velyn Wambui (not her real name) had her career and family life all planned out. She wanted to have three children and a stable career by the age of 36. Everything had gone according to plan by the time she gave birth to her third born in February 2018. She had a good career as a human resource manager at an insurance firm in Nairobi. She was also married with two children aged eight and five years. Six months after the birth of her third born, Evelyn started taking birth control pills. “Pills were my most favourable option at the time. I was not ready to use an intrauterine coil. I had also ruled out the Jadelle levonorgestrel implant because of previous heavy menses and constant spotting,” she says.
Having taken her pills faithfully, Evelyn was shocked when she started to miss her periods last year. It started in August, a year after she started taking the pills. “I was not alarmed at first. I had taken my pills well and there was no way I could have been pregnant,” she says. But she knew something was wrong when she missed her periods for the second month in a row. “I became very anxious. I wanted to take a test, but I was afraid. I decided to wait it out for another month,” she adds.
Evelyn finally took a pregnancy test after missing her periods in October. The test came back positive. “I was shocked and angry at the same time. I became very irritable. I had not planned to have another baby. I didn’t want another baby.” Evelyn decided to keep her pregnancy from her husband as she contemplated what to do. “I knew there was no way I could have another baby. I had to act fast before any pregnancy signs could emerge.” She decided to procure an abortion.
“I had calculated and figured out that I was about 12 to 13 weeks pregnant. I evaluated my options with a close friend in the medical field and got a trustable referral,” she says. On Monday, November 4 last year, Evelyn took the day off work and drove towards Upper Hill for her secret abortion. “I was examined and informed that a surgical abortion using a suction method was my best option. The procedure lasted less than 15 minutes,” she says.
RAPID TEST
Currently, Evelyn is using a five-year intrauterine coil as her preferred family planning method. “I have no regrets. Conception is a choice and a right for every woman. I would still opt to procure another abortion if things went south instead of carrying a pregnancy I haven’t planned for,” she says.
Her sentiments resonate with data and experiences of many married Kenyan women procuring abortions today. According to a study conducted at Kenyatta National Hospital (KNH) in 2013, a significant number of women who procure abortion for the first time are likely to do it again.
It would be easy to assume the majority of abortion cases are procured by unmarried women or helpless, young girls. But, there are many women who procure abortions in Kenya in the same marital status as Evelyn. Married. For instance, the KNH study, titled ”Acceptability of Rapid HIV Test Screening Among Patients Presenting with Incomplete Abortion at Kenyatta National Hospital”, further noted that nearly two-thirds of women who seek post-abortion care services are married, 22 per cent single, divorced or separated (12 per cent) while 4.4 per cent are widowed. A related study conducted by Marie Stopes and published in the journal Plos One in November last year shows 22.4 per cent of women in Nairobi who procure abortions are married, partnered or cohabiting.
In most cases, married women procure abortions in secrecy. Take Kristie Nyachiro*. She had an abortion one year after getting married. “It was my first pregnancy. I wasn’t ready. I was already juggling my career and a Master’s degree,” she says. Kristie and her husband had planned to have their first baby after five years. “I got married at 28. I wanted to concentrate on my career and academic progression first. I knew I wanted two children, the first born at 33,” she says. When she fell pregnant a year down the line, Kristie saw abortion as the perfect solution to stop her career and academic plan from crumbling. “Having a baby is not as easy as it sounds. It takes sacrifice and commitment. It’s not like juggling tennis balls,” she says. At the same time, there are women who opt for abortion because they do not want to have any children at all.
CONTRACEPTIVE FAILURE
In any given instance, the procurement of abortion reflects the conception of unwanted pregnancies. According to the 2014 Kenya Demographic Health Survey (KDHS), unsafe abortions in Kenya accounted for 35 per cent of maternal deaths. This was not the first national data set to show the high cases of unintended pregnancies. Take the 2008 to 2009 KDHS. This survey showed 43 per cent of women had unplanned pregnancies. Out of these, 17 per cent were unwanted while 26 per cent were mistimed.
Some of the major reasons married women opt for abortion are failure to use contraceptives, failed and untimed contraceptives.
Nonetheless, the use of contraceptives within marriage has been on a steady increase. While speaking during the World Contraceptive Day in 2019, outgoing Health Cabinet Secretary Sicily Kariuki said contraceptive prevalence among married women in Kenya had increased from 46 to 58 per cent over the last decade. “For every Sh100 invested in contraceptive services, we are able to save Sh200 in maternal and newborn healthcare as a result of a decline in the number of unwanted pregnancies,” she said.
