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Inside Nigeria’s illegal backstreet abortion clinics

Unsafe termination of pregnancy kills thousands of women and girls annually in Nigeria, where abortion carries a heavy jail sentence.

[Muaz Kory/Al Jazeera]
[Muaz Kory/Al Jazeera]

It was shortly before noon on Friday, September 2, 2016. As an unrelenting downpour fell on D-line, an urban residential area of Port Harcourt, the capital of Rivers State, Ann* sought shelter in a nearby church, while her boyfriend paid the cab driver.

Then they entered a nondescript, unfinished one-storey building.

Ann was 17 and enrolled in a university pre-degree programme. After she fell pregnant, her boyfriend, a 29-year-old medical laboratory science graduate, had taken her to the building to see a doctor who ran a private, unregistered clinic. She did not want to be there.

“I was still a kid, just 17. I did not know anything about my body. I was more or less a child,” Ann explained, her voice strained, as she mined her memory for details.

The building was on a side street just off a main road and had shops on either side of it. The downpour had emptied the street, but for one roadside seller who still managed to display her snacks. Inside, a four-room apartment was used as a makeshift clinic. The interior walls were mildewed and stained; the white paint almost completely chipped away.

Ann met three other women in the waiting room; they were also there to see the male doctor who ran the place with two female nurses. One nurse briefly conferred with the doctor before Ann was called into the room they used as a theatre.

The procedure – a surgical abortion – would cost her boyfriend 7,000 naira ($17.95).

Inside the theatre, there was a brown leather gurney positioned diagonally. A wooden cabinet was mounted above it and nearby, stood a trolley with metal pans.

Just 20 minutes after Ann walked into the room, the procedure was over. “I was just whisked into a room …” she recalled, exasperated. “I was not given any pre-abortion [treatment] nor any post-abortion treatment.

“We got into business right on, immediately … there was this stuff that’s like a really big injection, like a really big syringe. Instead of attaching a needle like a normal injection, the doctor attached a very big metal object. I will liken it to six or seven TV (whip) antennas joined together … that is how long and how big it was.

“Immediately, he started sucking [and] I felt a pain I had not experienced before. It was so, so bad. At a point, I had to tell him to please pull it out of me. Please, please, please, I told him. I was writhing in pain but at the same time I could not move because I did not want to harm myself by shaking.”

When the procedure was finished, a nurse helped Ann into the recovery room; then, minutes later, she was told to vacate the space because another patient needed it.

Nigerian law

Induced terminations of pregnancy are common in Nigeria where it is estimated that 1.8 to 2.7 million abortions occur annually. That is 41.1 per 1,000 women. A vast majority of these abortions, like Ann’s, are unsafe and carried out secretly due to Nigeria’s anti-abortion laws.

The laws against abortion mean that a woman cannot access the service in standard healthcare facilities unless there is an immediate risk to her life. Coupled with Nigeria’s longstanding conservative leanings on women’s sexual and reproductive rights, abortion is widely considered a taboo and women who choose the procedure are often stigmatised.

Like Ann, many Nigerian women prefer to go through it under the cover of secrecy, away from the gaze and knowledge of the public. The consequences of this are the complications that arise from unregulated abortion methods, which can include other reproductive health complaints and in extreme cases, can even lead to death. Nigeria has one of world’s highest maternal mortality rates and recent research estimates there may be as many as 6,000 abortion-related deaths in the country each year, the majority of which are preventable. Globally, between 22,000 and 31,000 women and girls die as a result of unsafe abortions each year.

[Muaz Kory/Al Jazeera]
Nigeria’s abortion laws have their origin in colonial jurisprudence. Under the law, the only legal avenue for a pregnancy to be terminated is if a woman’s life is critically threatened. Beyond that, abortion is illegal and carries a heavy jail term.

Abortion is legislated against by the two legal codes in Nigeria depending on one’s geographical location.

In the southern part of the country where the Criminal Code is adopted, Sections 228, 229 and 230 punish abortion. Section 228 stipulates that “any person, who with intent to procure miscarriage of a woman whether she is or not with child, unlawfully administers to her or causes her to take any poison or other noxious thing, or uses any force of any kind, or uses any other means whatever, is guilty of a felony, and is liable to imprisonment for fourteen years”.

Section 229 punishes women who undergo an abortion, stating that they are “guilty of a felony” and are liable to imprisonment for “seven years”, while Section 230 stipulates imprisonment of three years for any person “who unlawfully supplies” materials intended to “be unlawfully used to procure the miscarriage of a woman”.

In the northern part of Nigeria, where the Penal Code is applicable, Sections 232 to 236 prescribe punishment for abortion. Section 236 says if “causing death of quick unborn child by act amount to culpable homicide” the person “shall be punished with imprisonment for life or for a less term and shall also be liable to fine”.

