Publish Date: Sep 10, 2012


The demand for abortion in Uganda is high, despite legal and moral proscription. John Semakula explores how a mere policy can bring great cost and pain to citizens.


Abortion is illegal in Uganda. According to the Penal Code, a doctor who thinks that an abortion is justified to save the life of the mother, must write to the director general of medical services in the health ministry, seeking approval to terminate the pregnancy. Upon receipt of the letter, the director general is supposed to convene a medical board, composed of experts, to scrutinise the case and, if satisfied, appoint a specialist to carry out the procedure.


But this is absurd, because there is never time for this red tape in times of emergencies. And, according to an official of the Uganda Medical and Dental Practitioners’ Council, there is no recorded case that has ever followed this procedure.


The code prescribes a prison sentence, ranging from three to 14 years, for procuring, assisting or supplying drugs to aid abortion.


All religions and cultures in Uganda preach against abortion and anyone associated with it is considered a social outcast. But, instead of purging it from Ugandan society, it is swept underground, where it sprouts into tremendous cost to society.


Abortion seekers usually go to illegal clinics, where procedures are performed under unhygienic conditions by under-trained practitioners. Such procedures usually lead to a high rate of death and severe complications, leading to diversion of substantial, scarce healthcare resources.


The problem

Research by the Guttmacher Institute, a US-based non-governmental organisation which promotes reproductive health including abortion rights, released at Grand Imperial Hotel in Kampala recently, shows that over 5% of Ugandan women aged 15 to 49, perform unsafe abortions every year. Almost half of these abortions are administered by non-professionals like pharmacists, traditional healers and women themselves, which poses a great risk to their lives.


According to Prof. Joseph Babugumira of the University of Washington, who carried out  research on induced abortions in Uganda, the problem is the fact that abortion is illegal.


Illegally performed abortions are unsafe, he said, and pose a large health risk to women because of inadequate skills of the providers, unhygienic conditions and hazardous techniques. “These increase the rate of immediate complications, such as severe bleeding, abdominal and genital injury or death,” he wrote in his 2011 report.


“If women survive the procedure, they may develop complications, most commonly haemorrhage, sepsis and genital perforation. Such complications need complex tertiary care, which is only available at referral hospitals with the capacity to perform extensive surgical operations, blood transfusion and intensive care. Patients with such complications tend to have long hospital stays, with 57% staying for more than 13 days.”


He adds: “This results into consumption of large amounts of healthcare resources, such as personnel, theatre space, medications and hospital beds. Some of the women who survive their hospital stay also suffer long-term complications such as pelvic infection, ectopic pregnancy, vesico-vaginal fistulae, urinary incontinence, utero-vaginal prolapse, infertility, and mental health problems.


“These complications usually require specialist care and are associated with increased health resource utilisation.”

Babugumira adds that because abortion is illegal, the majority of trained and untrained providers choose surgical techniques such as evacuation and manual vacuum aspiration to terminate pregnancies.


“Drugs like misoprostol and mifepristone, are the safest form of medical abortion. But they cannot be openly imported and have to be smuggled into the country at a higher cost,” he says.


Cost of abortions

Babugumira used computer projection to estimate the annual cost of induced abortions in Uganda and came up with about $64m (sh160b).


He divided this into societal and healthcare costs. Societal costs include productivity costs (52%) — death of young mothers, loss of labour to sick hours and attendants. Healthcare costs (48%) include direct medical and direct non-medical.


The average societal cost per induced abortion was at $177 (sh442,500). Of this, the average direct medical cost was $65 (sh162,500), while the average direct non-medical cost was $19 (sh47,500).


The average indirect cost was $92 (sh230,000). Patients incurred $62 (sh155,000) on average, while government incurred $14 (sh35,000).


In a country where total per capital health expenditure is only $44 (sh110,000), these costs represent a substantial diversion of public healthcare resources, which, if saved, could be better deployed.


Yet, Government, which should be responsible for providing healthcare, incurs only 17% of the total costs, with the bulk of the total healthcare costs (83%) incurred by patients and their families. That, he concluded, may be the reason for the policy-maker apathy that characterises efforts to reduce unsafe abortions in Uganda.


