Bethany, whose name has been changed to protect her identity, was 20 years old when she first went to a health center to get a pregnancy test. She had missed her period by two months and was alarmed. When the results came back positive, there was no time for a discussion of how it happened, or to cast blame on herself and her boyfriend for failing to use a contraceptive. Bethany was scared and confused, but she and her boyfriend both arrived at the same decision. She needed to get an abortion.
Bethany resides in Rwanda, born shortly after the 1994 genocide against the Tutsis in which nearly a million people were killed and millions more were displaced. Immediately after the genocide, an estimated 70% of the surviving population was female. As a result, women began to take up economic and leadership roles, both within households and outside of them, a power shift they had previously been denied.
While Rwanda now has among the highest female labor participation in the world, other changes have been more gradual. In the years following the genocide, the country has focused heavily on building its public health system and reforming some archaic laws to allow equal rights for women, such as land inheritance. In 2003, Rwanda also enshrined health as a human right. Today, there are about 60,000 community health workers across the country — more than half of them women — who occupy a place of trust and authority in their villages. These workers use mobile technology to monitor and report cases.
Women of reproductive age are also among the program’s biggest beneficiaries. Rwanda’s maternal mortality ratio has decreased drastically between 2000 and 2015 — from 1,020 deaths to 290 deaths per 100,000 live births — along with an increased rate of births by skilled health attendants and increased access to family planning methods.
And yet, Rwanda has been slow to acknowledge the gap between desired and unintended pregnancies. Nearly half of all pregnancies in the country are unintended, 22% of which end in induced abortions. In spite of legal restrictions, an estimated 60,000 induced abortions were performed in Rwanda in the year 2009, a rate of 25 abortions for every 1,000 women. Poor, rural women were most likely to seek untrained persons or self-induce, risking the chance of complications. Almost one-third of all women who develop complications in the country do not receive the medical attention they need.
For a country that relies heavily on international aid for its health budget and programs, this has cost Rwanda heavily. In 2012, the Rwandan government introduced a post-abortion care program, and paid an estimated $1.7 million — almost 11% of its reproductive health budget — to treat complications from unsafe abortions.
“We already know the incidence [of induced abortion, and implication of unsafe abortion] is high, but I don’t think we need a bigger magnitude for it to be recognized as important,” says Chantal Umuhoza, the founder of Spectra, a Rwanda-based feminist organization. “Even if there is one woman who wants the service, then by not providing this service we are literally telling the woman that she can go and die.”
“Nearly half of all pregnancies in the country are unintended, 22% of which end in induced abortions. ”
According to the World Health Organization, each year 4.7% to 13.2% of maternal deaths can be attributed to unsafe abortions. The likelihood of this is the highest in the African continent. By denying or limiting access to safe abortion, the life of many young girls like Bethany, who are less likely to have access to contraception, is put at risk.“I was raised in a religious family and knew that abortion was bad,” says Bethany. “But I couldn’t have raised a child.”
What she knew more intimately was financial struggle. Bethany lost her father at the age of six, and her mother was forced to leave the capital city Kigali to move to a village in the northern province of Rwanda soon after. Bethany, an only child, found herself in boarding school, growing physically and emotionally distant from her mother.
At 18, having completed her schooling, she was faced with the fact that there was no money to support her education any further. Her mother was sick and unemployed. The relatives weren’t willing to support her anymore. She needed to find a job. Though 70% of Rwanda’s population is employed in agriculture, months went by and she felt lost. Being a mother at that point, she reasoned, would be unacceptable.
“My boyfriend wanted me to get an abortion,” Bethany says. “I also had all these thoughts running in my mind like, what will I do with a baby when I don’t have a job? It will be a burden to my mom. I will be a shame to my family and they won’t help or support me… I really know them and they are not the kind to accept a young pregnant girl.”
In 2012, Rwanda revised its law to allow abortion before 22 weeks in the case of rape, incest, forced marriage, or medical grounds. On paper, Rwanda was hailed for taking a critical step in recognizing women’s fundamental rights but safe abortion continued to be inaccessible to women. Women were required to obtain a court order as well as the written consent of two doctors. This was a tough ask considering there is one doctor for roughly 17,000 people in the country, according to government data from the year 2015.
Organizations that had advocated and rallied for the revision of the law were dampened by these prohibitive conditions. They added an additional barrier to the existing stigma related to the service. According to Tom Mulisa, executive director of the Great Lakes Initiative for Human Rights and Development, a Rwanda-based legal nonprofit, only three cases went to court and received judgments following the revision.
A study by the Rwanda-based nonprofit Health Development Initiative (HDI), noted that during a three month period in the year 2014, only 5% of the women who visited the one-stop centers for gender-based violence and were pregnant as a result of rape, incest, or forced marriage requested for termination of pregnancy. None of them received a court order.
After Bethany had made her decision, she was connected through a friend to a doctor who administered her pills for a fee of $65 (60,000 Rwandan francs). When she began bleeding the next day, Bethany was panic-stricken and reached out to the community health worker for assistance. The village leader was immediately informed. An ambulance was called to take her to the hospital. A day later, the police took her away and she was sentenced to two years in prison for an illegal abortion.
Bethany did not initially receive a lawyer from the government — she faced two court proceedings all alone — and learned about the law only while in prison when she was trying to appeal for a reduced sentence. Prison wasn’t tough, she recalls, because other women with similar experiences and sentenced for the same crime were warm and comforting toward her. “Most of them were poor. No one was there because they really wanted an abortion,” she says.
