Less than one-third of Ugandan women use any form of birth control, according to the country’s 2011 Demographic and Health Survey. Credit: Andrew Green/IPS

By Andrew Green
Nov 14 2012 (IPS)

Every day at least five women are brought to the gynaecological ward of Uganda’s Mulago National Referral Hospital in Kampala for treatment for complications caused by crude attempts to terminate their pregnancies.

According to Dr. Charles Kiggundu, the head of the hospital’s gynaecological department, some of the women who come here drink gasoline or take untested combinations of herbs and drugs to induce an abortion. Others insert sticks into their vaginas.

The women at the Mulago National Referral Hospital are a small percentage of the estimated 150,000 women who suffer complications from unsafe abortions each year in this landlocked East African nation, where 1,200 women die annually from unsafe abortion attempts, accounting for a quarter of all maternal deaths in the country.

Here a “failure of knowledge about contraceptives” is driving up the rate of unsafe abortions, especially among young women, Kiggundu told IPS.

Less than one-third of Ugandan women use any form of birth control, according to the country’s 2011 Demographic and Health Survey.

A number of the women treated by Kiggundu are unmarried students, many of whom have been abandoned by their partners, he said.

According to The State of World Population 2012 report titled “By Choice, Not by Chance; Family Planning, Human Rights and Development” published on Wednesday Nov. 14 by the United Nations Population Fund, unsafe abortions represent almost half of all abortions globally. According to the report, nearly all unsafe abortions take place in developing countries, with the greatest number occurring in sub-Saharan Africa.

The most recent data found that adolescents and youth account for approximately 40 percent of unsafe abortions worldwide.

“In sub-Saharan Africa, adolescents between the ages of 15 and 19 have, on average, 120 births per 1,000 per year, ranging from a high of 199 per 1,000 girls in Niger to a low of 43 per 1,000 girls in Rwanda. Over half of young women give birth before age 20, and adolescent fertility in most countries in sub-Saharan Africa has shown little decline since 1990,” the report stated.

Moses Mulumba, the executive director of the Centre for Health, Human Rights and Development (CEHURD), said the issue of unsafe abortions was a growing concern among young people in the country.

“The majority of people who are affected are high school and university students,” he told IPS. “There’s no question about it. It’s a problem of the youth.”

But some of the unsafe abortion attempts could have been avoided had women been more aware of efforts to expand legal access to the procedure. There is still a widespread perception that all abortions are illegal in the country, according to Elisa Slattery, director of the Centre for Reproductive Rights’ Africa division.

In 2006 the Ministry of Health legalised abortion in cases of serious risk to the life or mental health of the mother, severe foetal abnormalities, health issues like cervical cancer or HIV/AIDS, or when the pregnancy is the result of rape or incest.

Greater knowledge about the law’s interpretation could reduce unsafe abortion rates, not just by allowing access to women who legally qualify, but by reducing the stigma around the issue, Slattery told IPS.

Policy guidelines released this year by the government affirmed all women are entitled to post-abortion care – even if the abortion was illegal. But Mulumba said that officials have not done enough to explain to women when they are entitled to a safe abortion.

“Historically people (consider) abortion to be a bad practice,” Mulumba said. “Many people don’t want to talk about it.”

That includes doctors and other health care providers, he said, who could offer the service if they felt morally comfortable doing so.

Kiggundu explained that some health care professionals were reluctant to conduct abortions because of the stigma that surrounds the procedure. Most doctors are either not well informed about the country’s abortion policy or are averse to performing the procedure, and are unlikely to recommend it even in cases where it is necessary, he said.

Reducing the number of unsafe abortion attempts in Uganda would require overcoming that stigma and educating both women and doctors about the current legislation, Slattery said.

“We have to empower healthcare providers, within the legal and policy frameworks,” she said.

Easing the stigma will not only facilitate access to abortions for women who qualify, but it will also encourage more women who are considering an abortion to consult a professional first, said Joy Asasira, a programme assistant at CEHURD.

“It’s not to say that if she wants one, it’s her right, so let her do it,” Asasira told IPS. But by “letting information flow,” she said, women would be more likely to talk to a health worker first and learn the risks of unsafe abortions.

That will not solve the problem of the high number of unsafe abortions attempted by young, poor and undereducated women who have difficulty accessing medical services, Slattery said. There will still be women who want to terminate a pregnancy, but who do not qualify for a legal abortion and are unable to afford a safe, illegal one.

Asasira said one answer was better access to family planning and contraception.

“(People are) becoming sexually active at a younger age and this is exacerbated by the fact that there is a high unmet need for contraception, while information about reproductive health services is lacking…  If training in family planning and how to use these services is done, we will definitely bring down the incidence of unsafe abortions,” she said.

