By Zofeen Ebrahim Reprint |    

KARACHI, Sep 12 2012 (IPS) – “I can’t imagine life without misoprostol,” says Dr. Azra Ahsan, a gynaecologist and obstetrician who has, for more than a decade, been using the controversial drug to stop women from bleeding to death after delivery.

Originally intended for treating gastric ulcers misoprostol has since 2000 been gaining in popularity for its ability to induce labour and stop post partum haemorrhage (PPH).

“I knew that it can save women from dying long before 2009 when it was registered for use in Pakistan,” said Ahsan, a member of the government’s National Commission on Maternal and Neonatal Health.

WHO guidelines advocate the use of misoprostol against PPH, while the International Federation of Gynaecology and Obstetrics (FIGO) suggests using the drug in situations where regular ‘uterotonic’ drugs like oxytocin and ergometrine are not available.

Doctors like Ahsan are dismayed at moves to get WHO to reverse its listing in April 2011 of misoprostol among essential medicines that “satisfy the healthcare needs of the majority of the population” and are  “available at all times in adequate amounts and in appropriate dosage forms, at a price the community can afford.”

Findings of scientific studies published in the August issue of the Journal of the Royal Society of Medicine are being cited in suggesting that WHO should “rethink its recent decision to include misoprostol on the essential medicines list.”

Allyson Pollock, who led the study, stated that there is insufficient evidence to suggest that misoprostol works in preventing PPH. Instead, she urges poor countries to improve primary care and prevent anaemia to lower the risk of haemorrhage following delivery.

Ahsan, however, says that in Pakistan some 80 percent of pregnancy cases end up with the mother’s uterus failing to contract naturally after delivery, calling for the use of uterotonic medicines to reduce bleeding.

“Nearly 27 percent of maternal deaths in Pakistan are caused by excessive blood loss after childbirth,” Ahsan explained to IPS.

According to the latest Pakistan Demographic and Health Survey (2006), Pakistan’s maternal mortality ratio stands at 276 for every 100,000 live births, and is among the highest in South Asia.

Bleeding, the leading cause of maternal deaths worldwide, is defined by the WHO as blood loss greater than 500 ml following a delivery.

The fact that misoprostol is also misused in Pakistan – and other developing countries like Brazil – to induce abortion cheaply, has added to controversies over the drug.

“I don’t care if people think it is used, misused or even abused…I know it saves mothers from dying,” says Ahsan.

Unlike other uterotonics, misoprostol has the advantage that it does not need refrigeration for storage and can be easily administered orally by trained birth attendants, Ahsan said.

A joint statement by FIGO and the International Confederation of Midwives states: “… in home births without a skilled attendant, misoprostol may be the only technology available to control PPH.”

Zulfiqar Bhutta, head of women and child health at the Aga Khan University, Karachi, and member of the independent expert review group for maternal and child health to the United Nations secretary-general, agrees with Pollock that misoprostol needs to be evaluated more robustly.

“But I wouldn’t throw out the baby with the bath water yet,” Bhutta told IPS. “There is a need to increase its use in the right circumstances and also carefully monitor misuse. It is no magic bullet and should not lead to complacency in provision of essential maternal services,” he said.

“I think the point of the paper published recently is to try and separate  science from messianic zeal,” says Bhutta who is also co-chair of ‘Countdown to 2015’, a global scientific and advocacy group tracking progress towards the U.N. Millennium Development Goal Five pertaining to maternal health.

“Misoprostol is promising and we should do our best to evaluate its safe use,” said Bhutta. “But, there are people in Pakistan who are recommending large scale distribution to families for use in all births. Will this be cost-effective or indeed safe?”

Pollock’s study has stirred international concern. International Planned Parenthood Federation’s Upeka de Silva told IPS in an e-mail that if WHO withdraws misoprostol, it would mean “countless women will be denied life-saving care and forced to suffer pregnancy-related complications which are entirely preventable.”

“We are fully aware that all studies have limitations and that continued research on best practices for maternal care is needed,” de Silva said.

