When Cynthia was raped by her abductors, who later released her, she knew she was in for more trouble. Missing her menstrual period for two months heightened her fears.
Testing positive for pregancy broke her further.
She wasn’t ready to swallow another bitter pill – keeping the unwanted pregnancy from ‘evil’ men.
The unpreparedness, stigmatisation and fear of the unknown got the larger part of the 35-year-old and her blood pressure became high. She thought of only one way to get out of her troubles – termination of the pregnancy.
She unfortunately opted for a ‘quack doctor’ to avoid shame but, alas, the unsafe abortion resulted in complications that took her life.
Sadly, Cynthia is among 14 per cent of Nigerian women who have died as a result of unsafe abortion.
According to the World Health Organisation (WHO), unsafe abortion is a leading but preventable cause of maternal deaths and morbidunsafe
It can lead to physical and mental health complications and social and financial burdens for women, communities and health systems.
Unsafe abortion, as defined by WHO, is a procedure for terminating an unintended pregnancy, carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards or both.
Data from WHO shows that globally, 4.7 per cent to 13.2 per cent of annual maternal deaths can be attributed to unsafe abortion.
Every year, an estimated 287,000 maternal deaths occur globally to which Nigeria contributes 14 per cent. Unsafe abortion accounts for about 10 to 14 per cent of maternal morbidity and mortality in Nigeria.
In an effort to reduce preventable maternal deaths, Lagos State Government, on June 28, released a document entitled “Guidelines on Termination of Pregnancy for Legal Indications.”
The 40-page document modelled after the National Guidelines for Legal Indications (2018) prepared by the Federal Ministry of Health is designed to provide guidance to medical practitioners and other stakeholders on when it is lawful or unlawful to terminate a pregnancy.
According to Lagos State Government, the goal of the document is to serve as a tool for provision of safe termination of pregnancies within the legal framework in circumstances whereby continuation of such pregnancies threaten the lives or physical and/or mental health of women.
It hopes that the Guidelines will help to reduce maternal morbidity and mortality in Lagos and, by extension, Nigeria.
It notes that Nigeria has the second-largest burden of maternal mortality globally, after India, regretting that many of the deaths are of known causes and preventable.
According to the state, a neglected area of preventable maternal deaths is related to the provisions of the Nigerian Abortion Law.
It acknowledges that the Nigerian Abortion Law permits termination of pregnancy in circumstances where the continuation of pregnancy threatens the mother’s life but “unfortunately, no formal efforts have been made through the development of policy instruments, guidelines or tools to implement these provisions to save the lives of Nigerian women whose existence is threatened by continuation of their pregnancies”.
It points out that induced abortion is illegal in Nigeria except when performed to save a woman’s life and that the penal code and the criminal code allow this exception, with specification of criminal penalties for non-compliance.
Lagos State had reviewed its abortion law in 2011 to extend the provisions to the mother’s physical health.
“Consequently, this Guidelines for Lagos State is intended to standardise practice and build the capacity of medical professionals in public and private facilities to identify pregnancies for which the law is intended so that ethical and safe management can be instituted.
“The document provides information on subsisting Nigerian law on termination of pregnancy, Lagos State revised law 2011, a compendium of medical conditions and circumstances where the continuation of pregnancy endangers the woman’s life, and describes the step-by-step options for ethical and safe medical management.
“It is envisaged that the enunciation, deployment and use of this Guidelines will preserve the lives of pregnant women from dying and assist those whose physical or mental health would be compromised with the continuation of their pregnancies,” it says.
According to the state, medical conditions that may constitute a threat to the life and physical health of a pregnant woman and make her to benefit from safe legal termination of pregnancy include obstetric and gynaecological conditions such as genital tract cancers, severe fetal conditions or malformation not compatible with extrauterine life.
Other conditions are heart and vascular diseases, including uncontrolled hypertension in the first or second trimester, pre-eclampsia and eclampsia and pulmonary embolism.
Kidney diseases, cancers, blood diseases, autoimmune diseases, diabetes mellitus refractory to treatment or with organ failure, can pose a threat to the life and physical health of a pregnant woman.
Similarly, psychiatric and other mental disorders which include psychiatric disorders with suicidal ideation, severe depression with suicidal tendencies, which may occur in rape and incest, can constitute a threat to the life and physical health of a pregnant woman.
Lagos State believes that having guidelines on safe termination of pregnancy for legal indications is very important as no woman should lose her life or have her physical or mental health compromised from conditions that can be prevented or addressed.
“It is in this regard that it is important to disseminate and implement the Guidelines as accepted by the Government of Lagos State to ensure that every woman in Lagos State gets the right care she deserves at the right time and place for safe termination of pregnancy for any legal indications,” the government states in the document.
It highlights standards and best practices with regard to legal indications, pre and post procedure care, methods and monitoring.