Doctors’ efforts

Last month, the Association of Uganda Women Medical Doctors (AUWMD) organised a three-day workshop at Makerere, where they discussed abortions vis-a-vis the present legal framework.


Stephen Sserumaga, a coordinator with the Uganda Youth Empowerment Scheme, Kawempe, explained how the youth resort to abortion for fear of financial implications, stigma, expulsion from school and health problems like HIV.

Prof. Florence Mirembe of Mulago Hospital said abortion-related complications were some of the leading causes of admissions to the gynaecological wards in hospitals countrywide.


Mirembe, who is also an associate professor at Makerere University, said Uganda spends about sh7.5b a year treating complications resulting from unsafe abortion.


The situation in other countries

In England, a doctor who refuses to carry out an abortion on the basis of religious convictions is guilty of manslaughter, if the woman dies.


In many African countries, the colonial laws on abortion have been revised in response to the increasing calls for respect of women’s health rights. In Ghana, Ethiopia, South Africa, Benin and Chad, laws regarding abortion have been liberalised.


In 2004, Ethiopia changed the law on abortion to allow termination of pregnancy, resulting from rape or incest, where the foetus has an incurable or serious deformity, or where the pregnant woman, owing to a physical or mental deficiency, is unfit to raise the child.


In South Africa, the Choice of Termination of Pregnancy Act allows a woman to get an abortion on request during the first trimester of a pregnancy (first 12 weeks).


In Ghana and Botswana, the law allows abortion to be carried out if the pregnancy involves risk to the life of the mother, or injury to her physical or mental health.

Abortion illegal in Uganda

While the debate on legalising abortion has lingered on, the proposal is opposed by many Ugandans.  Most arguments are based on religious, cultural and moral grounds.


On religious grounds, the right of the unborn child to live is equivalent to that of the mother. Traditionalists favour large families, while moralists refer to abortion as murder.


But women activists are demanding the expansion of grounds upon which abortion can be made legal, to include incest and rape.


Way forward

The annual abortion expenditure in Uganda is a testament to the economic impact of abortion in countries where it is illegal. Uganda has an obligation to improve maternal health as dictated by the Millennium Development Goal number 5. This must include unsafe abortions by increasing contraceptive coverage or providing safe, legal abortions.


The AUWMD meeting made the following recommendations:


Increase access to reproductive health information with a focus on the youth and adolescents (bodaboda, market vendors, footballers and fans, students and pupils)


Increase access to contraceptive commodities (condoms, morning after pill, hormonal methods, etc)


Build capacity by providing up-to-date legal and medical information to health workers on abortions.


Conduct more formative research on abortion to inform policy-makers at the national and regional levels.


Revising the laws on abortion to ensure safe abortion.


Babugumira appealed to policy-makers like parliamentarians and health planners to find ways of dealing with the high levels of unsafe abortion and low levels of contraceptive use in Uganda to reduce death and diseases associated with unsafe abortions.


He advised the Government and donor agencies to increase resources to programmes which aim at sensitising women and improving post-abortion care.



Real life experiences

Madina died while trying to abort

Madina’s sudden death is something her family will never easily forget. She died while attempting to abort.

She said she was advised to do it by a colleague, whom she told about her pregnancy.


Madina was in high school when she got pregnant. She chose to abort for fear of what her strict parents would do. Her lover also encouraged her to abort because he could not take care of the baby.


On the fateful day, Madina waited for everyone in the house to sleep, before taking a concoction of Jik and black tea. Her parents were awoken by her groaning as she writhed in pain. She died on her way to hospital.


Madina’s mother has never stopped blaming herself for her daughter’s death. She says she should have talked to her about the dangers of early sex, including pregnancy and abortion.


Joan survived, but was sent away from home

Joan was at university when she became pregnant. Her boyfriend accused her of being careless and cut off communication.


Frustrated, Joan resorted to abortion. She feared that if her uncle, a religious leader, found out that she was pregnant, he would be disappointed. She also feared that pregnancy would affect her health, since she was HIV-positive.