Effiom Effiom, Nigeria’s country director for Marie Stopes, an international NGO that provides reproductive health services including abortions, believes women should be able to make their own decisions about their health. “I think it is chauvinistic and really backward to begin to sit and legislate around women’s bodies,” he explained.

An inevitable service

It was a quiet, sunny afternoon in early January and Dr Adeniyi* had just carried out an abortion in his clinic in Itire Ijesha, a suburb of Lagos. It was dilation and curettage (commonly called D&C), an abortion method that Dr Kingsley Odogwu, the director of clinical services at Marie Stopes, described as “obsolete” because “medical science has found it not to be … safe”.

Still, it remains popular among those Nigerian medical practitioners who carry out abortion procedures illegally.

A few minutes past noon, the clinic at Itire Ijesha was quiet. The power had gone out and only one woman sat waiting in the reception area, while three nurses walked briskly past in the passageway that linked all three rooms in the facility.

The walls of Dr Adeniyi’s office were covered in black wallpaper with white horizontal stripes. Cardboard covered the only window, leaving the room largely in darkness. Still, it was possible to make out a table on which there were stacks of paper, a stethoscope, two Bibles and a Quran. To one side of the room was a gurney with a flat-screen television above it. On it, slouched against the wall, sat a middle-aged woman – the fixer – who arranges things between the doctor and the women and girls seeking his services.

You can never stop abortions, never ... If abortion is legal, almost all doctors will be doing (the procedure) and everyone will access normal healthcare. Nobody will have to hide or cut corners.

Dr Adeniyi

Seemingly unfazed by the fact that his work is illegal, Dr Adeniyi spoke with the assurance of somebody rendering an inevitable service.

“You can never stop abortions, never,” he said. “All of these (the deaths and complications arising from unsafe abortions) happen because there is a law. If abortion is legal, almost all doctors will be doing [the procedure] and everyone will access normal healthcare. Nobody will have to hide or cut corners.”

Nigeria’s chronically underfunded health system leaves room for uncertified doctors and healthcare workers to flourish, with little or no disturbance from the authorities. According to the Nigerian Medical Association, the professional body for registered doctors and dentists in the country, only 40,000 doctors cater to an estimated population of 200 million people.

Other than the clinics where abortions are carried out covertly, like Dr Adeniyi’s, procedures are mostly done in places run by people without a medical licence who may have picked up some skills doing apprenticeships at private or cottage hospitals – small facilities offering basic healthcare to the surrounding population.

“There are a lot of [uncertified] nurses who have worked with doctors before and they have seen the doctors perform it several times. They go and set up their own clinic for money, without having the equipment. They only improvise. They think: this is how the doctors do it,” Dr Adeniyi explained.

[Muaz Kory/Al Jazeera]

Unlicensed practitioners

Eniola*, a 24-year-old mother of one, is one such nurse; one of the thousands who are uncertified but running unsafe, backdoor abortion clinics. Eniola has carried out about 50 abortion procedures since 2017, when she was just 21.

“I am not licensed [but] I practice [nursing] fully,” she answered when asked how she came to be treating patients.

Eniola was 18 and fresh out of secondary school when she first got pregnant. At that time, and by what she considers a stroke of luck, she was apprenticing at a private hospital in Lagos, through which she would later receive a certificate of apprenticeship as an “auxiliary nurse”. When she fell pregnant, she decided not to keep the baby, and sought out the advice of her colleagues who prescribed medication and an injection.

It worked. So she decided to make a living out of selling the medication and administering the injection to other women, charging 5,000 naira ($12.82) to abort pregnancies during the first month. The charge increases the further along in a pregnancy the woman is.

Then, when she completed her apprenticeship at the hospital, Eniola took the knowledge she had gained and started carrying out medical abortions without any equipment in the single-room she shares with her husband and child in Ilupeju, Lagos.

Every six out of 10 abortions happening in Nigeria are considered unsafe. This is a high number; we cannot turn our heads to that.

Effiom Effiom, Marie Stopes

With its heavy curtains closed, the room – one of 10 in a bungalow, each occupied by different families – was dark on a sunny afternoon two days before Christmas. On one wall a wooden cupboard housed syringes, medicine and surgical scissors. Across from it was a large bed on which the family sleeps and Eniola tends to some patients.

Carrying out abortions is just one part of her practice as an “independent nurse”; she also delivers babies and treats ailments such as malaria and typhoid – mainly by prescribing medication and administering injections.

When asked about her equipment, Eniola explained: “I do not have the equipment because of the police. If the police come and say I am doing abortion, I can deny it because they cannot see any equipment.”

According to Effiom from Marie Stopes: “Every six out of 10 abortions happening in Nigeria are considered unsafe.”

“This is a high number; we cannot turn our heads to that,” he added.

