Towards the decriminalization of abortion in Zimbabwe: A public health perspective.

Dear Editor

Significantly reducing the global maternal mortality ratio (MMR) to less than 70 maternal deaths (MDs) per 100 000 live births by 2030 is a key priority of the sustainable development goals (SDGs) [1]. Furthermore, no country should be left with a MMR of greater than double the global average [1]. For Zimbabwe, a country with one of the worst MMRs globally, estimated to be in excess of 450 maternal deaths (MDs) per 100 000 live births [2], a lot of work needs to be done to make reasonable progress towards attaining SDG3. Identifying the contributory factors and putting in place mitigatory measures is a key step in making progress towards resolving a challenge. The direct leading causes of MDs in the country are obstetric hemorrhage and sepsis [3].

Unsafe abortions contribute significantly to both sepsis and hemorrhage [4], thereby making them important contributors to the high MMR in Zimbabwe. Sepsis occurs due to the unsterile conditions under which the abortions are carried out, lack of access to prophylactic antibiotics, and poor health-seeking behaviors among those who practice unsafe abortions. The poor health-seeking behaviors in these populations result from a complex interplay of psychological, socioeconomic, and legal factors. On the other hand, uncontrolled post-abortion hemorrhage can result in mortality and significant morbidity, including the need for blood transfusion, which can be worsened by delayed presentation. Other notable complications include perforation of surrounding structures including bowel due to use of penetrating objects. Apart from these complications on the individual, unsafe abortions are costly to the healthcare system due to requirements for treatment of sepsis including pelvic abscesses, organ perforation and blood transfusion, and prolonged hospital stays.

In Zimbabwe, abortion is illegal except under conditions of rape, incest, fetal abnormalities or maternal conditions dangerous to the wellbeing of the mother. Unfortunately, the circumstances forcing the women, who are usually adolescents or younger women into abortions, will usually be so compelling to them that they will seek other recourses through illegal routes, hence end up with unsafe abortions [5]. Hence, we argue that prohibitive pieces of legislation do not deter women from aborting, but rather cause them to do it in conditions that are detrimental to their wellbeing and have socioeconomic repercussions for the country. We thus make a call for decriminalization and legalization of abortion in Zimbabwe within a broader sexual and reproductive health and rights (SRHR) framework, to allow access to safe abortion services.

Part of the solution towards reducing the incidence of unwanted pregnancies and unsafe abortions is to provide appropriate sexual and reproductive education to both boys and girls within schools from primary education. Sexual activities are commencing early among teenagers in Zimbabwe as elsewhere, increasing the risk of unwanted pregnancies and acquisition of sexually transmitted infections such as chlamydia, gonorrhoea and the human immunodeficiency virus (HIV) as well as the human papilloma virus (HPV). Thus, a significant number of unwanted pregnancies in Zimbabwe are associated with high-risk sexual behaviors with long-term consequences, including subfertility, ectopic pregnancies, cervical cancers and social instability. The issue of providing condoms and modern contraceptives to adolescents in the country has remained contentious over the years. Legislators and religious leaders opposed to this usually cite religious and moral reasons based on personal convictions but overlook the SRHR of the adolescents. Provision of condoms and contraceptives coupled with education on abstinence, safe sex and risks associated with early indulgence into sexual activities might help to reduce the dangers associated with teenage sex, including unwanted pregnancies and consequent unsafe abortions. Appropriate targeting of high-risk populations such as commercial sex workers where the risk of unintended pregnancies is high with risk-reducing strategies such as ensuring smooth supply of condoms and education on dual contraception is important. Legislative frameworks also need to consider that unwanted pregnancies could also occur in the context of stable unions at undesirable times/intervals, for example due to contraceptive failure.

A discourse between legislators, the legal fraternity, SRHR champions, educators, public health stakeholders and the medical fraternity is needed to resolve this issue. Consideration of the women SRHR is critical and should not be overshadowed by personal or religious convictions, as the benefits of legalizing and decriminalizing abortion outweigh the dangers associated with unsafe abortions in Zimbabwe.

Disclaimer

The views presented in this piece are of the authors and do not necessarily represent the official position of their institutions.