Women’s experiences of the abortion law in Cameroon: “What really matters”

Abstract

While prosecutions of women who have had an illegal abortion are rare in Cameroon, women who have a legitimate claim to a legal abortion, e.g. following rape, can rarely take advantage of it. This is because the law in Cameroon is not applied, either when it is violated or when it is indicated. This paper examines the histories of four young women who became pregnant and had an abortion in the Anglophone region of the Cameroon Grassfields. Three of them became pregnant following rape or sexual coercion, in one case by the girl's priest, in the second case by her employer's son, and in the third case by a stranger. The fourth young woman, who sold sex for survival money and food, had two abortions while in prison for committing infanticide following a failed attempt to abort an earlier pregnancy. The four young women were interviewed as part of a qualitative, hospital-based study among 65 women who had had abortions in 1996–97. The women's affecting personal histories illuminate the reality of living under a restrictive abortion law, the troubling conditions in which they have to manage their lives, and the harsh circumstances in which they become pregnant and seek (but may not find) a safe abortion.

Résumé

Si les femmes qui ont avorté illégalement sont rarement poursuivies au Cameroun, celles qui ont une raison légitime de demander un avortement légal, par exemple après un viol, peuvent rarement l'obtenir. C'est parce que la loi au Cameroun n'est pas appliquée, que ce soit en cas d'infraction ou d'indication. Cet article examine les récits de quatre jeunes femmes qui ont avorté dans la région anglophone de Grassfields au Cameroun. Trois d'entre elles sont tombées enceintes après un viol ou une coercition sexuelle, dans un cas par le prêtre de la jeune fille, dans le deuxième cas par le fils de son employeur et dans le troisième cas par un étranger. La quatrième jeune femme, qui se vendait contre des vivres et de l'argent pour subsister, avait avorté à deux reprises alors qu'elle était emprisonnée pour avoir commis un infanticide après avoir précédemment tenté sans succès d'avorter. Les quatre jeunes femmes ont été interrogées dans le cadre d'une étude qualitative menée dans un hôpital auprès de 65 femmes ayant avorté en 1996–97. Les expériences personnelles des femmes illustrent la réalité de la vie sous une législation restrictive en matière d'avortement, les conditions difficiles dans lesquelles elles doivent se prendre en charge et les circonstances pénibles dans lesquelles elles se retrouvent enceintes et demandent (mais n'obtiennent pas forcément) un avortement sûr.

Resumen

Aunque las mujeres que han tenido un aborto ilegal rara vez son enjuiciadas en Camerún, aquéllas que tienen motivos legítimos para tener un aborto legal, por ejemplo después de una violación, rara vez pueden hacerlo. Esto se debe a que la nueva ley de Camerún no se aplica, ya sea cuando es violada o cuando está indicada. En este artículo se examinan las historias de cuatro mujeres jóvenes que quedaron embarazadas y tuvieron un aborto en la región anglohablante de las Praderas de Camerún. Tres de ellas quedaron embarazadas después de una violación o coacción sexual: en un caso por el cura de la joven, en el segundo por el hijo de su empleador y en el tercero por un extraño. La cuarta joven, quien vendía sexo para obtener dinero y alimentos para sobrevivir, tuvo dos abortos mientras estaba en prisión por haber cometido infanticidio tras un intento fracasado de abortar un embarazo anterior. Las cuatro jóvenes fueron entrevistadas como parte de un estudio cualitativo hospitalario entre 65 mujeres que tuvieron un aborto en 1996–97. Las conmovedoras historias personales de las mujeres iluminan la realidad de vivir bajo una ley de aborto restrictiva, las penosas condiciones bajo las cuales tienen que manejar su vida y las duras circunstancias en las que quedan embarazadas y buscan (pero no siempre encuentran) un aborto seguro.