Asasira said the mounting number of deaths forced policymakers to re-evaluate the issue. The new guidelines from the ministry of health have made post-abortion care an integral part of sexual and reproductive health services. This includes both emergency services and counselling for women on how to prevent unwanted pregnancies.

She said hopefully this opening would spur government health workers to push information more systematically – about contraception, but also about where women who qualify can access safe, legal abortions.

“Sometimes the duty of the government is to give the people what they need, even if (the government) doesn’t agree,” she said.

As the process of reintegrating South Sudan’s child soldiers into their old lives begins soon, the Sudanese People’s Liberation Army renewal of its lapsed commitment to release all child soldiers from its ranks in March could mean that within two years children will no longer constitute part of the country’s militia groups.

Southern Sudanese soldiers from the Sudanese People’s Liberation Army. Militia groups affiliated with the army still recruit child soldiers. Credit: Peter Martell/IRIN

The SPLA, which is the military wing of the South Sudanese political party, the Sudan People’s Liberation Movement, is one of the few remaining national militaries in the world on the United Nations’ list of parties to conflict who recruit and use child soldiers. The U.N. Children’s Fund (UNICEF) estimates there are 2,000 child soldiers in South Sudan. Though none are within the official SPLA, they are affiliated with militia groups that have earned amnesties from the government and are being integrated into the national military.

If the SPLA follows the action plan it has drafted and signed – removing all child soldiers from the militias and working to get them education and training opportunities – the country could be off the list in as soon as two years.

For the child soldiers, though, the process of reintegration could take much longer, as they enter schools or learn skills that will provide other opportunities for making a living outside army barracks.

The process will begin, according to Fatuma H. Ibrahim, the chief of UNICEF’s child protection unit in South Sudan, by identifying and securing the formal release of all child soldiers. On their way out, they will be given civilian clothing, because “what is military remains with the military,” she said.

The youth, who can range in age from as young as 12 up to 18, will undergo some group therapy sessions with social workers to try to understand how they came to join the militias and to talk about any violence they may have encountered.

She said there will be about one percent who “really need some clinical management,” though their options will be limited in a country with few psychiatric resources. “It’s a very big problem. Most receive tablets, but that’s it.”

Family members will also meet with social workers to discuss reintegration and ensure that the children will be welcomed back and discouraged from re-joining.

“The parents have to be ready to receive them,” Ibrahim said. In some communities in South Sudan that includes a symbolic transition ceremony.

In a country that has known war for more than two decades, the military is often one of the few viable economic opportunities for young men. Many of the children UNICEF and its partners remove from the ranks followed that pattern – looking to a position with a militia to provide some financial security for themselves and their families.

One of UNICEF’s big challenges is providing opportunities that deter the delisted child soldiers from going back. After the new release rounds take place, the youth will be given an opportunity to choose between going to school, which many of the younger ones will opt for, Ibrahim said, or learning a trade. The country’s limited job market means older youth are encouraged to learn skills like carpentry, which is in increasing demand in rapidly growing towns. In the future, they will be trained in two skills, in case the first one does not prove marketable.

UNICEF and other organisations are also working to provide incentives to keep the child soldiers from re-enlisting. Ibrahim pointed to a livestock-rearing project, where former child soldiers are given a goat to raise and breed.

If the programme is going to work, she said, the incentives have “to be meaningful.”

South Sudan’s new action plan was officially signed on Mar. 16 by the country’s Ministry of Defence, the U.N. peacekeeping force in South Sudan – UNMISS, UNICEF and Special Representative of the Secretary-General for Children and Armed Conflict Radhika Coomaraswamy.

Since it achieved independence last year, South Sudan has seen sporadic violence flare up across the country. In the north, there are ongoing hostilities with Sudan. And various parts of the country – especially Jonglei state – have seen consistent intertribal conflict over land rights and cattle.

Coomaraswamy said most of the country’s child soldiers are found in the north, where violence has been most consistent.

South Sudan has been on the U.N. list long before its independence in July 2010. The earlier incarnation of the SPLA – the Sudanese People’s Liberation Movement – was one of the original groups included when the list was drafted in 2002.

In 2006 a Comprehensive Peace Agreement was signed between north and south Sudan, which ended decades of fighting and paved the way for South Sudanese independence. At the time, the SPLA committed to an action plan to release its child soldiers, though it did not completely follow through.

By 2009, monitoring organisations had found no child soldiers within the main SPLA, though they still existed in the militia groups.