At the launch of the document, Dr Olusegun Ogboye, Permanent Secretary, Lagos State Ministry of Health, had said that the document was for safe termination of pregnancies within the ambit of the Criminal Law of Lagos State.
According to Ogboye, the document will provide evidence-based data and other information for health workers in public and private sectors with the requisite skills to provide safe termination of pregnancy to reduce preventable deaths.
He gave the assurance that the document had undergone consultations with relevant technical stakeholders within the legal and health service context in the state and also with key opinion leaders in South-West Zone.
However, the state government’s release of the Guidelines has been frowned at by some residents and religious groups.
The Catholic Archbishop of Lagos, Most Rev. Alfred Martins, describes the release as legalising abortion through the backdoor.
Martins is worried that the Guidelines will create room for indiscriminate procurement of abortion.
He says it is untrue that all stakeholders were consulted in the process of drafting the Guidelines.
“The issue of abortion touches very much on ethical and religious sensibilities, and religious bodies were not consulted.
“Certainly millions of Catholics, who have always maintained their strong opposition to legalization of abortion in any guise, were not consulted.
“The baby in the womb is a person that is distinct from the mother though he is in the mother’s womb; so, not even the mother has the right to kill him, talk less of the government purporting to give legal backing for their murder.
“We need to continue to explore ways of providing support for women who find themselves in difficulty as a result of their pregnancies rather than thinking of aborting a child who is innocent of the difficulty that the mother may be going through.
“Any attempt to terminate the life of an unborn child is tantamount to murder and should be treated as a capital offense,” Martins argues.
The cleric advises that the focus should be on proper enlightenment on human sexuality and collaboration, in order to support women who get pregnant without being ready for the pregnancy.
Prof. Adetokunbo Fabamwo, Chief Medical Director, Lagos State University Teaching Hospital and a contributor to the development of the Guidelines, clarifies that the document does not support indiscriminate and illegal procurement of abortion.
“There are only two lawful grounds for therapeutic termination of pregnancy, and they are for the preservation of a mother’s life and preservation of the woman’s physical health.
“We are not allowed to conduct pregnancy termination because someone says ‘I don’t want this baby; I’m not ready for it or I’m too young for it.
“The guidelines make it clear to public and private hospitals in the state what is allowed under the legal ambit in Nigeria,” Fabamwo, a Professor of Obstetrics and Gynecology, explains.
On the implications of the Guidelines to the state’s maternal health indices, Fabamwo is convinced that it will reduce maternal mortality and morbidity arising from unsafe abortion since therapeutic abortion will be conducted by specialists in obstetrics and gynecology.
For Dr Tunji Akintade, a former Chairman, the Association of Nigeria Private Medical Practitioners, the state government should be praised for coming up with the Guidelines which, he says, will improve maternal health.
He regrets that many women have died as a result of unsafe abortion.
Akintade is of the opinion that restricting access to safe abortions means will drive women into unsafe abortions, resulting in complications and, in some cases, deaths.
“Over the years, medical practitioners have been scared of prosecution, even when the life of a woman, her baby or her mental health is threatened due to pregnancy; they feel so reluctant to do anything to save her.
“Such a woman does not need to suffer based on a medical condition that got worse due to her pregnancy, and delay in providing medical intervention for such a woman can lead to death.
“We need to remove prejudice when lives are at stake. More so, every pregnancy is not the same; some women might have it easy while some might not.
“People should move beyond criticism and trying to force their religious beliefs on others,” he argues.
Akintade points out that proper documentation of the process is emphasised on the Guidelines to check abuse.
In reaction to the condemnation of the release of the Guidelines in some quarters, the state Gov. Babajide Sanwo-Olu, on July 7, directed suspension of the implementation of the Guidelines.
In a statement released by the state Commissioner for Health, Prof. Akin Abayomi, the governor directed further sensitisation of key stakeholders and members of the public to ensure a clearer understanding of the objectives of the Guidelines.
According to him, the state ministry of health is seeking different methods to eliminate illegal abortions and ensure that a mother does not die at childbirth and disrupt an entire family unit.
The governor is worried that illegal abortions and high risk pregnancies leading to unresolvable complications, rank high among contributors to maternal mortality.
According to him, the focus of the Guidelines is on creating opportunities to reduce maternal mortality in line with existing laws.
“In this regard, it became imperative to examine, in keeping with existing national and state laws and policies, if there are indeed justifications and medical reasons to offer abortion to a woman whose life is threatened by a pregnancy.”
Sanwo-Olu says suspension of the implementation of the Guidelines will enable the state executive council to deliberate on the matter and ensure adequate public sensitisation and stakeholder engagement to reach a consensus required for a successful guideline development.
Analysts urge expedited deliberations, sensitisation and engagement of stakeholders to ensure timely resolution of any issues around the Guidelines and take desired actions that will save lives of more pregnant women.