condemnation of abortion.

The implementation of the law, which prohibits abortion except in cases where the mother’s life is in danger, is ambiguous, however.

The penal code says women who abort illegally can be jailed for seven years. But wealthier and more educated women take advantage of “medical guidelines,” which allow terminations in the interests of a woman’s physical or mental health but require the signatures of multiple doctors.

“In Kenya, we don’t know whether to procure an abortion is legal or illegal. We are just in between,” said one doctor who performs abortions.

Public hospitals rarely provide the service but it is easily available in private practices, such as the prestigious Nairobi Hospital where women pay around $1,000 for a termination.

International charity Marie Stopes performs abortions in clinics for $25 to $60, which is still unaffordable for the majority of Kenyans.

“If we were to charge a lower price, we would be overwhelmed,” said a doctor working for Marie Stopes.

NEEDLES AND STICKS

Women and teenage girls who are poor often have no option but to turn to quacks in backstreet hovels.

“They use bicycle spokes, knitting needles … putting sticks, pens through the cervix,” said Joseph Karanja, an obstetrician-gynaecologist who works at Kenyatta National Hospital in Nairobi.

Other painful, often lethal, methods include drinking detergent or overdosing on malaria pills.

The hospital’s acute gynaecology ward receives five women each day seeking post-abortion care. It has 30 beds, sometimes shared between up to 70 women.

Women often delay seeking treatment until they are very sick due to fear, lack of money or emotional turmoil.

“They come at the point of death,” said Karanja, who estimates one or two women die from post-abortion complications at the hospital each month.

“They stay at home scared because they are afraid they will be arrested. So the uterus goes rotting inside. They get a very bad kind of infection called septic shock, where there is tissue damage, kidney damage, and then they finally die.”

Unsafe abortions account for 35 percent of maternal deaths in Kenya, versus the global average of 13 percent.

“We are losing many people through the botched and backstreet abortions,” said the Marie Stopes doctor.

“If we legalise it, we shall find that the number of deaths will go down or maybe there won’t be any deaths at all.”

For Karanja, the problem is the divide between Kenya’s rich and poor.

“The high and mighty don’t have a problem. In those ivory tower hospitals, these services are available as a routine,” he said.

“These services should be provided in all public health facilities because that is where ordinary people go.”

(Editing by Sonya Hepinstall)

 

Kenya: Misoprostol Re-Ignites Abortion Debate

http://allafrica.com/stories/201106140148.html

Business Daily (Nairobi)

13 June 2011

The Kenya Obstetrical and Gynaecological Society has ignited a debate over abortion with its push to have the controversial Misoprostol tablets dispensed to pregnant women with an aim of curbing bleeding after birth.

The director of public health, Dr Shahnaz Shariff, said the drugs would provide an option for treating the bleeding, for which an injectable drug, oxytocin, is the primary mode of treatment.

There have been fears that the tablets would be abused to procure abortion.

“We are yet to establish the facilities where the drug will be rolled out as a back-up treatment. The primary treatment remains oxytocin; there will be no need to dispense it in all the facilities,” he said.

Misoprostol has been in the market for a while and has been used to stop post-birth bleeding and clean the uterus especially where unsafe abortions have taken place. It can also be used to terminate pregnancies.

Some doctors have accused the society of seeking to legalise abortion in the pretext of saving women’s lives. “I can’t imagine a situation where vaginal bleeding is so life-threatening that you can’t make it to the nearest health centre or hospital,” said Dr Caesar Mungatana, a Nakuru-based surgeon. “How much blood does an average healthy human being need to lose before his life is in danger? Perhaps 30 per cent and that can only happen if your blood vessels are cut and in such a situation one is likely to die in 10 or 15 minutes. Bleeding in the womb is as life threatening but some of the gynaecologists are pro-abortion.”

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality. The situation is worse in Kenya where more than half of pregnant women give birth outside health facilities because of inaccessibility of health facilities, cultural beliefs and high cost of health care. The government intends the drug to reach women in areas where oxytocin is not available. Because of its tablet form, misoprostol is easier to administer even for attendants with average skills.

About 8,000 women die in Kenya from pregnancy and child-birth complications every year, a third of them attributed to unsafe abortions. The gynaecological and obstetrics society (KOGS) says the tablet would help contain the increasing maternal deaths in rural areas and slums.

According to Dr Dominic Karanja who chairs the Pharmaceutical Society of Kenya, if the use of the drug is to be adopted, it should be accompanied by relevant training.

“Midwives, especially in rural areas do the work gynaecologists are supposed to do as most of them are found in major towns only. It would be wise to train midwives on how to administer the drug so that it does not have negative impacts on the patient,” he said.

Safe births in Kenya is difficult because of, among others, culture that hinders women from seeking health care during pregnancy and a shortage of trained health workers.

At least 105,000 community health workers are needed to attend to more than half of children and mothers who cannot access a health facility at a radius of five kilometres.

An associate professor of obstetrics and gynaecology at the University of Nairobi Joseph Karanja says the drugs will save thousands of pregnant women in remote and areas who die due to lack of doctors and health facilities.

“In some parts like North Eastern we have less than 10 doctors and yet we have a dozen midwives spread all over who could be trained on how to administer the drugs,” he said.

While the debate on the adoption of Misoprostol rages, controlling unwanted pregnancies would reduce demand for unsafe abortion, other doctors say. “The government needs to urgently revive the family planning services to stem the upsurge of unwanted pregnancies that leads to abortions,” said Dr Hillary Mabeya, a lecturer at the Moi University School of Medicine.