At nine weeks, Joan went to a clinic in one of the city suburbs and paid sh70,000 for an abortion. Joan was writhing in pain and bleeding severely, after a clinic attendant had conducted a procedure on her. She ended up in Mulago Hospital, where she was hospitalised.


Her uncle learnt about the incident and sent her away from home.


Amanda dropped out of school after abortion

Amanda was made pregnant by her paternal uncle in 2004, and when she revealed this to her relatives, she was scorned for bringing a curse to her family.


Overwhelmed by shame, Amanda decided to abort. Her uncle provided her with sh30,000, which she paid to a herbalist, who gave her a local herb to take.


Unfortunately, the abortion was not successful and Amanda had to be hospitalised for the foetus to be removed.

Although Amanda had just completed Senior Four, her parents refused to take her back to school.


These are some of the stories women narrated to researchers in a study carried out in July last year. The research, conducted by Associate Professor Christopher Mbazira of Makerere University’s law department, shows how society’s intolerance has worsened women’s pregnancy challenges.




The number of women who get pregnant by accident every year. About 38% of these pregnancies result into abortions



The estimated number of induced abortions in Uganda in 2009. This was up from 297,000 in 2003



The number of maternal deaths caused by unsafe abortions in Uganda, compared to about 13% of all maternal deaths globally

geoffrey york

KAMPALA— From Monday’s Globe and Mail
Published Sunday, Nov. 06, 2011 9:16PM EST
Last updated Sunday, Nov. 06, 2011 9:32PM EST

Health activist Denis Kibera has seen women bleeding to death from illegal abortions. He has seen women dying after quack doctors used crude equipment to kill their fetuses.

The solution, he believes, is to decriminalize abortion and bring it into safe clinics and hospitals. Yet as a Christian in Uganda, he would never dare to say so publicly. “I’d be targeted by religious people,” he said. “I’d be attacked.”

The top bureaucrat in Uganda’s health department, Asuman Lukwago, is also in favour of legalizing abortion. But he, too, would never say so in public in this heavily Christian country, where abortion is a taboo subject. “People would hate me.”

Around the world, an estimated 67,000 women die from unsafe abortions every year, including about 1,500 in Uganda. Thousands more are maimed or permanently injured, mainly because the criminalization of abortion forces them into the hands of dangerous backroom practitioners.

Now, for the first time, a senior United Nations official is openly calling for the decriminalization of abortion. Supporters say it could trigger a long-overdue debate – even though it is unlikely to bring immediate reforms in religiously conservative countries in Africa and Latin America where abortion is illegal.

The new UN statement is unambiguous. “States must take measures to ensure that legal and safe abortion services are available, accessible, and of good quality,” said Anand Grover, the UN special rapporteur on health, in a report that has galvanized support from women’s groups and health activists.

“Absolute prohibition under criminal law deprives women of access to what, in some cases, is a life-saving procedure,” he said. “Criminalization of abortion results in women seeking clandestine, and likely unsafe, abortions.”

About 25 per cent of the world’s population is living under legal regimes that prohibit all abortions, except those following rape or incest, or when necessary to save a woman’s life, Mr. Grover noted. He described how women suffer “enormous anguish” – or even commit suicide – because of the pressures caused by criminalization.

Human rights and health groups say the UN report is a ground-breaking moment for the abortion issue in the developing world. “This report is the first of its kind in the way that it talks about abortion, because it isn’t constrained by the usual political considerations that are in operation in UN spaces,” said Meghan Doherty, a communications officer at Action Canada for Population and Development, an Ottawa-based advocacy group.

“Now that these arguments have been made publicly and unapologetically, and the report has the UN logo, it has already pushed the discussion forward.”

But in countries such as Uganda, the debate on abortion has yet to begin – even though experts acknowledge the need for reform.

Dr. Lukwago, the permanent secretary in Uganda’s health ministry, practised medicine for 12 years and says he saw hundreds of women dying from illegal abortions. He estimates that unsafe abortions are responsible for a quarter of the 6,000 annual pregnancy-related deaths in Uganda. An entire ward at Kampala’s leading hospital is full of women injured by unsafe abortions, he said.