Endemic

Dr Adeniyi’s clients are mainly teenagers. For every 10 clients who walk into his clinic, eight are aged between 13 and 21. Most struggle to pay the 4,000 to 6,000 naira ($10.25 – $15.38) he charges. His costs also increase as a pregnancy progresses.

He considers his clinic one of the cheapest around, and reels off a list of doctors he knows who would not go below 10,000 to 15,000 naira ($25.64 to $38.46). In addition to the legal challenges associated with abortion in Nigeria and the stigma, the high cost of the procedure is another reason many women bypass more competent doctors and facilities.

“Some of them come in and haggle and haggle. Because of the price, they go to visit those quacks. People come in here and even beg me,” Dr Adeniyi explained, recalling one client who offered him sex in exchange for an abortion.

Abortion stigma by the society is so bad, no one can come out to say I have had an abortion ... Safe abortion means ending a pregnancy safely and then prescribing contraception so it does not occur again.

Sanasi Amos, sexual health expert

According to the 2018 Demographic Health Survey, one in every five girls aged 15 to 19 in Nigeria are already mothers or expecting their first child.

“Abortion stigma by the society is so bad, no one can come out to say I have had an abortion. If we have a law in place, abortion would be regularised; safe abortion means ending a pregnancy safely and then prescribing contraception so it does not occur again,” said Sanasi Amos, a sexual health expert and sex columnist in Abuja.

“It is mostly done by teenagers who were probably raped, and do not want to face societal stigma [so] they end up meeting quacks and the consequences are a lot – from sepsis, haemorrhage and death.”

Sanasi believes that sex education, instead of an abstinence-based approach, must be introduced in schools, and should cover everything from contraceptive use and safe abortion to sexual violence.

Dr Adeniyi recounted the case of one client, a 13-year-old girl who was still in primary school when her mother brought her to the clinic.

The girl had not realised that she was pregnant, but her mother had noticed changes in her body. The girl denied that she had had intercourse. The doctor recommended a scan, which revealed that she was five months pregnant.

“At the end of the day, we did the abortion and if we are to do abortion at that stage [five months and above], we have to do it like it is a proper delivery,” he said, explaining that the labour-induced method was the only option. “She went to the toilet and pushed it out.”

[Muaz Kory/Al Jazeera]
Less than six months later, the mother and daughter returned to his clinic. “I was shocked when I saw them again. It was the same pattern as the first. The girl denied, the mother was confused because she knew the girl’s daily routine, we did a scan, and she was far gone again. We had the abortion again.”

This time the mother responded by betrothing her daughter to another man. “It was in this hospital that [the betrothal] happened,” Dr Adeniyi recalled, knocking on the wooden table in front of him for emphasis, “just right here.

“The only thing the mother requested from the man was the money she had spent on the procedure. It was about 40,000 naira ($102.56),” he added. “I also collected the money that I had used for scan and I billed him for post-abortion procedure which he paid for; but the girl could not have it because to my knowledge, she was already taken to [the] northern part of the country.”

Abortion care

After Ann had her abortion in 2016, she was sent off without any care, save for a prescription for Flagyl, a staple antibiotic in Nigeria, commonly used to treat a wide range of infections.

The next day, she started to feel an intense pain in her stomach and became feverish. “It was so bad,” she recalled. “[On the third day] I started bleeding profusely … what constituted the bleeding, I think, was tissues and blood.”

When her fever reached its peak, Ann’s boyfriend reached out to the doctor. But he only recommended malaria drugs. For the next four days, the pain and heavy bleeding continued. “The pain was just out of this world,” she said. After that, she was sick for another week.

Aishat*, a 26-year-old radio presenter in Lagos, experienced something similar. It was October 2020 and after finding out that she was pregnant, she called a laboratory in Lagos to ask if they carried out abortions.

“The first thing the person that spoke to me on the phone asked me was if I was married. I said no. He asked if I was a Christian or Muslim. I said no. He asked if I had talked to the person that impregnated me and I was like … I am only asking you for a medical opinion, why are you asking me all of these questions?” Aisha recalled.

“And the speaker was like, do you know God is against abortion? I told him if I needed judgement, I would go to a priest. Then he hung up on me.”

[Muaz Kory/Al Jazeera]
After making enquiries with some friends, Aishat ended up in a three-bedroom apartment in a neighbourhood of upscale Lekki. The doctor who lived there used one of the bedrooms as an abortion clinic.

The room was empty save for a wardrobe where medical instruments were kept, a hospital bed, a plastic chair and a bucket with hot water for sterilising the instruments.

“He charged 45,000 naira ($115.38) but I beat it down to 35,000 naira ($89.74). [That day] the doctor talked me through the process and let me know it is a normal occurrence. He said he scheduled abortions for three other people that day,” Aishat explained.

