Kenya's Slum Abortions Pit God Against Death

Martin Robbins is a writer and talker who blogs about weird and wonderful things for the Guardian and New Statesman. Here Be Dragons is a new column that explores denial, conflict and mystery at the wild fringes of science and human understanding. Find him on Twitter @mjrobbins, or email tips and feedback to martin@mjrobbins.net.

We had hiked for more than an hour across Nairobi’s hot and dusty Kibera slums to reach the clinic, and found ourselves sitting awkwardly while we waited for our friend Jobe to make the necessary arrangements. Through a contact at a local radio station, my American companion Jeff Sharlet and I had been able to gain access to an illegal abortion clinic, run by a Catholic doctor.

The pharmacy was no bigger than my bedroom. At the back of the tiny room a wooden door blended into the wall, beneath one of the portraits of the Kenyan President, Mwai Kibaki, that are ubiquitous in businesses across Kenya.

Peter, a doctor from Kisii, had opened the clinic several years earlier. Working in the slums could be tough, and occasionally dangerous – during the violence in Kenya after the 2007 Presidential Election, which killed a thousand people and forced a quarter of a million forced to flee their homes, he patched up fighters in return for protection. In spite of the risks though, the large population and lack of competing medical facilities in the slums meant he could run a lucrative business, generating more income than some of the doctors at the major hospitals.

Through the wooden door we found a treatment room where Peter carried out minor surgeries. Inside we found little more than a couple of chairs, a wooden desk and a blue plastic bed with grimy yellow stuffing poking out through several large tears. Abortions were being performed here four or five times per month, either chemically, using Misoprostol, or through manual vacuum aspiration.

Abortion remains illegal in Kenya, and women can’t discuss it or ask about it openly. “People are ashamed to talk about abortion,” Peter told us. “They know it’s going on, but they fear talking about it and they are ashamed.” Instead, a careful and secretive negotiation takes place: “First they come in for the pregnancy test and then maybe the test is positive. Then the lady tells you ‘I’m unmarried’, ‘I’m divorced’, maybe ‘I’m supposed to go for a job somewhere’, and then ‘I don’t want this pregnancy’.”

If the woman is married, then the husband must be consulted, even in the direst emergencies. “I won’t perform the abortion until the husband comes, and then we agree.” It turns out there’s a very practical reason for this rule. “If you do it without consulting the husband you will get violence in this place. They will attack you. The husband will get a mob of his guys and they attack you, so I don’t do it.”

The amount charged varies between 3,000 and 5,000 Kenyan Shillings (about £20 - £40). Cash must be paid upfront, and if the woman doesn’t have it then she’s turned away. The price is kept deliberately high to discourage younger women, and avoid abortions Peter considers to be unnecessary. “Whoever comes should be adult and responsible.” Most of his patients are unmarried and over the age of 22, many of them unable to afford to raise a child. Sexual violence against woman – and girls – is widespread in the slums.

Peter performs abortions up to around 16 weeks. The woman comes in, is given the treatment, rests for ten minutes, and leaves, returning a few days later for a follow-up appointment. Although none of his patients have died, the procedure isn’t without risks – haemorrhaging is the most serious complication. If things go drastically wrong the patient finds herself bundled into a taxi to the nearest hospital, knowing she may face arrest when she arrives.

These risks are far more acceptable than the alternative. Denied legal access to abortion, families simply terminate pregnancies at home instead. The methods used are barbaric: “They take a drug overdose with quinine, and they can prick the cervix using maybe a sharp object.” Often these result in incomplete abortions or serious internal injury, the victims carried bleeding to the clinic.

In common with most of his peers, Peter believes abortion should be legal: “Many women are dying from abortions being done in the villages. In Lindi you cannot wait a month without hearing that some woman is dying, due to abortion that was done by a quack somewhere. You can get two cases in a month.” As is the case in many places across the world, making abortions illegal in Kenya hasn’t stopped them from happening, it's just made them far more deadly.

Getting the necessary gear is fairly trivial for a doctor. Misoprostol is regulated, but because it’s also used to treat stomach ulcers it can be stocked without too many questions. The MVA kit for vacuum aspiration can be obtained discreetly from some NGOs, and in Peter’s case is stored in a secret location near the clinic. Police visits in the slums are very rare, but if they were to search the premises they would find no evidence of any wrongdoing.

Since abortion is illegal, doctors aren’t taught how to do it. Instead, the profession relies on word of mouth to keep their skills alive. We also saw evidence of assistance from various Western NGOs. Peter told us they were aware of his activities, and had provided training and advice to him and other doctors.

While we were talking, I noticed a Bible in his desk drawer. “I’m religious, I’m a Catholic.” It turned out that Peter was a family man, with a wife and three children. His wife ran the clinic with him, working as a pharmacist. A devout Catholic herself, she took a dim view of his extra-curricular activities: “She’s against it, she’s so much against.”

His wife had encouraged him to renew his faith, but returning to the church led to a crisis of conscience over his work as an abortionist: “For the last three years I’ve not been attending church. Now I’ve been attending I believe I am on the wrong side.” Motivated by his new faith, he told us he wanted to quit the black market. “I’m trying to do it the last time this month. It’s sinful. Life starts at conception. But if you reach a place where you understand it’s a sin, I think god can forgive.”

But what about the women who would die without his help? Peter faced a horrible dilemma. “What I am going to ask [his priest] is: 'What if I am a medical person, what do I do?' Because you get somebody, maybe her mama was doing an abortion in the house, then maybe she has been brought to me with an incomplete abortion, what way do I proceed? Do I proceed and help the mother not to die? Or do I leave these people because I am a Christian? What do I do? The villagers, the people know there’s a doctor here who can help us. Then they bring that lady to me. If he says that you leave these people to die, the village will be against me.”

Peter can’t win. Continuing would make him a criminal and a sinner, while stopping may condemn women to death. For many that’s the stark reality of abortion in the real world, away from abstract debates in blogs and newspapers, churches and parliaments. Conservatives have a fantasy that abortion can be stopped through legislation or social pressure. In reality, abortion happens, and it will continue to happen: the only choice we have to make is how many women we want to die in the process, and whether doctors like Peter should be criminalised for trying to save them.

Follow Martin on Twitter: @mjrobbins

Previously: Here Be Dragons – I Met the Woman Trying to Cure Malaria with Sugar and Water