“I’ve seen girls swallowing aspirin to create toxicity so the baby won’t come out,” Dr. Lukwago said in an interview. “I know illegal abortion kills women.”

He personally believes that decriminalization should be supported, but he doesn’t expect it to happen for generations. “We’re a religious country.”

Religion is a powerful force in Ugandan politics, as it is in many African countries. Churches are key leaders in the controversial Ugandan campaign for an anti-homosexuality law, which would impose life imprisonment or even the death penalty for homosexual acts. Ugandan President Yoweri Museveni’s wife, Janet, is a born-again Christian who praises God on almost every page of her autobiography, and she is reportedly a key supporter of the anti-gay bill. Church leaders often rail against abortion in their Sunday sermons.

About 300,000 abortions are performed annually in Uganda, mostly in dangerous conditions. “I feel so bad when I see a woman bleeding to death, and I know it could be stopped,” said Mr. Kibera, who works for the Coalition for Health Promotion and Social Development.

He doesn’t see any prospect of abortion being decriminalized – “Not in this generation.”

Moses Mulumba, a Ugandan lawyer who heads a centre on human rights and health, is one of the few activists willing to launch a constitutional challenge against the anti-abortion laws. But he said he would be lucky to find any women willing to be involved in a test case.

“People don’t want to speak about it,” he said. “Many people can talk about it privately, but never on television. We need to open it up and normalize it.”

In his UN report, Mr. Grover acknowledges the difficulty of decriminalizing abortion. He suggests, as an interim step, that governments consider a moratorium on the enforcement of anti-abortion laws.

“This recommendation shows that this is a serious issue that requires immediate attention in order to prevent needless suffering,” said Sandeep Prasad, executive director of Action Canada. “Even if a state is having problems repealing its laws criminalizing abortion, it should not be prosecuting women for undergoing illegal abortions.”

By Wambi Michael
MBARARA, Uganda, Jun 28, 2011 (IPS) – When the monthly contraceptive injection that Bernadette Asiimwe, a mother of four, got from government health centres in western Uganda was out of stock for weeks, she fell pregnant with her fifth child.

By the time Assiimwe decided to pay for the contraceptive and went to Reproductive Health Uganda, a family planning association, she was already four weeks pregnant.

Asiimwe is not alone, many mothers like her in western Uganda have had unintended pregnancies due to shortages of commonly used contraceptives at government health facilities. Depo-Provera Contraceptive Injection is one of the most commonly used.

Donata Muhereza, a counselor at Reproductive Health Uganda in Mbarara, told IPS that the one-month contraceptive injection that Assiimwe used is popular because rural women find it easier to use compared to pills. Women also preferred it, Muhereza said, because they could take the contraceptive without the knowledge of their husbands. But the injection is rarely available at government health facilities.

“Mothers come here late after failing to find their injections at government hospitals. When we test them we find that they are pregnant. We cannot put them on any contraceptive. So we counsel them and let them go home.”

She said it was a common problem that usually occurred when government clinics ran out of the two most-used contraceptive injections. Muhereza added that women were subjected to violence by their husbands when they unintentionally fell pregnant.

“It happens that the husband was aware that his wife was on a contraceptive, but you find that the husbands become hostile (when they find out that their wives have fallen pregnant). Sometimes they abuse their wives. In the long run when a mother is not counseled well, then they resort to backyard abortions,” said Muhereza.

She said unintended pregnancies and abortions in Mbrarara are common and that non-professionals perform most abortions. An estimated 297,000 abortions are performed in Uganda because most of the pregnancies are unintended according to a study conducted in 2005 by the Guttmaacher Institute between 2003 and 2005.

A health worker at Kakooba Health Centre, who declined to be named, told IPS that the centre has not had three types of the commonly used contraceptives for about two months.

“We are equally in a dilemma. We want to help the women because we know the dangers of not taking the pills as required,” she said.

“We instead give them condoms advising them to convince their husbands to use protection until we have restocked. But some women are not be able to convince their husbands (to use condoms) so they fall pregnant,” she added.

Kaguna Amoti, district health officer at Mbarara District Administration said the shortages were not widespread in the district. “We are aware of the problem but it is not affecting all contraceptives. Our counselors are suggesting other types of contraceptives until when we have stocked again,” said Kaguna.