Key Words:

• abortion law and policy
• rape
• personal histories
• unsafe abortion
• infanticide
• Cameroon

In Cameroon, induced abortion is only permitted when a woman's life is at risk, to preserve her physical and mental health, and on grounds of rape or incest.¹² Abortion is not allowed on socioeconomic grounds, even though these play a key role in women's decision for abortion.³ Illegal abortions are punishable by a fine of up to two million CFA^* and imprisonment of up to five years for the abortionist, one year for the woman herself, and two years for anyone supplying drugs or instruments to induce abortion.² While in Cameroon legal prosecutions for women who have had an induced abortion are exceptional, women who have a legitimate claim to a legal abortion within the law cannot take advantage of it. In other words, the law in Cameroon is not applied, either when it is violated or when it is indicated.

When a country's restrictive abortion law is described in publications, often the grounds for which abortion is allowed are listed without a critical look at the procedures that must be gone through to access a legal abortion. It is not only the legal indications for abortion that are important. Restrictive regulations also place tremendous obstacles in women's paths. For example, to authorise a legal abortion to save a woman's life, Cameroonian law requires that:

“The doctor shall obtain the opinion of two experts each chosen respectively from legal experts and members of the National Council of Medical Practitioners. The latter shall testify in writing that the life of the mother can only be safeguarded by means of the intervention. The protocol of consultation shall be made in 3 copies one of which shall be handed to the patient and the other two to the consultant physician and legal expert. Besides, a protocol of the decision taken shall be sent by registered mail to the chairperson of the National Council of Medical Practitioners.”^*

Not every hospital or health centre is located in a setting where the infrastructure exists and medical professionals are available to fulfil these requirements, particularly given that in Cameroon the population of around 19 million⁵ is served by only 1500 physicians practising mainly in public hospitals,⁶ very few of which are in rural areas.

Moreover, obtaining such permissions is a time-consuming process for women, even in the best of conditions, and likely to cause delays, increasing the risk of complications and even death. Moreover, to take advantage of the law, women and medical professionals have to be informed about women's entitlements as regards abortion. This paper looks at these issues through the stories of four women from the Anglophone part of the Cameroon Grassfields, which offer insights into “what really matters”^† to women affected by Cameroon's abortion law and regulations.

Setting and methodology

The interviews reported in this paper took place within a hospital-based study^** over 16 months between May 1996 and November 1997 in an urban area of the Anglophone Cameroon Grassfields. This qualitative study was carried out to gain deeper knowledge of why women have abortions, despite possible legal and medical consequences, and to what extent cultural and social grounds prevent a greater acceptance of ‘modern’ contraceptives, apart from lack of information and availability. Three categories of women were recruited for the study. First, women who were admitted on the gynaecological ward because of medical complications of unsafe abortion; second, women who were admitted for other reasons and had an induced abortion in their medical history; third, women who were identified for interviews through a snowball sample. Fifty-eight out of the total of 65 interviews were conducted with women who had been hospitalized because of abortion-related medical complications or other reasons. Two of the four women, Justine^†† and Vivian, whose abortion histories are presented in this article, were in this first category. The other two, Lilian and Pauline, belonged to the third category. A semi-structured questionnaire was used, allowing women to respond in an open-ended way. The in-depth interviews were conducted separately in a physician's room. Informed, oral consent was obtained and privacy and anonymity were assured. First, background information and medical history were elicited, and then more intimate questions regarding contraception and abortion were asked. A main focus of the interviews was on aspects of the abortion experience, including how the decision to seek an abortion was made, knowledge of possible legal and medical consequences, and knowledge and practice of contraception. The interviews were audio-taped, transcribed verbatim and analysed with reference to thematic content. The interview data were complemented by participant observation, use of hospital data for 196 women with abortion-related morbidity and mortality, and 23 key informant interviews including medical personnel.

Sixty-one of the 65 women interviewed were not prosecuted for illegal abortion, even though the law was violated, as they were not reported to the police. This also goes for Pauline, whose history is presented here. For the other three women, whose histories are also presented here, who had become pregnant due to rape and had had an abortion, the abortion law was not applied even though it was indicated. Vivian, a student, was raped by a Catholic priest at her school and Justine, a housemaid, by the son of her employer. The third, Lilian, reported having been raped by a stranger on her way to the farm. None of them took advantage of the law even though they could have tried to do so.

