Monday, April 19, 2010

It's Public Policy, Stupid!

As the referendum on Kenya’s new constitution draws near, the debate over abortion is taking centre stage and threatening to derail the two-decade old project. Despite the fact that abortion has never been legal in Kenya, and the new draft expressly provides for matters to remain that way, Christian church leaders have vowed to mobilise their followers to reject the document.

The church objects to the section of Article 26 that empowers doctors to end a pregnancy if it endangers the woman’s life or she needs emergency treatment. Christian leaders are also opposed to the retention of Kadhis' courts in the proposed Constitution under Article 169 and 170, which limit their authority to disputes over personal status, marriage, divorce or inheritance, where all the parties are Muslims and agree to take the case to a Kadhi.

The controversy over the termination of pregnancy has pitted the church against pro-choice activists and is largely fought on the battlefields of values and morality. The debate has degenerated into shouting matches over the viability and humanity of foetuses and when exactly life begins. Lost in all this is the fact that, from a public policy perspective, these considerations are largely academic.

Banning abortion, as has been the experience worldwide, does not stop it. A survey of 197 countries carried out by the Guttmacher Institute — a pro-choice reproductive think tank — found that abortion occurs at roughly equal rates in regions where it is legal and regions where it is highly restricted.

Despite the current prohibition on abortion in Kenya’s laws, it is estimated that fully a fifth of total pregnancies in the country are terminated. Couching the ban in new phraseology is unlikely to alter this fact. This is not to say that the law has no effect. For nearly 300,000 women who seek abortions each year, it has proven to be a millstone around their necks.

The report, In Harm’s Way: The Impact Of Kenya’s Restrictive Abortion Law, compiled by the Centre for Reproductive Rights between June 2009 and February 2010, reveals that over 2,600 women die annually in Kenya and 21,000 are hospitalised each year in public hospitals due to complications arising from incomplete and unsafe abortions. The World Health Organisation thinks these numbers are gross underestimations due to underreporting. Worldwide, there are 19 million unsafe abortions every year, and they kill 70,000 women, accounting for 13 percent of maternal deaths. The vast majority occur in countries where abortion is illegal.

Why do so many Kenyan women seek abortions? Women’s activists say that women and girls, thrust uninformed and unprepared into a world of sexual politics, and then abandoned and condemned when their naivety predictably bears fruit, have little choice other than to turn to backstreet quacks. Though fertility levels have been halved since the 1970s, they are still double the government’s target. According to a 2003 study, 25 per cent of Kenyan girls and women aged 15 to 19 are either pregnant or have children. The 2003 Kenya Demographic and Health Survey revealed that close to half of all births are either unwanted or mistimed (wanted later). In a 1998 Alan Guttmacher Institute survey entitled Into a New World, 74 per cent of unmarried women aged 15-19 and 47 per cent of the married women reported their current pregnancy unwanted. If one also considers the pregnancies already terminated, it is then likely that significant majority of all conceptions are undesired and unplanned for.

This is compounded by ignorance of, and lack of access to, contraceptive methods. In 2003 70 per cent of all adolescents in the country engaged in unprotected sex and 85 per cent of girls and women aged 15 to 19 and 72 per cent of women aged 20 to 24 did not use contraceptives. A 1998 survey of Kenyan secondary school students found that only a third of males and a quarter of females knew that contraceptive pills had to be taken by the woman and not by the man; and even fewer knew the pills had to be taken daily, not just before sex. A report in the Nation last year revealed that young women used emergency pill far more regularly than recommended and that when it came to choosing emergency contraception, they consulted their schoolmates, the Internet and their boyfriends.

The consequences of pregnancy can be grim. The Nairobi-based Centre for the Study of Adolescence estimates that up to 13,000 Kenyan girls drop out of school every year as a result of pregnancy. These young girls are often treated as outcasts by their families. Many migrate to cities where they face unemployment, health risks and malnutrition. This, combined with the fact that the responsibility to care for a child born out of wedlock is placed squarely on the mother, condemns many to lives of hardship and grinding poverty.

The case of Ruth Njeri, a 20-year old domestic worker, is typical. She had to leave school after getting pregnant and then moved to Nairobi from her village in the Nakuru district in search of work as her father refused to support her or the baby. "I had completed my Form-IV (higher secondary) but after the child was born neither my family nor my school wanted me back. If I had wanted to study further at all, I had to go to a different school," she told the Inter Press Service news agency.

Many women already in informal or casual employment also fear for their jobs as employers are generally unwilling to afford them maternity leave. The social stigma too, can be overwhelming. “My parents would probably kick me out should they find out that I’m sexually active, so I don’t even want to imagine their reaction should I get pregnant today,” Sheila, a 22-year-old who is about to graduate from college, told the Nation last year. A Population Council study indicated that fear of pregnancy outweighs fear of contracting the HIV virus among E-pill (morning after pill) users — 79 per cent cited pregnancy as their biggest fear, while only 45 per cent thought they were at risk of contracting HIV through unprotected sex.

Further, despite the sharp decline in the number of women dying at childbirth over the past decade, Kenya still remains one of the most dangerous places in the world to give birth, ranking 13th out of 181 countries. In 2008, according to a study published in The Lancet, 6,200 Kenyan women died in childbirth, translating into roughly 413 maternal deaths per 100,000 live births, compared to a global average of 251 per 100,000 live births.

