International

Abortions in Nigeria are legally restricted, unsafe – and common

In the West African country, unsafe abortions are a major cause of maternal death

Bunmi Aiyenuro, 23, at a Wednesday-evening service at Christ Embassy Church in Lagos, Nigeria, Sept. 4, 2013.
Allison Shelley

LAGOS, Nigeria — Bunmi Aiyenuro slips through the cramped alleys and crowded marketplaces that twist through her neighborhood. Mostly, her impeccable manners and quiet demeanor help her fade into the mass of vendors and pedestrians. But every so often, she runs into teenage boys catcalling her or clashes with an uncle, her evening walk devolving into a screaming match next to the train tracks.

Aiyenuro grew up in Badia East, a crowded slum tucked off a Lagos highway, hugging a rail line. The neighborhood is dense and urban, and Aiyenuro has learned to negotiate the frenetic scene. But at 23, she is still learning to juggle the conflicting expectations for her as a young woman.

At 16, she fell in love with her second boyfriend, a student. They spent seven years together. Over the course of the relationship, she had seven abortions.

In Nigeria abortion is legally restricted, permitted only to save the life of the mother. But at least 760,000 abortions happen every year, mostly outside the legal parameters, and from 3,000 to 34,000 women die annually from unsafe abortions, according to reports by the Guttmacher Institute and the government of Nigeria. (The numbers range widely because of the difficulty tallying the secret procedures.) While safe abortions have a very low complication rate, unsafe ones — those performed by providers without adequate training or in a setting that does not meet medical standards — can lead to hemorrhaging, infection and perforation of the bowels or uterus and death.

Abortion providers here are part of a shadowy economy. Many are poorly trained, and the market is unregulated. But while abortions are secret, they happen all the time and across the social spectrum. Some wealthy Nigerians can access and afford skilled doctors; many poor women like Aiyenuro are left with dangerous, cut-rate quacks.

In the United States, where abortions are legal, there are 0.6 deaths for every 100,000 procedures; in sub-Saharan Africa, the rate is 460 deaths per 100,000 procedures, according to Guttmacher. Africa has a higher abortion rate than the U.S., despite restrictive laws in most countries. Across the continent there were 29 abortions per 1,000 women in 2008, compared with 19 in the U.S., Guttmacher figures show.

Nigeria has one of the highest rates of maternal death in the world, with 545 per 100,000 live births in 2008, though estimates vary. In Lagos, abortions cause half of the deaths of pregnant women, according to the Campaign Against Unwanted Pregnancy, an advocacy group.

"We all know that septic abortion precisely has a lot of impact on maternal mortality in Nigeria," said Dr. Bose Adeniron, head of the reproductive-health division at the Federal Ministry of Health. 


Abiodun Ibrahim lives in Nigeria and is debating whether to have an abortion.
Abiodun Ibrahim, 24, is debating whether to have an abortion.
Allison Shelley

SLIDESHOW: IN LAGOS, A WOMAN FACES A DIFFICULT CHOICE

Abiodun Ibrahim lives in Badia East, a slum built on a marshy landfill. She is four months pregnant and newly homeless. The man she calls her husband is in prison. In a country where abortions are legally restricted and often unsafe, dealing with an unwanted pregnancy is particularly difficult. 

Watch a slideshow of women in Badia East and read more here


But aside from a few abortion-rights activists who are pressing to promote safer conditions and to liberalize laws state by state, abortion remains taboo. Reproductive-health activists are reluctant to discuss the issue for fear of undermining progress in other areas, such as access to contraception.

Nigerian President Goodluck Jonathan last year pledged $33 million to increase funding for contraceptives and push states to provide free contraception in public clinics. But that program generated controversy, with Catholic organizations calling for the money to be redirected to education and other health issues.

This summer, meanwhile, the southern state of Imo passed a law that would have permitted abortion in cases of rape, incest or mental or physical health consequences for the mother. Abortion-rights activists considered this policy a victory. But after intense lobbying by the Catholic Medical Practitioners Association, the state assembly repealed the law.

Along with national and state laws, cultural perceptions of fertility, morality and religious obligation — Nigeria is the second-most religious country in the world, according to a 2012 Gallup poll — have created a deep stigma around abortion.

Clinics and pharmacies provide abortions that are paid for under the table. In Badia East, women can buy abortifacients from herbalists hawking homemade remedies or from drug vendors with pharmacies crammed into baskets on their heads. Women also go to clinics, but the low price they pay there (typically $12.64 to $31.64) is an indication that the service will be substandard and may lead to long-term pain, infertility or other complications.

"The one person who will do it for really cheap is the quack, and he will cause the abortion complications," says Olasurubomi Ogedengbe, a professor and consultant ob-gyn at the public Lagos University Teaching Hospital.

I wanted the baby, but my boyfriend didn't want it. We had a big quarrel about it. He said if I don't go remove it, I would raise the baby by myself.