But it is not just the lack of or wrongly used contraceptives that is leading married women towards abortion. For instance, women who took part in the Marie Stopes study reported they did not have an agreement with their partners on the number of children they wanted to have before getting married. While some women like Evelyn are able to procure safe abortions, the vast majority take the unsafe route in unlicensed backstreet clinics. The life and financial consequences of unsafe abortions have been extreme.
A study titled ”The Costs of Treating Unsafe Abortion Complications in Public Health Facilities in Kenya” conducted by African Population and Health Research Centre (APHRC) and the Health ministry between 2012 and 2016 found that Kenya used Sh500 million on cases of unsafe abortion during that period. The report estimated that in Kenya, about 464,690 abortions are procured every year.
“These cases could be higher since these are only figures officially reported at health centres,” says Dr Janet Thuthwa, an obstetrician-gynaecologist in Nairobi. Out of these figures, the report further shows that seven women die every day in Kenya from unsafe abortions.
LANDMARK RULING
Strikingly, nearly one-third of women who procure abortion do not care that it is illegal. According to Murigi Kamande, a lawyer, abortion is outlawed, save for certain instances such as when, in the opinion of a trained health professional, there is a need for emergency treatment or the life or health of the mother is in danger.
“Section 159 of the Penal Code provides that any woman who procures an abortion outside the boundaries stipulated by the law shall be guilty of a felony and will be liable to imprisonment for seven years upon conviction by a court of law,” he says.
The effects of unsafe abortions and the legal and moral dilemma in Kenya are exemplified by the case of an 18-year-old girl identified as JMM who died in 2018.
JMM died after suffering complications from an unsafe abortion. In 2014, at the age of 15, JMM had procured an abortion after getting raped and falling pregnant. The abortion cost her Sh1,500 from a chemist who used metal rods to terminate the pregnancy. Her legal guardian, identified as PKM, received a call informing her JMM was vomiting and bleeding profusely at a clinic where she had sought medical attention after procuring the abortion. While JMM received post-abortion care at numerous hospitals, she sustained a chronic kidney disease that eventually claimed her life in June 2018.
Following JMM’s predicament, the Centre for Reproductive Rights filed a case challenging the government’s withdrawal of Standards and Guidelines for Reducing Morbidity and Mortality from Unsafe Abortion in Kenya.
The guidelines cover, among others, prevention of unwanted pregnancies through contraception, and prevention and management of unsafe abortion. They state that facilities providing sexual and reproductive health services should have protocols for providing abortion services to survivors of sexual violence and all termination of pregnancy should be carried out in a health facility with appropriate equipment, but in accordance with the article 26 (4) of the Constitution.
A landmark ruling by the High Court on June 12 last year termed abortion illegal, save for certain instances. However, the judges also ruled that any Kenyan woman can go to a licensed health facility and procure an abortion on the basis of these guidelines. This ruling effectively restored the abortion guidelines withdrawn by the Health ministry in February 2014.
“The withdrawal of the national guidelines on safe abortion amounts to discrimination, violated right to life, violated the rights of women and adolescent girls, violated access to information, consumer rights as well as having access to scientific progress,” the judges ruled.
ABORTION PILL
Despite abortions being undertaken in tens of thousands every year, the number of cases reported to the authorities remain acutely low. This suggests unsafe abortions occur unnoticed by the national legal apparatus. For example, according to the Economic Survey 2019 report, only 18 cases of procured abortions were reported to the police.
Nonetheless, Dr Thuthwa says for many women, procuring an abortion is not so much about the legality of the process, but the morality and stigma associated with it.
“No woman wants to walk down the street bearing the abortion tag. The stigma associated with abortion is one of the reasons women are reporting the effects of unsafe abortions when it is already too late for post-abortion care,” she says.
In the Marie Stopes survey, 56 per cent of women who confessed having an abortion took abortion pills while 44 per cent had surgical abortion. However, more women faced difficulties in meeting the actual cost of the abortion.
In Kenya, Marie Stopes International is one of the facilities that provide post-abortion care services. Post-abortion care service providers have been on the spotlight for many reasons. For example, in 2018, Marie Stopes was ordered to stop providing abortion- related services by the Health ministry over what was termed running abortion-by-choice adverts. The ban was, however, lifted in 2018. Over the three weeks the ban was in effect, the clinics reported turning away three women who needed post-abortion care services.