A local Non-Governmental Organisation; Great Lakes Initiative for Human Rights and Development (GLIHD), has filed a public litigation case with the Supreme Court in which they seek to challenge two articles within the Penal Code regarding safe abortion. Article 72 of the law determining the jurisdiction of courts stipulates that any person or company and association with legal personality can petition the Supreme Court to declare a law unconstitutional if they have any interest. The government, through the Ministry of Justice, is the respondent in the case. In the petition, GLIHD, a local organisation that works on issues of sexual and reproductive health and rights, delves into Articles 125 and 126 of the Penal Code that state that an abortion must be performed by a medical doctor who is by law someone who has at least a Bachelor’s degree in medicine. In an exclusive interview with The New Times, the Executive Director of GLIHD, Tom Mulisa said that his organisation is seeking an amendment of Articles Article 125 paragraph two and article 126 paragraph 3 that restrict provision of abortion services to only medical doctors and exclude other trained healthcare providers such as nurses and midwives. GLIHD says this requirement impedes women and adolescents’ right to access safe abortion services under the stipulated grounds by imposing stringent requirements. In 2018, the law relating to abortion was changed requiring only consultation between a woman and her doctor unlike previously when the final decision over whether a woman could have the procedure subject to a court ruling. However, the law still provides for specific circumstances under which abortion is legally permissible, for example in cases of rape, forced marriage, incest, or instances where the pregnancy poses health risks to the mother or unborn child. “This requirement not only brings about unnecessary delays but also denies women and girls’ right to access a health service that they are legally entitled to. Barring nurses and mid-wives from performing abortions is problematic in Rwanda where the number of doctors is very limited,” he said. A report published by the Ministry of Health in 2019 indicates that the total number of registered medical doctors in Rwanda is 1,648. Only less than half of these are currently practicing. 452 are practicing in the public sector. The rest are either not actively practicing or are employed in private or faith-based facilities. On the other hand, there are 15,050 registered nurses and midwives, making up 69 per cent of the entire health workforce in the country. Of these, 7,593 are employed in public health facilities. Mulisa explained that according to the structure set up by the government, health centres are only staffed by nurses and midwives and other support health care professionals. General practitioners and specialists are available only in district, referral and national hospitals. He pointed out that this indicates that many health care facilities in the country are staffed by mid-level providers as opposed to doctors. “This means that health centres, which are the primary care facilities in the country are more accessible to many women and girls, particularly to those living in rural areas and low-income earners, are staffed with only mid-level providers,” he explained. Mulisa said that by eliminating health centres and insisting that abortions be conducted at district, referral and national hospitals, young girls and women who cannot easily access these facilities are at a very high risk of using rudimentary and risky methods to abort or even having children that are unwanted. He said that an independent assessment carried out by his organisation indicates that of the 42 hospitals that were visited, only 16 (38 per cent) had at least one specialist in obstetrics/gynaecology. In total, the assessment covered 42 hospitals and 10 private clinics. “There are also some hospitals that do not have doctors with this specialty. For instance, out of the five provincial referral hospitals assessed, only three have gynaecologists,” he said. In Eastern province, five gynaecologists are available in five hospitals out of nine, in Northern province, only three gynaecologists are deployed in two hospitals out of seven while in Western province, six gynaecologists are deployed in four of 12 hospitals. In Kigali City, five gynaecologists are deployed in three hospitals while in Southern province with 11 hospitals, only one specialised gynaecologist is available at Kabgayi Hospital. He said that besides this indicating that this was further proof that even at the hospitals where the women and girls are being sent, there were not enough gynaecologists. “Besides the shortage, you must also factor in that of the 42 hospitals, seven are managed by the Roman Catholic Church and therefore, do not provide abortion services. This further limit the number of health facilities from which women and girls can obtain safe abortion services,” he said. Ministry responds In a letter sent to the Ministry of Justice which will be the respondent in the case, the health ministry admitted that unsafe and unregulated abortions can be avoided if safe and legal abortions are provided by trained people. However, it said that safe abortion procedures cannot be performed at the health centre level to avoid failure to manage complications that may arise, like severe bleeding. The letter explained that severe bleeding requires blood transfusion and possible hysterectomy (surgical removal of uterus) which can only be done at hospitals where doctors and infrastructure are available for proper management of the cases. “Two hours are sufficient for a pregnant woman to die due to haemorrhage. To ensure that abortion is safe and that such associated complications are managed, a setting with a medical doctor and a multidisciplinary team make a hospital a good setting for abortion,” it reads in part. ‘Friend of the Court’ Meanwhile, the Health Development Initiative (HDI) is expected to appear in court as ‘amicus curiae’ – a ‘friend of the court’. A ‘friend of the court’ is a non-party with an interest in the outcome of a pending lawsuit who presents information in support of or against one of the parties to the lawsuit. Speaking to The New Times, HDI’s head of human right and litigation; Christopher Sengoga said that they will make submissions as an institution that deals with reproductive health rights related cases on a daily basis. He said that HDI will base on their experiences to explain why a midlevel health worker at a health centre can perform an abortion in the first trimester of pregnancy. “We will be speaking from experience because the team that runs HDI includes doctors but also, we work with health centres from all over the country and train their staff while also dealing with these women and girls who are usually in need of these services on a daily basis,” he said. Sengonga gave a recent example in Nyanza district where one of the girls who needed such a service required Rwf3, 500 to use a taxi moto to and from hospital since there is no connecting bus. As a result, he said that the girls who come from poor families opt to use methods that put their lives in danger. “When a girl swallows local herbs or uses other means to abort, the emergency services where a patient’s womb may require cleaning out at the health centre. How can such a place not perfume safe abortion?” he wondered. HDI says that it has assisted up to 154 women who approached them via their toll-free telephone lines inquiring about abortion between January and June last year. Of these, 84 were asking for information, 60 wanted to have abortion services (and got them), while 10 didn’t manage to get these services because their pregnancies were over 22 weeks. The case now awaits scheduling by the Supreme Court registry.
