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Debate rages over ban on ‘safe’ abortion rights

By Chukwuma Muanya and Ijeoma Nwanosike
12 January 2023   |   3:29 am
In recent times there have been global uproar on merits and demerits of abortion, especially in the United States (U.S.) and Nigeria. The US, which used to be liberal on issues of abortion, recently banned the procedure in most states in the country.

Pregnancy

• Experts examine merits, demerits of procedure
• Vasectomy as one of most effective ways to avoid practice

In recent times there have been global uproar on merits and demerits of abortion, especially in the United States (U.S.) and Nigeria. The US, which used to be liberal on issues of abortion, recently banned the procedure in most states in the country. In Nigeria, an attempt by the Lagos State government to legalise the procedure was shut down, forcing Governor Babajide Sanwo-Olu to suspend the plan.

Until now, the levels of unintended pregnancy and unsafe abortion continue to be high in Nigeria due to low contraceptive prevalence. A substantial number of women have unintended pregnancies, many of which are resolved through clandestine abortion, despite the country’s restrictive abortion law.

Statistics has shown that an estimated 1.25 million induced abortions occurred every year in Nigeria, equivalent to a rate of 33 abortions per 1,000 women from the age of 15 to 49.

According to a study published in a peer review journal, International Prospect on Sexual and Reproductive Health, 56 per cent of unintended pregnancies were resolved by abortion and about 212,000 women were treated for complications of unsafe abortion, representing a treatment rate of 5.6 per 1,000 women of reproductive age. Additional 285,000 experienced serious health consequences but did not receive the treatment they needed.

Women go through abortion due to a number of reasons, which may include: when the family is complete, rape, a relationship breakdown, financial challenges, incest, high-risk pregnancy and complications, to avoid passing on a hereditary disease, pressure from other people and amongst others.

Most often, women are expected by their spouses to care for themselves by taking pills or other methods of contraception to prevent pregnancies, especially when they have given birth to the number of children they want but these pills have been for the longest time associated with a lot of adverse effects. The effects can be short or long term and they include: mental health disorders, allergic reaction to some of the medicines, Ectopic pregnancy, blood clots in the uterus, bleeding too much or too long, risk of breast cancer, secondary infertility and other effects.

The Lagos State Government had developed a policy document on safe termination of pregnancy toward guiding healthcare professionals to provide safe and lawful abortion services in the state.

Permanent Secretary, Lagos State Ministry of Health, Olusegun Ogboye, had said the 40-page policy document; titled “Lagos State Guidelines on Safe Termination of Pregnancy for Legal Indications” sets out guidelines for safe termination of pregnancy within the ambit of the criminal law of Lagos State.

Ogboye noted that the document provides evidence-based data and information for health workers in public and private sectors with the requisite skills to provide safe termination of pregnancy to reduce preventable deaths.

He said that while therapeutic termination of pregnancy was permissible under the state’s law, the absence of clear guidelines had stalled the effective implementation at appropriate levels of care resulting in preventable deaths.

“In 2011, the Lagos State House of Assembly updated the criminal code, providing for abortion to save the life and protect the physical health of the woman.

“While physical health is covered under the Lagos legal framework, services conforming to the law have not been available in Lagos State health sector.

“This document provides information on relevant laws applicable in Lagos State, while providing standards and best practices with regards to legal indications, pre and post-procedure care, methods, and monitoring.

“I must state that this document has undergone wide consultation with relevant technical stakeholders within the legal and health service context in the state,” he said.

Ogboye said the process to develop the guidelines started in 2018 with the ‘Safe Engage Project’ led by the ministry and hosted by the Society for Obstetricians and Gynaecologists of Nigeria (SOGON), with support from the Population Reference Bureau (PRB).

He added that stakeholders in the state health sector worked with key opinion leaders in Lagos and the Southwest region to develop a tailored advocacy tool for terminations within the legal context.

According to him, the advocacy messages on the Safe Engage project focused on two immediate outcomes. He noted that the outcome include ensuring that safe abortion services were available within legal indications in Lagos and domesticating the Violence Against Persons Prohibition Act, supporting women to terminate a pregnancy caused by rape or incest.

“To guide the implementation, one of the follow-up recommendations of the project was the adaptation of the National Standards and Guidelines for Safe Termination of Pregnancy within Legal Indications within the Lagos State context.

“The Federal Ministry of Health had developed and disseminated the national guidelines on safe termination of pregnancy, which highlights the compendium of conditions and circumstances under which termination of pregnancy could be instituted.

“The guideline was intended to build the capacity of health professionals to identify pregnancies for which legal termination could be instituted.

