How the Mexico City Policy Perpetuates the High Rate of Unsafe Abortion in Nigeria

Dr. Ejike Oji

Country Director

Ipas Nigeria

Abuja, Nigeria

October 31, 2007

House Committee on Foreign Affairs

U.S. House of Representatives

Chairman Lantos, members of the House Committee on Foreign Affairs and distinguished colleagues, I feel privileged to be invited here today to speak on the issue of the Global Gag Rule. The Global Gag Rule is a great barrier in Nigeria to our work to improve women’s health and save women’s lives. I am pleased that the Committee has chosen to spend this time considering the dangerous implications of this policy.

I am Dr. Ejike Oji and I have spent the last 28 years of my life working to improve women’s health. I have extensive experience in medical practice and consultancy, advocacy, and project management. I have worked as a medical officer in a number of health facilities and was at one time National Coordinator for the National Program for Prevention of Blindness. I have organized and facilitated several national and international medical conferences, workshops and seminars to encourage exchange of medical and scientific knowledge. I have an MBBS degree and a postgraduate diploma in management. In 2005, I received the “Advocate for Maternal and Child Health” award from the National Council of Women’s Societies in Nigeria due to the work I have been doing to reduce deaths from complications of unsafe abortion in the country. Currently I am the Country Director for Ipas Nigeria.

Ipas is a non-governmental organization based in Chapel Hill, North Carolina. Ipas implements programs aimed at preventing death and injury from unsafe abortion and promotes women’s reproductive rights globally. In Nigeria we expand access to and availability of care for complications from unsafe abortion and comprehensive abortion care up to the limits of the law, including post-abortion family planning. Ipas Nigeria works to create and strengthen policies and alliances to support women’s reproductive health and rights and we advocate for increased funding for reproductive health. We support the media to be strong advocates and empower them to educate the public on women’s rights to health and life. Finally, we work with the community to get their participation in reproductive health issues and services.

Women in Nigeria are dying and are maimed daily and needlessly from lack of access to reproductive health care and the all-too-often resulting unsafe abortions. U.S. policy – the Global Gag Rule – is directly at odds with efforts to address these threats to maternal health. In Nigeria, we face more maternal deaths than all but one country in the world, and a major contributing factor to our high rates of maternal mortality is lack of access to basic reproductive health care, particularly family planning services. Complications from unsafe abortion are rendering women infertile, causing chronic health problems, and taking lives.

High rates of unsafe abortion are inevitable where women face unwanted pregnancy and a lack of safe abortion facilities. Unwanted pregnancy is a reality in Nigeria because of low use of contraception.

The most effective way to decrease the number of abortions is by preventing unwanted pregnancy. High rates of unwanted pregnancy generally correlate with low levels of contraceptive use. The majority of women in Nigeria who have obtained an abortion were not using family planning when they became pregnant.[1]

USAID plays an important role in increasing access to family planning services in Nigeria and throughout Africa. However, the effectiveness of USAID is undermined by the Global Gag Rule. The policy dictates that USAID can only choose implementing partners based on their support for the current restrictive abortion law, not on the basis of who can best provide the services. Organizations that do receive USAID funding are unable to voice their support for changing the law, which is a major contributing factor in the deaths and injuries of women in Nigeria.

Background on Nigeria

Nigeria is a country with a very large population and high levels of poverty. We have 137 million people, more than any other country in Africa.[2] One in every five Africans is a Nigerian. The average Nigerian born today will live to age 44 and at least 15% of Nigerian children die before reaching age five. Seventy percent of Nigerians live on less than $1 a day.[3]

Women in Nigeria are confronted by insurmountable barriers in their pursuit of full, healthy and productive lives. Forty-two percent of Nigerian women have never attended school.[4] The average Nigerian woman gives birth to around six children. We have a high unmet need for contraception and low rates of contraceptive use. According to the most recent official statistics, the 2003 Demographic and Health Survey, only 8.2% of currently married women of childbearing age are using modern methods of contraception.[5]

Maternal Mortality in Nigeria

Nigeria has the second highest number of maternal deaths in the world. According to the World Health Organization, the number of maternal deaths – 59,000 – is second only to India and India’s population is ten times that of Nigeria. One in 17 women in Nigeria will die from pregnancy-related causes. As a comparison, in the United States the risk of dying from pregnancy-related causes is one in 4,800.[6]

Lack of access to reproductive health care is a major contributor to maternal mortality in Nigeria and across Africa. The Global Gag Rule exacerbates this public health crisis. Women seek abortion because they are faced with unwanted pregnancy. The majority of unwanted pregnancies can be prevented through family planning services. USAID has been working in Nigeria and across the African continent to increase access to family planning services through working with governments and with non-governmental organizations.

