Rwanda: Where Abortion Can Lead to Prison

Women anywhere in the world can find themselves in a position where they have to choose whether or not to carry a pregnancy to term, but depending upon where they live, abortion may be safe and available, or, as it is in Rwanda, laden with needless dangers that destroy women’s lives each year. The right to make this decision whether or not to have a child has been confirmed in international governmental agreements such as the Programme of Action from the International Conference on Population and Development (Cairo, 1994), which says that governments should respect the rights of individuals to decide and act freely and responsibly regarding how many children they want to have and when. Nevertheless, many countries that theoretically recognize reproductive rights still hold on to their restrictive abortion laws, and thus the unsafe clandestine abortion services that thrive under such conditions. Rwanda is one country where women risk not only their lives but their freedom when they decide to have an abortion. Rose, a 23-year-old serving a five-year prison sentence on abortion–related charges, summed up what is lacking in Rwanda’s commitment to women’s health and rights: “I really think prison should not be the solution to solve the problem of unwanted pregnancies that end in unsafe abortions; this could be resolved if these abortion services were made legal,” she told researchers in a study published by Rutgers WPF in 2011.

Though there are glaring exceptions, Rwanda has made tremendous progress in advancing women’s rights and promoting gender equality. The country is known for having many women in political positions; more than 60 percent of the seats in parliament are filled by women. Many laws and policies to eliminate discrimination against women have been put in place, such as those affirming property rights and fighting gender–based violence, and progress has been made in promoting girls’ education. Women’s health hasn’t been ignored in Rwanda, which is among the most populous sub-Saharan countries with a population of 11 million and has a fertility rate, or ratio of live births to total population, of 4.6 per 1,000. More women are using contraception: as the Guttmacher Institute reported in 2010, 44 percent of married or cohabiting Rwandan women were using modern contraception at that time, up from 4 percent in 2000.

But the increase in contraceptive use has not kept pace with the growing desire for smaller families, nor does it extend to the increasing proportion of unmarried young women who are sexually active. The unmet need for family planning in Rwanda is 19 percent according to 2013 figures from USAID, but this number does not adequately convey the consequences suffered by some women who cannot obtain contraception—unintended preg-nancy, unsafe abortion and possibly death or imprisonment.

The Many Perils of Unsafe Abortion

There is plenty of research documenting the connection between unintended pregnancy and the unsafe abortion services that are many women’s only recourse. Findings from the first national study on the incidence of unintended pregnancy and abortion in Rwanda show that nearly half (47 percent) of all pregnancies in the country are unintended and approximately 22 percent of all unintended pregnancies end in induced abortion. According to a 2009 study, Rwanda’s abortion incidence is 60,000 abortions per year, or 24 per 1,000 among women aged 15–49. The abortion rate is relatively low—Rwanda’s rate is significantly lower than that of Eastern Africa (38 per 1,000), and lower than that for the African continent as a whole (28 per 1,000).

Still, abortion places a heavy burden on Rwandan women and the healthcare system because almost all abortions are unsafe: that is, performed by unskilled people, often using traditional methods, and in unsanitary environments where safety cannot be guaranteed. A 2004 study of four health districts in Rwanda estimated that 50 percent of obstetric complications were a consequence of spontaneous and induced abortion. Unsafe abortion and the resulting fatal complications affect poor women more than wealthier women because women with few means who are in desperate situations resort to the cheapest means to have an abortion, including using traditional medicines.

The risks of an unsafe abortion do not end with the procedure itself. The same Guttmacher study showed that 24,000 of the approximately 60,000 women who had an abortion in a given year suffered complications that required medical treatment. But of these, just 17,000 received adequate treatment in a health facility, meaning that 30 percent of the women who needed care did not receive it. Women fear accessing medical services for complications from an abortion because of the possibility that health professionals may judge them or even turn them into the authorities for prosecution—with good reason.