“Marie Stopes International in Nigeria in collaboration with the Population Reference Bureau proposed to support the state government to adopt the document,” he said.

However, the Catholic Archbishop of Lagos, Most Rev. Adewale Martins, immediately rejected the legalisation of abortion by Lagos State Governor.
Martins said it was untrue that all stakeholders were consulted in the guidelines’ preparation.

Lagos state recently unveiled a 40-page policy document tagged ‘Lagos State guidelines on safe termination of pregnancy for legal indications.’The Church, therefore, in a statement signed by Director of Social Communications, Lagos Archdiocese, Rev. Fr. Anthony Godonu, called on Sanwo-Olu to stop the implementation of the guidelines it has made public on the process to follow for abortion in the state.

The archbishop said the argument by the Lagos State Ministry of Health for giving the guidelines was nothing but a means of legalising abortion through the backdoor.

The cleric wondered why the state government seemed anxious to legalise abortion at a time when even the United States (US) and other more advanced countries were reviewing their positions on the legalisation of abortion as seen in the recent judgement of the Supreme Court of the United States of America on the matter.

Also, a social critic and lawyer, Sonnie Ekwowusi, told The Guardian: “The abortion directives issued by the Lagos State Governor to the effect that Lagosians can now ‘safely’ kill their unborn babies without any qualms are illegal and therefore null and void.

“Frankly speaking, I don’t know why Sanwo-Olu has allowed himself to be drafted into the simmering, highly-sensitive political, cultural, religious, moral and contentious issue of abortion. I don’t know any Nigerian politician who had promoted abortion without his or her political career being completely ruined. So, why is Sanwo-Olu toying with his political career? Already Sanwo-Olu’s abortion directives have sparked off demonstrations in Lagos and Abuja.

“The Governor’s abortion directives fragrantly violate sections 145, 146, 147 and 201 of the Criminal Laws of Lagos State (as amended in 2011); sections 228, 229,230, 297, 309, 328, of the Criminal Code Act CAP C38 (and their equivalent provisions in the Penal Code); sections 3,4, and 17 of the Child Rights Act 2003; Child’s Right Law of Lagos State 2015: sections 17 and 33 of the 1999 Nigerian Constitution; Articles, 3, 4 and 5 of the African Charter on Human and Peoples’ Rights; Preamble to the 1990 Convention on the Rights of the Child (CRC) (ratified and adopted by Nigeria). Therefore, as earlier stated, the aforesaid abortion directives issued last week by the Lagos State Governor are illegal and therefore null and void.

“Therefore, the State Governor is humbly advised to withdraw the abortion directives. Why? Because the abortion directives or policies cannot be enforced or obeyed in Lagos State. It is trite law that directives or policies that are ultra vires the existing laws of the land or do not fall within the ambit of the laws of the land or are in violation of the laws of the land cannot be enforced or obeyed in the State. Only enacted laws or Acts can be enforced or obeyed.

“Governor’s Directives that are in flagrant violation of the laws of the land cannot be enforced. The combined effects of sections 145, 146, 147, and 201 of the Criminal Laws of Lagos State (as amended in 2011) and sections 228, 229,230, 297, 309, 328, of the Criminal Code Act CAP C38 (and their equivalent provisions in the Penal Code) is that anybody who, with an intent to procure the miscarriage of a woman or intents to abort or kill her baby in the woman by unlawfully administering on her any noxious substance or contraceptives or pills or drugs or instruments or by inserting instruments into the womb of the woman and crushing her baby to pieces in order to achieve the aforesaid purpose is guilty of a felony punishable under the various sections of the Criminal Code of Lagos or the Criminal Act of the Federation. In fact, section 328 of the Criminal Act prescribes life imprisonment for killing an unborn child.”

However, following public outcry, Lagos State Governor directed the suspension of the “State Guidelines on Safe Termination of Pregnancy for Legal Indications” issued by the Directorate of Family Health and Nutrition in the Ministry of Health. Sanwo-Olu said that the new guidelines would not be implemented until adequate deliberation.

The governor added that the suspension would also allow for adequate public sensitisation and stakeholder engagement to reach a consensus required for successful guideline development.

Meanwhile, a school of thought believes that maternal mortality rates are expected to increase in states in the United States of America (U.S.A.) with restricted or banned abortion access, with people of Colour more likely to be affected.

While some people may resort to unsafe measures to terminate an unplanned pregnancy, many others may die from untreated pregnancy complications or even maternal homicide.

Education around contraceptives, prenatal care, and agencies that help subsidise abortions in states where they are legal could be life saving. The Supreme Court’s landmark ruling that overturned Roe v. Wade poses many threats to the physical and mental health of anyone who could become pregnant.