The most effective way to decrease the number of abortions is by preventing unwanted pregnancy. High rates of unwanted pregnancy generally correlate with low levels of contraceptive use. The majority of women in Nigeria who have obtained an abortion were not using family planning when they became pregnant.[7] According to USAID’s Nigeria Country Strategic Plan for 2004-2009, expanding the use of family planning is a major objective, and USAID regards partnerships with effective in-country NGOs as essential to achieving higher levels of contraceptive use. However, the Global Gag Rule effectively prohibits USAID from working with some of the organizations that would be the most effective in increasing the use of family planning. Instead, USAID can only choose among those organizations who pledge that they will not act to change the restrictive abortion law in Nigeria. The result is an increase in unwanted pregnancies, which often lead to abortion.

Unsafe abortion is common and every Nigerian is aware of it. If this room were full of Nigerians instead of Americans and I asked the question, how many of you know someone – a sister, a cousin, a friend of a friend – who has died of unsafe abortion, there would not be a single person without his or her hand raised. Unsafe abortion in Nigeria is a dangerous fact of life.

Unsafe abortion accounts for 14% of all maternal deaths in Africa.[8] In Nigeria, an estimated 760,000 induced abortions occur annually, 60% of which are unsafe.[9] More than 10,000 women die yearly from complications of unsafe abortion.[10] These are just estimates; the true numbers are probably much higher. Due to the stigma of abortion and because it is illegal in most cases, incidences of abortion go largely unreported.[11]

Women will take drastic measures, no matter the barriers, to terminate a pregnancy that they do not want. This is true in Nigeria and this is true everywhere in the world. Almost one-third of women in Nigeria say they have had an unwanted pregnancy and half of these have attempted an abortion at some time.

There are a host of reasons that women seek abortion in Nigeria – probably for many of the same reasons women seek abortion in the United States. The majority of women who procure an abortion in Nigeria are younger than 25.[12] Their reasons for not wanting to continue with their pregnancies are often because they are not married or they are too young. Some young people try to end their pregnancy because they want to finish their education, as pregnant girls in Nigeria are usually not allowed to continue with their education. Sometimes the pregnancy is a result of rape or the partner has abandoned the pregnant woman. Older women who are married and have children also seek abortion and their reasons typically include that they want more time between their most recent birth and their next, they do not want any more children or cannot afford to take care of an additional child. The majority of these unwanted pregnancies could have been prevented in the first place through the use of contraception.

For the typical Nigerian woman who is faced with unwanted pregnancy, her only choice for terminating her pregnancy involves dangerous methods and carries with it high risk of death or injury. A quarter of all women who obtain an abortion in Nigeria experience complications that are serious.[13] Women seek abortion from chemists’ shops, where they get concoctions, tablets or injections from people with little or no medical training and who certainly are not trained in providing abortion. Women who live in rural areas and don’t have easy access to health professionals turn to quacks or traditional healers. They otherwise try to induce an abortion on themselves or with the help of friends.

Methods of unsafe abortion involve the illicit and unthinkable use of chemicals, sticks, herbs and knives. Traditional healers will use ground ginger, alligator pepper, local chalk and native alum. A common method for quacks, traditional healers and that women use to self-induce abortion is the use of a sharpened stick from a cassava plant, or the sharpened edge of Bahaman grass. Untrained providers misuse medical equipment. These unsafe methods cause bleeding, septic shock, abdominal pain, fever, infection, uterine perforation, bowel damage, abdominal injury and death. Twenty-five percent of all women who obtain abortion report severe complications. Only one third of these women seek treatment.[14]

Treating complications from unsafe abortion pulls resources out of the already under-resourced health care system in Nigeria. Research in Africa has shown that treating complications from unsafe abortion in hospitals costs 10 times more than providing elective abortion in primary care facilities.[15] In Nigeria, women pay an average of almost $90 for care for abortion-related complications.[16]

USAID recognizes the need to do something to save women from losing their lives or experiencing long-term health consequences from unsafe abortion. USAID provides training to doctors and nurses in several states in Nigeria on treating complications from unsafe abortion. Training includes treatment for pain management, infection prevention and removal of any fetal tissue left after an unsafe abortion.

