Advocacy for Reform of the Abortion Law in Nigeria

Abstract

Safe abortion services are only legal in Nigeria to save the life of the woman. Widespread incidence of unsafe induced abortions often results in death or irreparable harm to women. The Campaign Against Unwanted Pregnancy (CAUP) was launched on 17 August 1991 to address this public health crisis through advocacy for reform of the abortion law, research, education and preparation of service providers, and development of a constituency to support provision of safe abortion to the full extent of the law. CAUP commissioned an evaluation in 2004 to examine and analyse the work of the campaign during its 14 years of existence, which included a review of documents, a participatory learning workshop with CAUP, and almost 50 interviews with different stakeholders. This article, adapted from the evaluation report, tells how CAUP took a taboo topic and, in the midst of an extremely complex political and cultural environment, made it a legitimate subject for public discussion and debate. The Campaign undertook groundbreaking research on abortion in Nigeria. Service providers are being trained to provide, to the full extent of the law, safe abortions and post-abortion care, and advocacy efforts are continuing to lay the groundwork for improving the abortion law.

Résumé

Les services d’avortement médicalisé ne sont autorisés au Nigéria que pour sauver la vie de la femme. Les nombreuses interruptions de grossesseàrisque se terminent souvent par la mort de la femme ou des séquelles permanentes. La Campagne contre les grossesses non désirées (CAUP) a été lancée le 17 ao t 1991 pour régler cette crise de santé publique par le plaidoyer pour la réforme de la loi sur l’avortement, la recherche, la formation des prestataires de services, et la création de groupes de soutien des avortements s rs conformesàla loi. En 2004, la CAUP a commandité une évaluation pour analyser son travail pendant ses 14 ans d’existence, avec un examen de documents, un atelier d’apprentissage actif et près de 50 entretiens avec différents acteurs. Cet article, adapté du rapport d’évaluation, montre comment la CAUP a abordé un sujet tabou et en a fait un thème légitime de débat public, dans un environnement politique et culturel extrÁmement complexe. La CAUP a entrepris des recherches pionnières au Nigéria. Les prestataires de services sont formés pour pratiquer, en conformité avec la loi, des avortements s rs et des soins post-avortement, et les activités de plaidoyer se poursuivent pour préparer une amélioration de la loi sur l’avortement.

Resumen

En Nigeria se ofrecen servicios de aborto seguro y legal únicamente para salvar la vida de la mujer. La gran incidencia de abortos inducidos en condiciones de riesgo con frecuencia propicia la muerte o daños irreparables de las mujeres. La Campaña contra el Embarazo No Deseado (CAUP) se lanzó el 17 de agosto de 1991 con el fin de tratar esta crisis de salud pública mediante la promoción y defensa de reformas de la Ley de Aborto, investigaciones, la formación y preparación de los prestadores de servicios, y un aumento en la inscripción de electores a favor de la prestación de servicios de aborto seguro al máximo alcance de la ley. En 2004, CAUP encargó una evaluación para examinar y analizar el trabajo de la campaña durante sus 14 años de existencia, la cual incluyó una revisión de los documentos, un taller de aprendizaje participativo con CAUP, y casi 50 entrevistas entre diferentes partes interesadas. En este artáculo, adaptado del informe de la evaluación, se explica cómo, en medio de un ambiente polático y cultural sumamente complejo, CAUP convirtió un tema tabú en uno legátimo para el debate público. La Campaña emprendió investigaciones pioneras sobre el aborto en Nigeria. Se están capacitando a los proveedores para que ofrezcan servicios de aborto seguro y de atención postaborto al máximo alcance de la ley, y los esfuerzos de promoción y defensa continúan preparando el terreno para mejorar la ley de aborto.

