FIGO INITIATIVEabout Unsafe Abortion
Situation analysis in Tunisia
Authors:Neji K; chechia L; Lebbi Issamzhioua F et al.
STGO
I .Tunisian main indicators and legal framework:
In 2006, Tunisian population was about 10.200.000 inhabitants, the literacy rate was 75, 3% with a demographic growth rate around 1,08%. So, the Total Fertility Rate was 1,9 , the rate of children[6-23years old] in school up to 73% .The urbanisation rate was 63,4% , the number of inhabitants for one medical doctor estimated about 994 and the primary health care (PHC) centres reached 2076 units.
First of all,unsafe abortion is very rare in Tunisia because abortion is legalised in Tunisia by the legal framework:
Law N° 65 (July 1965):
until 3 months of pregnancy
After the 5th child
In a hospital or another health structure or in an authorised clinic
By a doctor practising legally his profession
Law N° xx (1973):
Authorise « social abortion » until 3 months
In a hospital or a sanitary establishment or in an authorised clinic
By a doctor practisinglegally his profession
Second, the law is severe in front of the secret abortion regarding this decree which stipulatedin the Article 214 / N° 24 (July 1965):
“Anybody who try to perform an illegal abortion ,with or without the agreement of the pregnant woman, using medicine or another method, incurs 5 prison years and a
10 000 DT caution (about 7000 Dollars) or the both sentences “.
On the other side, the pregnant woman who try to abort or who underwent a secret abortion incurs two prison years and a 2000 DT caution (about 1500 Dollars)or the both sentences.
II . Unwanted pregnancies:
The incidence of Unwanted Pregnancy (UP) is not available on the web.
However,ONFP incollaboration with the Pan ArabProject for Family Health(PAPFAM) carried out in 2001 that 52% of pregnwomen desired to stop childbearing;
In Tunisia, many interventions are accomplished in order to prevent unwanted pregnancies and induced abortions among them,
a .Contraceptive information and services, including IEC :
Concerning the contraception access, the MICS 3 (Multiple Indicator Cluster Survey) study, realised with the Unicef-Tunisia and published in 2006, report a contraceptive prevalence of 61% among the procreative married women.
According to ONFP statistics, many contraceptive methods are distributed for free or at subsidized price, such as IUD (27,8%), pills (11%), injections ( 2%) and implants (1%). Female sterilisation and periodic abstinence are adopted in 10, 4% and 7, 2% respectively.
Year / ONFP servicesSurg. Abort Medical abort / MOH services
Surgical abortion / Total
2004 / 7233 4839 / 2330 / 14 4O2
2005 / 6979 5171 / 2390 / 14 540
2006 / 7118 4250 / 2127 / 13 495
2007 / 6366 5125 / 1953 / 13 444
safe abortion incidence
b . Comprehensive Sexual Education:
TheThirdof Tunisian population is aged between 15 and 29 years.Among them, studies objective a great and specific need for health services (particularly,Information and Reproductive Health Care)
.This high proportion of youth, added to an importantpolitical involvement towards youth policy (free education for all, facilities for employment, health care, leisure and social activities...)conducted on an easy way to the Development of a national strategy for RH towards adolescents and youth in order to:
-facilitate the access to IEC Structures in the whole country ,
- organise the medical consultations for adolescents and young people (Mainly in the public sector)
-.and promote school health services (CIC/ Sexual and RH).
There is an efficient governmental program for comprehensive sexual education .Indeed,24 Counselling Information Cells/RH (one for each region at least) offeredIEC services to students in secondary schools and universities. The professional providers are doctors, midwives and female educators .But there arealso peer-to-peer educators among teenagers for mobilization and sensitisation in daily environment (studying places, dormitories, leisure time …). Furthermore, compulsory school programs (about20 hours) are developedat the 9th year of the basic school (15-16years old) about physiology and anatomy sexual matters and at the Baccalaureate (STIs /HIV).
c – Social protection of pregnant women and mothers of children under 5;
After delivery, new mother systematically enjoys a maternity time off during 2 months (open) while she perceive herwhole salary. At the end of this time off, and with a signed agreement of the administration, asupplementary 4 monthshalf sold time off is possible at request of the mother (Tunisian Labour Code Article N° 48)
This law is really enforced in the Tunisian administrations .But there is a disparity between public and private sectors about this law
d- Supporting women who wishes to give baby to adoption.
From 1300 to 1400 babies are annually born in Tunisian maternities from unmarried women They are taken care of by governmental structures .such as: health, social welfareand family and childhood ministries .
So that, law N° 27 /1958 (Art 8) authorises adoption under strict conditions to adoptive parents.
In fine, a national centre for abandoned childhood undertakes all legal and medical measures in respect with law.
III. ABORTION
Abortion incidence:
In 1996, official statistics estimated 19.000 the total number of induced abortions in the public sector; this number lowed to 16.000 in 2003;
It is estimated that about 10-20% of abortions take place in the private sector and are not included in the present statistics.
Year / 2000 / 2001 / 2002 / 2003 / 2004* / 2005 / 2006 / 2007Number / 892 / 1042 / 1159 / 1301 / 2034* / 2126 / 1796 / 1943
“Safe“abortionevolution in unmarried ladies- Source: ONFP/MoH
In 2006, the urban national annual abortion rate /1000 MWRA were 27 versus 18 in rural context.
IV . Unsafe abortion
In Tunisia, Induced Abortion is safe and legal till 12 WA and done in respect of Tunisian law.
Over 12 WA, these illegal abortions become « unsafe » ,often performed by MD but these(rare) cases are not well documented ,explaining the current “poor statistics “!.
What data are available on the magnitude and severity of the problem of unsafe abortion?
This information is not available, but illegal abortions are very rare as abortion is available on demand. However, illegal late abortions (> 12WA) still occurs particularly in rural areas in cases of premarital pregnancies; but we have no reliable statistics (recommending in such a statement an action both in private and public sector area)
V. Tunisian experience with medical abortion
OMS protocol (200 mg mifepristone+ 400 mg misoprostol ) is used by 25% of providers
Emergency pill is available in pharmacies but it is underused
Medical abortion in Tunisia
Cost of medical abortion
Drugs cost : 37,800 DT (25 Dollars) and reaches more than 50 dollars per the whole cost of medical abortion (US…)
Distribution channel :ONFP and Tunisian central pharmacy
Severe bleeding (7%), Spotting(73 %), partial retention (22%)
Expulsion happened in the clinic ( 61%) At home( 6 %)Not seen at expulsion (13 %)
Abortion related maternal mortality
WHO estimates the Rate of maternal deaths due to abortion in the sub region in which Tunisia falls at 11% !!! And 17O the number of maternal deaths in Tunisia in 2005 . these results are of course overestimated because abortion is legalised in Tunisia but not in the other lands of our subregion. These are our statistics about hole maternal mortality.
Maternal mortalityN/100.000 alive births / Year
69 / 1994
MoH
49 / 2004
MoH
36,5 / 2007
(PHCD estimation)
100 / OMS estimation (WEB !!)
Maternal mortality in Tunisia( MOH statistics)
There is an established national level mechanism for monitoring and evaluation of maternal mortality and morbidity resulting from unsafe abortion.
Since 1999, a maternal mortality confidential committee indexes and discusses the maternal mortality cases including those due to abortion.
About situations of restrictive laws
There is not any restrictive law punishing neither women nor physicians after legal induced abortion.