Dr. Ejike Orji is Country Director, Ipas, an International NGO in womenâ€™s health and reproductive rights., working globally to reduce maternal death from complications of abortion. In this chat with Chioma Obinna, he x-rays how contraception could be used to check maternal mortality as well as the problem posed by Nigeriaâ€™s restrictive abortion law. Excerpts:
Contraception as a check on maternal death
If you look at what leads to most complications of pregnancy and delivery, you will easily see the role of contraception to ameliorate them. There are four obstetric sins a woman could commit. One is having a baby too early in life.
A woman who gives burth below age of 18 is asking for trouble. There are complications such as VVF and many girls die from obstructed labour because the head of the baby is too big to pass the birth canal which is not fully developed. Now, even if the girl is sexually active, the only thing that can stop her from getting pregnant until she gets to age of conception is contraception.
Either she is using a condom or any other method. But we always say it is better for an unmarried, sexually active girl to use condom because it will also protect her from HIV. The next bad thing that can happen to a woman in pregnancy related issues is if she is having babies too frequently, that is, less than two years apart.
In an environment where nutrition is poor and because we are not also delivering babies in the best of condition, they lose so much blood even when it is normal delivery before the baby comes the third phase of labour would have been completed.
And because we donâ€™t have good nutrition, if they have baby too early again, they go into the next pregnancy with a deficit of blood.They are marginally anaemic. So, you can imagine getting into another pregnancy being marginally anaemic and bleeding a lot again, so she either dies of bleeding or her uterus will not have enough time to recover. So if she has a repeated assault on that uterus, it becomes flabby.
Now, the thing that would have made a difference is contraception and family planning that would have make sure that the woman did not get pregnant so soon after the last pregnancy even though she is sexually active. Too many too soon.
If the woman had spaced all her children two years apart and now gets up to four. The rule of the thumb is that she doesnâ€™t go for the fifth one because the fifth one can be so dangerous. What this means that when you get to the fourth child and you know that you are not going to have any other baby, you go for what we call long method of contraception. You can go for contraception that can last five to six years or you can even tie your tubes.
If you have had all your children and do not want to get pregnant say from 36 or 37 in terms of reproductive health age, and you are in sexual active union, the thing that will stop you from getting that pregnancy is contraception. It has also been seen that when women start having babies at that age of 36-38, they are looking for trouble. The obstetric risk is very high. So, if you look at all these, you see how contraception leads to good maternal health outcomes.
Letâ€™s look to other pregnancy complications like unsafe abortion. If there is proper contraception , before you see a case of unsafe abortion it means that woman has an unintended pregnancy. When you have unintended pregnancy, there are two outcomes. The women will say okay, I am now pregnant, there is nothing I can do about it and I donâ€™t wantÂ to terminate it.
But if she decides that she does not want the pregnancy she gets into another mode trying to terminate it and she might end up with unsafe procedure that could kill her. The one single thing that would have stopped all that is contraception. So this is the role of contraception plays in pregnancy outcomes, every maternal death due to abortion means a failure of fertility control and it is contraception that can take care of that.
Putting a check on unsafe abortion We preach abstinence which is also a form of contraception. So there is no other way really, but the ABC -Abstinence, Be faithful and use Condom. There is really no other way you can prevent the issue of unsafe abortion accept if that is in terms of prevention. The other way to stop unsafe abortionÂ happening is actually making sure we have safe abortion and for this to happen, we have to reform the present law that makes it impossible for women to have access to safe abortion. The way to eliminate it is to make the services available, safe and paid for by the government which is what governments have done outside the country.
In India, abortion has been liberalised for the past 30 years.. So that is why in India of 1.2 billion 8,000 women die from complications of abortion every year whereas in Nigeria we lose 34,000 women annually.
Role of the Church
The Catholic Church and other denominations are making the campaign difficult, in specific terms, they are confusing the women.They conscientise them.
We are thinking of staging litigation against some Churches who keep women in labour and prevent them going for Caesarian Section. Meanwhile, such women probably have narrow pelvis or the cervix refuses to dilate even if the pelvis is at the peak. They keep those women in those churches and leave them there and be praying for them. They are not doctors, they wait until there are complications then will now want them to go to the hospital they did not want them to go in the first place.
Traditional birth attendants are also a problem. They have no training in the anatomy or physiology of the pelvis or even pregnancy. But what we are recommending is that they should be trained to identify women that are in trouble and how to stablise them and refer appropriately.
Hope for MDGs 4 & 5
It will be a tall dream.Â The reasons are obvious. Nothing concrete has been done. Nigeria still has a restrictive law. One of the things that will make Nigeria meet the MDGs in 2015, is by reforming the abortion law. We have not changed the law neither have we have put services on the ground. Recently, Federal government said they are putting midwives into the rural areas which was my suggestion in the first place.
But I said, we should pay those midwives in the rural area about N75,000 per month. What they are paying them nowÂ is N30,000 and they are not recruiting. At the last count, they recruited about 2,500 out of the 10,000 required. So we are still paying lip service to the real thing. We should bring out money and spend to save womenâ€™s lives. We can still
meet the MDGs if we make the right decisions now and implement them.
Restrictive Abortion Law
The women groups have, for the past four years, been trying to include rape, incest, health, social economic status in the Law. The Law also does not specify who is to carry out the abortion. It says any body with good intents. So a carpenter who is not trained can even terminate the pregnancy.
Some women, regardless of how the pregnancy came, do not want to keep it. These women must be given a choice. What they want is paramount. That is why we are pushing for reformation of the abortion Law. It is only when we reform the Law, that people who want to keep pregnancies that arise from rape can keep such. It is their choice. We must support them to keep it. But for those who do not want, we must also help them terminate the pregnancy.
Nigerian women and reproductive rights
The way it is, nobody is listening to the women. Nobody cares about them. They are dying everyday in their scores. Nothing serious is being done. We are still paying lip service to womenâ€™s lives. We are not giving them space in the parliament, in the executive arm of government. In a way, they can bring their own resources to bear.
I am advocating that people should know that women have rights. Women have rights for information, for proper contraceptive counseling and methods. They have a right to be able to make decision for them selves.Â They must be given opportunity to use health services.
In totality, I believe the Nigerian woman has taken such a raw deal. There are good things already happening. There is a Violence Against Women Bill at the National Assembly right now and we do hope that they pass the law. Federal government is doing the Midwifery Service Scheme (MSS), All we need to do is support them to do more.