The emerging theme of the women leaders’ perceptions is: “strong barriers and numerous consequences of safe abortion”. Two categories developed from this theme are: 1) Perceived barriers of safe abortion and 2) Perceived consequences of safe abortion. The first category is divided into the following sub-categories: “Reluctance to fully support safe abortion due to perceived unjustified abortions”, “Abortion is against our culture” “Abortion is against our religious beliefs”, “Abortion-related stigma”, and“Emotional attachment to the unborn”. The second category is divided into the following sub-categories: “Physiological trauma”,“Cause of barrenness/infertility”, “Increase in abortion services abuse by adolescents/women”, “Increase of workload for healthcare providers (HCPs)”, and “Increase in sexual activities and STIs”.
Table 2 presents an overview of the theme, categories, and sub-categories that emerged from the analysis. This section will provide a summary of the category, followed by a presentation of its sub-categories. Quotes that illustrate participants’ views from FGDs and KIIs are presented in italics.
An overview of theme, categories, and sub-categories
Strong barriers and numerous consequences of safe abortion
Perceived barriers of safe abortion
Scepticism due to unjustified abortions
Abortion is against our culture
Abortion is against our religious beliefs
Emotional attachment to the unborn
Perceived consequences of safe abortion and reluctance to support the removal of the court order
Cause for barrenness/infertility
Increase in abortion services abuse by adolescents/women
Increase of workload for HCPs
Increase in sexual activities and STIs
Perceived barriers to safe abortion
Although women leaders are aware of the large number of abortion-related deaths among adolescents, some still feel that providing safe abortion services is tantamount to murder. They described instances where safe abortion is perceived as unnecessary. For example, a situation where a woman commits adultery and gets pregnant while her husband is serving a long prison sentence, and she is worried about potential repercussions on the husband’s release. In this case, some participants consider that the woman should have no right to access safe abortion services.
Skepticism due to unjustified abortion
Participants criticized current national efforts as focusing only on the provision of safe abortion rather than on raising awareness and preventing unwanted pregnancies. They would like to see more efforts directed toward preventing unwanted pregnancies among adolescents instead of toward discussion and provision of safe abortion. They suggest that all stakeholders need to be brought on board to ensure effective preventive measures, and mentioned inclusion of parents, teenagers, health providers, and religious leaders to encourage a common understanding toward prevention.
Additionally, when female MPs were asked if they would freely talk about safe abortion in their community, almost all of them indicated that regardless of age, or experience of rape or incest, abortion is never justified. But they do accept that safe abortion may be warranted for health reasons.
“There is a bad connotation on hearing ‘abortion’ in Kinyarwanda. The word ‘abortion’ disturbs. Even with safe abortion, the word ‘abortion’ outweighs the word ‘safe” (MP 1 KI1I)
“Why are all efforts toward killing instead of educating the people? I think all efforts should be directed toward awareness for prevention, and we can never fail because we have succeeded with bigger tasks in this country” (Participant 2, FGD 7)
Participants were asked from a body autonomy perspective if they think that women who get pregnant as a result of rape have any rights over their own bodies. One replied:
“Yes, she has rights, if raped… but should not abort because the unborn baby has a right to live too. Rights should not be absolute at the expense of others” (MP 3 KII 3)
In one FGD, the six participants were asked about circumstances where a teenager is too young to give birth. They were asked if they would regard this murder, or instead if it is saving the mother’s life. One replied, “It is killing because the baby is already alive. Actually what we are discussing is killing.” (Participant 2, FGD 1)
“When an adolescent is made pregnant by her father or brother, it’s a big problem. But even then, they should give birth to the baby regardless of how they will take care of the baby.” (Participant 4, FGD5).
Abortion is against our culture
Even though women leaders acknowledge that many adolescents die as a result of unsafe abortions, they think that those adolescents should be taught that once a pregnancy happens, a child has to be born. They feel they cannot promote safe abortion because of their cultural beliefs.
The reluctance of these leaders to support safe abortion is partly due to their fear that Rwandans are not willing to listen to any messages on the topic due to the subject’s sensitivity.
“I don’t know if Rwanda’s culture will embrace the safe abortion message. You need research around this to know how Rwandans will receive this message. Find out if they want it or not. You know laws are made for Rwandans but you should pay attention to how they interpret them. Maybe the youths can embrace it, but in our culture it will not be well received” (MP 2 KII 2)
Participants raised the concern that, in Rwanda, when you are talking to people it should be to those who are listening and are able to understand the message. They gave the example that when leaders talk about development, the masses pay attention. But when the subject of abortion is discussed among Rwandans, deep consideration must be given to how it will be interpreted.