“However, for the purposes of meeting the urgent needs of women, particularly in rural, underserved communities, we are confident about being guided by the abundant literature and expert evidence supporting the safety and effectiveness of misoprostol for multiple reproductive health indications,” de Silva said.

Further, she said: “The increasing number of clients provided with safe abortion services, treatment for incomplete abortion and PPH through clinics run by our member associations is further evidence that misoprostol should remain available and accessible.”

“It’s alright to stir confusion sitting in cushy offices, but the ground reality in Pakistan is quite different,” said Ahsan. “The conditions we work under are very, very constrained…let’s not forget the hot temperatures and long power outages (causing refrigeration failure).”



by Stratos Moraitis | July 16, 2012


The Globe Times/Advocating Human Rights


Pursuant to a month of heated discussions, Turkish government stated that they will not amend the existing laws on abortion in Turkey and restricted their changes to the subject of making caesar sections more difficult to implement. Social media whirled about a few days, press immediately forgot about the issue, but the snake never slept.


Since the debate was bipartisan and centered around the poles of who said what and belonged to which group, a subject so complicated and without a widespread consensus ended up being imprisoned within the walls of daily agenda. No real public discussion was enabled; the opinion makers yelled and gagged and powers to be let it go on while preparing for their real scheme.


Since the leader of the governing party made it clear that their “religious and vindictive” new youth should increase in numbers, abortions and family planning should be abolished. This author is fully aware of the fact that his rhetoric is exactly that and nothing more. But in reality AKP government and the state machinery need ignorant, scarcely educated majority to increase as a percentage of total population to guarantee their political and social existence. Since level of education and economical wealth has an inverse relationship with the number of kids in households, their “3 children minimum for each family” motto will evidently succeed only in undereducated and ill-informed population, increasing their vast numbers even more.


So while arguing publicly that the government has no immediate plans to ban abortion, Ministry of Health banned all drugs containing misoprostolused in medical abortion on July 9th with instructions by Turkish Medicine Informations Network. World Health Organisation declares that misoprostol can be used safely to induce an abortion up to nine weeks of pregnancy and places the substance on the List of Essential Medicines. In Turkish pharmacies medicine containing the banned substance-misoprostol; Arthrotec (used in osteoarthritis and rheumatoid arthritis treatment) and Cytotec (used in peptic ulcer and Gastroesophageal reflux disease treatment) are banned now. Turkish government is simply preventing ulcer and arthritis patients’ access to affordable treatment with no literature or explanation behind their decision to prevent medical abortions. No other drugs enabling medical abortions that contain Misoprostol or Mifepristone are available in Turkey.


Public fury started after Turkish Prime Minister’s mention that abortion is an equivalent of mass murder in a public speech. Turkey experienced historically very high death rates in pregnant women prior to the legalization of abortion in the early eighties. However, being a country with feudal traditions death rates among young women due to family feuds and sexual issues are still relatively high. With the influence of the rise of conservative values in the society death rates among women increased 1400% during the last seven years according to the Justice Department. Women’s Rights is a severe issue in Turkish society where women even when they are economically independent, are frequently abused by men due to the social and traditional factors. Even according to the existing abortion law, the right to undergo the operation is dependent on husband or father’s approval.


In Turkish politics devil is always hidden in detail. Rhetoric and reality does not usually match. The love story between engineering of the society and the ruling elite does not seem to fade away any time soon. While managing the public euphoria and the demands of society at large, the officials follow an unwritten strategy of oppression based on the changing needs of time. As we go through the commercialization of everyday life in Turkey with increasing number of shopping malls and conservatism on the rise, it has been the management strategy of the new elite to blackmail the society with economic growth: “obey, become one of as and prosper.” This strategy helped limit the fight for human rights to ethnic and religious minorities that refuse to join conservative ranks.


And with new pressures applied on freedom of women, religious, ethic or sexual minorities everyday, another “modern” era of assimilation is underway.


The state as a supplier of amenities decides who shall receive the charity and who is to be shunned. In a country which calls itself a democracy that is unthinkable. But then again, when you have a closer look, and feel how the Sunni Muslim elite takes on daily issues, the devil’s shining golden teeth grins between each golden ornament in the framework.

