The Ibrahim Malik public hospital in Khartoum, Sudan. Abortion is only legal in Sudan under very specific circumstances. As a result a number of women continue to access unsafe abortions. Courtesy: Abdelgadir Bashir

KHARTOUM, Jun 22 2020 (IPS) – Omnia Nabil*, a Sudanese doctor, who worked in one of the largest hospitals in Khartoum, the country’s capital, was devastated to witness the deaths of 50 young women who had unsafe abortions during a space of just three months.

“I would see 16 cases of failed abortions on a given day. I would insert my hand and pull out syringes or leaves, unsanitary items that were inserted by midwives to induce a miscarriage,” Nabil told IPS.

For Sudanese women, getting an abortion is often a very lonely and dangerous process because it is only allowed in very specific cases.

Article 135 of the Criminal Law of 1991 legalises “miscarriage” only to save the mother’s life, if she is a victim of rape in her first trimester or if the foetus is dead. However, in all cases, women need their husband’s consent for the procedure.

Women who do not meet these requirements generally end up going to traditional midwives. But it places the women s lives at risk. And if caught, it is an offence punishable with imprisonment of up to six years or a fine.

This Northeast African nation of some 41 million people was ruled for 30 years by dictator Omar al-Bashir until he was removed from power by the country’s military in April 2019 after mass pro-democracy protests.
Under Al-Bashir s rule the country experienced decades of war and repression resulting in the current internal displacement of 2.1 million people. 

Sudan’s transitional government, formed in August 2019, allocated 40 percent of its parliamentary seats to women. This resulted in laws restricting freedom of dress, movement and work being repealed and female genital multination being criminalised. However, there have been no changes to the law on abortion.

Abortion a dangerous and lonely procedure

But as international organisations working on reproductive health were slowly shut down in years prior to the transitional government being formed, small groups or networks of people have been working together to ensure that women are able to access safe abortions.
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Because most women can’t access hospitals or healthcare facilities because they fear arrest, they end up having the abortions alone, or with little help. Sarah Ali* was one of them.

When Ali found out about her pregnancy, she struggled to find a nurse or doctor who would help her obtain an abortion.

“I was running out of options and a midwife working at a private hospital had agreed to help me, but was unable to find the pills. I was entering my 11th week when I received the pills sent in a package by Women on Web,” Ali, who no longer lives in Sudan, told IPS.

The pills, a combination of mifepristone and misoprostol, were sent by , a Canadian non-profit organisation that “advocates for and facilitates access to contraception and safe abortion services to protect women s health and lives”, according to its website.

The organisation provides women with abortion pills within the first 10 weeks of their pregnancy, after an online consultancy, which allows those who have a problem accessing a safe abortion to have a medical abortion in their homes. According to the organisation, a medical abortion in the first 10 weeks is “very low risk of complications and resemble having an early miscarriage”.

“After the procedure, I was able to go back to the midwife for a check-up and make sure I didn’t get an infection,” said Ali.

There are no recent statistics on unsafe abortions in Sudan. However, , “An estimated 25.1 million unsafe abortions take place [globally] each year. Every year, approximately, 6.9 million women in developing countries are treated for complications from unsafe abortions, and complications from unsafe abortions cause at least 22,800 deaths each year.

Nabil watched as women who had unsafe abortions and came to the hospital for help eventually died.

“They would usually die from what we call septic abortion, which is essentially an infected abortion process and even though I was pro-choice from early on, this tragedy inspired me to start the abortion network,” said Nabil, who has since left the country.

Underground networks help women access safe abortions

With a core group of doctors, doctors-in-training and supporters, Nabil created a network to obtain misoprostol for patients and supported them if they had future complications. The network was a small and deeply-secure structure.

“The work was dangerous. At some point, we had a patient in the hospital and the doctor treating her suspected that she was unmarried, she called the police and I had to help her and her partner escape,” said Nabil.

Knowing the risks, Nabil took her precautions. She had a separate phone and always used a fake name with patients seeking abortions.

The core team worked for years without getting caught and recruited younger doctors when those in the team had moved on to other jobs.

“We tried to support girls from lower-income households and offered them the pills at reduced prices relying on our acquaintances in the field. But in the end, we were unofficial and dependent on word of mouth, so you have to know someone to make the initial contact,” said Nabil.

In the last few years, the network’s capacity was reduced as more of its members moved on to other countries seeking better economic situations. Nabil continued to help from a distance and her close friend was the last one in the network, until he also left the country.

Shrinking space for service providers 

The last statistics on the use of misoprostol dates back to 2011, when a health charity operating in Sudan and the largest non-government provider of reproductive health products and services at the time, published a report stating that 450,000 units of Misoprostol and 16,000 kits of MVA were used/sold that year.

came under attack in 2012 when radical parliamentarians clashed with the Minister of Health over family planning, abortion equipment and the distribution of condoms.

But things became worse when the government shut down another international organisation working on reproductive health.

“This organisation had provided an important device called vacuum aspirator or NVA for abortion and miscarriage cases and it was registered in Sudan until the government stopped it. It is life-saving and important and now few doctors have it and can only do it under the table,” said Salma Habib* an activist working on SRHR issues here.

In the meantime, there is one doctor in Sudan who is willing to perform medical abortions and support his patients in taking misoprostol, but he has been banned from working here since 2006.

When Dr. Abdelhadi Ibrahim, a young Ob/Gyn specialist moved to Sudan from the UK in the 1997, young women patients started asking him to perform abortions.

Ibrahim estimated that he had provided safe abortions to at least 10,000 women over a period of seven years and helped many others restore their hymens to indicate virginity.

In 2006, Ibrahim was and tried in a high-profile court case and was sentenced to six years in prison and his license was revoked by the Sudan Medical Council.

“Until today, I am fighting to get back my license. I won two law suits and the council continued to stall and now after the revolution, they just made appointments in the council and a committee should be formed to look into it, I must’ve visited the council’s building hundreds of times,” Ibrahim, who he has not worked in 14 years and was forced to sell some of his property to support himself, told IPS.

Abortion pills too costly for most women

In the meantime, prices of medical abortion pills have soared.

“Today, most women can not afford a safe abortion in Sudan. The pills could cost at least $142 to $214 or even more and the quality of the pills and their expiration date could be a problem because you are buying from the black market after all,” said Habib, who added that there are fake pills on the market also.

Most Sudanese women have to use traditional midwives as they can’t access the expensive pills. It places them at risk to unsafe abortions.

The procedures performed by midwives are often dangerous, but in addition the midwives often criminalise the behaviour of their patients.

“I know a girl who was circumcised by a midwife after an abortion and was told that this is to stop her from having sex again, it is clear that midwives could punish you or take advantage of your situation,” said Ali.

But as Nabil s abortion network closed, parallel networks sprung up. Habib supports her network by accessing pills from Women on Web and from trusted sources inside Sudan.

“There are people working now, I don’t know many of them, but one of my former clients is now leading the same efforts and helping other women,” said Nabil.

*Names changed to protect identity.