However, tragically – and ironically -- the Global Gag Rule is hindering the flow of U.S. assistance and resources that could prevent unwanted pregnancies and the numerous deaths to women from unsafe abortion.

The Public Debate on the Abortion Law in Nigeria

The problem of unsafe abortion in Nigeria is exacerbated by our restrictive and antiquated abortion laws, which deny women the opportunity to terminate a pregnancy safely. Advocates for women’s health and lives have long recognized this and Nigeria has a history of robust debate around the abortion law.

By limiting funding to organizations that comply with the Global Gag Rule, USAID effectively punishes organizations that are working to reform the abortion law. Some of these organizations could be the most effective at expanding access to contraception in Nigeria. At the same time, USAID supports organizations that are campaigning on the side of the current law, a law far more restrictive than the U.S. abortion law, and far more punitive than what the vast majority of Americans would support.

The law on abortion dates back to colonial times and is based on law that the British enacted in 1861. Abortion is criminal in Nigeria, except when a woman’s life is at risk. However, because abortion is in the criminal law, it is understood widely to be completely banned in Nigeria. The major relevant statutes in relation to abortion are the Criminal Codes of the different southern states of Nigeria and the Penal Codes of the different Northern States and the Federal Capital Territory of Abuja. The laws of Nigeria state that an abortion provider shall be imprisoned for up to 14 years. Women who seek abortion are also imprisoned under the law for seven to 14 years.

Islamic law is in effect in Nigeria and where it conflicts with statutory law such as the Criminal and Penal Codes, the statutory law is applicable over Islamic law. However, Sharia criminal law has been codified in many of the northern states, and state penal codes are no longer the only criminal statutes applicable. There are in some states parallel Sharia-based Penal Statutes and in others where the Penal Codes remain the criminal legislation, they have been amended to reflect Sharia-based standards. Amnesty International has found cases in such states, where Islamic law is codified, of women sentenced to death for abortion-related offenses.[17]

The laws on abortion throughout Nigeria are complicit in the death and injury of women. We know that when abortion is restricted by law, women will turn to unsafe methods. When we look to other countries we can see clear evidence that making abortion laws less restrictive reduces rates of maternal mortality due to unsafe abortion. According to the World Health Organization, where abortion laws have become less restrictive and safe abortion available, death and injury from unsafe abortion decreases. For example, in South Africa, where abortion became legal in 1995, maternal deaths from unsafe abortion have reduced by 90% since the law was changed.[18]

It is largely due to the restrictive abortion law that abortions are offered clandestinely and unsafely. The government of Nigeria and non-governmental organizations cannot make services widely available because the law prohibits most abortions. The narrow law is a disincentive to training health professionals working at all levels of the Nigerian health system and providers therefore remain untrained in safe methods. Legitimate health care professionals refuse to offer services to comply with the law, sending women away only to have them return to their health care facility with complications.

The crux of the matter is that our women are dying and something needs to be done. Recognizing the contribution of the law to the high rates of unsafe abortion in Nigeria, medical practitioners, civil society organizations, women’s rights advocates, legal professionals and grassroots activists have joined in an effort to work to reduce the number of unsafe abortions. They are campaigning for expanded use of family planning services and a change in the abortion law.

We have 760,000 cases yearly in Nigeria with a restrictive law. One thing is clear: in countries where abortion laws are more liberal, abortion will continue to occur but women will not die from it because they will get it done properly in an appropriate health care facility. When the law is restrictive, the same number of abortions will continue to occur and more deaths will occur because the women will instead go to unsafe providers. The law has no effect on number of the abortions that occur, but it does have effect on the consequences. Increased use of family planning services is the best way to prevent abortion in the first place.

The Global Gag Rule has silenced committed advocates for the reduction of unsafe abortion and has forced them into inactivity. Because of the Global Gag Rule, we have lost champions who were working to improve the reproductive health and save lives of women in Nigeria. Organizations in Nigeria that receive USAID funding for family planning and HIV related work do not even mention abortion as a leading cause of death in their public messages for fear of losing funding. The US government is even supporting the Catholic Secretariat of Nigeria and other groups who are working to retain the existing laws on abortion – laws that imprison women between seven and 14 years for obtaining an abortion and laws under which women have been sentenced to death.