With gratitude to Duygu Kara and Rebecca Gomperts for their insight.

Unspoken Violence on Abortion, a Case Study of Indonesia

by Samsara YK on Friday, June 15, 2012 at 3:43am ·

By : Inna Hudaya & Zulkamal Hidaayat Zakaria



Most people in Indonesia has been viewing abortion as an immoral action because it against the positive norms of society. As some countries did, Indonesia preserves cultural and religious based principles which support a banning on abortion. For sure, abortion is illegal in Indonesia. Unfortunately, the government seems unaware of the side effect of such policy and fails to communicate majority and minority interests which are involved. Majority is people who support government policy on banning abortion and minority is people who against government policy on banning abortion. In this setting, the government and society also failed to identify women as a victim of the government policy. This policy has disposed women who commit abortion as criminals. Those women have been dealing with people who can’t accept abortion although it is associated with women authority over their body and future. As a result, women are more vulnerable to violence because the policy has labeled women who commit abortion as criminal instead of victim.


Criminalization of Abortion

The important point in understanding abortion issue in Indonesia is to recognize that it is illegal but it can be done for some specific reasons. Abortion is illegal but it can be done if the pregnancy will jeopardize the mother or fetus and if the pregnancy is caused by rape. This abortion can be taken before the gestational age of six weeks unless to save mother’s life. Even if it is possible to have an abortion until 6 weeks of gestational age, women still do not have authority over their own decision. For instance, married woman needs consent from her husband and unmarried woman needs a parental consent. In case of rape, the parental consent needs to be given with the approval statement from psychologist or psychiatrist.


Based on the Health National Law No 36/2009, the penalties were 10 years imprisonment or a fine of 1 billion IDR for anyone who had induced abortion. In fact, due to the restricted access on sex education, reproductive health and health service especially contraception, women are more vulnerable to unwanted pregnancy that leads to the need of safe abortion.


Women who are young, unmarried, less educated, poor and living in rural area, are the most vulnerable groups and severely affected while dealing with unplanned pregnancy. At this point, unsafe abortion is the available and accessible option for them. On the other hand, the criminalization of abortion did not impact only on the number of unsafe abortion and maternal mortality but it had created many kinds of violence toward women’s rights. This policy has provided an open chance for industry of abortion to develop. Most of abortion clinics in such industry are illegal, especially in Java Island. Those clinics provide abortion services for women without the considering the rights of patients. Women were taking for granted in this situation. Moreover, many drug dealers used to cheat on women who could not report it to the police because abortion is illegal. Frankly, the circumstance has been creating many forms of violence and problem toward the issue of abortion to grow.


Based on the facts above, criminalization of abortion is violation against women rights instead of solution. The government policy was not only possessing women as an object of violence but it was also letting people to take advantage on the situation of women itself. It is hypocrisy of nation who they believe that abortion is sin and create other forms of sin which is violating women rights.


Criminalization of abortion is not a proper way to reduce the number of abortion. On the contrary, this policy made violence toward women remain unspoken. The only way to reduce the number of abortion is by giving sex education and reproductive health and an open access to health services so women will have a control over their sexual and reproductive life that will protect them from unwanted pregnancy.


SAMSARA Project for Change: Reclaiming Access to Safe Abortion

While the government and society failed to identify women as victim from the ongoing policy, women died and suffered from complications caused by unsafe abortion. There’s no time to wait any longer for the government to take action in saving women’s live. Saving the life of women doesn’t always mean to save women from severe complications, traumas, depressions and maternal deaths. Life also means the quality of women’s living condition which includes access to education, health, economy and bargaining position. Based on the situation in Indonesia, the most important thing is a real programs and strategies that will help women to access safe abortion services and create a supportive network in society to reduce stigma and discrimination. In the future, the social changes are expected to decriminalize abortion in Indonesia.


