By Scovia Mutesi
Nadine Akingeneye ( not her real name), an 18-year-old girl living in Ngoma district dropped out of school when she was in senior three due to poverty in 2019.
As a result, she got a domestic work where she then met a man who impregnated at a teen age.
“When I was pregnant I never went to the hospital for antenatal care. My family rejected me and no one else from who I could get support or give advice. The man who impregnated me advised me to do an abortion. He gave me some drugs for abortion but had never expected the bad impact they could have on me.
That is why after consuming them I started to blood a lot and felt pain. When my employers discovered it they took me to hospital,” she said.
However due to unsafe abortion, she said that till today her health is still not well and she has got some physical disability on her leg and can’t lift a heavy burden, she added.
She said that due to lack of family support and advice, limited knowledge about sexual reproductive health and not using contraceptives, limited access to family planning, stigma in the community led her to unwanted pregnancy and unsafe abortion.
Immaculee Ingabire, another girl from Rubavu district now aged 20 did unsafe abortion at a teen age after a man who impregnated her refused to give support.
“The bad situation started when I dropped out of school in primary six. I have no parents. Due to bad life because of poverty, I opted for domestic work. That is when I was impregnated in 2017. When the man who impregnated me refused to support me, a got an advice from a friend to abort. I went to a woman /traditional healer for help and gave me some herbs for abortion. These harmed my life because it was not safe.” she said.
She said that she was not aware that abortion can be allowed at the hospital because no health care provided had talked about it in their community.
She added that lack of knowledge about sexual reproductive health, limited access to family planning for adolescents, and expensive drugs that prevents pregnancy are still the main challenges.
These victims of teen pregnancies and unsafe abortion are among other thousands victims whose trend has been increasing in Rwanda.
Despite the measures implemented by the Government of Rwanda to reduce teenage and early pregnancies, research indicates that the rate is in fact increasing.
According to the Ministry of Gender and Family Promotion, in 2016 alone, there were 17,500 pregnant 16-19 year-old girls.
According to official statistics, 98,347 teenagers gave birth in the last four years in Rwanda, with many dropping out of school to become mothers.
In 2016, there were 17,849 teen pregnancies; in 2017 there was a slight decrease of 17,337, in 2018 this figure increased to 19,832 which means that compared to 2017 and 2018, the number of teenage pregnancies increased by about 2,495.
From January to August 2019, the number of teenage pregnancies was 15,696, which means at least 1,962 pregnant girls per month.
According to these figures, about 23,544 children were born to young mothers in 2019.
Defilement cases have been on trend.
Statistics from Rwanda Investigation Bureau (RIB) indicate that child defilement reached 7,480 cases of children aged below 10 and 17 years old between July 2018 and June 2020 (of whom 7, 289 female).
RIB says that from January to August 2021 alone, 3,877 cases of defilement were recorded and are on top of other sexual GBV and child abuse cases.
According Jean Marie Vianney Gatabazi,sexual Gender-based violence crimes continue to increase. GBV is a crime that should not have a place in our country, where rights and equality are key to our development.
He said that in a collaborative effort to fight against GBV, East African countries established a "Regional Center of Excellence on GBV and Child Abuse" headquartered in Rwanda.
IGP Dan Munyuza said that GBV cases are hardly reported and acknowledged which is harmful and costly to families and the society in general.
“We urge everyone to report timely in order to prevent or respond appropriately,” he said.
Most identified cases of GBV are; Child defilement, harassment of spouse, assault and battery, rape and fraudulent use of family property. We have to strengthen our partnership in educating, raising awareness and timely reporting to end gender based violence. He said.
What is behind trending teen and unwanted pregnancies?
According to a policy brief by Health Development Initiative (HDI) by age 19, at least 21 percent of girls in Rwanda have begun childbearing.
The increasing rate of unwanted and unplanned pregnancies among young people, it says, is indicative of the lack of access to reproductive health services.
It is reported that 93 percent of adolescent girls who are not using contraceptives have also not discussed family planning at a health care facility or with a health care worker.
