Common Reproductive Health Concerns in Anglophone Africa

May 2002

Key findings and regional trends from Women of the World: Laws and Policies Affecting Their Reproductive Lives, Anglophone Africa Progess Report 2001, reveal the continuing gaps in governments’ compliance with international standards on reproductive health and rights. The report is based on a two-year collaboration between advocates from Ethiopia, Ghana, Kenya, Nigeria, South Africa, Tanzania, Zimbabwe, and the Center for Reproductive Law and Policy.

HIV/AIDS Pandemic Bolsters Reproductive Health But Resources Lag Behind

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• In 1997, only Ghana, South Africa and Tanzania had explicit HIV/AIDS policies. Today, each of the seven countries has at least one policy document dealing exclusively with HIV/AIDS.

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• With more women affected than men, all countries include gender concerns in their HIV/AIDS policies and programs, and call for improved, more comprehensive reproductive health care services. Most policies link women’s lower socioeconomic status and harmful traditional practices to women’s greater susceptibility to the epidemic.

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• Despite the policies’ call for information on methods of prevention, access to affordable and voluntary testing and screening, and protection of the rights of infected individuals, none of these priorities have been translated into laws, and most policies fail to account for the costs of such measures. Zimbabwe’s policy advocates for voluntary testing and counseling to all couples considering marriage or children, but fails to address who will pay the bill.

Breastfeeding Controversial Due to HIV/AIDS

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• Vertical transmission from mother to child has complicated traditional wisdom about breastfeeding. Concerns about defective formulas and lack of access to safe drinking water to mix with the formula clash with concerns over HIV transmission through breast milk.

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• Countries have addressed this conflict in different ways. Ghana banned the sale, promotion and advertisement of formula in all heath facilities. Critics fear that this will undermine HIV-positive pregnant women’s access to alternatives to breastfeeding. Taking an opposite stance, after extensive protest and public outcry, South Africa has committed to providing anti-AIDS drugs and formula substitutes to pregnant women at no cost in some government hospitals.

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• Some women, regardless of their HIV-status, who decide not to breastfeed, have been shunned by their families, deserted by their spouses, or ostracized by their community who assume they are HIV-infected.

Contraceptive Use and Acceptance Remains Low

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• Knowledge about modern contraceptives is relatively high in the region, but actual use and general acceptance of contraceptives, especially condoms, remains low. In southern Africa, where HIV rates are highest, condom use is lowest. Similarly, in Ghana, only 3% of women and 7% of men have ever used a condom to prevent a sexually transmitted infection (STI).

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• Women frequently fear that their partners will disapprove or subject them to violence if they use contraceptives. Ethiopian women fear that their husbands will divorce them if they use contraception because they will assume they were unfaithful or are infected with an STI. In a Ministry of Health survey conducted in Ghana, nearly half of the respondents agreed that it was appropriate for a husband to beat a wife for using birth control without his knowledge or consent.

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• Providers’ attitudes and misinformation further discourage the use of contraceptives. In Tanzania, providers impose age and parity requirements on women and adolescents seeking contraception despite a government policy instructing them against this.

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• Adolescents often face unfriendly providers who disapprove of extramarital relations and refuse to give contraceptives to young men and women. In Zimbabwe, adolescents under 16 years of age must obtain parental consent to access contraceptives. Many South African providers refuse to offer emergency contraception to adolescents. Age and marital status are still cited as barriers to access to contraceptives in Ghana.

Harmful Traditional Practices Recognized But Not Criminalized by Governments

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• Despite a growing commitment by governments to outlaw female genital mutilation (FGM), most countries officially object to the practice in policy, but do not pass laws to condemn it. Nigeria’s policy aims to reduce by half the incidence of FGM by 2005, but shies away from making the practice a crime. Ethiopia, where 73% of women have undergone some form of FGM, has no explicit law or policy prohibiting the practice.

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• Many of these governments have recognized that harmful traditional practices, such as forced and early marriage and FGM pose health risks for women. Tanzania outlawed the practice of FGM as cruelty to children, subject to 5 to 15 years imprisonment. Kenya’s Children Act makes it a crime to subject children to any traditional or cultural practice that will harm their physical or psychological wellbeing.

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• In most of Anglophone Africa, forced and early marriage robs girls of their right to decide who and when they choose to marry and subjects them to the risks of early pregnancy. Most countries responded to the high incidence of early marriage by raising the minimum legal age for marriage. In Ethiopia, Ghana and South Africa, the minimum age for all types of marriage, including customary unions, is 18 for both men and women. Tanzania and Zimbabwe are exceptions. In Tanzania, girls as young as 14 may be legally married pursuant to a special court order. Zimbabwe’s law permits girls to marry at 16 years of age and boys at 18. Rapists in both countries may escape punishment by marrying their young victims.

Abortion Law Reform Rising Due to Serious Health Risks

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• African adolescents are at a high risk of complications from unsafe abortion. In Kenya adolescents make up 60% of cases involving abortion complications. In Ethiopia, the Ministry of Health has called the incidence of teenage unsafe abortion a "national epidemic." Ghanaian adolescents have the highest risk of all age groups for illegal and unsafe abortion, due in part to low access and use of contraceptives.

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• High maternal mortality rates in nearly all seven countries is attributed to unsafe abortion. In Ethiopia, by one account, clandestine, unsafe abortions account for 54% of all obstetric deaths. Unsafe abortion is the largest single contributor to the mortality rate in Ghana. The Ministry of Health attributes one-third of Kenya’s high maternal mortality rate to complications from unsafe abortion.

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• Support for the liberalization of abortion and the provision of care for abortion complications is increasing due to high rates of maternal mortality caused by unsafe abortion. With the exception of Tanzania, the trend toward liberalizing abortion has been gaining momentum, even in Kenya and Nigeria, which have the most restrictive bans. In Ethiopia, public debate on adding exceptions for legal abortion is about to commence.

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• In South Africa and Ghana where abortion laws are more liberal, but there is a severe lack of services, nurses and midwives are trained and permitted to perform abortions, paving the road for accessible abortions at conveniently located facilities.

For more information on reproductive rights in Anglophone Africa, see Women of the World: Anglophone Africa