SAMSARA, an organization based in Yogyakarta has been working to promote the reproductive health, sexuality, gender, spirituality, culture and human rights on abortion issues. SAMSARA also provides access to education, information and counseling on abortion based on sexuality and reproductive health and rights. Through its work, SAMSARA has found an urgent need to inform and empower women so they have sufficient knowledge and support to choose and access a safe abortion. We believe that changes are indisputably needed, not only by supporting and empowering the women but also taking a pro active part in providing education to people; influencing social movements; expanding discourses and strengthening a supportive network.


Since 2008, we started a program called Safe Abortion Hotline where we assist women in making decision and finding a safe clinic for abortion. Actually, women should find the clinic of abortion by themselves. Our main job in this program is to provide advice to women to recognize a reliable abortion clinic, affordable, meets the medical standard and avoid them getting deceived by service provider. Mostly, women have to go through the process by themselves without any companion. In this situation, the hotline is available to assist women in the process.



In 2011, we integrated a Medical Abortion into the hotline program. The hotline promotes the use of Misoprostol which is one of recognized method in medical abortion as an alternative option for safe abortion until 9 weeks pregnancy. Hotline is assisting women in making decision, provide information and open access to safe abortion. In this hotline program, women need to confirm their decision before the hotline counselors refer them to service provider or assist them to have abortion at home. It is necessary to ensure that abortion is the decision of the women, not the decision of her partner or family.


If the women can access clinic, hotline will refer women to have surgical abortion. But most women can’t access a clinic because of the distance and price. Most women choose medical abortion. Once women get the pills, a counselor will be available by phone to assist women when women have abortion at home. Usually counselor will ask women to make notes about the process so all information will be helpful for following up the consultation process. Follow up consultation is needed to ensure that the abortion is completed. Hotline also works on the improvement of its service to help women in every step so they won’t face abortion by themselves when it is being taken.


Between May 2011 to May 2012 we received 1.425 calls, emails and face to face session. 71,1 % of the clients are unmarried women. SAMSARA considers Medical Abortion as an ultimate option for safe abortion in a restricted setting like Indonesia. Medical Abortion is not only cheaper, but it also protects the privacy of the women, gives full control and authority to the women and encourages women to focus and care over their body.


Safe Abortion Hotline is an action in reclaiming access to safe abortion. Since our government failed in respect, fulfill and protect women life, it is a time for civil society to act. The absence of real actions to change the circumstance will remain the unending violence on abortion for women. We can’t rely on government to saves women in crisis. Only by listening, supporting and working together, with or without government assistance, we can save women life. The choice is ours, whether to let the unspoken violence to continue or to change the unjust to a just world.

