This is the seventh in a series of articles from Keeping Our Promise: Addressing Unsafe Abortion in Africa this week. The conference has brought together more than 250 health providers, advocates, policy makers and youth participants for a discussion of how to reduce the impact of unsafe abortion in Africa.
One in 13 women in the Democratic Republic of Congo dies in pregnancy or childbirth—that’s one death every half hour of every day.
Health problems related to pregnancy and childbirth remain the leading cause of ill health and death for women of childbearing age worldwide. But the impact is even greater in countries in the throes of a humanitarian emergency or crisis.
Addressing unsafe abortion in emergency situations at the ‘Keeping Our Promise’ conference in Accra last week, Dr Wilma Doedens of the Humanitarian Response Branch in UNFPA (the United Nations Population Fund) noted that, in the unstable environment created by a humanitarian crisis, women are at risk for an unwanted pregnancies, whether as a result of a breakdown in the health system (making family planning services unavailable), or as a result of rape that has become a consistent weapon against communities in eastern Congo.
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In this context, pregnancy is particularly dangerous.
“Malnutrition and epidemics increase risks of pregnancy complications and often the lack of access to emergency obstetric care increases risk of maternal death,”said Dr Doedens.
Testimonies of women survivors of war played at the conference starkly illustrated the impact of rape and a lack of reproductive health care in the Congo.
One woman simply called Cecily explained:
“We have had war for many years and nothing has changed. We have nothing now, I have six children. It is hard to feed everyone. We have one meal per day and only my sons go to school since I do not have enough money to take the girls as well. I have heard that women can stop getting pregnant but I don’t know how and no one has told me how. I wish I could stop. I don’t want to be pregnant anymore.”
In an interview, Dr Boubacar Toure, Reproductive Health Advisor to the International Rescue Committee in Congo, outlined challenges to quality reproductive and post-rape health care in Congo.
He said that in Congo, the average age of women at their first pregnancy was 15 years, the age at which many girls were married. In addition the risk posed by pregnancy at younger ages, many hospitals in unstable areas cannot provide the medication and supplies necessary to provide the very basic obstetric services, such as antibiotics, syringes and long gloves needed for certain procedures.
Similarly, the ability of the Congolese health system to offer family planning services and prevent infections is limited by the lack of essential supplies at health and hospitals. Contraceptives are for instance offered only in a limited number of hospitals.
Staffing is also a major concern. Due to the war, many of the health staff fled for their lives, leaving a lack of staff in the health centres and hospitals to perform emergency obstetric care—such as treatment for women with complications for unsafe abortion. Those who do stay are often not paid for months and many rural health workers migrate to cities or go to work for international agencies to seek employment with a regular salary.
Some hospitals are staffed with as little as one doctor and fewer than five nurses. It is estimated that Congo lacks approximately 42,000 health professionals needed to adequately staff their hospitals.
Another barrier to proper reproductive health care is lack of female health staff in rural areas. Traditionally, Congolese women do not discuss reproductive health issues with men, much less rape. But the physical injuries from violent sexual assault will drive survivors seek help. The scarcity of female medical staff providing post-rape treatment throughout Congo is therefore problematic.
Testimony from another assault survivor attested to this. In a recording played at Keeping Our Promise she said:
“One day, at the age of 19, I was in bed asleep when I heard guns. The rebels had entered the village. I was so afraid, and I run with no belongings only the clothes I was wearing. I had to sleep in the bush for three days and on the fourth day I was kidnapped by an armed soldier who threatened me with death. He took me far away to the bushes and he raped me. After some weeks I found I was pregnant. I felt so ashamed but I could not keep the baby. I went and had an abortion. It was so painful and I still think about it everyday.”
In addition to a lack of materials and staff, there is little in-service training available to health care staff in the public sector, unless specifically funded by an external donor. Lack of training on newer, safer procedures is also a major challenge.
Without systematic and consistent training in the clinical care of survivors of sexual assault, when survivors report to health centers they are often not offered appropriate and life-saving care (such as post-abortion care) because it is simply unavailable.
Finally, addressing unsafe abortion in emergency settings is blocked by silence—little air-time is spent on women who have survived sexual assault only to risk their lives with an unsafe abortion. However, programs like the RAISE Initiative and others are working to ensure that post-abortion care is included in health care programs in emergency settings.