By Lily Biddell
The coronavirus pandemic has wreaked havoc on pregnant people seeking abortion all over the world. Access to abortion varies widely and is country specific; from tight restrictions which completely ban abortion (such as in Angola and Iraq) or allow it only to save the mother’s life (Mali and Brazil), to terminations on demand until the point of viability (the UK and the Netherlands). Covid-19 lockdowns, curfews and social distancing measures have impacted abortion access majorly, causing over 5000 reproductive health clinics across the world to close. The impact has been particularly detrimental in Kenya, a country where already 43% of pregnancies are unintended. Unintended pregnancy has two main outcomes: unsafe abortion and unplanned births.
Roughly 465,000 unsafe abortions are sought out each year in Kenya, using various methods including ingesting harmful substances and herbal concoctions, inserting foreign objects into the uterus or cervix, or applying pressure to the abdomen. It is common for “quacks” - unqualified ‘backstreet’ providers - to perform unsafe and clandestine procedures, frequently resulting in severe complications, hospitalisation, and death. In Kenya, seven women and girls die from unsafe abortions every day.
Kenya’s Reproductive Healthcare Bill (2019) states that “a trained health professional can perform legal abortions when the health or life of a pregnant person is in danger, in cases of emergency, or if there is a risk that the foetus would suffer from a severe physical or mental abnormality that is incompatible with life outside of the womb”. In other words, abortion is permitted in Kenya if it preserves health, however it is not permitted on the request of the pregnant person.
Whilst the bill reaffirms the legal basis for access to abortion, which is already in the Kenya Constitution, unsafe abortion persists in Kenyan society. This is due to widespread stigma around the issue concerning religious and cultural beliefs. Many believe abortion is wrong, illegal, and a sin, and that a woman is promiscuous and shameful if they have one. Young, unmarried women with lower socioeconomic status are much more likely to bear the brunt of abortion stigma in Kenya. Consequently, unsafe abortion accounts for 35% of maternal deaths in the country, a figure that is much higher than the global average of 13%.
High-risk adolescent pregnancies have long been a societal challenge in Kenya. Premarital sex is common and childbearing begins early, with almost one-quarter of women giving birth by age 18. Girls who find themselves pregnant but cannot terminate the pregnancy are likely to drop out of school and undergo childbirth complications - up to 13,000 Kenyan school girls drop out each year. Despite the implementation of the “return to school” policy for teenage mothers being active since 1994, take up has been slow. The policy encourages teenage mothers to go back to school after delivery, and provides them and their parents with counselling. However, studies show that failure to implement the policy is because many girls, teachers and parents are not aware of it, and if they are, girls face high levels of stigmatisation and social exclusion upon their return.
Teenage girls and boys receive critical Sexual and Reproductive Health and Rights (SRHR) information and advice in school. However, with coronavirus forcing all educational institutions in Kenya to close from March 15th, this information is no longer accessible in the same way, resulting in what has been called a teenage pregnancy national disaster. With no school to go to, adolescents are engaging in sexual activity without taking the necessary precautions, having ‘survival sex’ for income, or experiencing violence from sexual aggressors. It was announced in July that schools and universities would remain shut until at least January 2021, however it has just been declared that schools will reopen on October 19th if the government adopts proposals by a committee appointed by Education Cabinet Secretary George Magoha. These school closures coupled with SRHR service reductions could mean 4000 additional unintended school girl pregnancies in Kenya, plus thousands of unsafe abortions and pregnancy-related deaths.
The Impact of Covid-19
It is not only school closures and reduced SRHR services that are fuelling unplanned pregnancies and unsafe abortions at this uncertain time. Supply chains that bring vital safe abortion medication and contraceptives from Asia to East Africa have been delayed and disrupted due to the pandemic. DKT International, one of the world’s largest providers of contraception and safe abortion products, ran extremely low on its stock of medical abortion pills (misoprostol and mifepristone) for its Kenya programme after air cargo delays caused thousands of packs to get stuck at New Delhi airport for nearly six weeks. Even after these were flown and shipped over, staff shortages at the port of Mombasa caused further delays, due to quarantine requirements.
Strict lockdowns and curfews in Kenya have added to the chaos so that girls and women are often not able to travel to clinics where they can receive the abortion care they require. If they are able to travel, rising transportation costs for matatus and compulsory face masks (a big expense for many Kenyans) once again restrict them from accessing critical SRHR care. It is at this point that they may choose to visit a local neighbourhood “quack”, thus putting their health and lives in danger. Poor, rural, and marginalised communities will be heavily affected because mobile outreach programmes cannot get to them at all.
Underpinning any Covid-19 rise in unintended pregnancies and unsafe abortions is insufficient funding. The US is historically a major contributor to Kenya’s healthcare budget, however, since the implementation of the global gag rule, Kenyan reproductive health and family planning organisations have struggled with reduced financing. Nelly Munyasia, head of the Reproductive Health Network Kenya (RHNK), a group of pro-choice health providers and advocacy organisations, says that “the global gag rule has worsened the situation because if only we had continued to get the funds, it would have been easy for us to be able to quickly integrate COVID into the existing [sexual and reproductive health] programmes.”