August 2, 2011, 5:53 pm 

by Ramya Kumar
The absence of safe abortion services in the public sector has obvious implications for both gender and class. First abortion, a health service required only by women, continues to be criminalized and second “safe” abortion services are currently only accessible to women who can afford them in the private sector. With the clamp down on Marie Stopes clinics that had provided abortion services at relatively low cost for more than 20 years, medical abortion has become an alternative that women in Sri Lanka have begun to explore. The drugs used for medical abortion, mifepristone and misoprostol, are reportedly available in private hospitals and pharmacies across the country at exorbitant prices. Both of them are currently unregistered for use in Sri Lanka although misoprostol was recently considered for registration. Their use in Sri Lanka is therefore technically illegal. Further, since Article 303 of the Penal Code states that abortion is permitted only to save a woman’s life, the use of these drugs for medical abortion (except to save a woman’s life) is unlawful in Sri Lanka. Why are these drugs not registered although widely available? And why is there no public debate on abortion law reform in Sri Lanka today?
Swarna: a forgotten statistic
The case of a woman, who I will call Swarna, illustrates some of the social problems associated with unsafe abortion. Swarna was admitted to the Surgical Intensive Care Unit (SICU) of a provincial hospital where I worked as a medical officer. Swarna, a resident of the Uva province, had three children, was poor and could neither read nor write. She had been transferred from a base hospital where she was suspected to have had a reaction to blood transfusion. While family planning services were provided free of charge through the public sector to Swarna, her social situation made her vulnerable to an unintended pregnancy. Criminalized abortion and the fear of law enforcement prevented Swarna from accessing post-abortion care until she was very ill and when she did she strongly denied having had any such intervention. The consultant obstetrician who had seen a similar clinical picture in other women who were admitted after unsafe abortion, decided Swarna should undergo a lifesaving surgical procedure in spite of her denying that she had had an induced abortion. Swarna remained in the SICU for two weeks with multi-organ failure and was lucky to have survived. Swarna and other such women who face the consequences of unsafe abortion are not included in the tally of deaths from unsafe abortion because they survive. When we talk about low mortality from unsafe abortion in Sri Lanka, the stories of Swarna and many others like her are overlooked or forgotten.
Global abortion politics
Abortion is a contentious issue globally. Intergovernmental organizations like the United Nations and the World Health Organization (WHO) are restricted in their dealings with the issue due to strong pro-life lobbies in powerful countries like the United States that impose funding restrictions on providing abortion services. The International Conference on Population and Development Programme of Action (1994) that was endorsed by Sri Lanka and many other countries incorporated a rights perspective on population issues including reproductive health. Although it was considered a watershed for reproductive rights, this document did not address abortion in any significant way. While its focus is on the prevention of unintended pregnancies and implementation of post-abortion care, it states that safe abortion services should be provided in countries where abortion is not against the law. This leaves women in countries like Sri Lanka, where abortion laws are very restrictive, with limited options.
Situation in Sri Lanka
Sri Lanka is doing extremely well in terms of maternal health. We have been able to achieve reductions in maternal mortality without addressing unsafe abortion. In fact our maternal mortality rate is the lowest in the South Asian region. Research shows that there is a high prevalence of abortion (a 1998 estimate suggests 650 abortions per day) and that most women resort to abortion to limit or space their families. In 2006, unsafe abortion became the second highest cause of maternal mortality in the country. While unsafe abortion was identified to be a problem on a review on maternal mortality published by the Ministry of Healthcare and Nutrition in 2009, the strategies they recommended included improving access to family planning and improving post-abortion care. There was no recommended strategy for abortion law reform. It is perhaps surprising that a government that shows much commitment to providing healthcare would leave unsafe abortion off the health agenda. Why does abortion law reform remain on the backburner? And could the potential use of misoprostol for medical abortion have influenced the recent decision on misoprostol registration?
Medical abortion and misoprostol
The WHO recommended regime for medical abortion includes two medications: mifepristone and misoprostol. While the combined regime has a success rate of over 95% in the first 9 weeks of gestation, misoprostol has been used alone for medical abortion in many settings with success rates roughly between 85 and 90%. Although less effective, it is used alone for medical abortion because it is cheaper and also because in many countries misoprostol is registered and freely available while mifepristone is not. The WHO does not recommend misoprostol alone regimens for medical abortion claiming the evidence for such a recommendation is inadequate.
Misoprostol is listed in the WHO Essential Medicines List (EML) for many indications. In 2005, misoprostol was listed for labour induction and with mifepristone for medical abortion, where legal and culturally acceptable (other drugs on the WHO EML do not include notes on cultural acceptability). In 2009, the EML listed misoprostol for incomplete abortion and this year in May for post-partum hemorrhage. Since misoprostol was initially developed for the treatment and prevention of gastric ulcers in 1988, it had been registered without controversy in many countries before its use for medical abortion was discovered. Therefore, today it is widely used by women for abortion in countries where it is registered but abortion laws restrictive. Such use without access to information could result in incorrect dosing with adverse consequences such as increasing rates of incomplete abortion and the occurrence of birth defects in fetuses that are not aborted.