According to participants, people find it very difficult to confront the issue; they think that rather than focusing on safe abortion, more efforts should be geared toward prevention and abstinence. They advocated for safe abortion on medical grounds, and in situations where it is unlikely the fetus will survive.
“We told you the truth as parents; it is difficult to tell a parent that if your child has an unwanted pregnancy, this [abortion] is how to help her” (Participant 3, FGD 7)
“In our culture, aborting is a sin. Our culture does not accept it; it’s a bigger challenge for people to encourage what they don’t believe in” (MP 2 KII 2).
Even a former care provider in a position of political leadership was not very enthusiastic to encourage safe abortion for those who need it. They asked why more effort is not put into preventing unwanted pregnancy before resorting to provision of safe abortion.
Another participant in one of the FGDs composed of social affairs workers at the cell level questioned who would be culpable if she encouraged an adolescent to abort. She feels she would be culpable herself.
“Myself, as a woman and as a former care provider, you cannot approach me for assistance to abort, I can’t manage it. I can direct you to others, but I can’t manage it.” (Participant 4, FGD 7)
“For me, of all available solutions shouldn’t be to legalize ‘killing’. There are other solutions. Instead there should be more promotion of condom use to prevent pregnancy and STDs. To me this [abortion] is not the first solution to ponder about” (Participant 3 FGD2)
A participant in an FGD comprising CHWs from Kigali is also reluctant to support safe abortion, saying:
Let me tell you, those things are difficult to say – that at the health facility there’s a service, go there tomorrow morning … go there and abort if you don’t want to give birth to that child. I can’t manage that.
Interviewer: “Uuu! You wouldn’t dare?”
Respondent: “Please, please, I can’t do that.”
Abortion is against our religious beliefs
Some of the women leaders from the 7th FGD were firm in their belief, to the extent of suggesting they would resign from their positions if they were required to provide information about safe abortion to their communities.
Interviewer: “What will be your role when it comes to sensitizing the community in order to get safe abortion services?”
Participant 1: “I would rather resign immediately”
Interviewer: “Would you resign?”
Participant 1: “Very much so.”
Participant 2: “Even me, I can’t afford to say it. I cannot manage to say it.”
“When it’s an embryo it’s already a human being in the eyes of God, so aborting it is killing a person. Those who believe in God cannot promote such a practice.” (MP 2 KII 2).
“Me, I cannot go there, grab a microphone and encourage fellow women to go and kill those in their womb. Anybody who knows pregnancy and the joy of having a child cannot do it, maybe men can manage because they don’t become pregnant, they can take on the job of encouraging abortion” (Participant 5, FGD 7)
Women leaders reiterated that mothers have rights over their bodies but so does the unborn fetus.
“Mothers have rights but also the unborn fetus has rights. You cannot put your own rights above the rights of the unborn. The child already exists, period. This is how I understand it. I can’t really support safe abortion” (Participant 2, FGD 6)
Abortion - related stigma
It was the view of participants that abortion-related stigma influenced women’s immediate course of action when confronted with unwanted pregnancy instead of the existing abortion laws. Skeptics of safe abortion cited culture and religious issues that further hinder their seeking of safe abortion. This was evidenced by one participant, quote:
“Those who have aborted are not accepted in the community. Women choose to move to other localities just to cover up or cleanse their reputation” (Respondent 3, FGD 2,).
Emotional attachment to the unborn
Alongside identifying faith-related barriers, some leaders describe themselves as mothers with emotions that are different from men’s emotions. They feel that a mother’s merciful feelings toward children will not allow them to accept abortion, that it is a violation of the rights of the unborn child. They attribute their reluctance to encourage abortion to having been raised to believe that any child should be born regardless of the circumstances.
“Women are always merciful… unlike men who always turn on women and blame them for poorly raised children, even though it’s a collective effort. In such a case, instead of thinking about abortion, a merciful mother will say ‘when this baby is born we will collectively raise him/her. I don’t have a grandchild and I cannot let this baby be killed. An embryo is already a child. That’s why you’re seeing that women tend not to agree [with abortion], because of the mercy of a mother” (Participant 6, FGD 6)
Participants went on to illustrate their difference from men by giving the example of ‘mad women on the street’ and how they handle their babies – suggesting that for women, no matter what condition they are in, children take priority irrespective of the available resources. They considered a situation where a grandparent raises a grandchild who then has an unwanted pregnancy. They say that, even then, grandparents cannot support abortion.