On paper, abortion carries fewer legal risks now than it used to in Rwanda. In 2012, recognizing how many women were obtaining clandestine abortions in defiance of the law, Rwanda revised its law on abortion, in force since 1977. The previous law had criminalized abortion in almost all circumstances; abortion was only allowed to save the life of a woman when two or three doctors authorized it.

Under the new abortion law there is no criminal liability in the case of pregnancy due to rape, incest or forced marriage, or if there are health complications for the woman or the fetus. However, abortion is still criminalized. A woman who carries out a self-induced abortion is liable to a term of imprisonment of one to three years and a fine of 50,000–200,000 FRW ($75-300 USD), and a person who causes a woman to abort with her consent risks a sentence of two to five years under Article 163 of the penal code. The law also requires that women seeking an abortion must obtain authorization from a court and the signature of two doctors. This can be a significant barrier for women because these authorizations can cost money, waste time and dangerously delay critical healthcare.

In a country where doctors are scarce and the court system difficult to access, particularly for poor women, abortion is, in effect, still prohibited for almost all Rwandan women. Women continue to be arrested and imprisoned for abortion in Rwanda, even those whose situations could be exempted from criminal liability under the new law.

Many faith-based organizations have consistently and actively advocated against the decriminalization of abortion in Rwanda.   

The Rwandese Association for Family Welfare (ARBEF), a member association of the International Planned Parenthood Federation (IPPF), was established in 1986 as the first NGO addressing and advancing women’s sexual and reproductive health and rights in Rwanda. As the leading organization in the country advocating for safe abortion, ARBEF has carried out studies about women who have been imprisoned on abortion-related charges and has engaged policymakers in debates about abortion to lobby for policy change. In the four prisons that were visited during a 2011 study, 152 women were serving sentences for abortion and eight of them were arrested when they were still minors (under 18 years old). Most had no legal representation during their trial, since most of them are from poor families and the vast majority of these women have little education. Women have been arrested and convicted for abortion in cases of miscarriage or stillbirth. Young women—who are particularly vulnerable to unwanted pregnancies given the social constraints on contraception—are at a high risk of being charged and imprisoned due to abortion. Of the women in prison for abortion, 90 percent were 25 or younger at the time of their arrest. Many were detained after seeking emergency medical treatment for complications from an unsafe abortion.

It is not hard to see multiple human rights violations in the detention of women for their healthcare choices. But Rwanda committed to uphold women’s rights in its 1979 ratification of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), a binding treaty requiring all countries that have signed to commit to ensuring respect for women’s and girls’ human rights and fundamental freedoms. Rwanda backed down from its initial reservations to Article 14(2)(c), the section affirming abortion rights in the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (the Maputo Protocol). Why would a country that has made remarkable progress in promoting women’s empowerment and gender equality still be repressive when it comes to a woman’s right to choose?

Culture and Contraception

As in many African countries, sexual activity is taboo in Rwanda, especially for unmarried people, and this belief has always been and still is embedded in its social structures. Traditionally, information about sex would only be given to people who were about to get married. Girls were expected to stay virgins until marriage. Those who got pregnant before they were married would become outcasts and sometimes would be thrown in rivers and lakes and left to drown.

Things have changed for people coming of age in Rwanda—an exposure to technology may be part of it—and many young people become sexually active before marriage. However, the traditional view of sexuality still plays a big role—not only in families, but also in different institutions and policies. Despite the reality of sexual activity among students and the risk of unintended pregnancy or STDs, there is no sexuality education in schools. When the government does attempt to address teenage pregnancies it mainly does so by promoting abstinence, and only sometimes the use of condoms.

Young people who do seek out contraception find that is not easily accessible, as it is available at health centers where adult and married women go for the same services. Young women who are brave enough to seek contraceptives at health centers are often judged by health providers. They are intimidated from seeking a service that is unexpected of unmarried girls and women, which demonstrates that the stigma against sex outside of marriage is com-mon among health providers. Emergency contraception (EC) is not included among the available methods and it is generally not known among young people. Only those in urban centers can buy EC from private pharmacies, but it is expensive.