Registration of misoprostol in Sri Lanka
Why was misoprostol, a drug with several obstetric indications, not registered in Sri Lanka? In my study, I focused on the misoprostol policy because it is the only policy related to abortion currently under review. Ten medically qualified experts engaged in women’s health policymaking and four women’s rights advocates with expertise in the social sciences and law were interviewed for this study.
Misoprostol (and mifepristone) is available although unregistered in Sri Lanka and is being widely used in the private sector. An application to register misoprostol was submitted to the National Drug Regulatory Authority (NDRA) by a pharmaceutical company in 2010. The decision to approve a drug for registration lies with the Drugs Evaluation Subcommittee of the National Drug Regulation Authority (NDRA) which consists of medical specialists from various fields and pharmacists. The misoprostol situation was described by one participant to be “tricky” because obstetricians have access to the drug through representatives of pharmaceutical companies who supply the drug to them directly. The drug is also believed to be smuggled into the country from India and Pakistan in “suitcases”. The NDRA wished to register the drug for regulatory purposes and quality assurance because it was known to be widely available in the country. The obstetricians probably wanted it registered so that they could use it legally in their obstetric practice.
The NDRA sought the opinion of the Sri Lanka College of Obstetricians and Gynaecologists (SLCOG) on registering misoprostol due to a conflict of opinion within the Drugs Evaluation Subcommittee. In November 2010, the SLCOG recommended misoprostol be registered with restrictions to be used only in the public sector. However, when the Drugs Evaluation Subcommittee met a month later, they could not reach a consensus on registration due to opposition from within the subcommittee. While complications of misoprostol (specifically maternal deaths from using misoprostol for labour induction) had been discussed at the meeting, the potential for using misoprostol for medical abortion had not come up for discussion. Eventually it was decided to keep the decision pending and the decision is still pending today.
Implications on health policymaking
The policy decision on misoprostol appears to have been a result of an undemocratic process based on obscure social values held by a few members of the Drugs Evaluation Subcommittee at the NDRA. Under these circumstances, it seems unlikely that misoprostol will be registered anytime soon.
It would be unfair to say that this policy making process exemplifies health policymaking in general in Sri Lanka. The controversial nature of this drug is likely to have influenced the process. But note that this was a closed process with little input from nonmedical experts. Even the recommendation of the SLCOG, the professional body of obstetricians and gynaecologists in the country, was overlooked. There was no contribution from women’s advocacy groups to the decision making process. Many policymakers in the sample believed that the policy decision on misoprostol was influenced by its possible use for medical abortion.
I would argue that the reason misoprostol registration became controversial in Sri Lanka was because both the NDRA and the SLCOG wished to register the drug for different reasons. Health policymaking is controlled by the Ministry of Health; the public has little access to information on who and how these decisions are made.
Implications for abortion policy
The Ministry of Health’s strategy to address unsafe abortion focuses on preventing unintended pregnancies and providing post-abortion care (PAC). Arguably, this narrow focus may be justified given the restrictive abortion legislation in Sri Lanka. Under these circumstances, one would expect a dynamic family planning programme and accessible sexual and reproductive health education and services. One would also anticipate the institution of effective PAC. However there is no evidence to show that this is happening.
Participants expressed concerns about contraceptive services targeting only married women and the absence of a state sponsored comprehensive sexual and reproductive health education program for adolescents. There is in fact a complete silence on sexual health in existing policy documents. Further, participants expressed concerns about the inadequacy of existing PAC services and the stigma and discrimination experienced by women who seek PAC. The interviews also demonstrated gaps in research on unsafe abortion, specifically current prevalence and groups most vulnerable to the problem. Significantly, Ministry of Health has not taken an official position on the need for abortion law reform in their policy documents. To compound the situation, in 2007 the government closed down clinics that were providing abortion services or “menstrual regulation” to a less well-off clientele while turning a blind eye on less affordable abortion services provided in private hospitals. All this suggests that addressing unsafe abortion even within the existing legal framework has not been prioritized in state policy. Addressing issues of health equity and gender/class based discrimination are clearly not on the health agenda.
Given this situation, leaving unsafe abortion to be addressed as a policy level debate restricted to the Ministry of Health is unlikely to be effective. The issue of unsafe abortion will not be addressed unless the debate becomes far more broad based than it is now. We need to advocate abortion law reform and the registration of abortion medicines now instead of reinforcing the silence by pretending that abortion does not take place in Sri Lanka. In reality women will access abortion services if they need them whether we like it or not. Decriminalization and registration will only make existing services cheaper and safer.
Ramya Kumar, MBBS is a graduate student in Public Health. This article is based on a presentation she made at the International Centre for Ethnic Studies, Colombo on July 13, 2011.

