Sexual and reproductive health (SRH) is one of the most heated debates in the global healthcare space and in our societies. In the western world and regions under its influence, the topic of the right to abortion has received considerable traction in public discourse, albeit contentious and highly emotive. As a result, it has been difficult to have a sane discussion around a very serious issue of enormous health consequences.
The invention of modern contraception in the 1960s revolutionized the concept of the family in one major way: it could be planned and under the control of would be parents. In other words, to give birth was a choice. And those who didn’t want to have “unplanned pregnancy” could enjoy sexual intercourse without fear of consequences – a child in this case – they were not prepared for.
From a public health viewpoint, contraception became a tool in the SRH policy arsenal to curb unplanned pregnancies, especially among teenagers. Abstinence stopped being the main focus in sexual education. However, despite the availability of contraception tools, unwanted pregnancies kept stagnating (or increasing in some cases), which give way to clandestine/unsafe abortion practices. In view of the socio-political implications and clinical complications of unsafe abortions, governments had to step in by regulating the practice, thus bringing it forth for discussion at the societal level.
The global data
The process of social reeducation on sexual knowledge requires so huge investments that even high-income countries still struggle to achieve total sensitization and widespread penetration of contraception tools in their communities. It is a lengthy process because it requires time for people to readjust their mindset and actions. However, the world has made tremendous strides in this direction. The United Nations Department of Economic and Social Affairs reported that, from 1990 to 2019, the contraceptive use in sexually active women was on average 25% in Africa, Central and Southern Asia (with sub-Saharan Africa hitting the lowest point at 12% in 1990 and 22% in 2019), while in Eastern and South-Eastern Asia, Latin America and the Caribbean, Europe and Northern America, the average is 55%, with almost all of them reaching 60% by 2019. The data suggest that, contrary to the global south, the global north has intentionally made contraception their primary tool in managing their national SRH policies.
Furthermore, besides improving contraceptive accessibility in order to address the social impact of unplanned pregnancies on young girls, governments started voting in favour of abortion laws in the years that followed. For example, in 1973 the Roe vs Wade case in the US gave women the right to choose what they want to do with an early pregnancy. This was followed by Planned parenthood vs Casey in 1992. In France, abortion on request for up to twelve weeks was legalized in January 1975 under Law 75-17 and permanently adopted in 1979, while in Germany, abortion is allowed when performed in the first trimester. In Switzerland, the cut-off for abortion on request is also 12 weeks since 2002, the same as Italy and almost 95% of Europe.
Conversely, in a 2016 report, the Guttmacher Institute published that, out of 50 Asian countries, 3 have prohibited abortion totally, 15 have legalized abortions only to save the mother’s life, 7 to preserve the mother’s physical health and 5 for socio-economic reasons; while 17 have legalized abortion without restriction. Other Asian countries such as Singapore and Vietnam, putting an emphasis on family planning since the 1970s, legalized abortion, while Thailand and Cyprus joined late in 2018 and 2021 respectively.
On that same note, in a 2017 report, the same institute published that 40 out of 54 African countries have restrictive abortion laws, 19 have total abortion prohibition laws and only 4 (Zambia, South Africa, Cape Verde and Tunisia) have abortion laws without any restrictions. Moreover, from 2010 to 2014, the rate of safe abortions in Africa was only 15%, compared to the global average rate of 56%. Of note, WHO reported in 2021 that (unsafe) abortions occur more frequently in the most restrictive countries with 97% of all of them taking place in low-income countries. As a point of reference, the more countries invest in modern contraception, the lower the rates of unplanned pregnancies, abortion and complications as evidenced by the case of Eastern Europe and Central Asia which registered the steepest declines in the early 2000s.
What we can learn from these statistics is that the global north has over the years invested in sensitizing its population about the imperative need for sexual education and in providing contraceptive tools. Africa has not made similar efforts and that is clearly reflected in the data.
Let’s note also that there is a universal consensus on therapeutic abortion, which refers to pregnancy termination in case the mother’s life is in danger, presence of foetal anomalies not compatible with life or in cases of rape and incest. However, these cases statistically represent a tiny minority as shown in most available studies such as Florida abortion statistics and Reasons why US women have abortions. Therefore, for the purpose of this article, the focus is on abortions on request.
