Low uptake of family planning services, aided by economic hardship, is taking its toll on some married couples who, burdened by unplanned pregnancies, now resort to unsafe abortions despite the associated risks. Angela Onwuzoo reports
Mrs Bisi Lateef (not her real name) borrowed the sum of N15,000 from a friend to procure an abortion in February, and it took her one month to finally pay it back.
The woman, now in her early 40s, recalled what she experienced while ending her fifth pregnancy.
According to her, she would have loved to keep it, but the resources to care for another baby were not available.
The trader, who already has four children, said she visited a quack to end the unplanned pregnancy without her husband’s knowledge.
Defending her decision, she explained that it was made to avoid the stress of having another child, which would further put a strain on the family’s income amid the biting economic hardship.
Bisi, who hawks soft drinks at Ikorodu garage, in Lagos State was not using any contraceptives and usually engages in unprotected sex with her husband who prefers the withdrawal method.
She told our correspondent that with the rising poverty, becoming pregnant now will be quite challenging.
The businesswoman, who admitted keeping the pregnancy and its termination secret from her husband, said she resorted to using a quack for the abortion to prevent the child from becoming an additional burden to her struggling family.
Poverty and low contraceptive use drivers of unsafe abortion
“I heaved a sigh of relief when I got the pregnancy terminated. I can’t imagine carrying another pregnancy in this economic hardship when I have four children already.
“I had to end the pregnancy because it was unplanned. It was my fifth and I couldn’t tell my husband about it because he would want me to keep it even when he knew that he didn’t have the means to take care of another baby.
“A friend of mine, who had a similar experience in November 2023, was the one that took me to a traditional birth attendant in her area, who aborted it in her centre. She charged N15,000 to remove terminate the pregnancy. I borrowed the money from a friend to pay her,” Bisi recounted.
Further sharing her experience with PUNCH Healthwise, the trader, who said she was gripped with fear about the outcome of the unsafe abortion, however, said she was compelled to do so due to poverty.
She said amid tears, “I had to do it because we are still struggling to take care of the four children that we have and things are so hard in the country.
“ When my friend took me to the traditional birth home, when the owner, popularly called nurse, saw the way I was anxious, she told me to relax and assured me that she is well known for the procedure. The building was on a side street, just off a main road and had shops on either side of it.
“She asked me to verify about her expertise from my friend who took me there. At that point, my friend, who already has three children, told me that she visited the home in November, 2023, to procure an abortion because she and her husband couldn’t take care of another child.”
Rigours of unsafe abortion
Bisi felt relaxed to take the risk of going through the rigours of an unsafe abortion when she realised her friend survived it and she was not the only one seeking such services.
She further narrated, “After my friend finished sharing her experience with me, the nurse told me that since January, married women have been trooping to her centre for abortions.
“So, she took me to her abortion room and asked me to lie on a six-inch wide bed with Mackintosh serving as the bedspread.
“She brought out a very big metal object like a radio antenna and passed it through my vagina to my uterus. I was shaking and writhing in pain. I was screaming and could not behold the sight of the heavy, scary bleeding.
“She warned me to stop shouting to avoid attracting the attention of passersby. When she finished, she gave me an injection to ease the pain, though the bleeding continued. I lost a lot of blood and she instructed me to take a lot of blood tonic.”
Narrow escape
The mother of four, who narrowly escaped death from severe bleeding told our correspondent that she had to lie about her condition to her husband to avoid trouble.
“For three days, I was not myself because the bleeding was severe. I lied to my husband that I was observing my menses coupled with malaria so that he would not know. I thank God I did not die during the procedure because it was painful and the bleeding was something else.
“I have no regret taking such a risk because of what we are going through. My children’s fees are not regularly paid and my husband’s furniture business has been struggling to stay afloat since last year due to low patronage”, she said.
The businesswoman attributed her decision not to use contraceptives to her husband, citing his refusal to allow her to access the service and concerns about potential side effects.
Experts say restrictive abortion laws, prohibitive costs, poor access to safe health services, and intense social stigma are barriers that prevent women from accessing safe and legal abortion.
They noted that unsafe abortion contributes to Nigeria’s rising maternal mortality ratio, which is among the highest in the world.
Rising cases of unsafe abortion among married women
The Society for Family Health recently disclosed that abortion among married women is currently on the rise, especially in the face of inflation across the country.
The country’s Social and Behaviour Change Coordinator, Michael Titus said married women do this because they want to take care of their families, and that an additional baby will reduce the purchasing power of the family.