Also in the same prison with Bethany was 23-year-old Judith, whose name has been changed to protect her identity. Judith was ashamed when she found herself pregnant for the second time while she was unmarried. She was barely supporting her firstborn with the money she earned from working as hired agricultural labor. When her friends pushed her to get an abortion late into her term, she agreed. “There was stigma and struggle after the first pregnancy and that is the main reason I wanted to abort the second time,” Judith says. She lived in a remote village in the northern province of Rwanda and did not have information about family planning methods. In the six months that she spent in prison and the months since, she has continued to carry the sinking feeling that justice was denied to her.
“Most of the women who went to prison were from poor communities,” reiterates Aflodis Kagaba, executive director of HDI. “They are people who do not have private spaces… that is how they are reported by the community.”
Earlier in April, Rwandan President Paul Kagame pardoned 367 women and girls who were imprisoned for abortion and infanticide. Bethany was one of them. Her sentence was reduced by six months. Judith was also let go.
In the last two years, there have been three such presidential pardons for these crimes, the most recent being a few weeks ago in October. Advocates for safe abortion in the country see this as a positive sign. They believe it sends a strong message to the general public that this is an issue they need to change their outlook toward.
The pardons this year came following another revision of the penal code in 2018. The requirement of a court order was removed and minors are now allowed to legally get an abortion if accompanied by the parents or guardian. In the event of a disagreement among guardians about the request for abortion, the minor’s decision will be considered. This progressive step, according to experts, might be difficult to take root on the ground.
“The advocacy for access to safe abortion has not ended. We still have a long way to go. We need to ensure that there is no legal restriction at all on abortions,” says Umuhoza, referring to the stories of imprisoned women which reflect that lack of access to services is one of the main reasons women are opting for abortions.
“When you have the legal framework revised, it allows you to have conversations about safe abortion,” Kagaba adds. “Now we have to change the attitude and values of everyone involved in the response systems. We have to create safe spaces for providing services.”
Five months after she received the presidential pardon, Bethany appears calm and solemn. She is dressed in a fitted shirt with jeans and a pair of black-rimmed glasses rest on her nose. “I accepted my sentence,” she says, “but now, I think there should be preabortion care and counseling instead of imprisonment. If the reason is meaningful, like poverty or the father of the child refusing to help, then it should be taken into consideration. Everyone has their own reasons so it should be respected. But people shouldn’t get abortion too late into the pregnancy.”
In spite of Rwanda’s best efforts to disseminate information at the grassroots level through community health workers, abortion and sexual and reproductive health of adolescents remains shrouded in stigma. This results in a lot of ambiguity in how issues are addressed.
Churches own and operate about 30% of health facilities at the community level in Rwanda. While they work together with the government, they do pose a challenge in the way certain policies are implemented.
In one of the largest health facilities in the country, a doctor who spoke on the condition of anonymity admitted that they were not updated with the revised law and he did not know the exact, legal procedure of seeking an abortion except that one needed to go through the one-stop centers for gender-based violence. He was sure, however, that a woman cannot approach a health provider directly for the service. “Many women come for post-abortion care but we don’t really know whether it was an unsafe abortion or miscarriage. We can ask some questions, access the situation, but abortion is illegal so they won’t really tell the truth,” he says. Some health providers, he added, even consider the use of an intrauterine device as killing the fetus and refused to provide it as a method of family planning to women. “If someone doesn’t want to get pregnant, it is good, you can’t refuse. But religious beliefs make some health providers reject some methods and services,” he says. “This is why there should be continuous counseling and training on it.”
Churches own and operate about 30% of health facilities at the community level in Rwanda. While they work together with the government, they do pose a challenge in the way certain policies are implemented. According to activists, the Catholic Church was the biggest, most vocal opposition to the revision of the abortion law. In June, according to the national media, the health minister reported the Catholic Church to the parliament for directing its facilities to return all government funding meant for family planning. When a health facility refuses a service to a woman, however, they are supposed to refer her to another facility in the vicinity — sometimes, that might make things difficult for her.
But some health facilities have been trained to provide post-abortion care to women without asking questions. In Gisenyi District Hospital, located minutes away from Rwanda’s border with the Democratic Republic of Congo, Nduwayezu Bosco, midwife and head of the gynae-obstetric department looked visibly uncomfortable and refused to inquire with a 24-year-old woman about what led to her miscarriage. She was admitted there as an emergency case for post-abortion care.
“The work we have today as a civil society is to have the law known,” says Mulisa. “The donors gave us money to make amends for law change but they are not supporting us to have the law known. We are feeling the [impact of the] global gag rule.”
Advocates also note that implementation usually takes time, and they were willing to work together with the Ministry of Health to reach the population. According to Rwanda’s Vision 2020, the government is striving to be self-sustained and reduce its dependence on international aid which could help change the way abortion laws are implemented. This could still take many years considering the fact that the highest proportion of Rwanda’s international aid is directed toward the health sector. But the minister of health, Diane Gashumba, emphasized in an interview that the country is increasing its investment in the health sector with each year and this is a priority for the government.
As for Bethany, she harbors no ill-feelings or blame toward anyone for what happened to her. But what keeps her up at night now is the feeling of shame, judgment, and rejection by the community following her release from prison. She has not received any support from the government in the months since and reintegrating into the community has been a long battle. Her focus now is to receive a form of skill training that can become her source of income.
“Now that we have been pardoned, I hope there can be some advocacy at the community level,” she says. “When I used those pills, I did not know whether it was safe or not. Many other women find themselves in the same situation. They need information and help.”
This reporting was supported by the International Women’s Media Foundation.