However, family planners have explained that not all forms of contraceptives are suitable for everyone. For example, pills are not suitable for rural women because they are required to be taken daily. Most rural women prefer to take a monthly contraceptive injection.

Wagama Theresa, a senior nursing officer in the neighbouring Bushenyi district told IPS that the situation there was no different from Mbarara. “We are lucky that some health centres have the injectables in stock but some don’t have so mothers are advised to try the next health centres where the contraceptive is in stock.”

She explained that persistent contraceptive shortages were frustrating for the husbands who supported their wives with family planning.

“Some men have begun supporting their wives in family planning. But when they come and don’t find their selected contraceptive (available), they get frustrated and you will never see the husbands back here,” said Wagama.

Eliab Tayebwa, the head of Reproductive Health and HIV/AIDS in Bushenyi district explained that the district experienced contraceptives shortages when there was a delay in delivery from National Medical stores.

“Contraceptives come in medicine kits like other drugs. So when the kits have not been delivered then you will not have contraceptives and other medicines,” he said.

Access to and use of family planning in Uganda has been identified as one of the factors in achieving 2015 United Nations Millennium Development Goals (MDGs), but progress in both these areas has been slow.

The 2006 Uganda Demographic Health Survey showed that 41 percent of women in Uganda needed contraception, but could not get it.

Dr. Moses Muwonge, a reproductive health expert, said government was not committed to family planning initiatives, which has led to the contraceptive shortages. Muwonge said that only 600,000 dollars was allocated to contraceptives in the financial year 2010/2011.

But Dr. Kenya Mugisha, the Acting Director General at the ministry of health services blamed some districts for causing contraceptive shortages. “Money is sent to districts with tentative budgets, but the districts re-prioritise and contraceptives may not get the vote they deserve,” he said.

Mugisha explained that his ministry has devised a new strategy to deliver family planning services to rural populations, given that 51 percent of Uganda’s population lives more than five kilometres from the nearest health facility.

The community-based access to injectable contraceptives, according to Mugisha, is expected to reduce unmet demand for family planning.

Mugisha added the strategy would only work once more money was made available to extend services and purchase the needed contraceptives. “We need more than double what we are offering today. And that is the big challenge we are facing, not just with contraceptives but in the general health sector,” he said.

Evelyn Lirri

28 May 2011

Many women in Uganda currently have more children than they want. Low contraceptive use or the lack of access to it is a contributing factor. But the social and economic costs of not filling the family planning gap may be greater for the country, writes Evelyn Lirri.

Hellen Adupa has just given birth to her ninth child. But she’s only 30 years old. The primary school dropout, who lives in Agali village in Lira district, says she doesn’t want to have more children.

However, until now, she hasn’t been on any family planning method. After her sixth pregnancy, Ms Adupa and her husband, a peasant farmer, had decided against having more children. But since she didn’t have access to any birth control methods which she said had run out at the health facility, this resulted in three more babies.

Ms Adupa’s is a case of unintended or unplanned pregnancy, a scenario that plays out too commonly among Ugandan women and which demographers and health experts say is driving the country’s fast growing population.

“I know feeding them is already a big challenge for me. But I wanted maybe five or six children. But now I have nine,”she said resignedly.

“I’m now starting on family planning. The health workers have already counseled me on the different birth control methods,” she added.

Ms Adupa has been given Depo Provera, a contraceptive administered through injection. A health worker explained that it’s the most preferred form of birth control in this remote part of Lira in northern Uganda.

This is because women who use it usually do so even without seeking permission from their husbands, as most men don’t approve of family planning.

While Ms Adupa is lucky to find contraceptives this time round, not many are as fortunate.

Frequent stock-outs, long distances to health facilities and the high cost of some contraceptive methods, especially the long term options, make access prohibitive for many women.

Mr Geoffery Lapat, a senior clinical officer at the Reproductive Health Uganda (RHU) clinic in Lira says although most women now prefer the long-term birth control methods, their high costs are the biggest barrier.

