Author: Kenneth Juma and Boniface Ushie
Site of publication: World Politics Review
Type of publication: Article
Date of publication: July 2022
In early July, Sierra Leone’s Cabinet unanimously approved the decision to draft a bill on safe motherhood and reproductive health, which, when passed, will provide access to sexual and reproductive health services across the country. The Cabinet paper detailing the decision provides a broad outline of issues to be covered in the bill. Among other provisions, the legislation will confer a constitutional right to safe abortion, reduce barriers to accessing the health system and eliminate barriers related to obtaining family planning services and contraception.
The bill responds to the dire health consequences of unsafe abortions in Sierra Leone. Under a colonial-era law dating back to 1861, abortions are illegal except when a woman’s life is at risk. These abortions often result in complications that require treatment in health facilities, where about 1 in 5 women treated present with clinically moderate or severe complications that require attention from high-skilled health providers. In addition to the health implications, this also results in higher costs of care and extended periods of admission. Unfortunately, many women experiencing complications from unsafe abortions delay seeking care due to fears of prosecution under the current law, and because the health system’s capacity to address these complications remains inadequate.
As a result, unsafe abortions account for 9-12 percent of the country’s high maternal mortality rate, which a 2019 demographic and health survey by Statistics Sierra Leone put at 717 per 100,000 live births. A World Health Organization estimate shows even higher rates, at 1,120 deaths per 100,000 live births. Sierra Leone also has a high unmet need for contraception as well as one of the highest adolescent pregnancy rates globally. Together, these contribute to high rates of unintended pregnancies, estimated at 88 per 1,000 women of reproductive age, which in turn drive unsafe abortions and maternal mortality.
The current effort isn’t Sierra Leone’s first attempt to address the dire situation of maternal health. In 2015, Parliament unanimously passed the Safe Abortion Bill,which would have made abortion legal during the first 12 weeks of pregnancy. It also allowed for abortion up to 24 weeks in cases of rape, incest and other felonious sexual intercourse; of fetal anomaly; or where there is a risk to the health and life of the woman. Unfortunately, the bill failed to clear the final hurdle to becoming law—presidential assent—due to massive public protests encouraged by an interfaith organization, the Inter-Religious Council, which accused Parliament of not consulting widely in formulating the bill. They also argued the bill was incompatible with the country’s religious values, notwithstanding the fact that Sierra Leone is a secular state.
Even if the law survives, it will still take work to make it effective in ensuring access to safe abortions and other reproductive health services
As a result, the substantial need for safe abortion services remained unmet, and preliminary findings from a national study on the incidence of abortion—yet to be publicly released—point to a high number of induced abortions that are mostly unsafe, with the aforementioned medical consequences, as well as wide-ranging social and economic implications.
The difference this time around is that, while the 2015 Safe Abortion Bill was introduced as an independent initiative by a member of Parliament, the Safe Motherhood Bill is being advanced by the executive branch and has already achieved unanimous backing from the Cabinet. And recent public pronouncements by President Julius Maada Bio suggest he has the determination and political will to see it through. During the 10th African Conference on Sexual Health and Rights, which was held in Freetown, the capital, days before the Cabinet announced its decision, Bio declared his government’s intention to decriminalize abortion, stating that, “at a time in the world when sexual and reproductive health rights for the women are either being overturned or threatened, we are proud that Sierra Leone can once again lead with progressive reform.”
Furthermore, the 2015 bill failed in part because Parliament and civil society conducted only limited public consultations with Sierra Leone’s population. This time, the Ministry of Health and Sanitation, or MOHS, other Cabinet agencies and civil society groups are engaging in a series of consultative events to garner public support. A technical working group responsible for advocacy and strategic communication has also been formed. Its work will be facilitated by the data from the aforementioned nationally representative survey on the incidence of abortion, which has now been validated and will soon be published. The survey will offer evidence for why access to safe abortions is critical for a reduction in maternal mortality, which is likely to have an impact on the debate over the bill.
However, formulating and passing the bill into law will only be the first step of a lengthier process, as opponents of safe and legal abortion may challenge the law’s constitutionality in court. As underscored by the U.S. Supreme Court’s recent ruling to overturn the Roe v. Wade decision that guaranteed the right to an abortion in that country in 1973, there is always the possibility that conservative judges will overturn the law. Therefore, the MOHS, civil society and Sierra Leone’s international development partners will have to continue their advocacy and engagement efforts to make sure that the gains are not reversed.
Sierra Leone’s decision to develop the proposed safe motherhood bill into law suggests that this wind of change will continue to blow across the continent
The first step in doing so will be to disseminate the clinical standards and guidelines for comprehensive abortion care and post-abortion care nationwide. That process will be expedited by the fact that the MOHS, with the support of the World Health Organization, already validated post-abortion care clinical guidelines on July 1. It will be equally critical to conduct trainings on the guidelines with service providers; develop an appropriate monitoring, evaluation and learning framework for the guidelinesonce they are put in place; and improve the overall capacity of the health system to provide quality care.
The Roe v. Wade decision in the U.S. sent shockwaves around the world among abortion rights advocates, especially in Africa, where conservatism regarding reproductive rights and sexuality is at its height. However, recent developments indicate that some African countries are taking active measures to ensure safe access to abortion and improve maternal health indicators. For example, in 2018, the Democratic Republic of Congo passed national legislation implementing the African Union’s Maputo Protocol, which guarantees extensive rights, including reproductive rights, for women. In October 2021, Benin revised its laws to provide more options for women seeking access to safe abortions. And Liberia’s parliament is on the verge of passing a public health bill to replace and remove obstacles to accessing safe abortions in the penal code.
Other countries will not be able to ignore the improvement in maternal health indicators in those that adopt these measures, making them more likely to follow suit. Benin, Sierra Leone and Liberia may also become champions for abortion rights among the other members of the Economic Community of West African States, or ECOWAS, and seek to table abortion issues before the ECOWAS Parliament, something that is currently nearly impossible to do.
But the law’s impact will be felt first and foremost in Sierra Leone itself. Its immediate consequence will be to reduce complications from unsafe abortions, leading to lower rates of maternal mortality. But it will also provide adolescent and young women with more options to prevent unintended pregnancies and, when they do occur, to decide the outcomes. That will potentially allow them to stay in school longer, facilitating more meaningful engagement in the economy and helping to close the gender inequality gap.