Legal, but they don't know it
In the hot sun of a Zambian winter, amidst the bustle of the traffic, beneath billboards promoting abstinence and hand painted signs advertising condoms and Coca-Cola, a young girl is fighting for her life.
In the emergency ward of the University Teaching Hospital, Lusaka, "Grace" a child-like young woman is haemorrhaging, struggling to breath and dangerously close to death. Her sister, apparently complicit in Grace's nightmare, is sobbing next to her. Dr Kamanga, a staff Obstetrician and Gynecologist tries to coax what has happened out of the terrified girl.
After the desperate chaos that often surrounds emergency healthcare, Dr Kamanga removes a large part of cassava root, a potato like vegetable, from the girl's bloodied and damaged cervix.
Grace is one of the lucky ones. She survived.
According to the World Report on Women's Health 2006, nearly 200 women die every day from unsafe abortions in sub-saharan Africa. In Zambia 80% of these are under 19. Of course, these statistics can only cover those who make it to hospital. In a rural country with a population of over 11 million, the real figure is probably much higher. Zambia has one of the highest rates of maternal mortality in the world, and 1/3 of these are estimated to be from unsafe abortions.
The terrible irony of all of this is that Zambia is one of the most liberal sub-saharan African states on the issue. It has an extensive law which permits abortions under certain conditions, for socio-economic, physical or mental health reasons. The Ministry of Health also launched new standards and guidelines in June 2009 to help confront the problem.
Loosely based on the laws of their former colonial ruler, England, The Zambian Termination of Pregnancy Act 1972 permits abortion where the continuation of the pregnancy can be proved to be detrimental to the mother, or the child, or both, and where this is agreed on by 3 medical practioners.
But Zambia is also a staunchly Christian nation many of whom are Roman Catholics and as poverty in the country worsens, mainly due to the world's dwindling desire for copper, far-right evangelical churches are becoming commonplace. Because of the sociological and cultural pressures, most women in Zambia consider abortion illegal. And whilst only 126 legal terminations were carried out in 2008, over 10,000 women were treated for the consequences of unsafe abortions.
"Lusaka is one thing", Holo Achonda, Clinical Director of the Planned Parenthood Association, Zambia tells me. "Here we have services, we have a hospital, we have physicians trained to terminate pregnancies. We also have counsellors, although due to their personal beliefs they often only try to persuade the girl to keep the baby. But imagine the situation in the countryside".
"Louise" is a 14 year old sex worker in Mpika, a truck stop on the Great North Road that runs from Cape Town to Cairo. Orphaned by AIDS at 9, her life has been one big scramble for survival, peppered with desperate tales of rape and hunger. Having left school when her parents died, and unable to get a job, she sells her body for 80p an hour, £1 without a condom. She uses the money to care for and feed herself and her sick older sister and nephew.
When she discovered she was pregnant, unable to find the 3 physicians to authorize the procedure or able to afford the medical care, Louise crushed up some glass, boiled it with coca cola and drank it, whilst inserting a cassava root deep into her cervix.
Others will visit traditional doctors whose remedies range from the insertion of twigs and sticks to remove the foetus to concoctions of fatally poisonous bark. Self-treatments include overdoses of paracetamol, drugs used for stomach ulcers or battery acid. Of course, anything that procures a miscarriage in this way, will also usually kill or severely injure the mother.
The Zambian state is trying to address the issue. In a significant speech in 2009, the permanent secretary for Health, Velepi Mtongo stated that "we still need to ensure that not a single woman dies from a pregnancy related condition" adding that it was worrying that so many of these cases involved teenage girls. It is adopting a holistic approach – not only providing safe post-abortion care to pick up the pieces when things go wrong, but also adopting a comprehensive care programme, integrating contraceptive, sexual health care with the reduction of the risk for unwanted pregnancies.
But in the next phrase, reference was made to protecting "the innocent child". This shows the inherent contradiction Zambia is grappling with on this issue. The government is faced with an impossible task; to protect women undergoing a procedure which runs inherently against the beliefs of the vast majority of the nation.
"We need to find a way to make a safe termination of pregnancy acceptable to the Christian community" Holo tells me. "We need to educate boys, as well as girls that condoms don't only prevent AIDS. We need a reliable health care system which people can access."
"We need to talk about abortion" adds Dr Kamanga. "We need to develop sensitization campaigns so that women know they don't need to put their lives at risk".
Grace made it. "I am so grateful" Grace tells her Dr. "I can now finish school without having a child to look after". She had a full hysterectomy following an infection she developed. She is now infertile and lucky to be alive. Grace is 15.
Back in the emergency room, the door crashes open as another young girl is rushed to Dr Kamanga, hemorrhaging and drifting in and out of consciousness. "A woman who needs an abortion has a right to safe care" he says hurriedly before turning back to attend to her. "Their lives depend on it".