All this leads to predictable results. Studies in Kenya showed that 47 per cent of all young people below the age of 20 years who got pregnant while in school resorted to abortion. “Young unmarried women would rather seek an abortion than let their parents know that they’re pregnant,” says Wanjiku Gikang’a, a family therapist and university lecturer.

Confronted with these realities, the church prefers to bury its head in the Bible. Apparently caring little for practical concerns, it proposes supposedly eternal and unchanging dictates revealed to a dozen tribes wandering aimlessly in the desert more than 3,000 years ago, as appropriate policy solutions for a globalised world of over 6 billion. In fact, a recent study of religious attitudes in sub-Saharan Africa revealed that 57 per cent of Christians in Kenya favor making Bible the official law of the land. This is similar to Uganda’s Lord’s Resistance Army's deranged suggestion that a complex and modernising country be governed by the Ten Commandments.

The church continues to oppose sex education in schools and the free provision of contraception in order to “protect” adolescents’ morality. In 1997, the Catholic Church and anti-abortion groups forced the government to shelve a sessional paper on family life education that was to be discussed by parliament. If the paper had been adopted, sex education would have been introduced in schools and integrated with primary health care. The document would have been the basis for making students aware of the dangers of adolescent pregnancy, abortion, drug abuse, HIV/AIDS, and sexually transmitted diseases.

The Catholic Church’s view, that sex education would itself lead to sexual immorality at too early age, resulting in more teenage pregnancy, backstreet abortions and further spread of HIV/AIDS, is contradicted by the findings of Scholasticah Nganda, a member of the Sisters of Mercy, a Catholic women's order, and a lecturer at Kenyatta University's Department of Psychology. She states that primary school boys and girls are already engaged in sex and they are likely to continue to engage in premarital sex with or without sex education, citing a 2003 study of the policy of the Catholic Church that revealed that 81 per cent of Protestants, and 47 per cent of Catholics as well as 81.8per cent of health workers supported the introduction of sex education in schools.

In addition, while the churches paint a picture of a world where God wills every pregnancy to go to term, this is at odds with the evidence of nature. Spontaneous abortion (sometimes referred to as miscarriage) is a common experience for women. It is estimated that between 25 and 50 per cent of all conceptions spontaneously abort. Researchers do not have an exact figure due to the fact that when this occurs very early on, many women do not even know that they were ever pregnant. Fully a third of all pregnancies are spontaneously terminated by week 10 LMP (Last Menstrual Period), with studies suggesting reasons as morally irrelevant as age (one study found that pregnancies from men younger than 25 are 40 per cent less likely to end in miscarriage than those from men 25-29 years; women over 45 spontaneously abort 75 per cent of the time).

This is not to say that the unborn should be fair game. Each abortion, spontaneous or not, is a tragedy for it involves the death of a human being. The questions for the state — which unlike the church answers to the citizenry and not to God — should be these: What policy would lead to the least number of abortions? Is deterrence achieved by criminalising the act? Does legalising abortion lead to an increase in demand for the procedure?

As the evidence shows, legal restrictions, however severe, do not lead to fewer abortions. And since prohibition does not deter, legalising the procedure will not lead to an increase in the overall number of terminations — it just moves abortions from the backstreet and into proper medical facilities, saving women’s lives.

Indeed, when combined with sex education and the availability of contraception, a legal regime actually lowers demand for abortion. According to the 1998 Guttmacher Institute survey, nearly 46 million abortions were performed worldwide that year. Five years later, in 2003, despite the fact that 19 countries had liberalised their abortion laws over the period, and only three had tightened them, the total number of abortions worldwide had fallen to 41.5 million — amazing when one takes into account population growth. However, the number of unsafe abortions, which are overwhelmingly illegal, remained almost static. Therefore all the reductions happened in countries where the procedure was legal.

Researchers have also noted that while liberalisation was a key element in improving women's access to safer terminations and lowering demand, it was not the only factor. Even in countries where abortion is legal, lack of availability and cost still created a barrier. In India, for example, where terminations are legally allowed for a variety of reasons, some 6 million took place outside the formal health system. Other factors that were seen to be relevant to reducing the number of terminations included effective family planning services — which currently cost four times less than the public bill for sorting out conditions, from sepsis to organ failure, that result from botched abortions.

In much of Eastern Europe, where abortion was treated as a form of birth control, abortion rates dropped by 50 per cent as contraceptives became more widely available while globally, the number of married women of childbearing age with access to contraception had increased from 54 per cent in 1990 to 63 per cent in 2003.

Therefore, if public policy aims at reducing the number of abortions, securing the health of women and girls, and saving money in the process, then criminalising the procedure is not the solution. Legal terminations coupled with sex education, family planning services, and knowledge about as well as availability of contraception, are indisputably the way to go. In fact, addressing the 37th session of the UN's Commission on Population and Development in 2004, the then chief executive officer of the National Co-ordination Agency for Population and Development in the Ministry of Planning and National Development, Dr Richard Muga, affirmed that Kenya upheld the 1994 Cairo Plan of Action, which called for the integration of sexual education into the school curriculum and invited open debate on controversial issues, including abortion.

Even with all these measures in place, unwanted pregnancies, though greatly reduced in number, will continue to occur. To further reduce the instances of these turning into abortion cases, the government, since the early years of this century, has reversed the situation that previously saw pregnant schoolgirls barred from continuing their studies. The church could help out here by teaching its flock to be more accommodating and tolerant of those who have “fallen by the wayside” — those, incidentally, that Christ said were the ones he came to save.

1 comment:

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