Perceptions of policymakers in Nigeria toward unsafe abortion and maternal mortality.

CONTEXT: In Nigeria, abortion is permitted only to save the life of a woman. Unsafe abortion is common and is a major cause of maternal mortality, yet policymakers have done little to address the problem. METHODS: In-depth interviews were conducted in 2008 with 49 Nigerian politicians and officials to assess their awareness of unsafe abortion and its role in maternal mortality, and to determine their perceptions of the policies and actions needed to address these problems. RESULTS: Participants had poor knowledge of Nigeria's abortion law and the number of abortions and abortion-related deaths, though many knew of women who had died or nearly died from unsafe abortion. Policymakers were guided by moral and religious considerations rather than by evidence-based approaches. About one-third of informants felt that abortion should not be legal under any circumstances, one-fifth supported liberalization on medical grounds and a similar proportion believed that abortion should be legal in cases of rape and incest. Strategies recommended by respondents to reduce maternal mortality included facilitating access to contraceptives, providing sexuality education, improving the health care system, empowering women and providing free pregnancy care. CONCLUSIONS: Intense public health education and advocacy targeting policymakers is needed to increase political will for reducing abortion-related maternal deaths in Nigeria. Presenting statistics on unsafe abortion together with compelling personal stories will likely resonate with policymakers and contribute to an informed public debate on abortion law reform. International Perspectives on Sexual and Reproductive Health, 2009, 35(4): 194-202 ********** Nigeria has one of the most restrictive abortion laws in the world: Abortion is permitted only to save the life of a woman, and persons who violate the law are subject to lengthy jail terms--up to seven years for a woman obtaining an abortion for other reasons and 14 years for any provider convicted of performing an illegal procedure. (1) As a result, many women with unwanted pregnancies seek clandestine, unsafe abortions. A 1998 study estimated that 760,000 induced abortions are performed in Nigeria each year, equivalent to an annual rate of 25 per 1,000 women aged 15-44, (2) and this may be an underestimate of the true Incidence of the procedure. (3) To date, the impact of unsafe abortion on the reproductive health of women in Nigeria has been poorly investigated, in part because of the paucity of data and the clandestine nature of most procedures. However, several reports indicate that unsafe abortion is a critical public health problem and a leading cause of maternal mortality in Nigeria. (2-4) Data from the Federal Ministry of Health (5) and other sources (6), (7) suggest that unsafe abortion accounts for 20-40% of maternal mortality in the country. Abortion has also been reported to be a leading cause of long-term reproductive morbidity--including chronic pelvic pain, ectopic pregnancy, infertility and recurrent pregnancy loss--in Nigerian women. (7-10) Despite the high rates of morbidity and mortality associated with unsafe abortion, the Nigerian government has taken very little action to address the problem. While Nigeria has national policies on reproductive health and safe motherhood, none explicitly address the problem of unsafe abortion. (11-13) In addition, although contraceptive use can prevent unwarned pregnancy (and hence reduce the need for abortion), very few government-funded family planning programs have been established, despite the fact that the prevalence of modern contraceptive use among married women in Nigeria in 2003 was only 8% (14)--one of the lowest rates in Sub-Saharan Africa. Government programs to provide postabortion care, which can reduce the burden of unsafe abortion, are also lacking. Most funding of family planning and postabortion care programs has been provided by donors, but many nongovernmental organizations have been reluctant to work on unsafe abortion for fear of losing U. …