So what is being done to combat this crisis?
Despite all these problems, the pandemic is presenting an opportunity to adapt, rethink, and restructure abortion services and care both in Kenya and around the world. Marie Stopes International has so far been effective in delivering accurate Covid-19 and SRHR information using megaphones, door-to-door visits, community radio messages, and social media - Facebook Messenger and WhatsApp have been particularly successful platforms for abortion referrals. In just one day at the start of the pandemic, Marie Stopes Kenya received around 300 WhatsApp messages from women and girls asking for advice.
Toll-free hotlines are springing up to replace face-to-face appointments: a group of RHNK youth advocates created messages and artwork for a new campaign called Nena Na Binti, meaning “speak up”. This number provides safe abortion and contraceptive referral services. Similarly, the Aunty Jane Hotline launched by the MAMA Network (Mobilizing Activists around Medical Abortion) has provided critical SRHR to girls and women around Kenya during the pandemic. MAMA’s #AbortionBeyondLockdown campaign for International Day of Action for Women’s Health was also vital in bringing awareness to abortion as an essential service.
The biggest change to abortion services we have seen in the face of the pandemic is the wider use of telemedicine to provide medical abortion at home. The UK has led the way with this since March, and just recently Italy has approved outpatient use of abortion medication as well. Those eligible can take both misoprostol and mifepristone for medical abortion up to ten weeks in their own homes, without having to take the first dose at a clinic. The abortion medications can be collected from a centre or posted, after a phone consultation. Hesperian Health’s ‘Safe Abortion’ App is a discrete and comprehensive way to learn about and prepare for self-managed abortion (SMA). It is available in many languages, including Igbo, Yoruba, and Swahili.
The MAMA Network has been trying to make SMA more accessible across Africa. It is hoped that it will become a viable option for Ghana and South Africa in the coming weeks since SMA offers a means of safeguarding women and providing for their critical healthcare needs, especially during a pandemic. Kenya, however, appears to be a long way off until this happens. Barriers the country faces include weak infrastructure, government policy, cost, and fierce backlash from religious and conservative groups.
Backlash and resistance
Kenya has a history of fierce opposition towards SRHR issues. In 2013 the Kenyan government committed to scaling up sex education in order to combat the increased rate of teenage pregnancies in the country, starting with courses in primary school. However, strong resistance from the Church in the form of online campaigns means that sex education still tends to focus on HIV prevention and abstinence. Misinformation is rife, including the common belief among secondary school students that using a condom during sexual activity is a sign of mistrust.
The recent reproductive rights bill has faced much criticism, with opponents claiming that the constitution of Kenya forbids abortion, which is incorrect. Others claim the bill is extending the legalisation of abortion beyond what is in the constitution - also incorrect -, and others falsely allege that the bill states medical providers must perform abortions regardless of their religious beliefs or values. The bill does in fact allow for conscientious objection.
What are the solutions?
Abortion is a time-sensitive service, with delays and denials leading to unsafe abortions and deaths. The pandemic is presenting the world with an opportunity to change this. We know that pregnancies do not pause for a pandemic - during the Ebola crisis, there was a 65% increase in teenage pregnancy in Sierra Leone for the aforementioned reasons. Kenya is experiencing a similar situation where its legacy of teenage pregnancy will almost certainly outlast the coronavirus.
Women and girls need free or low-cost telemedicine available for self-managed medical abortions in the first trimester. SMA is not only critical at a time when curfews and quarantines exist, but it also puts control over the process back into the hands of pregnant people, fostering privacy, autonomy, and confidentiality. For pregnancies in the second trimester, clinics must remain open so that surgical procedures can be performed, and people must be fully informed on the virus, so they are not put off from going in because of fear of infection.
For those in more rural areas with little or no phone or internet access, home deliveries via motorcycle taxi could be a good alternative, as has been done in Uganda with SafeBodas. Male boda boda drivers in Kenya should follow suit, having recently become ambassadors of change for the awareness campaign “Linda Binti” (meaning “protect the girl”). This collaboration between Woman’s Hope Kenya and Polycom Girls aims to educate motorcycle riders on ending teenage pregnancy, and they are given campaign reflector jackets to promote the message as they drive around. This is an excellent initiative, involving men in the conversation on teenage pregnancy and abortion.
To support telemedicine abortion as a common solution, Kenyan schools need comprehensive sex education including acknowledgment of the safety of medical abortion. States must recognise that safe abortion is an essential health service and a basic human right, so that there is sufficient SRHR funding. We know that where contraception and safe abortion are universally available, there is less need for abortion. There must also be action to ensure that supply chains remain open so that contraceptives and abortion medication can reach the people who need them. Reproductive rights do not stop for a pandemic; they are even more necessary and vital at this time.