Unsafe Abortion in Tanzania
LAW AND POLICIES ON ABORTION IN TANZANIA
• The penal code in Tanzania states that termination of pregnancy is legally permitted if it is performed to save a woman’s life. However, in 2007, Tanzania ratified the African Charter’s Protocol on the Rights of Women in Africa (also referred to as the Maputo Protocol), which requires the government to
"protect the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, [and] incest, and where the continued pregnancy endangers the mental and physical health of the [pregnant woman] or the life of the [pregnant woman] or the foetus."
Yet despite ratification, the Tanzanian government has not incorporated this provision into its national law. • A recent report by the Center for Reproductive Rights indicates that Tanzania’s law and policies on termination of pregnancy are unclear, confusing and often inconsistent. Given this ambiguity, women, health care providers and the community at large may lack a comprehensive understanding of the law on abortion.
• For example, contrary to widespread belief, a health care provider is not required to consult with other providers before performing an abortion, and the law does not specify what level of provider may perform a legal termination.
UNSAFE ABORTION IN TANZANIA
• No national abortion incidence data are available in Tanzania; however, there is evidence that abortion is widely practiced and is frequently unsafe.
• Many women who cannot access safe abortion services will try to abort the pregnancy themselves or turn to an unskilled provider, often putting their health and lives at risk.
• In Eastern Africa, there were an estimated 2.4 million unsafe induced abortions in 2008, which translates to 36 unsafe abortions per 1,000 women of reproductive age—the highest regional rate in Africa.
• In a Tanzanian study of women who were admitted to a hospital with complications from an induced abortion, 46% of those in rural areas and 60% of those in urban areas reported that the abortion had been performed by an unskilled provider. Other women reported that a midlevel provider (e.g., nurse midwife or clinical officer) or doctor had performed the abortion.
• Preliminary results from a qualitative study of women who had experienced an abortion in Arusha and Town West, Zanzibar, found that providers in nonclinical settings—such as traditional birth attendants and pharmaceutical retailers—were viewed as a preferred source for a pregnancy termination because they ensure greater privacy and lower costs than physicians.
CONTRACEPTION AND UNINTENDED PREGNANCY
• Unplanned pregnancy is the root cause of most abortions. Preventing unintended pregnancy, and thereby the abortions that often follow, would eliminate nearly all injury and death resulting from unsafe abortion.
• In Tanzania, one in four married women and one in three unmarried women of reproductive age had an unmet need for contraception in 2010; they wanted to delay or stop having children, but were not using contraceptives. This proportion has changed little since 1999. The level of unmet need was higher among poorer women, those who were less educated and those residing in rural areas.
• Although the contraceptive prevalence rate in Tanzania has risen over the past decade, it is still very low. Between 2004 and 2010, the use of a modern contraceptive method increased among both married women (from 20% to 26%) and sexually active unmarried women (from 36% to 44%). Nonetheless, the unmet need for family planning remains high in Tanzania.
• According to the 2010 Tanzania Demographic and Health Survey (DHS), 26% of recent births were unplanned, and the proportion has increased slightly since the 2004‒2005 survey.
MATERNAL MORTALITY AND MORBIDITY
• The Tanzanian government has shown, through various policies—including the implementation of the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania, 2008–2015—that it is committed to reducing maternal mortality.
• However, the 2010 DHS estimated that there are still 454 maternal deaths per 100,000 live births annually in Tanzania, one of the highest maternal mortality ratios in the world.
• Unsafe abortion is one of the leading causes of maternal deaths in Tanzania. According to the Ministry of Health and Social Welfare, 16% of maternal deaths are due to complications from abortion.
• For every woman who dies from an unsafe abortion, many more are seriously injured. In Eastern Africa, more than 600,000 women were estimated to be hospitalized for induced abortion complications in 2005.
• The prevalence of unsafe abortion in Tanzania has been documented in a number of studies, which have shown that up to 60% of women hospitalized with an alleged miscarriage had in fact had an induced abortion.
• The health consequences of unsafe abortion also constitute a serious drain on limited public health resources. Though no recent costing studies have been conducted, the proportion of hospital admissions for abortion-related complications accounts for a disproportionate share of hospital expenditures.
• In addition to the immediate health and direct costs associated with unsafe abortion, there are a number of indirect costs, such as loss of income and productivity due to the morbidity many women suffer as a result of an unsafe procedure.
• Making postabortion care (PAC) widely available is important in reducing maternal mortality. Improved PAC availability is also critical to addressing the unmet need for contraception among women who have resorted to an unsafe abortion, as studies have shown that women who receive comprehensive PAC, including contraceptive counseling services, are likely to leave the facility with a contraceptive method.
• Since 2000, the Tanzanian government—through its National Package of Essential Health Interventions and Postabortion Care Clinical Skills Curriculum—has committed to providing PAC as an essential service and is working with other stakeholders to achieve this goal.
• In 2007, EngenderHealth, through its ACQUIRE Project Tanzania, began working with the Ministry of Health and Social Welfare to decentralize PAC services to lower-level health facilities in an effort to increase the availability of services throughout the country.
• The problem of inadequate medical supplies remains a major barrier to service provision. A study of health facilities in three districts of Tanzania found that on the day of the survey, only 24% of facilities had manual vacuum aspiration kits in stock, and only one of the five hospitals surveyed had both misoprostol and the kits, which are needed for the treatment of incomplete abortion.
• Reduce unmet need for contraception by increasing access to family planning, intensifying family planning education, and offering a wide range of contraceptive methods and counseling. Preventing unintended pregnancies will lower the incidence of unsafe abortion and its consequences.
• Increase access to comprehensive PAC services. These must include the use of modern and less invasive technology, a choice of treatment methods, training of midlevel providers, offering services at lower-level health facilities, and ensuring that facilities are adequately stocked with drugs and supplies. Postabortion contraceptive counseling and the provision of a wide range of methods should be incorporated into PAC services.
• Improve health care providers’ awareness of Tanzanian abortion law and equip them with appropriate training to provide safe abortion services within legally permitted circumstances.
• Conduct research to obtain national data on abortion incidence, abortion-related complications and the cost of unsafe abortion to the Tanzanian health system.
For more information on unsafe abortion in Tanzania, see Woog V and Pembe AB, Unsafe abortion in Tanzania: a review of the evidence, In Brief, New York: Guttmacher Institute, 2013, No. 1. <http://www.guttmacher.org/pubs/IB_unsafe-abortion-tanzania.pdf>