Conclusion

The Global Gag Rule is one of the most negative international policies damaging public health in developing nations like Nigeria. US citizens who have an unwanted pregnancy have safe choices to make. They can choose to use contraception to avoid unwanted pregnancy. Pregnant women in the U.S. can keep their pregnancy and be supported with good antenatal services and a safe delivery of their babies. If they instead chose to terminate the pregnancy they have the option of a safe service and they can get on with their lives and live them to the fullest.

I cannot say this is true for my wife, daughter, sister, or my fellow country women. More often than not, a woman in Nigeria does not have information to make a choice in controlling her fertility. Being pregnant in Nigeria is like being a soldier on the frontlines. It is simply dangerous. Many, many women in Nigeria do not have the opportunity to avoid unwanted pregnancy with the use of contraception, to carry out a safe pregnancy or to safely terminate a pregnancy they do not want. For some women in Nigeria, in carrying out their choice, they pay the ultimate price.

Policy makers in the U.S. should spend less of their valuable time trying to stop debate about reforming our deadly abortion law and more on helping women prevent unwanted pregnancy. We can reduce rates unwanted pregnancy and abortion first and foremost with increased use of family planning.[19] However, the Global Gag Rule hurts the efforts in Nigeria to reduce the number of unwanted pregnancies and reform the dangerous law. The Global Gag Rule exacerbates the situation in Nigeria whereby women have no choice about how to manage their own lives. That is what makes me so angry, because at the end of the day it is our women – our wives, daughters, and sisters -- who are dying.

References

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[1] Bankole, Akinrola, Boniface A. Oye-Adeniran, Susheela Singh, Isaac F. Adewole, Deirdre Wulf, Gilda Sedgh and Rubina Hussain. 2006. Unwanted Pregnancy and Induced Abortion In Nigeria: Causes and Consequences. New York and Washington, DC: Guttmacher Institute. Available online at http://www.guttmacher.org/pubs/2006/08/08/Nigeria-UP-IA.pdf, last accessed 22 October 2007

[2] United Nations Population Fund. 2007. State of World Population 2007 Unleashing the Potential of Urban Growth. New York: United Nations Population Fund. Available online at http://www.unfpa.org/swp/2007/presskit/pdf/sowp2007_eng.pdf, last accessed 22nd October, 2007.

[3] United Nations Development Programme. 2007. Human Development Report 2006 Beyond Scarcity: Power, Poverty, and the Global Water Crisis. New York: United Nations Development Programme. Available online at http://hdr.undp.org/hdr2006/statistics/countries/data_sheets/cty_ds_NGA.html, last accessed 22nd October, 2007.

[4] National Population Commission (NPC) [Nigeria] and ORC Macro. 2004. Nigeria Demographic and Health Survey 2003. Calverton: National Population Commission and ORC Macro.

[5] National Population Commission (NPC) [Nigeria] and ORC Macro. 2004. Nigeria Demographic and Health Survey 2003. Calverton: National Population Commission and ORC Macro.

[6] World Health Organization, United Nations Children’s Fund, United Nations Population Fund and The World Bank. 2007. Maternal Mortality in 2005 Estimates developed by WHO, UNICEF, UNFPA and The World Bank. Geneva: World Health Organization. Available online at http://www.who.int/reproductive-health/publications/maternal_mortality_2005/mme_2005.pdf, last accessed 22nd October, 2007.

[7] Bankole, Akinrola, Boniface A. Oye-Adeniran, Susheela Singh, Isaac F. Adewole, Deirdre Wulf, Gilda Sedgh and Rubina Hussain. 2006. Unwanted Pregnancy and Induced Abortion In Nigeria: Causes and Consequences. New York and Washington, DC: Guttmacher Institute. Available online at http://www.guttmacher.org/pubs/2006/08/08/Nigeria-UP-IA.pdf, last accessed 22 October 2007

[8] World Health Organization, United Nations Children’s Fund, United Nations Population Fund and The World Bank. 2007. Maternal Mortality in 2005 Estimates developed by WHO, UNICEF, UNFPA and The World Bank. Geneva: World Health Organization. Available online at http://www.who.int/reproductive-health/publications/maternal_mortality_2005/mme_2005.pdf, last accessed 22nd October, 2007.

