Years after it happened, Tosin Falana still vividly remembers her friend Amara’s* traumatic abortion. They were in university. “She called me and said she was pregnant. She was so ashamed because we were still in school,” Falana says.

Ultimately, Amara decided to terminate her pregnancy. But abortions are illegal in Nigeria and can attract prison sentences of up to 14 years unless they are done to save a pregnant person’s life.

“In my view, those who mostly seek abortion are young girls and poor women,” says Falana, now a 38-year-old teacher in Ogun state, in the country’s southwest.

“When there is food for them, children are welcome. But if there is none, ladies go for abortion.”

Amara, like many others who are young and/or poor, was forced to have an abortion at a shadowy underground clinic. The next time Falana heard from her, Amara was calling to say there had been complications.

She told Falana that the health worker who performed the procedure had said it had not completely ended the pregnancy, so she would have to do it again.

It’s unclear whether this was true, or if the healthcare worker was simply scamming Amara. Either way, she was subjected to multiple visits to the clinic before finally being given a clean bill of health.

A bleak warning

In the coming months, the United States appears poised to overturn the 1973 Roe v Wade ruling, reversing the country’s federal protections for access to abortion. The experiences of many in Nigeria offer a bleak warning of what may lie ahead.

Some 1.25 million abortions are induced in Nigeria each year, according to a 2012 estimate, with most performed at facilities like the one Amara went to.

“If you want to procure abortion and you end up with a trained service provider, good. They will do the abortion very well. But most of the time, people end up with quacks,” says Okai Haruna Aku, the executive director of the Planned Parenthood Federation of Nigeria.

Aku has been practising medicine in Nigeria for the past 30 years.

He has seen many patients left with perforated wombs, foreign bodies stuck in their birth canals or sepsis after backstreet abortions – and others who have either overdosed or underdosed on abortion medication.

“After all this damage, they eventually come to the hospital in a terrible state,” he says.

The World Health Organisation says abortion is “safe when carried out using a method recommended by WHO, appropriate to the pregnancy duration and by someone with the necessary skills”.

But, as Aku says, this is often not the case when abortions are restricted. This contributes to Nigeria’s unenviable position of having the second-highest number of maternal deaths in the world.

Complications in pregnancy and childbirth kill around 23,500 Nigerians a year, according to WHO data on causes of death. Despite being home to only 2.64% of the world’s population, the country was responsible for 12% of the world’s pregnancy- and childbirth-related deaths in 2019, the latest year for which this data is available.

Nigeria’s public health system will deal with abortion patients only when they experience complications. All too often, that is when it’s too late, or nearly so.

In a 2019 study, researchers examined the 5,779 admissions for abortive complications at 42 major hospitals across Nigeria in a single year and found that 8% of these people nearly died (366 patients) or died (78 patients).

Despite patients with abortive complications representing only 5.8% of the admissions to maternity wards, they made up 18% of those that suffered severely and 8% of those that died.

Of all the patients admitted to the wards, the fatality rate was worst for those with abortion-related infections, with almost a fifth dying.

Abortions in the US

Already, despite Roe v Wade, “more than 1,000 laws or regulations restricting access to abortion were enacted in the United States”, say researchers from Tulane University, who have examined how these policies impact maternal mortality. Some “483 of these restrictions were enacted in the past decade”.

If Roe v Wade is indeed overturned, as a memo leaked last month suggested it will be, states will be free to set their own abortion laws. Recent trends suggest that many will pass very restrictive legislation.

This is likely to have fatal consequences. The Tulane researchers found that, between 2015 and 2018, states with higher abortion restrictions had a 7% increase in total maternal mortality.

“We found that two abortion restrictions – requirement for licensed physician and prohibitions against use of Medicaid funds to pay for abortion care – are particularly prominent potential contributors to maternal death risk,” the researchers’ report, published last September, says.

Today, around 800 people in the US die from pregnancy and childbirth complications each year, putting the world’s second-richest nation at 60th out of the 184 countries for which the WHO published mortality data in 2019. Clearly, this is not a situation that needs to get any worse.

*Names have been changed