“In case of pregnancy resulting from rape, abortion by a qualified medical practitioner after certification by the prosecutor of a good case shall constitute no offence.”^*

Legal prosecution for illegal abortion in Cameroon mostly took place when the abortion was at a late stage of pregnancy; infanticide was also prosecuted.^38† While in prison for infanticide, Pauline had two abortions, one of which came to the attention of the authorities, but she was not prosecuted for that.

Studying unsafe abortion requires sensitivity to women's need for privacy and confidentiality, and more so when abortion is linked to sexual violence and imprisonment. The delay in publishing these personal histories was due to my concern to ensure anonymity for the women, particularly Pauline, whose story was reported in the media at the time, and whose court records were used. For this reason, I changed their names and do not reference a newspaper story about Pauline. Although all the interviews were conducted at the end of the 1990s, the issues of sexual violence and unsafe abortion have not diminished in relevance in Cameroon. The extent of unsafe abortion remains high and has even increased, according to WHO data, despite international and national efforts in the area of family planning. An estimated 5–14 unsafe abortions per 1,000 women aged 15-49 took place in Cameroon in 1990.¹⁰ In 2000 and 2003, the estimate ranged from 20–29 unsafe abortions per 1,000.¹¹¹² Moreover, a recent countrywide survey of 37,719 women between 15 and 49 years in Cameroon has shown a national prevalence rate for rape of 5.2%.¹³

Pauline

Pregnant for the first time at age 15, Pauline left school without finishing her education. The child was sent to live with Pauline's grandmother. While dreaming of an apprenticeship as a tailor, Pauline worked on the farm and sold groundnuts in the street, relying also on the support of different “boyfriends”. A further pregnancy miscarried due to malaria. At age 19, Pauline became pregnant for the third time, while she was living with her stepfather and her half-brothers and sisters from his marriage to her mother. Her mother was absent and unable to provide support. The father of Pauline's expected child refused to take her into his compound and requested that she have an abortion. Pauline tried to self-induce an abortion around the fourth month of pregnancy but did not succeed. Finally, she delivered a baby weighing an estimated 3.5 kg, according to court data. During the delivery she was alone in the compound, without any assistance. She ran away and when she was missed by her family they started to search for her. When they found her, she was no longer pregnant. She said she had delivered a stillborn baby and had thrown it into the neighbour's latrine. The baby's body was found in the latrine but with a rope around its neck. Pauline was charged with infanticide and was convicted and sentenced to five years in prison. The court records contained no information about her reasons for killing the newborn infant or the conditions that led her to do so.

While in prison, Pauline became pregnant twice more. She terminated both pregnancies. The second termination attracted the attention of the prison administration and a local newspaper. Pauline identified the man who had made her pregnant as another prisoner who had been helping her with money and food, and had convinced her to have sexual intercourse with him.

The newspaper headline announced that a prisoner had had an abortion; the article carried her photograph and described her as a “child murder convict”. The abortion itself was not actually discussed in the article; the main focus was on how a woman had become pregnant in prison and that the young man who had made her pregnant was severely punished. Her fellow prisoners accused a female warder of arranging for her to “meet” the young man and reported other abuses by warders of prisoner's rights as well. Attempts to get the prison administration's side of the story did not succeed, according to the article, but eyewitnesses reported that they had seen Pauline after the story came out with all her hair shaved off, as a punishment.

Pauline had asked for an intrauterine device, to help her to escape the vicious cycle of repeat abortions, but this had been refused by prison personnel because of a fear of promoting promiscuity. Condoms were difficult or even impossible to access in prison, according to Pauline.