Keywords:

• unsafe abortion
• abortion law and policy
• advocacy and political process
• medical curriculum
• Nigeria

Nigeria is the most populous nation in Africa, with 25% of the continent’s 500 million people. The population is characterised by a high fertility rate of 5.7 per woman and a population growth rate of 2.8%. The high maternal mortality ratio of about 1,000 to 100,000 live births as well as the current high perinatal and neonatal mortality rates of 90 per 1,000 births and 35 per 1,000 births, respectively, constitute strong evidence of poor sexual and reproductive health and rights. An upward trend in the infant mortality rate from 91 per 1,000 births in 1991 to 100 per 1,000 births in 2003 reflects deteriorating socio-economic conditions.¹

Unsafe abortion in Nigeria

Nigeria has a federal government system with 36 states and a Federal Capital Territory. The 19 states in the northern part of the country and the Federal Capital Territory are governed by the Penal Code while the 17 southern states are governed by the Criminal Code. Termination of pregnancy in Nigeria is highly restricted under both the Penal and Criminal Codes and carries a heavy jail term of up to 14 years imprisonment for the provider unless it is performed to save the life of the woman.² A woman who has an illegal abortion is liable to a jail term of up to seven years. Neither the Criminal nor the Penal Code prevents the large number of abortions that are performed clandestinely in Nigeria, but they do greatly increase women’s vulnerability to unsafe abortion and are a major impediment to the improvement of the sexual and reproductive health and rights of Nigerian women.

Unsafe abortion is a major cause of maternal mortality and morbidity in Nigeria, accounting for 30—40% of maternal deaths.³, ⁴ The abortion rate in Nigeria is 25 per 1000 women aged 15—44 years and there are about 610,000 pregnancy terminations annually.⁵ About 60% of these are in young women, mainly carried out by unskilled practitioners.⁶ However, the fact that 60% of terminations in Nigeria are still being done by unskilled providers, using unsafe methods like dilatation and curettage, a range of often harmful and ineffective drugs and insertion of solid or sharp objects into the cervix to perform abortions, suggests a high post-abortion complication rate. These high levels of morbidity and mortality could be prevented by improving access to contraceptive services, sexuality education, safe abortion procedures and treatment for abortion complications.

When carried out by a skilled provider in safe conditions, abortion is very safe. There is also an association between availability of legal abortion and the safety and survival of women. When legal restrictions are removed, the number of deaths from complications of induced abortion reaches almost nil. It is, therefore, imperative that the law be reformed to prevent Nigerian women from dying from unsafe abortions.^{7 8 9 10}

The Campaign Against Unwanted Pregnancy

The Nigerian Campaign Against Unwanted Pregnancy (CAUP) was launched on 17 August 1991 as a multi-disciplinary initiative to focus attention on the health problems of women caused by unsafe abortion in Nigeria. During the 14 years since 1991, the political environment in Nigeria has been a complex and volatile one, with strong religious and ethnic tensions and a very conservative public attitude towards abortion. Nonetheless, support for safe abortion has been growing quietly, spreading primarily through the medical community, which has become increasingly knowledgeable about women’s reproductive health in general and abortion in particular. In addition, more general support for women’s rights has grown gradually, due largely to the work of women’s organisations.

The initial motivation for creating CAUP was the concern of three medical doctors specialising in obstetrics and gynaecology, who were having to treat women with severe complications and morbidity who came to their hospitals for care in the aftermath of unsafe abortions.⁴ Many women were dying and many more suffered irreparable harm as a result of dangerous procedures.¹¹ They viewed this as a public health crisis and wanted to take action to stop the unnecessary suffering and death.

On 16—17 August 1991, CAUP convened a consultative group of 27 people committed to the promotion of women’s sexual and reproductive health and rights, drawn from a variety of disciplines, including women’s health, law and rights, grassroots organisations, academia and media. The group discussed the extent of unsafe abortion and its consequences and agreed to create CAUP. They chose four people to coordinate the campaign, three of whom have continued as coordinators to the present day: two are obstetrician—gynaecologists and one is a social worker and activist with grassroots organisations. The current fourth coordinator is a lawyer and judge, who joined CAUP in 2000.

CAUP’s vision, agreed at the founding meeting, was a Nigeria free of unsafe abortion. Its mission was to create a prominent organisation committed to reducing the burden of unsafe abortion among women in Nigeria.

In 2004, CAUP commissioned an evaluation to examine and analyse its work in the 14 years of its existence, which included a review of documents, a participatory learning workshop and some 50 interviews with different stakeholders. This article, adapted from the evaluation report, shows how CAUP took a taboo topic and made it a legitimate subject for public discussion and debate, even in the difficult political environment in which they were working.