[9] Bankole, Akinrola, Boniface A. Oye-Adeniran, Susheela Singh, Isaac F. Adewole, Deirdre Wulf, Gilda Sedgh and Rubina Hussain. 2006. Unwanted Pregnancy and Induced Abortion In Nigeria: Causes and Consequences. New York and Washington, DC: Guttmacher Institute. Available online at http://www.guttmacher.org/pubs/2006/08/08/Nigeria-UP-IA.pdf, last accessed 22 October 2007.

[10] Health Reform Foundation of Nigeria. 2006. Nigerian Health Review. Abuja: Health Reform Foundation of Nigeria.

[11] World Health Organization. 2007. Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortions and Associated Mortality in 2003. Geneva: World Health Organization. Available online at http://www.who.int/reproductive-health/publications/unsafeabortion_2003/ua_estimates03.pdf, last accessed 22nd October, 2007.

[12] Bankole, Akinrola, Boniface A. Oye-Adeniran, Susheela Singh, Isaac F. Adewole, Deirdre Wulf, Gilda Sedgh and Rubina Hussain. 2006. Unwanted Pregnancy and Induced Abortion In Nigeria: Causes and Consequences. New York and Washington, DC: Guttmacher Institute. Available online at http://www.guttmacher.org/pubs/2006/08/08/Nigeria-UP-IA.pdf, last accessed 22 October 2007.

[13] Bankole, Akinrola, Boniface A. Oye-Adeniran, Susheela Singh, Isaac F. Adewole, Deirdre Wulf, Gilda Sedgh and Rubina Hussain. 2006. Unwanted Pregnancy and Induced Abortion In Nigeria: Causes and Consequences. New York and Washington, DC: Guttmacher Institute. Available online at http://www.guttmacher.org/pubs/2006/08/08/Nigeria-UP-IA.pdf, last accessed 22 October 2007.

[14] Bankole, Akinrola, Boniface A. Oye-Adeniran, Susheela Singh, Isaac F. Adewole, Deirdre Wulf, Gilda Sedgh and Rubina Hussain. 2006. Unwanted Pregnancy and Induced Abortion In Nigeria: Causes and Consequences. New York and Washington, DC: Guttmacher Institute. Available online at http://www.guttmacher.org/pubs/2006/08/08/Nigeria-UP-IA.pdf, last accessed 22 October 2007.

[15] Johnston, Heidi, Maria Gallo and Janie Benson. 2007. Reducing the costs to health systems of unsafe abortion: A comparison of four strategies. Journal of Family Planning and Reproductive Health Care, 33(4).

[16] Bankole, Akinrola, Boniface A. Oye-Adeniran, Susheela Singh, Isaac F. Adewole, Deirdre Wulf, Gilda Sedgh and Rubina Hussain. 2006. Unwanted Pregnancy and Induced Abortion In Nigeria: Causes and Consequences. New York and Washington, DC: Guttmacher Institute. Available online at http://www.guttmacher.org/pubs/2006/08/08/Nigeria-UP-IA.pdf, last accessed 22 October 2007.

[17] Amnesty International. 2004. Nigeria: The death penalty and women under the Nigerian penal systems. London: Amnesty International Press Release. Available online at http://news.amnesty.org/index/ENGAFR440072004, last accessed 22 October 2007.

[18] Jewkes, Rachel, Helen Rees, Kim Dickson, Heather Brown and Jonathan Levind. 2002. The impact of age on the epidemiology of incomplete abortions in South Africa after legislative change. British Journal of Obstetrics and Gynecology. 112:355–359; World Health Organization, United Nations Children’s Fund, United Nations Population Fund and The World Bank. 2007. Maternal Mortality in 2005 Estimates developed by WHO, UNICEF, UNFPA and The World Bank. Geneva: World Health Organization. Available online at http://www.who.int/reproductive-health/publications/maternal_mortality_2005/mme_2005.pdf, last accessed 22nd October, 2007.

[19] Sedgh, Gilda, Stanley Henshaw, Susheela Singh, Elisabeth Åhman, and Iqbal H Shah. 2007. Lancet. 370(9595):1338-1345.