According to figures by Rwanda Demographic Health Survey, 13 percent of adolescents without formal education started childbearing compared to only 9 percent of adolescents with primary education and 4 percent of adolescents with secondary education.
These statistics show that vulnerable groups such as those living in rural areas, have limited education and income and encounter greater challenges in accessing reproductive health information and services.
Limited access to safe abortion services
HDI mentions that the limited access to safe abortion services also leads to mortality and morbidity.
As the latest available data indicates, an estimated 60,000 abortions are carried out annually, almost all of which are unsafe.
Further, half of all abortions in Rwanda are performed by untrained individuals and are considered to be very high risk.
An estimated 34% are provided by traditional healers and 17% are induced by the women themselves.
As a result, 24,000 women and girls develop complications, out of which one-third do not receive treatment.
In addition to the health consequences, Rwandan women and girls continue to face incarceration for procuring abortions.
A study conducted by HDI, for instance, revealed that from all those incarcerated in the four prisons covered in the study, more than half are young girls below the age of 24.
Out of these, 18% are between the ages 15-19.
As research indicates, adolescents in Rwanda encounter multiple impediments in accessing reproductive health information and services.
These include lack of information, refusal of health care providers to provide services to young people, lack of parental support, cost of services and limited youth-friendly services.
Other barriers are based on the fact an estimated 60 percent of health service centres and hospitals are owned by faith-based organization that do not provide family planning, contraceptives and abortion services.
In a tweet by Cardinal Antoine Kambanda, he said: “Life is the gift from God. Respecting life is respecting God. Abortion is a serious sin. It means killing a baby. It is taboo and atrocity.”
According to Theobald Mporanyi, a public health expert with Health Development Initiative (HDI), urged churche-owned health hospitals to start providing abortion services allowed by the law.
He said safe abortion service services will also reduce a number of suicides caused by those who lack access to safe abortion.
Gaps in laws
According to the 2018 law on abortion women including girls below 18 years have a right to terminate a pregnancy before it is 22 weeks old, under certain conditions including: in case the pregnant person is very young, in case the pregnancy is a result of incest (up to second cousins), in case the pregnancy is a result of rape, and in case the pregnancy was a result of forced marriage.
A person may also seek abortion if the pregnancy poses a health risk to their lives.
In October 2018, the government removed the requirement for court approval prior to an abortion procedure among other changes.
These changes came into effect with a ministerial order established in April 2019.
The ministerial order outlined the conditions for a medical doctor to approve and provide abortion care.
However there are still challenges on access to safe abortion.
The Human Reproductive Health Law, which was drafted in 2016, defines reproductive health as “a state of human, physical, mental and social well-being in all matters relating to the reproductive system and its functions and processes.”
It further recognizes that “every person has the right to access education and medical services related to human reproductive health” and that “no person shall be denied such rights based on any form of discrimination.”
However, contrary to these affirmations, the legislation provides: “every person having attained the majority age has the right to decide for oneself in relation to human reproductive health issues.”.
This clearly discriminates against adolescents by denying them the right to make decisions about their reproductive health since the age of majority in Rwanda is 18 years, as stipulated under article 113 (1) of Law Nº32/2016 of 28/08/2016 governing persons and family.
While imposing this restriction, the legislation is silent on how adolescents can access the reproductive health information and services that it affirms everyone has the right to access.
In addition, according to the WHO, safe abortion services are core aspects of reproductive health services and the Rwanda’s National Family Planning and Adolescent Sexual and Reproductive Health Strategic Plan (2018-2024)30 recognizes post-abortion care as a component of sexual and reproductive health services that should be available to all including adolescents.
Further, the Law Determining the Offences and Penalties in General recognizes that adolescents can legally obtain abortions.
However, in contradiction to all of these, the law relating to Human Reproductive Health fails to recognize safe abortion and post-abortion care as key components of reproductive health services.
