Unsafe abortion practices and the law in Nigeria: time for change.

The abortion law in Nigeria states that abortion is illegal unless done to save the life of the mother.[1] Otherwise, the laws of Nigeria criminalise abortion with a steep penalty for both the woman and the personnel performing the abortion procedure. If caught, those who violate the law risk a 7-year (the patient) or a 14-year (the performer) jail term.[1,2]

To highlight the reality and implications of the restrictive abortion laws in Nigeria, we report on our collated experiences over the last three to five years in the care of women with complications of unsafe abortions, as clinicians working in a large tertiary referral hospital and healthcare professionals working on driving access to quality healthcare for women. Women presenting with complications are usually in their twenties, unemployed and without formal education. Single and married women both feature and some have used contraceptives in the past. The abortions tend to have taken place in the first trimester. Presentation to the hospital may take place immediately, or a few weeks after the abortion procedure. Abortions are reportedly done by patent medicine vendors, auxiliary nurses, health attendants and, less commonly, by licensed medical doctors, probably depending on the numbers of doctors available in different locations.[3,4] Findings from our patients revealed that the places where abortions were done include clinics, chemist shops and homes. These patients also commonly reported the use of sharp objects such as bicycle spokes and clothes hangers. Other unsafe methods of abortion which can cause external and internal injuries have been reported, including the insertion of herbal preparations or foreign bodies (twigs or chicken bones) into the vagina or jumping from heights to cause blunt trauma to the abdomen.[5]

In our hospital, we found that the reasons women give for having an abortion include a desire not to disrupt their education, that they had completed their families or that their partners refused paternity. After the presentation of the complication, the women can spend over a month in the hospital, usually with varying forms of surgical site infection. Mortalities occur and we estimate this occurs in about a quarter of cases.

In Nigeria, various studies have quoted unsafe abortions to be responsible for up to 30% of overall maternal mortality.[6] A high unmet need for contraception in Nigeria and in low- and middle-income countries contributes to unsafe abortions. However, meeting the demand for contraception alone may not be enough to prevent unsafe abortions, and we believe that liberal abortion laws which allow for safe abortion are needed. The risks of a previous abortion do not seem to preclude subsequent abortions despite the stringent abortion laws; for example, a study in Nigeria found that 66.7% of patients presenting to a health facility with a complicated unsafe abortion had a previous abortion.[7]

In a study, 80% of politicians and policy-makers interviewed admitted that unsafe abortion is a major cause of maternal mortality but only 20% favoured the amendment of the existing law.[1] Some anti-abortion and religious organisations have put up a strong front against the legalisation of abortion in Nigeria, although this change has been taken up by some policy-makers. In 2012, an attempt at amending the law to make it less restrictive in one of the states of Nigeria was met with resistance from several organisations.[8] The amendment was eventually repealed in 2013 and a public apology had to be offered by the then State Governor.[8] The Nigeria Medical Association (NMA) and the Society of Gynaecology and Obstetrics of Nigeria (SOGON) have been in the forefront of the drive for reform of the abortion laws in Nigeria.[9] During its 52nd Annual General Meeting and Scientific Conference in 2018, the SOGON called for the liberalisation of current restrictive abortions laws so as to give women the opportunity to access quality healthcare.[10]

Unsafe abortion contributes to a significant proportion of maternal mortality and morbidity in Nigeria.[4,6] Current laws which criminalise abortion in Nigeria do not reduce the number of abortions, instead, these strict laws mean that many women are forced to seek the service of unqualified practitioners with resultant high morbidity and mortality, both of which are an unacceptable price to pay for pregnancy. While debates over the right of the mother to her privacy and body and the rights of the foetus to life rage on, women in Nigeria continue to suffer the consequences of restrictive abortion laws.

Our experience marks a well-trodden path, nevertheless the intention of this perspective is to re-emphasise that, despite the fact so much is known concerning this topic, women’s lives continue to be lost due to unsafe abortion practices. To improve the current situation, change is needed at many levels, including the potential for law reform. Multisectoral collaboration between the legal, health and cultural sectors will help. In-depth understanding of the existing abortion law and its implementation, and how the judiciary, policy-makers, healthcare providers and women seeking abortion services interpret the law, should be developed. Practices and beliefs in the health system, the unregulated sector and amongst women and their families should be examined further. Abortion services are safe when they are carried out by a skilled healthcare worker in a safe environment, thus the obtainability of legal abortion upsurges the well-being and survival of women.[11] As suggested by Okorie and Abayomi, newer laws could include the legalisation of abortion on request in the first three months of pregnancy by qualified practitioners and the encouragement of widespread dissemination of information on contraceptive use to prevent unwanted pregnancies.[12] These efforts would decrease the need for unsafe abortion with its attendant high rate of maternal mortality and morbidity.