Pauline's voice was missing in the newspaper article, as it had been in the court records of her case. While “child murder”, getting pregnant in prison, and the warder's behaviour were all seen as important, the article never mentioned Pauline herself. In my interview with her which took place while she was still in prison, details of her personal, familial and socio-economic circumstances emerged for the first time. These included having to trade sex for money and food as a consequence of poverty, a broken home and limited access to effective contraception. Pauline's story was that of a young woman who did not have much of a chance in life and was in no position to take care of children.

Lilian

Lilian was 21 years old at the time she was raped, and was a single mother living in her mother's compound in the village. She was on her way to the farm when the rape happened:

“There were no people around. When I refused he threatened me with a knife, I was so afraid and then…” she stopped talking and remained silent for a while before she continued: “I didn't see my menses.” She was depressed when she realised that she was pregnant due to this rape: “I felt empty. I couldn't eat anything. I was very sad.”

She was afraid to confide to her mother because she feared her anger. She clearly did not want to keep the pregnancy, so she decided to talk to a married girlfriend and mother of three children of whom she said: “She had a lot of experience and she could give me some advice.”

This girlfriend gave her the money for an abortion, and in return Lilian helped her on the farm. The abortion was performed without the required certification from the prosecutor, even though the physician was aware that the pregnancy resulted from rape. While the physician knew that in cases of rape an abortion is legal, it remains unclear whether he was aware of the requirements of the abortion law or if he ignored them intentionally. But he reduced his usual price of 10,000 CFA by half.

In this case, a certificate would have made no difference. Lilian's abortion was not entirely legal but medically safe, and she did not suffer complications afterwards, as her companions in misfortune on the ward did. Safe abortion is available in Cameroon despite its illegality, but only for women who can afford it and know a provider.¹⁴ By complying with the requirements for a legal abortion in cases of rape, by informing the prosecutor, Lilian would have been forced to disclose her experience in detail. Instead, she was able to obtain an abortion illegally without exposure. In that sense, and what emerged from the interviews with all 65 women in my research, was that from these women's perspective, the essential issue was not whether the abortion was legal or illegal but whether it would be safe or unsafe.⁸ Lilian had the advantage of access to a comparatively inexpensive abortion performed by a medical practitioner using manual vacuum aspiration through her friend, and the knowledge and financial means to access a safe abortion without going through the legal requirements.

Vivian

Vivian was a 20-year-old, single high school student who lived with her mother and her stepfather in the compound with their three children. Her mother gave birth to her when she was still at school, so she grew up with her grandparents. She does not know her biological father. She described her relationship to her family this way:

“I just stay in the house. They give me food, that's all… My stepfather doesn't like me. I am just in the house like a stranger.”

When Vivian reached high school her family stopped sponsoring her. Her stepfather reasoned that he has his own children to take care of. After that she received financial support from Father Peter, a Catholic priest. He paid for her school fees, her books and even the sanitary pads for her monthly periods. He was the person she talked to: “He became the father I never had.” Then, one day, when she went to his house, he started to touch her:

“I refused… he wanted to go to bed with me… When he started, I thought (he must think) it's a kind of repayment to him for everything he was doing for me… I thought, he is like a father, he wouldn't do this to me… I am not going to him anymore. So, I don't know what I will do.”

When she said this, she started to cry. She missed him but at the same time she was afraid to go there alone again because she feared that: “He will start to touch me and I will be rude… I don't want to be rude to him. I want to avoid any problem with him.”

It was clear for Vivian that she did not want to keep the pregnancy. She had a dilatation and curettage (D&C), performed by a senior male nurse in a private clinic, of whom she heard from a male friend. He did not follow the legal requirements either. After the D&C she started to have severe lower abdominal pain and heavy vaginal bleeding. At this stage she left her parents' house since: “My stepfather was just waiting for the opportunity to throw me out.” She went to her girlfriend's, who brought her to the hospital, and finally informed her parents. It took two days before her mother came to the hospital, which was a further disappointment in their relationship: “When my stepfather says go out, she says nothing!… She is always shouting. She cannot sit down with me like this and talk… She says things to me that a mother should never say to her daughter.”