Advocacy for safe abortion: addressing power in the broadest sense

In many countries a comprehensive approach to addressing the problem of unsafe abortion has evolved, which rests principally on three stands: liberalisation of the abortion law, provision of safe, available and effective abortion care services and availability of contraceptive information and services.¹² Basic to all of these are health education and public awareness-raising, to create an enabling environment in which women’s right to decide the number and spacing of children is upheld.

Advocacy efforts may fail if they look at power only in a narrow sense, without seeing the broader dynamics of the political process. These dynamics are present not only in policymaking, but also in the powerful interests that shape agendas and ideology, and the socialisation that shapes people’s understanding of issues. Advocacy efforts need to address not only visible power, i.e. the making and enforcing of formal laws and regulations, structures, authorities, institutions and the procedures of decision-making, but also how and by whom the agenda is set. The latter includes the ways in which powerful people and institutions maintain their influence, by controlling access to decision-making and excluding and devaluing the concerns and representation of less powerful groups. Poor women, adolescents, medical students and other service providers have the potential and credibility to be forceful advocates for safe abortion, but they may lack the information, awareness and social support necessary to act. Yet their support is essential to change. The power of values and the perceived meanings and definitions of what is normal also shape the psychological and ideological boundaries of participation. Significant problems and issues are not only kept from the decision-making table but also from the minds and consciousness of different stakeholders, even those most directly affected by the problem.¹³

CAUP’s advocacy work has evolved over time from an initial focus on the power of legislative reform to addressing all the critical dimensions of power. Through media sensitisation, research, information materials and public meetings, training young medical advocates, constituency-building with other NGOs and community-based organisations, working with policymakers, changing the medical curriculum and a renewed focus on law reform, CAUP is challenging the status quo of unsafe, illegal abortion in Nigeria.

First attempt at legislative reform

In the first phase of its work, starting in 1992, CAUP focused on legislative reform of the existing abortion law. Its first activity was to commission a senior advocate to review the law. Five people from the Ministry of Health and the Ministry of Justice worked on this review. The then Minister of Health, Professor Olikoye Ransome-Kuti, wanted a new, more liberal abortion law, and the Nigerian Medical Association (NMA), whose then president was one of CAUP’s coordinators, supported law reform as well. The NMA at that time served as the legal and institutional base for CAUP activities. Because the country was under military rule, it was thought that a new law on abortion could be put into effect just by having the Minister of Health and the President both sign it. CAUP’s coordinators worked closely with Ransome-Kuti on the substance of the proposed new law. However, shortly before the law was to be signed by the President, opponents of abortion learned of the effort and raised objections publicly. A furore arose in the Nigerian press and the reform attempt failed.

Media sensitisation

Building on the lessons from CAUP’s failed attempt to change the law, the Campaign began to educate journalists about the scope of unsafe abortion and its consequences. The media have the power to influence law and policy, both to support or to change the status quo. CAUP recognised the importance of creating allies among editors and journalists in support of safe abortion in order to expand the political space needed to place the issue of safe abortion on the table and to be able to debate abortion issues without a severe backlash. This enabled CAUP to begin to educate the public — although in a limited way — about the magnitude of unsafe abortion and to prevent opponents from minimising the importance of the problem.

CAUP’s coordinators met with the editorial boards of all the major Nigerian newspapers in the country to try and convince them to develop an editorial policy that took a public health stance in support of safe abortion. These newspapers represented the full political spectrum from conservative to liberal.

CAUP also carried out media sensitisation workshops between 1996 and 2001 for journalists to increase their knowledge about abortion, unwanted pregnancy and other reproductive health issues and to encourage them to speak out for a revised abortion law. As a result of these workshops, various newspapers ran articles on the need for safe abortion to the full extent of the law from time to time. Three journalists became members of CAUP’s Consultative Group, which advises the Campaign on advocacy strategy.^* They often write articles during or shortly after CAUP activities, such as workshops or conferences. Some experienced women feature writers have also developed a strong relationship with CAUP and are supportive of its work.

