Wafa Mudawi Ibrahim Adam, a sexual and reproduction health (SRHR) Champion working with RCOG’s Making Abortion Safe Programme, writes about policy and challenges around abortion in Sudan.
For 30 years, Sudan was governed by an authoritarian regime. The Omar El Bashir dictatorship introduced a scale of oppressive measures, particularly onto women and girls.
This included the introduction of restrictive policies related to reproductive and women’s health. Women require male permission (usually their husband, father or brother) to receive sexual reproductive health (SRH) care.1 There are police units in public hospitals and police officers patrol maternity wards.2 It is illegal for unmarried women and young people to have sex. By law, women are expected to only have sex to please their husbands and to reproduce.
Due to the assumption of abstinence, policies related to reproductive health only address married heterosexual couples. The use of modern contraception is only 12.2% among married women and 7.1% among all women.3
Under the Sudan Penal Code there are three grounds for an abortion: 4
- To save a women’s life;
- If the pregnancy is the result of rape and if the pregnancy duration is <90 days and the woman wants to terminate; and
- Proven foetal death in-utero.
The first ground for abortion requires a specialist medical assessment and signature. The ground for termination after rape requires filing police charges, obtaining a police form and a court order allowing the abortion. Sadly, the flawed rape legislation, the legal ban on sex outside marriage and the 90 days’ time limit on abortions, make it almost impossible for people to access safe, legal abortion after rape.5
Social stigma related to abortion and sexual activity is very high. Unmarried women seeking abortion or postabortion care (PAC) are perceived as promiscuous women, who want to hide the evidence of their crime of fornication. Health providers will often report patients seeking healthcare if a ‘crime’ is suspected, despite the Medical Ethics Guidelines of the Sudan Medical Council stating that no healthcare professional has an obligation to do so. This includes sex outside marriage, attempted suicide, pregnancy outside marriage (illegal pregnancy), and abortion. As a result, reporting women and denying their care are now common practices.6
The context described above doesn’t give women many choices when it comes to abortion. Unmarried women are in an even more dire situation, as for them the law considers being pregnant a crime in and of itself. Single mothers are not accepted by the community nor the state, children born out of wedlock are stigmatised and called names. Women can’t issue a birth certificate without the father’s name and approval. This context results in unsafe abortion being common practice. Illicit abortions are available and widely practiced. The safety of the illicit procedures varies greatly depending on the price of the service, ranging from traditional midwives inserting foreign objects through the cervix to specialised physicians in fully equipped healthcare settings.
A chance for reform?
A lot can be done to expand access to safe abortion in Sudan. Provision of non-judgmental women-centred comprehensive abortion care should be the standard, where confidentiality and privacy is guaranteed.
Legislative and policy reforms are needed to make abortion safe in Sudan. We need urgent legislative reform to remove the time-limit for obtaining abortion after rape; rape laws need to be improved; and protective laws against gender based violence. The penal code should be reformed to expand the legal grounds for safe abortion care, including to preserve the physical and mental health of the women or girl, along with economic, and social grounds given the increased poverty. Police presence in maternity wards should be stopped.
Development of policies and guidelines
Clear policy and guidelines on safe abortion and post abortion care should be developed, clearly emphasising no patients seeking care should be reported to the police. Youth-friendly SRH services and comprehensive sexuality education should be introduced.
Register and make available drugs for safe abortion and post-abortion care management
Misoprostol and mifepristone are drugs used to induce abortion. There should be fewer restrictions on and more access to misoprostol, especially with accumulative evidence that self-administered abortion with the pills can be safe and efficient. Mifepristone should be registered to improve abortion outcomes.
There needs to be more mid-level health care professionals providing abortion care. In the large and disbursed Sudan, usually lower level healthcare professionals are the ones giving care in the rural areas constituting 70.2% of population.7 General practitioners, midwives, medical officers, health visitors, and medical assistants can be trained on appropriate methods to provide safe abortion and post abortion care services. Training on comprehensive abortion care should be included in medical schools and training curricula.
Information and data related to maternal mortality, unsafe abortion, PAC, contraception, and other SRH services should be made accessible to the public.
In this post-revolution era of civic freedoms and increased mobilisation, there is a great chance for us to improve the health and rights of women and girls in Sudan. Conversations about the impacts of unsafe abortion on the society and the state should be held. These should highlight the economic cost of unsafe abortion and effect on Sudanese economy, bodily integrity, women’s rights, and contraceptive access.
Healthcare professionals have an important role to play in influencing change in our communities and at government level, from starting conversations to advocating for Sudan’s commitments such as the Sustainable Development Goals (SDGs). We have access to data that can be used for research to improve abortion care for all.
We can also educate upcoming medical professionals on the importance of comprehensive abortion care, their role as care provider, and considerations of medical ethics. It may feel like we have a long way to go to ensuring women and girls get the respect and dignity they deserve when seeking an abortion, but there are many opportunities to create change in our day to day lives and I feel positive we will achieve it.
Wafa Mudawi Ibrahim Adam is an independent sexual and reproductive health and rights (SRHR) and gender-based violence expert, and reproductive justice activist from Sudan. She has an MSc in Reproductive Science and Women's Health from University College London and was an SRHR fellow at Lund University. She is a founding member of AmplifyChange and a Youth Committee member of Young Activist Network for Abortion Advocacy (YANAA).
1. Sudan Federal Ministry of Health. Reproductive Health Communication Strategy, 2007.
2. Tønnessen, L. and Al-Nagar, S. The Politicization of Abortion and Hippocratic Disobedience in Islamist Sudan. Health and Human Rights Journal. December 2019. Volume 21; Number 2. Abortion in the Middle East and North Africa 7 – 9.
3. Central Bureau of Statistics, Sudan Ministry of cabinet. Multiple Indicator Cluster Survey Report, 2014.
4. Sudan Federal Ministry of Justice. Sudan Penal code, 1991.
5. Liv Tønnessen. Women’s Right to Abortion after Rape in Sudan. CHR. MICHELSEN INSTITUTE (CMI). April 2015. No 02. CMI INSIGHT
6. Op cit 2.
7. Central Bureau of Statistics, Sudan Ministry of cabinet. Multiple Indicator Cluster Survey Report, 2014.