Vivian was forced into sex by a person she relied on in a very trusting way and on whom she depended financially, and then had the trauma of a subsequent unwanted pregnancy. She paid three times more than Lilian for her abortion but the procedure was less safe, with a higher risk of infection. The abortion took place in her 13th week because she had problems putting the money she needed together. It turned out that the abortion was incomplete, and Vivian's mother had to pay 10.000 CFA for a second surgical intervention in the hospital.

Justine

Justine, a 15-year old housemaid, had 15 brothers and sisters from the two wives of her alcoholic father. Justine was forced twice by the 40-year-old son of her employer to have sexual intercourse with him. She was still a virgin at the time of the first rape and had recently started to menstruate. Justine completed primary school only. Due to her limited knowledge of the female body and the reproductive cycle she discovered relatively late that the “stomach bite” (as she described it) was a pregnancy. She sought help from her elder sister, who was employed in a supermarket in town, and from the perpetrator himself. When the drugs from a local traditional healer failed to induce an abortion, what she called “an instrumentation” (local description of rupture of the membranes) was performed in her fifth month, discernible by the cervical lacerations diagnosed when she had a vaginal examination.^* Both rupture of membranes and an ascending infection could cause uterine contractions and subsequent expulsion of the fetus. Justine was admitted to hospital with severe vaginal bleeding and expelled a “female stillbirth”, as noted in the file. On the ward, she behaved very shyly and gave the impression of being rather naïve with little prospect of protecting herself. The experience of sexual coercion as the reason for a woman's first sexual intercourse in Cameroon is unfortunately not exceptional.¹⁵

What matters really?

These four histories illustrate the troubling conditions in which young women living in poverty have to cope with trading sex for survival and sexual coercion, and the resulting pregnancies. None of these incidents were reported to the police nor were clinical examinations performed as documentation in case of criminal prosecution. Except for Vivian's mother, who finally came to the hospital and paid for the intervention there, the support by parents, whether emotional or financial, was totally absent. These young women had to rely solely on their social networks for psychosocial, logistical and financial support. Neither governmental nor non-governmental services were available.

There exists an obvious need to establish comprehensive post-rape care and to strengthen access to legal abortion services in cases of rape. Women and medical professionals need to be informed of the conditions and procedures when abortion is legally entitled and reliable statistics are needed to monitor for deficiencies in the delivery of abortion services.¹⁶ Furthermore, “judicial or administrative requirements should be minimized or removed, and clear protocols established for both police and health workers to facilitate prompt referral and access to appropriate care for women”.¹⁷

Still, most rapes go unreported and many resulting pregnancies are terminated illegally. A recent study on rape in Cameroon found that only 33% of rape victims had a medical examination, while 24% of rape victims got pregnant, of whom 31% had an abortion. Furthermore, only 0.4% of the victims confided they had been raped to health personnel, the forces of law and order or others.¹³

In the matter of rape, Brazil has chosen a noteworthy approach. The government has combined the efforts of the Brazilian Federation of Gynaecology and Obstetrics Societies, women's health advocacy groups and the Brazilian Ministry of Public Health to “clarify how women can effectively access abortion services in case of rape.”¹⁶ For example, judges, public prosecutors and professors of criminal law were consulted to define the requirements for proceeding with a legal abortion and to develop common protocols and procedures.¹⁸ Further, to establish legal abortion services, medical professionals who wanted to provide legal abortions participated in training programmes including technical skills and sessions on gender issues, ethics and reproductive rights. Through local feminist groups the existence of legal abortion services were publicised and the services monitored.¹⁹

There is also an urgent need to “Bring rape out of the shadows” as an upcoming campaign for victims of sexual violence in Cameroon is headlined.²⁰ An estimated 432,000 women and girls have been raped in Cameroon in the past 20 years, with a sharp increase in reported rapes.²⁰ Already in the late 1990s a newspaper article reported:

“Police records indicate that cases of rape have become… frequent in the North West Province and Bamenda, in particular. At least one rape case is reported every fortnight in the North West.”²¹