Research on the magnitude of unsafe abortion

After the failed attempt to change the law, Professor Ransome-Kuti asked CAUP for data on the scope of unsafe abortion in the country, in order to garner support from within the government. The Campaign realised that there were no reliable data with which to convince government officials and others in the community of the seriousness of the problem. Between 1995 and 1997, CAUP carried out a joint study with colleagues from the Alan Guttmacher Institute (AGI) in New York. Interviews for this national study were carried out in a sample of 672 health facilities, conducted by experienced physicians trained by CAUP and AGI. The study found that there were approximately 610,000 abortions a year, a rate of 25 abortions per 1,000 women aged 15—44.⁵ This study is still considered the most authoritative research on abortion in Nigeria. Both it and subsequent research carried out by CAUP are widely used by advocates, educators, journalists and medical personnel across the country.

Campaign information materials and public meetings

As research data became available, CAUP began to create fact sheets, a newsletter, posters, and stickers for automobiles and windows. The fact sheets covered such issues as characteristics of abortion seekers, factors leading to unwanted pregnancy and induced abortion, quality of abortion care services, complications of induced abortion, family planning methods and usage, and views and attitudes towards induced abortion.

In addition to posters addressed to women and girls, some of the CAUP posters and stickers are addressed to men, urging them to behave responsibly (“Making a schoolgirl pregnant may ruin her life”“Don’t violate that young girl. It could happen to your daughter”). These materials continue to be distributed to a wide array of groups, including medical students, non-governmental organisations (NGOs), community-based organisations (CBOs), university students and policymakers.

In the second half of the 1990s, CAUP also began to hold large public meetings and educational events, including a public symposium “So That Our Daughters Do Not Die”, which took place in August 1997, a news conference to release the CAUP/AGI abortion study data in February 1999, and a national conference on unsafe abortion in July 2000, described below.

Training young medical advocates

A large proportion of Nigeria’s young people have little or no knowledge of sexual and reproductive health. A survey of adolescents in five cities in Nigeria found that friends or schoolmates provided information on reproductive health and contraception for 26.2% of the young women surveyed and 34.1% of the young men,¹⁴ and some of the information was incomplete or incorrect.

In October 1997, CAUP launched a major education and advocacy initiative for young people, the Action Group on Adolescent Health (AGAH). Through this initiative, CAUP taught students in the medical schools of Lagos University and the University of Ibadan about reproductive health, sexuality, family planning and induced abortion, so that they could become peer educators in their medical schools and advocates for sexuality education, family planning and safe abortion more widely.

This initiative continues today in both of these pioneering medical schools and is now being expanded to six additional medical schools in Ilorin, Zaria, Jos, Kano, Nnewi and Calabar. This training has often led medical students to re-direct their medical career plans to work in reproductive health. AGAH members serve as resources in their medical schools and increasingly, for the wider university community and surrounding neighbourhoods. They carry out peer education and sexual and reproductive health education awareness days at central locations on their campuses, and provide individual counselling for students, maintain a hotline phone service and distribute emergency contraceptive pills. On the Lagos and Ibadan campuses, they provide referrals to the adolescent-friendly clinics that have been established. These clinics each have a nurse, with the AGAH members working as volunteers.

In Ibadan, the AGAH members have begun to collaborate with law school students and together have held mock trials of those sexually abusing women. The Lagos group is now developing links with law students as well. The Ibadan students also stage drama presentations on unwanted pregnancy and unsafe abortion, in which the actors are medical students. Other NGOs, especially those run by youth or serving young people, often partner with the AGAH chapters to take advantage of their medical expertise.

Current and former members of AGAH display an enthusiasm for its work that is impressive. Of the ten former and present AGAH members interviewed during the evaluation of CAUP’s work, almost all described it as a life-changing experience:

“My future in medicine would not be the same without AGAH. Now I see myself involved with CAUP. I want to do a master’s degree in public health as well.”

Working with other NGOs and community-based organisations

In the past six years, CAUP’s advocacy strategy has been multi-dimensional, combining efforts to shape policy, institutions and opinions about abortion. Its advocacy approach has been expanded to incorporate civil society groups. In April 1999 a workshop on sexuality education was held for ten major community-based, micro-credit, development organisations, and in June 1999 CAUP held an advocacy skills workshop for women’s rights organisations.