Aware Girls was trained by Women on Waves/Women on Web and has launched a safe abortion hotline in Pakistan    

by Nondo E. Ejano, Women Promotion Centre; Kigoma

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative in all Africa and in Tanzania particularly. As with other more visible global-health issues, this scourge threatens women throughout Tanzania.

The annual number of induced abortions in Africa rose between 1995 and 2003, from 5.0 million to 5.6 million. In 2003, most of the abortions occurred in Eastern Africa (2.3 million), Western Africa (1.5 million) and Northern Africa (1.0 million). In Eastern Africa the rate was 39 abortions per 1,000 women aged 15-44 and in Tanzania abortion complications contributed 18% of maternal deaths in 2008 (The National Road Map Strategic Plan To Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania, April 2008).

Unfortunately, unsafe induced abortion is one of the most neglected and “unspoken” problem, a taboo and difficult topic of health care in Tanzania as in many places of developing countries (WHO 2004). Women that have or need abortions often think they are an exceptions, they are in shame, are scared and do not speak following the existing restrictive abortion law and religious fundamentalism. This make hard to know the magnitude of the problem as in such a setting it is difficult to get reliable information about the proportion of alleged miscarriage due to unsafe induced abortions.

In Tanzania, induced abortion is only legally available if the pregnancy is a threat to the woman’s life (The World’s Abortion Laws 2008). Consequently, women who want to terminate an unwanted pregnancy have to resort to illegal interventions and thereby put their lives and health at risk.

The problem of unsafe induced abortion is reflected in hospital statistics, which show significant numbers of alleged miscarriage. For instance, in hospitals in Zanzibar, in Mwanza Region and in Kagera Region, abortion complications are listed as number 2–4 on the hospitals’ top 10 admission causes, only exceeded by malaria, acute respiratory infections and anaemia (The Tanzanian Health Management Information System 2006). Yet hospitals often see the ghastly results of botched abortions by untrained practitioners. “Very sharp objects are inserted into the vagina to disturb the pregnancy,” said John Bosco Baso, a spokesman for Marie Stopes Tanzania, which runs a network of health clinics here. “The women get infections, they get fever, and some die. Many of them hide it. We only see them at the critical stage, when there’s infection.”

However evidence points in the direction that the majority of the women are admitted because of complications after an unsafe induced abortion (Rasch et al. 2000, 2004; Singh et al. 2005) and many women in rural Tanzania have testified to know one, two or more of their relatives who died attempting to induce an unsafe abortion (WPC survey, 2009).

This proves that the lack of access to safe abortions, does not make women not to seek abortions, it just forces women to take risk and try unsafe methods – “they go to people without medical knowledge, they punch their bellies, they insert sharp objects in the uterus. This is a reality that we know of, many of us have heard those stories; some of us lost friends or family to unsafe abortion. Women die because of those unsafe practices” testified a woman leader in rural Tanzania.

What should be done in this country?

• Legalizing abortion would be a simple way to access safe abortion methods which is absolutely necessary to prevent women from dying and from suffering the long term health complications. This is a matter of social justice and would open space to talk about this community issue.

• Introducing Misoprostol (already introduced by the Ifakara Health Institute at ANC visits in four districts – Kigoma, Kilombero, Rufiji and Ulanga -) as a component of a Comprehensive Abortion Care (CAC) at multiple levels of health system including village-level health post should be seen as a strategy to prevent these unnecessary deaths of women.

• Educate people and disseminate information on medical abortion with misoprostol should gives them the possibility to take informed decision about abortion with the little risk on their lives and health.

• Increased accessibility, availability and affordability of this life-saving pill (Misoprostol) should help to most rural women prevent themselves from unsafe abortion as the country is still facing shortage of skilled health professionals.

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.