The African context
Africa has always had a particular relationship with sexual education on a societal level. The social approach to the issue of sex immensely depends on the traditional orientations to sex education, which has direct palpable impacts on people’s sexual lives from a public health perspective. Sexual education is a taboo subject in most African societies, and this negatively impacts people.
Contrary to the situation before the information age and despite a myriad of available educational tools, the African society keeps holding onto its secrecy approach to sexual matters. A typical African child will hear, for the first time, reliable information about sex in their mid-teenage years in a basic anatomy course provided in the national high school curriculum. It is rarely mentioned in the family and social settings. This increases the chance of personal experimentation which, in turn, gives birth to long-term consequences such as cervical cancer as discussed here and short-term ones such as unintended (teenage) pregnancies and unsafe abortions with their devastating life-threatening complications.
The numbers are horrifying. As per WHO, every year, over 12 million girls aged 15–19 years and at least 777,000 girls under the age of 15 give birth in low-income countries; at least 10 million unplanned births occur among young girls aged 15–19 in low-income countries.
Pregnancy and delivery complications are the greatest cause of mortality for 15–19-year-old females worldwide. Approximately 3.9 million of the estimated 5.6 million abortions performed each year among teenage females aged 15–19 years are unsafe, contributing to maternal death, morbidity, and long-term health concerns. Add to that the socioeconomic consequences such as young girls dropping out of school in order to have a fuller picture of how serious a public health crisis this is. The most vulnerable population strata are girls in rural areas, girls who have uneducated parents and in regions with no contraception availability.
In the presence of such an abundance of data, we can deduce that Africa is still at the phase of basic societal sexual education and the region is indeed in a dire need of it. However, Africa has refused to let go of its cultural taboo approach to SRH, which will, in one way or another, push governments to act unilaterally to address this social health crisis stemming from teenage pregnancies and unsafe abortions.
Putting the abortion question in the hands of western NGOs is bringing few solutions and more confusion. One would argue that the amount of pro-choice propaganda or NGO financing provided by the West hasn’t changed Africa’s sexual perspective as a whole, except in the very few metropoles and in selected westernized neighbourhoods. And, indeed, Africa does not want that change – at least not that way.
A legitimate argument that might explain this refusal to adopt liberal practices in sex education is the “Kirazira/Imiziro” culture: a set of behaviours that are socially considered inconceivable, unthinkable, unacceptable and undoable. For instance, it is forbidden to raise one’s voice at one’s parent or an elderly person however wrong they might be. The assumption is that if a child can openly raise their voice at an elderly person, there will be no mental limit to disrespectful behaviours as they grow up.
Fundamentally, the “Kirazira/Imiziro” culture is a culture of social discipline and self-respect. Sexual matters are upheld to that standard and the assumption is that if brought forth too early in the education of the child, the youth will engage in sexual promiscuity owing to their lack of self-discipline. The tension between Western liberalism and African traditionalism lies at that very level. So, the general approach in Africa is to mention the sexual subject only when people are about to get married. The taboo approach is so ingrained in African society that it can be palpable in most national SRH policies. And it doesn’t seem that this cultural reality is going anywhere anytime soon.
On the flip side, faced with the uncontrollable sexual (mis)education resources available on the internet, the taboo approach loses its intrinsic power and purpose. Many Africans would argue that western approach to sex education has gone beyond its goal and openly rendered sexual activities meaningless by promoting the idea that one can engage in them with anyone, even strangers. And that is exactly the reason why Africa is so defensive when it comes to western liberal policies: the fear of derailing its “Imiziro” culture and degrading the sexual question from its upheld standard, thereby altering Africa’s very identity.
However, the data also suggest that Africa needs to focus on the basics: frame sexual education as a societal issue and confront cultural barriers accordingly. Africa needs to massively invest in and provide modern contraceptive tools from high schools to work environments. These two measures might appear simple, but their efficacy has been proven worldwide. Additionally, healthy recreational activities to occupy the minds of the youth such as the promotion of sports, competitive reading clubs and the likes might be considered but only as add-ons. There is no simple answer to this crisis; it has to be multi-approach solutions that respect the African cultural setup while not turning a blind eye to the current realities. The elephant in the room cannot be ignored any longer.
It is only after engaging the population and availing SRH tools which will be evaluated and quantified by a reduction in unintended pregnancy rate (especially adolescent pregnancies) and an increase in contraception use that we will be ready to procure an informed consensus decision about the abortion dilemma.