In March 2001 and again in June 2002, CAUP carried out sexuality education workshops for the ten micro-credit organisations. Each of them developed a workplan to carry out sexual and reproductive health educational sessions at community level, subsequent to the CAUP workshops, including in remote areas of the country. This interaction has proved to be a powerful way of replicating sexuality education. One group uses church functions and its work with youth groups to hand on the information provided during the CAUP workshop, for example.

More recently, in August 2004, Ipas Nigeria invited CAUP to give a lecture on the consequences of unsafe abortion to members of the governance structure of the National Council for Women’s Societies (NCWS) and to women legislators. After the lecture, the NCWS voted for the first time to support efforts to reform the abortion law and to promote safe motherhood in the country.^* The NCWS is a 46-year-old, nationwide federated network, comprising independent NGOs and CBOs that use the NCWS platform to formulate and disseminate information and views on women’s issues. Through its own advocacy efforts, the NCWS takes the concerns of its members from the grassroots to all levels of government and society at large. If the NCWS educates its constituency about unsafe abortion and can convince them of the need for abortion law reform, they will become a very important partner and force for change in achieving CAUP’s goals.

Working with policymakers

In July 2000, CAUP carried out a national conference on abortion in Abuja entitled “Reducing Maternal Morbidity and Mortality from Unsafe Abortion in Nigeria”,¹⁵ which featured remarks by Nigeria’s First Lady:

“The emotive nature of the abortion debate has often blinded all sides from acknowledging the obvious: that no woman ever got pregnant with the sole aim of terminating [it] through an abortion… Society should, therefore, focus on what to do in order to eliminate or minimise the social and environmental factors that give rise to these situations.”

This conference was well attended by representatives of the federal and state governments and began to lay the groundwork for a new round of work on reform of the abortion law.

CAUP again held a workshop for policymakers in Abuja in November 2001. Present at this workshop were representatives of the House and Senate committees on health, information, education, justice and women’s affairs of the National Assembly. Representatives of the corresponding five federal ministries also participated. The workshop discussed the need to reform the abortion law and developed a plan of action to reduce unsafe abortion. Unfortunately, in the elections for the National Assembly in 2003, an almost entirely new slate of members was elected, with the result that CAUP has had to begin getting to know and work with new legislators all over again.

Updating the medical curriculum

In February 2001, in response to the need to upgrade the knowledge and skills of health service providers, CAUP carried out a review of the sexual and reproductive health modules in the Nigerian Medical School Curriculum, including on family planning and the need for safe abortion. In a three-day workshop, CAUP brought together senior representatives from 16 accredited Nigerian medical schools, medical students, medical professional associations, the National Universities Commission, the Nigerian Educational Research and Development Council and federal policymakers from three Ministries. The result of the workshop was a set of guidelines for the Nigerian Medical School Curriculum on Sexual and Reproductive Health and Rights.¹⁶ This new curriculum has now been formally adopted and is being implemented in all 16 accredited medical schools. This was a major accomplishment.

New efforts to reform the law at federal and state level

Since 2002, CAUP has returned to its efforts to reform the abortion law and has worked to develop a new draft abortion bill to be introduced in the National Assembly. CAUP held a Consultative Group meeting on the content of such a bill in June 2002. Women’s groups and NGO representatives also attended. An experts’ meeting was then arranged in 2003 in which lawyers, medical personnel, women’s rights specialists and others discussed preparation of the bill. Some of them have worked together to edit and review the various drafts that were produced. The bill is now in its eighth draft. The participatory drafting process used has created a strong sense of ownership on the part of those involved, although it has probably resulted in a more complicated bill. Such a result is perhaps inevitable when the process has been shared by so many different interest groups to ensure ownership and acceptance of the final product.

Some of CAUP’s allies in Nigeria argue that one of the ways to reform the abortion law in Nigeria is to seek to amend the criminal codes at state level, because the laws which criminalise abortion are state-level criminal statutes. They argue that if the criminal statutes can be changed in the states where CAUP has allies, then other states may follow suit. Other advocates feel that other states would probably not follow suit, for example, that the Northern states would be unlikely to replicate changes passed in the Southern or Eastern states. However, they argue, if a federal law is enacted, then the Northern states would be more likely to follow it.