Coomaraswamy said the country’s renewed commitment comes from “the power of the list” and pressure from international partners.

And while the U.N. has never sanctioned South Sudan over its inclusion, she said there was always a possibility that would happen. The Democratic Republic of Congo (DRC), for instance, has suffered sanctions as a result of its inclusion.

Coomaraswamy said her office is currently in negotiations with the DRC, Myanmar, also known as Burma, and Somalia – the only government militaries who have not yet signed on to an action plan. 
 *Andrew Green is reporting from South Sudan on a fellowship from the International Reporting Project,
 an independent journalism programme based in Washington, D.C.

Before Bor B Primary School built latrines on the school grounds two years ago, students would leave during their first break to head home. Most did not come back until the next morning.

Before Bor B Primary School built latrines on the school grounds (pictured in background), students would leave during their break and not return. Credit: Andrew Green/IPS

Teachers ended classes early, because they did not have access to latrines, either. They would go to the nearby town, ask permission to use the facilities at one of the hotels, and then come back and reassemble the students who were left.

Madin Chier, the deputy head teacher at the school in the capital of Jonglei state, said the quality of the school’s education suffered. But now that 16 latrines have been installed, “there are no more problems,” he said.

Building a functional education system in South Sudan requires more than just latrines. Less than half of children who should be in school are. The country does not have enough classrooms, teachers or basic school supplies to educate all of its children.

Younger pupils compete for spots that are available in primary classes with teenagers, who were denied educational opportunities during the country’s decades-long war. The majority of those classes are held in the open air or under trees. That means when the rainy season hits, the result is a six-month break until the storms pass.

But for those students who have managed to get into a school – even those held under a tree – access to latrines is critical to keeping them there. That is especially true for girls, according to Emily Lugano, the education technical advisor for Save the Children in South Sudan.

Save the Children has built or rehabilitated toilet facilities in 71 schools across seven of the country’s states. These include hand-washing stations. It is part of the NGO’s initiative to improve learning environments, she said. But it is also a safety precaution for girl students.

In South Sudan, girls are more likely to be pregnant by 15 than they are to be in school. When they do attend, they are often subjected to harassment and intimidation, Lugano said. This is exacerbated in some of the schools where Save the Children works. In many places girls were expected to share latrines with boys or to use a field near the school.

“They get abused and harassed when they’re sharing latrines with the boys,” Lugano said. And “the girl feels very unsafe going to the bush to help herself… It’s a very, very crucial safety issue for girls at school.”

During their menstrual periods, girls refused to come to school, where they would have no opportunity for privacy. Chier said some of the girls at his school would not show up for a week or more every month, dropping them further behind the rest of the class.

“Across most of the developing countries,” Lugano said, lack of access to private latrines “contribute a lot to girls actually performing poorly in school, because they miss out on the syllabus.”

Because it is a school, there is also an educational component that comes along with the latrines and hand washing stations that extends beyond gender boundaries. Chier said his school uses the facilities to teach students about basic hygiene, which has helped reduce illness.

The initiative has been popular at Bor B, leading the students to form a Sanitation and Hygiene Club. Simon Peter Maiur, a 20-year-old in Grade 7, joined the group recently. He’s learning the club’s skits and songs, which encourage students to wash their hands and take care of themselves. He also helps patrol the school grounds for trash.

“It shows us how to clean our body, by cleaning the school,” he said.

Part of the concept behind the club is to turn the students into teachers, taking their messages about basic hygiene from the schools back to their communities.

“Hygiene promotion practices are not effective in this country,” Lugano said. Most towns and rural areas lack basics, like running water, but she said the students can still help “translate basic hygiene back to the community.”

Maiur said that is part of the club’s mission, to share information with friends and family. He said, with his encouragement, his family now does the best they can to practice better hygiene, like hand washing.

But these efforts only work in areas where there is a structured education system. South Sudan’s government allocated less than six percent of the 2011 budget to education. And the vast majority of that, Lugano said, goes to paying teacher salaries. Overall government funding for education looks to drop, as the shutdown of the country’s oil pipeline has taken away 98 percent of the country’s revenue.

At Bor B, Chier had let his Grade 8 students leave early, because the classrooms were all occupied by younger students, some with 150 students crammed in.

It is left to NGOs, like Save the Children, to continue to fund infrastructural development and to get basic materials, like textbooks, into the hands of students.

While programmes to improve sanitation and hygiene within schools can have a far-reaching impact on health and safety outside school grounds, Lugano said, those efforts are only effective if there are schools to deploy them in.

*Andrew Green is reporting from South Sudan on a fellowship from the International Reporting Project, an independent journalism programme based in Washington, D.C.