“Abortion among married women is something that is on the rise. For married women, it is obvious because our men are shying away from the fact that family planning uptake is important and beneficial to them and their families.
“Look at the situation in the country. We have so many issues like inflation, which is causing the purchasing power of each family to reduce, especially now that the cost of buying pampers and school fees are on the rise.
“Women love their families; they love their husbands and don’t want a situation whereby the purchasing power of the family would decline. So you find women who go behind to carry out abortions.
“They don’t want the situation whereby, they get pregnant again as another child added to the number they have would be seen as burdensome on the family, and that is why abortion among married women, we found, is rising”, he explained.
Several Nigerian households are feeling the brunt of the current economic hardship ravaging the country.
Many hungry and impoverished citizens have resorted to desperate measures to survive the hardship.
The World Bank said rising inflation had driven an additional four million Nigerians into poverty in 2024
Risk of having too many children
A 39-year-old mother of five, who simply identified herself as Chika, told PUNCH Healthwise that if she knew that things would be this difficult for her family during this period, she would not have given birth to many children.
The Lagos housewife said the biting hardship pushed her into procuring an abortion.
“We now feed from hand-to-mouth. I was pregnant in March this year and never knew even though I was not using family planning. When I realised in May, that I was pregnant, I could not sleep anymore. So, I vowed not to keep the pregnancy but didn’t tell my husband because I was afraid he might not agree to the termination”, she said.
Chika told our correspondent that after two days of making inquiries about where to secretly have an abortion, her elder sister eventually linked her to an auxiliary nurse who eventually terminated the pregnancy by giving her a series of injections.
“I almost fainted when I was given the injection. Less than 10 minutes after receiving the injection, I started bleeding. I bled for five days before the abortion was completed. My menstruation has not returned since then. Once it returns I will go for family planning because I can’t take the risk of having an unsafe abortion for the second time and having another child under this harsh condition will be horrific for me”, she said.
Another woman, Mrs Hope Michael, 36, (not real name) who is still recovering from complications of unsafe abortion, said the prevailing economic situation inflicted poverty on her family.
The local drink maker and mother of three children said she and her husband were unprepared for another baby amid the hardship in the country.
Unreliable method of family planning
She explained, “My husband uses the withdrawal method because he doesn’t like condoms. But I don’t know how it happened because I don’t use any contraceptives. My husband said he wouldn’t allow me to go for family planning until we were done having the number of babies we wanted. Because of the hardship, I had to end the pregnancy.”
“I went to a TBA, where it was terminated. I later had a complication because the abortion was not initially successful. I had an infection and was on treatment for over a month before recovering from it.”
On why she failed to tell her husband about the pregnancy, the businesswoman said, “I lied to my husband that I had a miscarriage when he noticed I was battling with the bleeding and infection. I lied to him because he would have forced me to keep the pregnancy.
“While we are struggling to feed the three that we have, he still wants me to have another baby because he is the only son of his parents.”
Also, another mother of four, simply identified as Josephine, told our correspondent that she used both orthodox and traditional medicine to procure an abortion when she discovered she was pregnant.
Other married women who spoke to PUNCH Healthwise shared similar experiences with unsafe abortion and explained why they felt compelled to undertake such a risky procedure.
Experts seek liberalisation of abortion laws
Maternal health experts say abortion laws need to be liberalised in Nigeria for women to have safe abortion services.
The Chief Medical Director of the Lagos State University Teaching Hospital, Ikeja, Professor Adetokunbo Fabamwo, told PUNCH Healthwise that there are many social and economic situations that propel women to desire abortion, stating however, that the law of Nigeria does not allow that yet.
Fabamwo, who is a Professor of Obstetrics and Gynaecology at the Lagos State University College of Medicine, Ikeja, said, “So, people have to secretly go to private providers. Some don’t even know where to go and that’s why they go to quacks and they will perform an unsafe abortion. So, abortion laws need to be liberalised in Nigeria and the Lagos State Safe abortion guideline needs to be brought back.”
The LASUTH boss urged women to embrace family planning to avoid unwanted pregnancy, stating that it was unacceptable that women are still having unwanted pregnancies with all the various contraceptives available.
The don added, “To me, it’s amazing that in this day and age, some women are still getting pregnant when they don’t want to with all the contraception available; all the family planning methods available, and all the noise we have been making about the use of contraceptives.