What is most concerning about restricting or banning abortion access is the anticipated increase in maternal mortality rates, with Black women more likely to be affected.

Even before Roe’s reversal, the United States had the highest maternal mortality rate of any developed nation. Data from the Centers for Disease Control and Prevention (CDC) shows that in 2020, the maternal mortality rate was nearly 24 deaths per 100,000 live births.

In many situations, abortions can be life saving, and experts say banning them or severely restricting them can increase maternal mortality. But a rise in maternal mortality is unlikely to be largely attributed to abortions that are self-managed, particularly those that are managed with United States Food and Drug Administration (FDA)-approved abortion medications. Instead, experts say the reasons maternal mortality may increase due to abortion bans are complicated.

Abortions are statistically safer than childbirth. Research from 2012 shows the risk of death during childbirth is 14 times higher than a safe and legal abortion.

What is more, research from 2022 indicates that even self-managed abortions, when performed under the guidance of a physician, can be safe and effective. In 2021, the Food and Drug Administration issued a permanent approval for prescription abortion pills by mail, permitting doctors to meet with out-of-state patients via telemedicine and prescribe the medication.

Dr. Sarah Prager, MAS, a UW Medicine professor in the department of obstetrics and gynecology, told Healthline the primary way people will likely try to self-manage an abortion will still be with medication regimens using mifepristone and misoprostol. But these medications are only approved for up to 10 weeks gestation, which means that self-managed abortions beyond 10 weeks are unsafe.

“People who cannot access abortion [may] become desperate quickly and will resort to any means they can to not be pregnant.” Experts have warned that people of all backgrounds will die from untreated pregnancy complications, such as an incomplete miscarriage. Others have expressed concern for pregnant people experiencing intimate partner violence, which could increase the number of maternal homicides.

But restricted abortion access is more likely to increase maternal mortality rates among People of Colour, especially Black women. The United States Centres for Disease Control and Prevention (CDC) reports that Black, American Indian, and Alaska Native (AI/AN) women are two to three times more likely to die of pregnancy-related causes than white women.

According to the CDC, contributing factors to higher pregnancy-related deaths among People of Colour may include: structural racism and implicit bias; lack of access to quality healthcare; underlying chronic conditions; and social determinants of health that prevent people from receiving fair opportunities for economic, physical, and emotional health (that is, rural location, transportation issues, lack of insurance).

Research from 2022 estimates that 26 per cent of pregnancies end in miscarriage — that is over a quarter of all pregnancies. Miscarriage care, including medications or medical procedures, is similar to abortion care.

Limitations on medical miscarriage care due to pregnancy complications can be fatal, putting medical professionals in a complicated ethical position in the emergency room.

“Doctors are ethically obligated to treat patients, and it may [also] be a violation of the states’ anti-abortion laws,” Prager said. “Even if it’s not in violation, there will be confusion for many clinicians about what is and is not allowed, which will also potentially create confusion about how they can legally proceed.”

Already media reports have cited stories from people who faced obstacles in getting miscarriage care. Ectopic pregnancies — when a fertilised egg implants outside of the uterus — affect about one–two per cent of all pregnancies. These pregnancies are not viable and can result in a medical emergency. Delaying treatment due to abortion bans may cause further complications or even result in death.

“A person with an incomplete miscarriage can bleed to death if the uterine contents aren’t evacuated, an ectopic pregnancy can rupture and the [person] can bleed to death,” said Kecia Gaither, MD, MPH, FACOG, the director of Perinatal Services at NYC Health + Hospitals/Lincoln in New York City. “In both cases, intervention is necessary.”

Maternal sepsis, or “septic uterus,” affects 11 per cent of maternal deaths globally. In fact, the World Health Organisation (WHO) reports that maternal sepsis is the third most common cause of maternal mortality.

For instance, if a pregnant person’s water breaks before 20 weeks gestation, it could cause a severe bacterial infection and sepsis (or blood poisoning) if left untreated. Sepsis may also occur during an incomplete miscarriage.

In these cases, physicians may be forced to wait for the patient to become severely ill before providing an abortion or wait until the fetal heartbeat stops.

In some cases, cancer care during pregnancy may be delayed since it may cause harm to the fetus.

“A variety of cancer treatments compromise the immune system and suppress bone marrow, which increases the risk of bleeding,” explained Mitzi Krockover, MD, host of the women’s health podcast, Beyond The Paper Gown. “Denial of [abortion] care can cause a patient to lose too much blood or become septic.”