A lack of access to contraception—and a poor understanding of how contraception and reproduction work—were recurring themes in the personal stories of women imprisoned for abortion collected by ARBEF in its 2011 study. “I had little information on contraceptives at that time but had difficulties on where I could get those services,” said Brenda, a former university student. “I had never before heard of contraceptive pills,” a young woman named Charlotte said. Maria, another woman serving a sentence for abortion, said that, as the only girl in a family of boys, the only sex education she received was from friends.

Cultural norms may be very concerned with controlling young women’s sexual activity, but a different standard exists for men. A study about sexual violence in Rwanda conducted in 2008 by UNIFEM discovered that 86 percent of female respondents had been forced into having sex, or had experienced an attempt at forcing them to have intercourse, in familiar settings such as the family or the workplace. Several of the women interviewed by the ARBEF team mentioned being coerced into sexual activity, whether by a teacher, an older man or an employer, or exploited because of their economic needs. Among these was Anne, who was 17 years old when she was imprisoned for having an abortion. She was made pregnant by her secondary school teacher, who offered to pay for some of her educational costs. She was reported to the police by her elder brother.

Family plays a powerful role in enforcing the traditional stigma associated with unwanted pregnancies among unmarried women. Often, girls who get pregnant before marriage are shoved into arranged marriages to avoid bringing shame on the family. Girls’ decisions to have an abortion are also often made to avoid bringing shame to their families. In fact, one of the reasons the investigation into abortion in Rwanda led to prisons is that in “no other place” could the researchers “find women who aborted ready to accept this status [of having had an abortion] and to accept our interview; the same for health providers or other people who conducted or helped to abort illegally,” according to the 2013 paper by ARBEF and IPPF. Otherwise, stigma made it very unlikely for women to admit to having had an abortion.

Different religions play a big role in suggesting what sexuality is and should be in Rwanda. More than 70 percent of Rwandans belong to one of several Christian religions. Sexual activity and pregnancy out of wedlock are considered to be sins that must be avoided. “Out of fear of my dad who is a pastor, I arranged with the local leader to get me traditional medicine to do an abortion,” recounted Clarisse from prison. Religion also plays a role in the development of public policies; for instance, many faith-based organizations have consistently and actively advocated against the decriminalization of abortion in Rwanda for many reasons, one of these being that accessible abortion is considered likely to promote promiscuity among young people.

The study by ARBEF and IPPF examined the views about abortion held by a group of policymakers, public servants and representatives from faith-based organizations. “Policymakers were guided by moral and religious considerations rather than by evidence-based approaches,” the researchers said, characterizing the overall attitude towards abortion as “disapproval.” Possible adverse health imiplications for a woman or a fetal abnormality were the circumstances in which there was the most support for legal abortion. Study participants were unaware of the number of deaths due to unsafe abortion that occur each year in Rwanda, but when asked for methods to improve the situation, there was some support for improving contraceptive access and sexuality education.

Not even comprehensive and youth-friendly contraceptive services can prevent unwanted pregnancies completely, and as long as these exist, so will abortions. The question shouldn’t be whether to restrict abortion or not, because even restrictions do not stop women from having abortions—they are merely left with only unsafe options. Unsafe abortions are preventable and a woman’s decision to have an abortion should be respected. Rwandan culture attempts to control young women’s sexuality by denying them information about sex or contraception, and society denies them any safe, legal alternative to bearing an unwanted pregnancy. As Rose said from the penitentiary, “I really think prison should not be the solution to the problem of unwanted pregnancies that end in unsafe abortions.” This should be just as evident to policymakers—many of whom, in the IPPF study, knew of women who had died or almost died as a result of an unsafe abortion. Perhaps Rwanda’s first step must be to acknowledge something noted by Dr. Mahmoud Fathalla, former president of the International Federation of Obstetricians and Gynecologists:

“Women and girls are not dying because of diseases we can’t treat…. They are dying because societies have yet to make the decision that their lives are worth saving.”