“Why should any woman still be having an unwanted pregnancy in a marital situation? It is still amazing.
“So, when they now get pregnant, instead of going to a safe provider, they go to quacks and that is because abortion is still illegal in Nigeria. And so, one of the advocacies that we are making is that the government should liberalise abortion laws.”
According to the Nigeria Demographic and Health Survey 2018, the country has a 12 per cent modern contraceptive prevalence rate and a 19 per cent unmet need for contraception among married women.
An Associate Professor and Consultant Obstetrician and Gynaecologist at the University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu State, Dr Uche Agu, cautioned women against depending on the withdrawal method for birth control.
He told our correspondent that the method is unreliable for preventing pregnancy.
According to the maternal health expert, the withdrawal method also known as pullout is ineffective and has a very high failure rate, and warned couples not to depend on it for family planning.
Agu said while the method works for some people, it is, however, flawed by inconsistencies and failures.
Unsafe abortion preventable -WHO
Unsafe abortion, according to the World Health Organisation, is an important preventable cause of maternal deaths and morbidities.
The WHO warned that lack of access to safe, affordable, timely, and respectful abortion care, and the stigma associated with abortion, pose risks to women’s physical and mental well-being throughout their life course.
According to the 2020 Performance Monitoring for Action abortion survey, in Nigeria, an estimated two million abortions occur annually.
The report indicated that more than six out of 10 abortions were considered the most unsafe, and 11 per cent of women experienced complications for which they sought post-abortion care at a health facility.
It also showed that women in rural areas (73 per cent), women with no education (81 per cent ), women in the lowest wealth quintile (82 per cent), and girls aged 15-19 (88 per cent ) were most likely to have an abortion that is considered most unsafe.
Experts worry
Physicians who spoke with PUNCH Healthwise said it calls for concern, saying that they were seeing a steady flow of cases of women with complications following unsafe abortions in their facilities.
They lament that the situation may increase Nigeria’s high maternal mortality rate.
Already, unsafe abortion contributes significantly to Nigeria’s high maternal mortality ratio estimated at 512 maternal deaths per 100,000 live births.
Complications of abortion can include incomplete abortion (failure to remove all of the pregnancy tissue from the uterus), haemorrhage, vaginal, cervical, and uterine injury, and infections.
LASUTH CMD, Fabamwo, expressed worry over the rising cases of unsafe abortion and its complications, some of which he said are brought to his facility daily.
The don, who is a Fellow of the Nigerian Academy of Medicine, said, “There is not a day that we don’t see one or two cases of unsafe abortion in LASUTH. We have a steady flow.”
Speaking on Lagos State policy guidelines on the provision of safe abortions for residents, which was later suspended by the Governor, Babajide Sanwo-Olu, the gynaecologist said the guidelines are for women who get pregnant and whose lives are threatened by the continuation of the pregnancies and not married women who get pregnant carelessly.
“It is not for women who are in marital situations, who just feel they don’t want another baby without thinking of not having another unprotected sexual intercourse.
“The guidelines are for people who are sick; for instance, people who have kidney failure, cancer, or heart disease, and those who inadvertently get pregnant. Those are some of the cases under those guidelines’’, he explained.
In addition to sick women, the LASUTH boss emphasized that other categories of women may require abortion services for various reasons, which he believes should be accessible to them.
The don explained, “Apart from sick women that I have mentioned before, there are women who just don’t want the pregnancy for one or two reasons. For instance, a woman is pregnant and gets a job with an airline and the airline says no pregnancy for the first two years, she has to remove the pregnancy for her to continue the job.
“For instance, if a woman gets pregnant for a guy and they were hoping to get married and suddenly the guy gets a brain wave and says we are not getting married again, would she carry a pregnancy for somebody who says I no longer want to marry you?
“So, there are numerous socio-economic situations in which women may desire to terminate a pregnancy, but as it stands, Nigerian law does not permit it.
“So people have to go secretly to private providers. Some don’t even know where to go, that is why they go to a chemist and they will perform unsafe abortions. So, abortion laws need to be liberalised in Nigeria and the Lagos State Safe abortion guidelines need to be brought back.”
He urged women to embrace family planning whether their husbands like it or not, adding that women must be empowered to take their lives into their own hands.
Why Lagos should lift suspension on abortion guideline
Another maternal health expert and First Vice President of the Nigerian Medical Association, Dr Benjamin Olowojebutu, told PUNCH Healthwise that abortion among married women was on the increase.