The structure of CAUP

In addition to their own full-time work, the four CAUP coordinators provide the leadership for the Campaign, determine strategy, raise funds, design initiatives and carry out a large part of the work. CAUP holds annual Consultative Group meetings. Although the coordinators do a great deal of the work, they are careful about their public pronouncements about abortion, given the widespread religious and social opposition to the issue in the country.

Some members of the Consultative Group and other allies of CAUP speak publicly, write articles, and promote safe abortion, always as individuals rather than as representatives of CAUP. Those who are willing to speak publicly on safe abortion constitute an informal Speaker’s Bureau; this protects CAUP as an organisation, given the sensitivity of the issue. The membership of the Consultative Group is somewhat fluid. The coordinators decide whom to invite to the annual meeting based on the topics that will be discussed. Nevertheless, some have been members of this group for a significant length of time and are experienced advocates.

Future perspectives and priorities

Since 2001, the posture of the United States government towards reproductive health and rights has become more and more restrictive, especially as regards abortion. This could have negative implications for efforts to expand the frontiers of sexual and reproductive health and rights in Nigeria, as regards access to funding for NGOs working for sexual and reproductive health.

Other constraints CAUP will continue to face in its future efforts to change the law include the strong religious and ethnic values against abortion, the scarcity of resources available to carry out advocacy for safe abortion, the fact that legislators in the National Assembly are virtually all new since 2003, and the time and resources it takes in a country the size of Nigeria to create awareness among key stakeholders and mobilise a large constituency in support of this effort.

Given the fact that the political, ethnic and religious environment in Nigeria continues to be a difficult one in which to promote safe abortion, CAUP plans to continue to campaign in the same way it has done to date, namely, as a public health initiative. A next step in the expansion of its constituency is to seek the support of political, religious and ethnic leaders for safe abortion.

CAUP’s activities reflect careful political choices based on an assessment of potential risks and available political space. The strategy has focused a great deal of attention on the structural and cultural aspects of the abortion issue. Because those with sufficient resources can afford safe abortions, secretly provided, those who do not have access to safe abortion are primarily poor women without information, resources or any way to avail themselves of safe services. CAUP’s focus on the creation of AGAH, the review and reform of the medical school curriculum, its promotion of adoption and fostering, and research on various aspects of abortion and reproductive health have all worked to begin to change the structures which keep the inequity of abortion access in place. As medical students, nurses and midwives become aware of unsafe abortion and its consequences, they will be prepared to advocate for reform of the law and to provide safe abortion services and post-abortion care.

The greatest strength of the Campaign has been its ability to create a public dialogue on the need for safe abortion and to carry out related reproductive health initiatives to prevent unwanted pregnancy. Moreover, the Campaign’s decision to remain “below the radar” in promoting work on this issue has enabled CAUP to expand the number of people in the country committed to speaking out and working on the issue. It has also enabled the Campaign to adapt its actions to political realities and to think long-term.

CAUP has seen itself as being in a learning mode throughout its existence, an essential ingredient for successful advocacy efforts. In its first 14 years of existence, it has succeeded in taking a taboo topic and making it a legitimate subject for public discussion and debate. Furthermore, it has gone a long way towards preparing current and future health service providers to be willing and able to provide safe abortion and post-abortion care. Its commitment to a long-term advocacy effort has brought CAUP closer to changing the law and making safe abortion accessible to every woman who needs it.

Girls’ football team, Nairobi, 2003

Acknowledgements

Many NGOs, individuals and foundations have supported CAUP’s work. Just Associates conducted the evaluation which informed this paper. The International Women’s Health Coallition supported the evaluation and the production of this paper, and has supported CAUP since its inception.

Notes

* The Consultative Group was originally comprised of some 27 individuals drawn from different disciplines, and advise the coordinators regarding CAUP’s strategy and programmes. They include leaders of NGOs working on sexual and reproductive health and rights, lawyers, women’s rights activists, medical and health professionals and social scientists.

* In 1992, NCWS and its members vehemently opposed the attempt to reform the abortion law.