DAR ES SALAAM, Tanzania — When Yusta Michael (not her real name) unintentionally fell pregnant in the first year of her university, she realised her dreams had been shattered. A hard-working student at the Institute of Social Welfare in Tanzania’s largest commercial city, Michael was aspiring to become a social worker and help addressing the plight of street children in the sprawling city. At three months pregnant, Michael decided to terminate the pregnancy because her boyfriend disowned it, and she didn’t want to disappoint her deeply religious parents.

Distraught, the 21-year-old student secretly visited a backstreet clinic in the bustling Manzese suburb in Dar es Salaam as she desperately tried to terminate the pregnancy or “Kusafisha Kizazi” as it’s known in Swahili euphemism.

“I had to do it, to avoid being expelled from school,” she told Health Policy Watch.

Abortion is illegal in Tanzania except to save the life of a mother and is punishable by up to 14 years imprisonment. Despite being illegal, hospital-based statistics suggest hundreds of women and girls often try to terminate the pregnancies themselves. Others turn to amateurs, who may secretly dose them with herbal concoctions, beat their bellies or insert objects vaginally, thus causing severe bleeding even contracting infections.

Abortions and childbirth are some of the greatest risks women face in Tanzania. The country has one of world’s highest maternal mortality rates at 556 deaths per every 100,000 live births. Some of the deaths are due to abortion-related complications, according to National Bureau of Statistics data. In the United States the figure is 11 and it’s even lower in other developed countries.

Nearly quarter of women, aged between 15-24, who had an abortion in 2012 confessed it was performed by untrained, clumsy hands of quacks, according to Andrea Pembe, a researcher at Muhimbili University of Heath and Allied Sciences (MUHAS).

Horrified by her burgeoning circumstances, Michael secretly visited a shabby clinic, housed in a dilapidated residential home covered with purple curtains on its windows.

When she arrived, Michael met a tall man, likely in his late 40’s, dressed in a knee-length lab coat, with a stethoscope slung on his shoulders.

“I told him I urgently needed to have an abortion and wanted to know how much it would cost,” she said.

According to Michael, the “doctor” politely told her, he could help her but she has to pay Tanzanian shillings 45,000(US$20).

In the impoverished neighbourhood, “doctors” in many such shady clinics perform “fast & safe” abortions albeit clandestinely to avoid prosecution, local residents said.

“I had just received my student subsistence allowances so I used some money to pay him,” she said.

Fear crept in when the “doctor” handed Michael some pills to swallow in a dimly lit dingy room.

“I was too ashamed to tell my mother,” she recalls.” I didn’t realise it could have gone terribly wrong”

The procedure involved that she lie still on the examination table for an hour to allow the membranes of the womb to tear, Michael said.

With his nicotine-stained fingers, the abortionist then applied a white jelly in the vagina and repeatedly punctured the membranes inside with a metal object, she said.

“It was a very painful procedure, I begged him not to show me the foetus,” Michael said.

Despite being a quack, the “doctor” was considerate to cover it with a stained gauze lying in a bloody puddle on the edge of examination table, before lifting her to her feet.

When the procedure was completed, the abortionist returned to his consulting room. However, what shocked Michael is that he didn’t bother to wash his hands as he lighted a cigarette, blowing a plume of white smoke in her direction as she was about to hand him his money.

Illegal abortions in Tanzania have been documented in a number of studies that suggest that nearly 60 percent of women admitted to public hospitals with a suspected miscarriage had in fact undergone an abortion, health officials said.

“This tells you there is definitely something wrong,” said Martin Sinje, a medical analyst at UMATI, local non-profit organisation providing sexual and reproductive health education. “People don’t feel safe to go to designated health-care facilities.”

In Tanzania, an estimated 405,000 abortions were performed in 2013. This number translates to a rate of 36 abortions per 1,000 women aged 15–49 and a ratio of 21 abortions per 100 live births, according to a study conducted by the US-based Guttmacher Institute, which researches reproductive health issues.

Approximately 22 million unsafe abortions take place worldwide, which contribute to a significant global burden of maternal mortality, according to World Health Organization (WHO) study entitled, Expanding Access to Medical Abortion, published in February 2015.

A few days after the procedure, Michael was racked by severe pain in the lower part of her belly. There was blood clotting and cramps that confined her to her bed for many days afterwards. She kept crying due to the agony of an infection which festered where the “doctor’s” unsterilized tool had torn her private parts.

“I was trying to hide it, but when it got worse I told my mother everything,” she said Michael’s mother, rushed her to Mwananyamala hospital where doctors examined her and confirmed she had an incomplete abortion and that she needed specialised care to remove infected membranes from her ruptured uterus.

“When she came here, she was still bleeding heavily, she had a fever, was anemic and septic,” said Fabian Tumai, a senior gynaecologist at Mwananyamala Hospital.

“As professionals, we helped her and she recovered well,” he said.

However, for Michael, the secret abortion she underwent was a life-changing decision because doctors confirmed she would not be able to conceive children again.

“I have spoiled my future, I regret it,” she said.

While Tanzania has a law and policies that govern medical grounds for abortions, local health analysts say they are ambiguous and are often inconsistent.

The country’s Penal Code, which is broadly understood to authorise abortion to save a woman’s life, does not categorically state whether the procedure is legal to preserve the woman’s physical or mental health.

Although Tanzania ratified the African Charter on Human and People’s Rights protocol on the Rights of Women in Africa in 2007, which permits medical abortions 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 foetus, the government has not yet woven in those provisions into its law and policies.

“We as medical personnel think abortion should be legal so a qualified person can do it and you can have safe abortion,” Dr Tumai told Health Policy Watch.

Haunted by the rising tide of unsafe abortions and crippling deaths related to childbirth the government has shown a strong commitment to reduce maternal mortality and morbidity by building a comprehensive post abortion care services to lower level facilities across the country, officials said. However, gaps still exist as most women do not receive the care they need.

At Mwananyamala hospital in Dar es Salaam a dozen of patients in the women’s ward were recovering from attempted abortions. One, a 24-year-old banker, lay in bed groaning and squirming. She had been treated at the hospital a week earlier for an incomplete abortion and now was back, bleeding and in severe pain. She was taken to the operating theatre once again and anesthetized, and Dr. Tumai, who had treated her the first time, discovered that she had also failed to get rid of all the membranes formed during the pregnancy. Once again, she scraped the inside of her womb with a metal instrument known medically as curet.

“It was a forceful, bloody procedure, but we succeeded to save her life,” Dr Tumai said.

Image Credits: Kizito Makoye.