“He told me to lie on the bed. He gave me two injections, one in my arm and one in my thigh. I think the injection was supposed to numb me but they didn’t, they only made me drowsy. I was drowsy and felt like throwing up. I was present in every moment,” she continued.

After the procedure, the man gave Aishat some medication and told her to report back on how she felt. For two weeks, Aishat bled and endured excruciating pain. She took a photo of the bleeding and sent it to the doctor.

“He said maybe he did not finish. I went back and went all over the process again. What got me scared was there were already fibrotic tissues, it took a lot of pain. Before it came out, I almost passed out. It was like holding a raw meat in your hand,” she said.

Filling the vacuum

Nigeria is a party to the Maputo Protocol, the first pan-African treaty that explicitly regards abortion as a human right. It went into effect in 2005 but Nigeria has yet to implement it.

Meanwhile, different organisations are filling the vacuum created by the country’s laws, to continue providing healthcare services for women.

One of these organisations is Prochoice Nigeria, a team of women working under the radar to help organise reproductive healthcare services, including abortion, at affordable rates. Walking a legal tightrope, they operate covertly as more of a “middle-man organisation”: connecting women with medical services that operate discretely to provide safe abortions in safe hospitals.

They also provide counselling and checkups “to make sure that if they decide to go through with the abortion, they know how it will affect them and the options they could take,” explained Aderinsola Ajayi, the chief operating officer.

“What motivates my team and I is knowing that we can save lives … women and girls are dying because they don’t have access to these services and if we can somehow reduce that number, it will be better. It is never easy to change policies in a country like Nigeria where everyone is opposed to women wanting to take control of their bodies.”

[Muaz Kory/Al Jazeera]
Knowing the gravity of their operations, they employ a digital option where a woman can log in and speak to doctors and counsellors, who also advise clients about ways to get a medical abortion at home – including what drugs to buy, how to use them and how much to take. This, she said, was designed to reduce the risk of arrest.

“We use this digital option first but if you need to see a doctor [physically], then we refer them to these places where they can get attended to by trusted and known providers,” Aderinsola explained. “The laws make it very hard because we have to be careful about just how much we give out to people and, you know, when and where we decide to give the information because we could also easily be arrested. These services have to be done in secrecy because we just cannot be out there … we are also endangered doing this kind of work.”

Although initiatives like this do what they can, many say it is not enough.

“So far, women have created help for themselves but it is not enough. We have seen NGOs like STER [Stand to End Rape] created by a woman to help women but there is a limit to how much an organisation can handle,” Sanasi explained.

“We have been implementing short-term policies all along. Almost every year we see new agencies formed to protect women but what always becomes of it? Nothing. If we need to change, we need to do things the right way [getting the government to work]. Create and implement a policy that would last not [just for the] short term.”

‘He is a quack’

In April 2017, months after her abortion, Ann returned to the clinic after missing a period.

By then aged 18, and having already consumed all the information she could find on the internet about surgical abortion, she was determined to minimise the risks this time.

In the queue that day, there was another young woman. Ann watched as she walked into the theatre only to hobble back out again a couple of minutes later, propped up with with the help of a friend. She was “writhing … in pain”.

Then it was Ann’s turn. She went in to see the doctor, expecting him to recommend a blood test to confirm whether she was pregnant. Instead, he palpated her stomach and “the next thing he just said ‘you are two months pregnant, you need an evacuation'”.

So far, women have created help for themselves but it is not enough. We have seen NGOs ... created by a woman to help women but there is a limit to how much an organisation can handle.

Sanasi Amos, sexual health expert

Ann recalled how the clinic had been upgraded since her first visit: the walls were now freshly painted and there was a GO-TV satellite television receiver and a flat-screen TV in the reception.

She insisted on a pregnancy test. About 30 minutes later, a nurse returned with the result. It was negative.

“I was not even pregnant to start with. I am sure he had already counted the money in his head … probably the additional 3,000 naira ($7.69) [because he had said she was in her second month of pregnancy],” Ann said.

“I began to wonder, if I had gone through the process in the absence of a pregnancy, what will have happened to me on that table that day? I will probably have lost my life or my womb. That is why I would tell you he is a quack.”

Despite her narrow escape the second time, she still faced complications resulting from the first procedure. Sometimes she would bleed for a month and at other times she would not bleed at all for as long as five months.

“When I went back to see him and complain that I am not seeing my menstruation, the doctor said ‘you should even be happy, that means you won’t be wasting money on pads, even if you don’t see it for one year that is fine; even if you don’t see it for two years, even if you don’t see it for five years’. And he laughed about it,” Ann recalled. “After that incident, I did not return there. 2017 was the last time I saw him and his Godforsaken facility.”

*Names marked with asterisks have been changed to protect the identity of those who spoke to Al Jazeera on condition of anonymity.

Source : Al Jazeera

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