Krockover added that delaying cancer treatment that could harm a fetus, such as chemotherapy or radiation, could decrease a person’s chances of remission, thus decreasing their overall chances of survival.

In some scenarios, Krockover explained, doctors may elect to use suboptimal therapy that is less harmful to the fetus but not as effective for successful cancer treatment.

Pregnant people with significant comorbid conditions face additional risks if they cannot terminate a pregnancy, which may result in death. A cohort study of California mothers delivering between 1997 and 2014 published in 2020 shows that severe maternal mortality (SMM) increased by 160 per cent during that time. The study noted that medical comorbidities made up a substantial number of maternal mortality rates, increasing 111 per cent during the study period; and obstetric comorbid conditions increased by 30 per cent to 40 per cent.

According to Gaither, comorbidities elevating the risk for maternal mortality may include: underlying cardiac malformations; high blood pressure; cardiac dysfunction; and advanced kidney disease.

According to the American Psychological Association (APA), restricting abortion access may increase the risk of mental health issues. Being denied an abortion might lead to an increase in anxiety, depression, post-traumatic stress disorder (PTSD), and even suicidal ideation, according to the APA.

Suicide is a leading cause of maternal mortality in the United States. In fact, a 2021 study looking at data from 2006 to 2017 shows that suicidal ideation and self-harm significantly increased among pregnant people during the year before and after giving birth.

“According to the Turnaway study, people who were denied abortion access experienced higher levels of depression and anxiety and overall worse mental health outcomes than people who were allowed to have an abortion,” said Dr. Mary Jacobson, chief medical officer at Alpha Medical.

By contrast, Jacobson cited another study, which showed that levels of suicidal ideation were similarly low between people who had abortions and people who were denied abortions.

The researchers concluded there’s not enough evidence to suggest that having an abortion increases a person’s risk for suicide. They noted that some studies had shown a higher risk of deliberate self-harm among women denied an abortion but concluded that more rigorous research is still needed.

“Based on these facts, one may hypothesize that maternal mortality due to suicidality may increase, but this hypothesis is debatable,” Jacobson said.

Domestic violence and maternal homicide
Research from 2021 shows that homicide is another top cause of maternal mortality in the United States, with marginalised groups and People of Colour more likely to be impacted, particularly those of younger ages.

Data shows there were about four homicides per 100,000 live births among people who were pregnant or within one year postpartum, which was 16 per cent higher than homicide prevalence among non-pregnant and non-postpartum people of reproductive age.

Intimate partner violence is associated with maternal mortality. Advocates for survivors of domestic violence have said that pregnant people are especially at risk for an increase in intimate-partner violence in a post-Roe world if they’re denied an abortion.

According to Jacobson, there are a few ways you can help support pregnant people who may be seeking an abortion, particularly those who may be dealing with intimate partner violence or those in marginalised groups:
•Spread accurate information about contraceptives (that is, the pill, patch, ring, injection, implant, and IUD), which help prevent unplanned pregnancies.
•Recognise that sexual coercion and domestic violence exist regardless of socioeconomic status.
•Engage and educate people about intimate partner violence.
•Screen and rescreen patients for sexual coercion and domestic violence.
•Provide resources and alternatives for people in abusive relationships.
•Recognise and learn from our own implicit biases and take the Implicit Association Test.

To help reduce the risk for maternal mortality overall, Gaither said that anyone who can become pregnant should educate themselves on the availability of: Long-acting reversible contraceptives (LARCS); States that perform safe and legal abortions; Early entrance into medical care upon positive pregnancy tests; and Agencies that can assist with costs and access to abortion services (that is, the National Abortion Federation).

Meanwhile, a number of alternate contraceptives have been found to be with little to no consequence, one of the alternate solutions is vasectomy.
Vasectomy is an outpatient procedure that is minimally invasive, so most men do not experience significant pain afterwards. It is a form of male birth control that cuts the supply of sperm to the semen. The surgery is done by cutting and sealing the tubes that carry sperm, it has low risk of problems and can usually be performed in an outpatient setting under local anesthesia.

Couple that do not want children or that has already given birth to their desired number should opt for Vasectomy because it’s a reliable form of birth control as you can get. It’s also less likely to cause problems than a woman having to take pills or having her tubes tied (aka tubal ligation).

The procedure is less expensive and it’s a one-time cost that may even be covered by insurance plan.Experts have also confirmed that vasectomy does not affect the sex drive, testosterone level, erections, climaxes or any other part of the man’s sex life.

It is effective, convenient, and permanent birth control. It takes the stress of preventing pregnancy off your partner, and can even make your sex life better.