Olowojebutu said, “It is very true that unsafe abortion is currently on the rise. We are seeing a lot of women having septic abortions after going to quacks to abort them.
“They now come back to the hospital with very sad complications. So, it is important we now have a very good model for policy-making guidelines.
“We have shown the Lagos State Government the importance of implementing the guideline and hopefully, we expect it to be implemented soon.”
He was optimistic that the Lagos State safe abortion guideline would reduce maternal mortality associated with unsafe abortions in the state if the governor lifted the suspension.
The outgoing Lagos State NMA chairman noted, “If we have the suspension lifted, it means we will have safe termination of pregnancy in Lagos State and women can seek help in the hospital and not go to quacks anymore. And there will be fewer complications of unsafe abortions and maternal mortality.”
Lagos suspended abortion guidelines
Sanwo-Olu had on July 7, 2022, directed the suspension of the policy titled, “State Guidelines on Safe Termination of Pregnancy for Legal Indications”, issued by the Directorate of Family Health and Nutrition in the Ministry of Health.
According to a statement issued by the state’s Commissioner for Health, Prof. Akin Abayomi, the governor directed the suspension of the guidelines to allow for more time for sensitization of the public following the interest generated over the matter.
Despite national and international commitments, abortion is illegal in Nigeria unless to save the life of the mother. This has made many women consult quacks and at times, trained medical personnel who do the job shoddily.
Nigeria ratified the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (the Maputo Protocol) in 2004, effectively pledging to protect the rights of women and girls and guarantee the right to sexual and reproductive health.
Article 14 (2) (c) of the Maputo Protocol, urges all ratifying countries to “protect the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the fetus.”
Ignorance fuelling low family uptake
On his part, a Professor of Maternal, Reproductive, and Child Health, Oliver Ezechi, Identified lack of knowledge as a major reason for the low uptake of family planning services by women going to procure unsafe abortions.
The Director of Research at the Nigerian Institute of Medical Research, Yaba, Lagos, reminded women not to use contraceptives for fear of side effects and that the inherent danger in unsafe abortion cannot be compared to the side effects of contraceptive use.
The gynaecologist said, “That someone had an issue with the use of contraceptives doesn’t mean that you will have the same issue.
“We need public awareness of the dangers involved in unsafe termination of pregnancy and the benefits of using contraceptives to prevent pregnancy.
“In using contraceptives, you need to consult with trained health workers to take you through and know which contraceptives match your body. This is important so that there won’t be complaints of side effects and then you won’t abandon it and use termination of pregnancy as a method of contraceptive.”
He said the government should adopt a comprehensive approach to tackling unsafe abortion by first making contraceptives accessible, providing abortion services within the laws of the land, and then providing post-abortion care for persons who had unsafe termination of pregnancy.
He argued that worldwide, simply liberalizing abortion laws alone has not effectively reduced unsafe abortions and unwanted pregnancies.
Improved access to contraceptives
Continuing, the researcher noted, “So you have to combine it with increased access to contraceptives. Once you improve access to contraceptives and people are willing to have access to them, and then you now complement it with safe termination of pregnancy for eligible cases based on the laws of the country, you will address unsafe abortion.
“What it means is that you will now reduce the number of women who want to terminate a pregnancy by providing contraception. So, it is a combination of all the modalities to ensure that women don’t die from unsafe termination of pregnancy.
“Also, there should be availability of post-abortion care in public hospitals for women who have had unsafe abortions.”
According to him, what is important is educating people on the importance of family planning, health education on the dangers of unsafe abortion, having fewer children, and making family planning readily available.
Restricting access to abortion threatens women’s lives
A 2017 study by the Lancet publication revealed that restricting access to abortion by law does not reduce the number of abortions but only increases the risks to the lives of women and girls.
According to the study, 25.5 million unsafe abortions were carried out yearly between 2010 and 2014 worldwide, with 97 per cent occurring in developing countries in Africa, Asia, and Latin America.
The study, which was carried out by the World Health Organisation and the Guttmacher Institute, showed that countries such as Nigeria, which have anti-abortion laws raise the health risk for women because most of the abortions there were illegal and often done by untrained personnel.
The study stated, “In countries where abortion is completely banned or permitted only to save the woman’s life or preserve her physical health, only one in four abortions were safe; whereas, in countries where abortion is legal on broader grounds, nearly nine in 10 abortions were done safely. Restricting access to abortions does not reduce the number of abortions.”