The Law Determining the Offences and Penalties in General specifies the conditions under which abortion services can be provided legally.
Per Article 125, there is no criminal liability if the pregnant person who has the abortion is below the age of 18.
Before a minor can obtain an abortion, the law requires the person who has parental authority over the minor to file the request before a medical doctor and provide the child’s birth certificate.
When there is a disagreement among those who have the parental authority or when they disagree with the minor, the wish of the minor will prevail.
The same requirements are affirmed under the Ministerial Order, which was issued to guide implementation of these provisions and determine the conditions to be satisfied for a medical doctor to perform an abortion.
However, while it is commendable that the revised law enshrines provisions aimed at facilitating adolescent’s access to safe abortion services, there is still limited evidence regarding whether they have managed to expand adolescents’ access to the service; some implementation challenges can be envisaged.
For instance, neither the Law Determining the Offences and Penalties nor the implementing Ministerial Order provide guidance on the process the health care provider should follow to ascertain the position of the parents particularly when the parents disagree with the minor’s decision to terminate the pregnancy.
Therefore, rather than taking into consideration the statement of the minor regarding the parents’ position and deeming it to be sufficient, a health care provider might adopt a more restrictive approach and ask the minor to provide evidence showing the position of the parents.
This creates an additional burden and can discourage adolescents from seeking the service and defeat the purpose of the law, which is to ensure that adolescents can safely terminate pregnancies without putting their lives and health at risk.
Recommendations
According to the policy brief, activists recommend amendment of article 7 of the law N° 21/05/2016 of 20/05/2016 relating to human reproductive health.
It recommends to allow all adolescents to access the reproductive health services without needing authorization from a parent or guardian, recognize safe abortion and post-abortion care as essential components of reproductive health services.
It also recommends amending article 11 of the law N° 49/2012 on medical professional liability insurance, with the view to allow all adolescents to seek health care services, without prior parental/ guardian consent or authorization from a second health care professional.
“Undertake awareness raising activities targeting both in school and out of school adolescents to ensure that they are aware of their sexual and reproductive rights; the laws and policies that regulate these services; and where and how they can access information and services,” HDI recommends.
Key recommendations International Safe Abortion Day and Contraception Day
28 September 2021 marked International Safe Abortion Day.
For this year’s international day of action, stakeholders around the world are coming together behind the call “Make Unsafe Abortion History”
On the day, FIGO said that that access to safe abortion is time-sensitive essential health care and that providing access to safe abortion is imperative for women and girls to achieve their human and reproductive rights.
Unsafe abortion remains a preventable public health tragedy and a violation of women and girls’ human rights.
It accounts for 13 percent of global maternal mortalities, with hundreds of thousands of survivors living with long-term complications, including infertility and chronic pain.
The organization launched key recommendations on safe abortion.
These include addressing barriers to safe abortion, Improving Access to Abortion beyond 12 Weeks of Pregnancy, Post-Abortion Contraception, including Long-Acting Reversible Contraceptives and Abortifacient Product Quality.
On Contraception Day 26 September themed: “Let’s adopt family planning to be healthy.”, family planning services were mentioned to be so helpful but activists said there are still barriers to adolescents to have access.
Dr Felix Sayinzoga, the Division Manager of Maternal health at Rwanda Biomedical Center (RBC) said that discussions to remove barriers of laws has started between the Ministry of Health and law makers and more interventions to increase infrastructures are under progress.
“We are looking on how to increase training to healthcare providers and increase health facilities that give family planning services so that all people manage to access these services near them and on low cost.” Sayinzoga said.
“It has been realized that adolescents aged between 15, 16, and 17 years old are sexually active. Most of them face early pregnancies as a result of lacking access to contraceptives.
This, in the end lead them to a miserable life where themselves and their children get stunted and face other issues including lack of capacity to pay health insurance for example.
It is a must that all the laws that deprive them the rights to access contraceptives are revisited, ” said Aimable Mwananawe, National Coordinator of Ihorere Munyarwanda Organization (IMRO).
