Abortion is strictly outlawed in Tanzania in virtually all circumstances. The word itself is taboo, rarely spoken in polite society. Yet it takes only a few minutes to find a man in the backroom of a slum neighbourhood pharmacy who is quite willing to perform an illegal abortion.
His shabby dispensary is on a dusty street in Manzese, the biggest squatter community in Tanzania's biggest city. It's become known as a place for desperate women to go.
The Globe and Mail asked a Tanzanian man to pose as the boyfriend of a young woman wanting an abortion. He was referred to a man in a white coat, in a backroom, who appeared to be a doctor. After a brief warning that the procedure was illegal, the white-coated man began haggling over the price, agreeing eventually to do it for the equivalent of about $18. "It should be done before one o'clock because inspectors pass by in the afternoon," he told his customer. "The government doesn't allow it, so don't tell anyone. It has to be a secret."
Unsafe abortions, especially those done covertly or illegally, are one of the leading causes of maternal deaths in Africa, killing at least 25,000 women annually and injuring a staggering 1.7 million every year. Many are maimed or killed by horrific "home remedies" that include catheters, roots or herbs placed in their vaginas to induce bleeding.
One-seventh of African deaths in pregnancy and childbirth, and nearly one-fifth in Tanzania, are caused by complications from unsafe abortions. Yet governments in Africa - and Canada - are reluctant to discuss the problem, even as Ottawa puts maternal health on top of the agenda for the G8 summit next month.
For decades, Africa's crisis of maternal deaths has remained stubbornly intractable, even as the death rate has declined sharply in most Asian countries. More than half of the world's maternal deaths are now occurring in sub-Saharan Africa, compared with fewer than a quarter in 1980, according to a new study in this month's Lancet, the British-based medical journal. Of the 20 most dangerous countries for women to give birth in, all but one (Afghanistan) are in Africa.
The failure to reduce Africa's maternal death rate is partly due to the political and cultural sensitivity of some of the leading causes: abortion, AIDS, early marriage, genital mutilation and the unequal status of women. Many African countries are so culturally conservative that their politicians are unwilling to consider any liberalization of abortion laws - despite strong evidence that illegal abortions are killing and maiming thousands of women.
In Kenya, for example, the country's new constitution would prohibit abortions in any circumstance except when a woman's life is in danger. This is essentially the same as Kenya's current laws. But anti-abortion church groups have lobbied against the constitution, perceiving it as a loosening of the abortion laws, and Kenya's politicians have been forced to promise that abortions won't become any easier under the new constitution.
In Tanzania, there's little discussion of changing the abortion ban. Yet hospitals often see the ghastly results of botched abortions by untrained practitioners. "Very sharp objects are inserted into the vagina to disturb the pregnancy," said John Bosco Baso, a spokesman for Marie Stopes Tanzania, which runs a network of health clinics here. "The women get infections, they get fever, and some die. Many of them hide it. We only see them at the critical stage, when there's infection."
More than 90 per cent of Africans live in countries where abortion is restricted. Abortion is completely prohibited in 14 African countries, and in most others it is permitted only to preserve the life or physical health of the woman. As a result, virtually all of the estimated 5.6 million abortions performed annually in Africa are unsafe. Only about 100,000 are done by properly trained professionals in a safe environment, according to a report last year by the Guttmacher Institute, an advocacy organization for sexual and reproductive health.
"In urban areas, people know where to find illegal abortions, and in rural areas they go to quacks," said Catherine Slater, an official with Marie Stopes South Africa, which provides abortions at 29 government-approved clinics. "I've seen gruesome backrooms doing backstreet abortions in Sierra Leone. You wouldn't wish it on anyone."
Legalizing abortion would be a simple way to reduce the maternal death rate. In South Africa, the number of abortion-related deaths fell by 91 per cent after the procedure was legalized in 1997, according to a Lancet study.
"Making abortion legal, safe and accessible does not appreciably increase demand," the Lancet study concluded. "Instead, the principal effect is shifting previously clandestine, unsafe procedures to legal and safe ones."
A recent editorial in The Lancet said Canada and the other G8 countries should be challenging the ban on abortion in many developing countries, rather than tacitly supporting it.
Even in South Africa, charlatans and quacks still take advantage of the desperation of uneducated or low-income women who cannot afford to travel to a legal clinic. Advertising leaflets and posters for fly-by-night abortion services are littered across South Africa's poorest communities, even plastered on the walls of police stations and government offices. In most cases, only a mobile phone number is provided in the advertisements, making it easy for those who offer illegal abortions to escape justice.
"The unsafe abortion market is huge," said Laila Abbas, a spokeswoman for Marie Stopes. She estimates that hundreds of people are performing illegal abortions in South Africa, and the number keeps rising, even though her organization frequently reports them to the police.
Often the abortionists provide a pill that simply opens the woman's cervix, she said. "The fetus literally falls out, causing great danger and extensive bleeding, often resulting in death. The unsafe service providers tell the women to go to the nearest public toilet and flush the fetus."
Geoffrey York