“I raised you after your mother gave birth to you and gave you to me, give birth to that baby and I will raise it as long as I live. And if not, you can raise the baby too” (Participant 4, FGD 4)
“The reason men may support safe abortion is because it’s men who cheat on their wives. They say ‘whoever tells me I got her pregnant, I’ll tell her to abort’ ... You find that he made them his mistresses … women are visionary, they’re preventing adultery, men are going to benefit” (Participant 6 FGD 3)
Perceived consequences of safe abortion
While the ministerial order scrapping the requirement for a court order was seen by some as progress in the right direction, others viewed it with grave concern. Women leaders raised concerns and expressed fears that it may backfire. They suggested that abortion services might be abused because previously the court would investigate the circumstances of the pregnancy, but now people might see abortion as a quick fix for unwanted pregnancies.
Women leaders also identified post-abortion trauma as a consequence of safe abortion. Participants expressed concern about the potential for trauma when the only option available is abortion.
Some participants advocated for promoting abstinence over safe abortion, and suggested that instead, severe punishments should be put in place for those who perform unsafe abortions.
“A colleague of mine … who aborted is still traumatized to this day. It has haunted her; even after getting married and giving birth to children she continues to pray but cannot forgive herself” (MP KII)
Participants expressed respect for women’s rights but at the same time they were firm in their unwillingness to support abortion. They reiterated that this applies even in the case of pregnancies arising from rape, citing the example of victims of rape during the genocide who gave birth.
“Genocide victims of rape bore children and were traumatized, but abortion traumatizes even more and I think the baby should be born. Who knows what the future holds for the unborn?” (MP2 KII 2)
Cause of barrenness/infertility
Some participants cited the possibility of infertility as a consequence of safe abortion. They were concerned that even though it is considered safe, they doubt it is 100% safe.
“There are those that abort and are not able to conceive again” (Participant 5, FGD 1)
Increase in abuse of service by women and adolescents
Participants were concerned that abortion services could be misused. They questioned what proof could doctor without base on without a court’s endorsement. They asked what documents a woman could take to the health facilities to show that she was impregnated by a brother, other relatives, raped or victim of other forms of sexual violence.
“Services will be misused, at least court was a means to scrutinize all circumstances, such as genuine or none genuine rape” (MP 1 KII 1).
“Now men are going to impregnate women/adolescents with ease –a person laughingly told me that because safe abortion services will be accessed with ease” (Participant 5, FGD 7)
Increase of workload for HCPs
Participants anticipate an increase in workload for healthcare providers because the number of women seeking services will increase.
“Truthfully, I don’t know how they will handle it – the service is complicated and will need a lot of employees. There’ll be so many women seeking the health services I don’t think health care providers will ever get time to rest” (Participant 4 FGD 5)
After seeing that participants were concerned about changes to the abortion law, the interviewer wanted to know why, and asked:
Interviewer: So, do you find it a problem – making it simple to access safe abortion services?
“Personally I don’t agree that making the law simple played a positive role. Accepting it remains a challenge for me” (MP 1 KII 1)
Interviewer: “What can be done to remove those constraints?”
Participant: “In order for people to not be afraid, there should be ongoing awareness. But I’m not going to endorse it, and I can’t steer anyone that might seek it from me” (MP 3 KII 3)
Increase in sexual activity and STIs
Participants were also concerned that making safe abortion accessible without a court order will likely increase sexual promiscuity amongst adolescents, because abortion will be made easy. They predict it will be abused by some women in unstable relationships; for example, a woman might tell her husband or partner that she will abort his ‘useless kid’ and never see him again.
Other concerns raised were related to an increased risk of STIs. Some women leaders believe encouraging safe abortion would result in increased sexual activity amongst adolescents, thus increasing the incidence of HIV/AIDS transmission. They reiterated that adolescents are afraid of unprotected sex due to the risk of pregnancy rather than contracting HIV.
“Adolescents used to be afraid of unprotected sex due to the shame of unwanted pregnancy. When abortion services are freely accessible, there’ll be more sexual activity and an increase in HIV/AIDS” (Participant 7 FGD 2)
“In most cases girls use condoms for preventing pregnancy rather than avoiding HIV infection. They say there’s palliative care for HIV – if safe abortion is freely provided, condoms will be ignored completely and HIV will increase” (Participant 5, FGD 4)