“In many of the public facilities, women only get the short term methods like pills, yet majority of them say they would prefer the long term methods because of its convenience,” explained Mr Lapat.

At the RHU clinic, contraceptives like pills cost Shs500, while longer term contraceptives such as implants go for as high as Shs20,000 – a prohibitive cost for many women who largely depend on subsistence farming.

“For most women this is too high, given that majority are peasant farmers. Many would rather go home without contraceptives than spend as much as Shs20,000 just to get a birth control service,” he said.

With nine children, Ms Adupa already has more than the average number of children a typical Uganda woman has — seven.

Although women admit they want to space or stop producing more children than they already have, the lack of access to contraceptives, especially long term methods, limits then from doing so.

The result has been the high number of unwanted pregnancies and unintended births – at 1.5 million and 519,000 respectively – according to a position paper on family planning in Uganda published by RHU.

“Unintended pregnancies result in high abortions and maternal deaths,” said Prof. Augustus Nuwagaba, a development expert and author of the report by RHU.

One critical factor that influences family planning is contraceptive use.

With fewer women using contraceptives – at 23 percent – many will have unwanted pregnancies and population will grow rapidly.

Prof. Nuwagaba says unintended pregnancies and the high abortion rates could reduce drastically if all the unmet need for family planning, currently at 41 percent, was met.

According to him, the cost of not providing services to women to stop unplanned pregnancies far outweighs the additional investment that would be made in buying family planning commodities.

Explaining the net cost of investing in family planning, Prof. Nuwagaba said that for instance, the government spends about $268 million on managing unintended pregnancies in any financial year.

On the other hand, if up to 50 percent of this unmet need for family planning were met, the cost of managing unintended pregnancies would reduce to $105 million.

And if the entire unmet need was met, that figure would further drop to $32 million annually.

Lower maternal deaths

Besides the economic costs, if Ugandan women had half as many pregnancies, there would be only half as many maternal deaths and the likelihood of achieving Millennium Development Goals (MDGs) four and five, which directly relate to the health of mothers and children, would be within reach.

An estimated 435 Ugandan women die from pregnancy and delivery -related causes for every 100,000 live births. This translates to about 6,000 deaths annually, with induced abortion contributing a greater share of these deaths.

Although legally restricted and only allowed in cases where the pregnancy causes a grave risk to a mother, the high rate of unintended pregnancy has not prevented women from having abortions, which according to the Uganda Demographic and Health Survey contributes 16 percent of all maternal deaths.

A report by the US based Guttmacher Institute shows that addressing the unmet need for family planning in Uganda can potentially avert some 16,877 maternal deaths and more than 1.1 million child deaths by 2015. Besides maternal and child deaths, it could also avert up to 4.6 million unintended pregnancies that could have occurred between 2005 and 2015.

“The use of modern contraceptives enhances maternal and infant health by preventing high-risk births, such as those that are too closely spaced, those that occur among women younger than 18 or older than 35, and those that occur after a woman has already had many children,” notes the report.

The Guttmacher report further reveals that if women delayed their next birth or had fewer children, the rate of population growth would decline, increasing the potential to train, educate and meet the economic demands of the population.

Outgoing state minister for planning Fred Omach agrees that more investment in family planning is needed to avert these deaths, adding that despite government interventions, services have not reached all those who need them, especially in the rural areas

“Our reproductive health and family planning services remain mainly urban-based, yet the majority of our women are in rural areas where accessibility remains poor,” said Mr Omach.

Population boom

The cost of not meeting the huge family planning gap is already having an impact on the country, with population growing at an alarmingly higher rate than planners can handle.

Already at 33 million people and with a 3.2 percent population growth rate, the country is projected to have 60 million people by 2030 and eventually hit the 100 million mark in 2050.

Demographers say much of this bulge is directly the consequence of high fertility rates and an equally high unmet need for family planning services.

In fact a report just released by the United Nation names Uganda among the world’s “high fertility countries.”

Health experts say one underlying reason for the high fertility rate is the equally high teenage pregnancy where women start child bearing as early as 14 years.

As a result, at 25 percent, Uganda has one of the highest rates of teenage pregnancies on the continent.