Bunmi Aiyenuro

Aiyenuro has been living in a clinic — an open-air concrete structure run as an informal community center called Better Life — since she and nearly 9,000 of her neighbors were evicted from their homes to make way for a new housing project. She unrolls her mattress and lies down with dozens of other displaced people. She tries for privacy in hallways and corners, so when she speaks of her abortions, her voice and gaze drop in secrecy.

Both of her parents died when she was young, she says, so she depends on an unstable tapestry of friends and extended family. Before that, she depended on her boyfriend, who supported her and made the decisions in their relationship, including when to have her abortions and where she would go.

He paid $18.87 for each of her procedures, on the lower end of the scale. She declined to say where she got them done but described it as a clinic. The health worker suspended her legs, then, she said, "pumped" out her uterus and gave injections for the pain and antibiotics. Aiyenuro most likely had a manual vacuum-aspiration procedure, which is a suctioning of the uterus and, from the rate she paid, most likely was not seen by a doctor.

She said that, in between her abortions, she never used contraceptives. In fact, she said she didn't know what contraception was. While it seems implausible that an urban woman who studied to sixth grade, speaks English and styles hair around the city wouldn't know about birth control, only half of young Nigerian women surveyed in a 2005 study had heard of contraception. While almost two-thirds had had sex, only 11 percent had ever used contraceptives. Contraceptives are free at government health centers, and the rate of contraceptive use has crept upward, but it remains in the midteens.

After Aiyenuro's seven abortions, her boyfriend decided he was finally ready to have a baby with her. But after two miscarriages, he lost patience. "After the miscarriage, he started hating me, beating me, talking to me anyhow because I didn't have the pregnancy," she said. He left her and started dating her best friend.

Terminating her pregnancies was never her idea, Aiyenuro said. "I wanted the baby, but my boyfriend didn't want it. We had a big quarrel about it. He said if I don't go remove it, I would raise the baby by myself."

For many Nigerian women, providing their partner with children is a central role in their lives. Fear of long-term infertility, meanwhile, surfaces regularly in family-planning and abortion debates.

Adeniron said this is a key reason abortions are controversial and secret. "If a woman continues to do that, eventually when she gets married legally, she may not be able to have children, so there is a lot of stigma attached to it," she said.

"It's the cultural setting," she said. And a huge part of the culture is the country's boisterous religiosity.

Abortion is no good. If you abort, you are going to hellfire.

Bunmi Aiyenuro

A local
A local hawker sells drugs from a basket in the Badia neighborhood of Lagos, Sept. 14, 2013.
Allison Shelley

In Lagos, churches and mosques dot almost every street, and services can be heard every day of the week. In addition to influencing politics, religion plays a central role in Nigerians' daily life. Nowhere is this more obvious than in the abortion debates. One former provider, who requested anonymity, said that he quit his practice after being hounded by Pentecostal Christians, who would call and tell him he was headed to hell.

Aiyenuro has attended church for many years, if not with perfect consistency; her evangelical faith has left her with regrets about her abortions. "They say in church, 'Don't do it. Anyone who does it is a sinner,'" Aiyenuro said. She was vehement, a sense of guilt evident in her voice as she said, "I've killed an innocent soul."

Walking through the bustle of sunset in Badia, she looked fresh in her pink plaid shirt, ready for church. But when she arrived for a prayer service, she wilted next to Kudi Okere, the pastor's wife, clad in pumps, a fitted blazer, business pants and pearls. Okere has been leading services for several years and saw Badia as a neighborhood ripe for revival. "We used to call this neighborhood Sodom and Gomorrah," Okere told Aiyenuro. "Now we call it Jesus City. We go inside there and minister to them, and some of them, their lives have changed, through the word of God." Aiyenuro listened politely.

They were chatting on a balcony just over the busy paved avenue as the sun set. The sidewalk market spilled onto the road, competing with pedestrians, SUVs and rickshaws for space.

Later, after the service started, Aiyenuro prayed in an empty row. The six rows of plastic chairs, stamped with "I love God" on their backs, were more than enough to seat the small congregation, composed of three adults, three lounging toddlers and five organizers from the Christ Embassy Church. "Abortion is no good. If you abort, you are going to hellfire," she said later. "So I'm thinking when he's praying, I'm begging God for forgiveness for my sins."

Adeniron said she felt the country would not shift its approach to abortion.

"In the life of any country there are stages," she said. "The stage (where) we are now is that, for us, abortion is illegal, although we know that a lot of abortions do occur." She said she did not think Nigeria was ready to move past that yet, though she had faith that eventually change would come and policies would liberalize. "The next stage is … (to) review the existing policy on (the) ground so that we will be on the same page with other countries of the world."

But not, she added, anytime soon.

 

The reporting of this story was supported by a grant from the Pulitzer Center on Crisis Reporting.

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