For rape victims to seek help from the police, the police must be informed about existing post-rape and legal abortion services and cooperate with these services. Information should be treated with confidentiality and sensitivity in face of the stigma and shame attached to rape. Appropriate post-rape health services, such as treatment of STIs, HIV post-exposure prophylaxis and emergency contraception where a risk is identified, professional counselling and psychosocial support, accompanied by members of women's social network, form important components in helping rape survivors to recover.²² First steps are already taking place in Cameroon. For example, an SOS telephone hotline and e-mail address are offered to victims of sexual violence.²³

The abortion experiences of Pauline, Lilian, Vivian and Justine raise the question: how safe is a safe abortion in a country where abortion is illegal? This question calls for critical reflection on the consequences of restricted access to safe abortion on the part of providers. Due to the illegality of abortion, many providers still use outdated methods such as D&C, with a higher rate of morbidity.²⁴ Medical professionals should be trained in safe abortion procedures, because circumstances exist where abortion is not against the law.¹⁷ The introduction of mifepristone and misopristol in Cameroon would be an essential step in this regard. Yet their use is still illegal in Cameroon.²⁵ Cameroon has recently ratified the Maputo Protocol, which includes a call to liberalise abortion laws in Africa. But this has sparked a vehement controversy in Cameroon and is strongly opposed by the Catholic Church.²⁶

Beyond these considerations is the issue of sexual violence and coercion itself, and the dependent relationships to the perpetrator in which these young women experienced them. This and the fact that an adolescent of Pauline's age has to trade sex for survival money and food, even in prison, is disturbing. Their stories are not isolated cases, however. In a study of sexual abuse at schools in Yaoundé, the capital of Cameroon, 269 of 1,710 students reported sexual abuse before the age of 16.²⁷ Teachers constituted nearly 8% of the perpetrators. A study in Cameroon on rape and incest by Ndonko et al found that most victims knew the rapist, that 4% of the rapists were teachers or priests, among others, 18% were family members, 22% neighbours or tenants, 27% classmates or friends, and 33% strangers.¹³ Sexual encounters involving coercion can include a complex spectrum ranging from unwanted sex to violent rape.²⁸ Women and girls in non-marital relationships characterised by large age and economic asymmetries with the man concerned may be more at risk of sexual coercion and have little control over contraceptive use.²⁹³⁰

The reality of the practice of abortion contrasts greatly with the existing restrictive abortion law. At the same time, the ambiguity surrounding the law and its implementation creates “room for manoeuvre” that enables providers to do abortions and women to access them. The women's affecting stories illuminate the reality of living under a restrictive abortion law, the troubling conditions in which they have to manage their lives, and the harsh circumstances in which they become pregnant and seek (but may not find) a safe abortion.

Acknowledgements

The research was supported by a dissertation grant from the German Academic Exchange, and scientifically supported by Hans-Jochen Diesfeld, former Head, Department of Tropical Hygiene and Public Health, University of Heidelberg. I am grateful for the helpful comments of Pamela Feldman-Savelsberg on a previous draft. I would also like to thank all the women who participated in the study and the hospital staff who provided assistance.

Notes

* Communauté Financière Africaine Franc (CFA). 2 million CFA is equivalent to around US$4,200.

* From Article 38 of the French Decree 1955, introducing the “Code of medical ethics”, as quoted in Cheka.⁴

† This notion of what really matters to ordinary people is shaped by Arthur Kleinman's book: What Really Matters: Living a Moral Life amidst Uncertainty and Danger.⁷

** For further details of the full study, see Schuster.³⁸

†† All names are pseudonyms.

* Article 337. Cameroon Penal Code. Quoted in Cheka.⁴

† For example, there was a newspaper report of a girl who was observed by a boy to have delivered a child beside a stream, into which he said she dropped the newborn. He alerted other villagers. Although attempts to find the baby failed, the case was brought to court.⁹

* The women often could not describe the instruments used to perform their abortions. Sometimes their abortions took place in the dark.