In Rwanda, unsafe abortion poses a grave risk to women’s health and, by extension, to the well-being of families and society. Although induced abortion is legal in very limited circumstances, virtually no safe legal abortions take place in the country. Examining the hidden and stigmatized practice of induced abortion is very difficult, so its incidence can be estimated only indirectly. This report presents the first attempt to quantify the incidence of abortion in Rwanda, by using a methodology that builds on the only accessible data on the subject—the number of women who seek care at health facilities for abortionrelated complications. The report also discusses progress in and remaining constraints on Rwandan women’s ability to plan their pregnancies, which is key to enabling them to avoid the unintended pregnancies that can lead to induced abortions.
Progress has been made on several fronts
■ Increased access to reproductive health services has helped to rapidly expand women’s use of contraceptives to prevent unwanted pregnancy: As of 2010, 44% of Rwandan women in union were using a modern method of contraception, compared with 4% just one decade earlier.
■ The progress made in assuring equitable access to health care—including to modern contraceptive services—is evident in the virtual absence of commonly found differentials in levels of modern contraceptive use between urban and rural areas.
■ As a result, Rwandan women have an average of one child fewer now than they did just 10 years ago (4.6 lifetime births as of 2010, compared with 5.8 as of 2000). Yet unintended pregnancy and unplanned births are widespread
■ Unfortunately, the improvements in contraceptive use are not occurring fast enough, given that women in Rwanda continue to have more children than they desire: Women’s average family size is 4.6 children, compared with their wanted family size of 3.1.
■ A gap between wanted and actual fertility implies unintended pregnancy. Each year, nearly half (47%) of all pregnancies in the country are unintended, meaning they come too soon or are not wanted at all.
■ This translates to an annual rate of 114 unintended pregnancies per 1,000 women aged 15–44. This rate is very similiar to the rate of 118 unintended pregnancies per 1,000 women estimated for Eastern Africa as a whole in 2008.
■ Unintended pregnancy often leads to unplanned births. Some 37% of births in Rwanda each year are unplanned—a proportion that varies slightly by province, from 34% in the West and the North to 37–40% in Kigali City, the South and the East.
Some unintended pregnancies end in abortion
■ Despite legal restrictions on and strong stigma around abortion, an estimated 22% of unintended pregnancies in Rwanda end in induced abortion.
■ The proportion of married women with an unmet need for contraception—that is, they want to postpone or stop childbearing, but are not using any contraceptive method—has fallen from 36% in 2000 to 19% in 2010.
■ This means that each year there are 25 induced abortions per 1,000 women aged 15–44 (or one for every 40 women in this age-group). This rate is lower than the 36 abortions per 1,000 estimated for all Eastern Africa by the World Health Organization.
■ The province containing the nation’s capital, Kigali City, accounts for a disproportionate number of abortions relative to its population: An estimated one-third of Rwanda’s induced abortions occur there, despite its having only one-tenth of the country’s women of reproductive age. This finding is likely explained by both Kigali City residents’ stronger motivation to avoid unplanned births and by women from surrounding provinces traveling to the capital in search of anonymity and quality health services.
Unsafe abortion endangers women’s health and burdens the health system
■ Each year, approximately 26,000 women are treated in health facilities for complications of both induced and spontaneous abortions; some 9,000 (35%) of these complications are likely the result of late spontaneous abortions (and are thus removed from the analysis of abortion incidence) and 17,000 (65%) are likely from induced abortions. ■ The annual number of treated complications from induced abortion translates to a treatment rate of seven cases per 1,000 women of reproductive age. The rate is highest—and the drain on scarce medical resources strongest—in Kigali City, where 18 cases per 1,000 women of reproductive age are treated annually.
■ An induced abortion performed outside the law often is unsafe. In Rwanda, an estimated 40% of clandestine abortions lead to complications requiring treatment in a health facility.
■ Unfortunately, one-third of women experiencing abortion-related complications do not receive treatment, and these women are especially likely to suffer debilitating consequences. ■ Abortions among poor women—in both rural and urban areas—are far more likely to result in complications (an estimated 54–55%) than those among nonpoor rural women (38%) or nonpoor urban women (20%).
■ The likelihood of complications is directly linked to who performs the abortion. In Rwanda, half of all abortions are performed by untrained individuals—the 34% by traditional healers plus the 17% that are self-induced by women. The other half of abortions are provided by physicians (19%), nurses or medical assistants (16%) and midwives (14%).
Action is needed to improve women’s health and lives
Our findings on the incidence of unintended pregnancy and unsafe induced abortion point to the need for concerted efforts to help women better prevent unintended pregnancy—the root cause of most abortions. Several steps could help reduce unintended pregnancy and lighten the burden that unsafe abortion creates for women’s lives and for the nation’s medical system.
■ Strengthen contraceptive services. Women and service providers need better information about correct and consistent method use, so current methods are used as effectively as possible. Couples currently using a traditional method (8%) should be given better access to contraceptive services so they can switch to a modern one. Emergency contraception use, which is rare in Rwanda, needs to be expanded to improve women’s ability to avoid unwanted pregnancy after unprotected intercourse. Tailored interventions are needed for women at the highest risk for unwanted pregnancy because of their high unmet need: single and sexually active 15–29-year-olds (56% of whom are not practicing contraception despite not wanting to become pregnant). Other women with high levels of unmet need—at roughly one-quarter—are the poorest women, the least educated and women living in the West.
■ Improve postabortion care services. Postabortion services need to be extended and their quality improved. The country’s postabortion care protocol, newly issued by the Ministry of Health, should be followed by all facilities providing postabortion care. Implementing the protocol would ensure that the relatively safe and inexpensive method of manual vacuum aspiration quickly replaces the currently widespread use of dilation and curettage in hospitals and digital curettage in health centers. Medical personnel should be trained in providing compassionate postabortion care, so women need not forgo care out of fear of being mistreated.
■ Improve implementation of current provisions defining legal abortion. Public education campaigns are needed to educate women, providers, law enforcement and the judiciary about the circumstances under which abortion is legally permitted. It is also vital to continue to carry out studies to document and understand the types of barriers to legal abortion that women and providers currently face.