Women are dying from botched backstreet abortions in Liberia, a country where access to terminations is severely restricted. Because of the stigma associated with abortion, they often refrain from seeking out medical help until it’s too late.

Two years ago, during Liberia’s Ebola outbreak, Mamie Tarr began hemorrhaging. When she arrived at the clinic, clutching her abdomen and complaining of intense pain, health workers at first suspected Ebola. In fact, without telling her family, the 30-year-old had visited a backstreet abortionist who used a combination of herbs, chalk and a rusty syringe to terminate her five-month pregnancy.

At the time, Mamie’s husband, Edwin, was sick. “My wife saw me being carried to the Ebola treatment center as a suspected Ebola case, and she thought I was going to die,” he said. “She got scared about raising the child without me, so she spoiled her belly. Then she just closed her mouth, she said nothing, until she started bleeding.”

Edwin was released from the Ebola treatment center without ever testing positive for the virus, but Mamie died from complications of the botched abortion.

Knives and Chicken Bones

Known as “spoiling the belly” or “taking the belly,” abortion is severely restricted in Liberia. As in most African countries, it is only legal in cases of rape, incest or if a woman can prove that childbirth would pose a serious threat to her health. In such instances, written justification must be provided by at least two medical doctors, and in cases of rape or incest, police and legal investigations are required.

So every month, hundreds of desperate girls and women take matters into their own hands — or place them in the ungloved hands of clandestine providers who offer backstreet abortions from $20. Some use speculums and syringes; others resort to using knives or sharp chicken bones. Some also use country herbs, boiled and ground avocado, or chalk.

According to a 2013 study by the Clinton Health Access Initiative, 32 percent of more than 3,000 surveyed Liberian women aged between 15 and 49 said they have had an abortion. Another study across six Liberian counties concluded that at least one in 10 women had undergone an unsafe abortion, with one young woman attempting to pull out the fetus herself, using a pair of iron handcuffs.

Regina Hodges, medical coordinator of the International Planned Parenthood Federation in Liberia, saw the photographs.

“It was really terrible. The girl brought her whole intestine into the uterus,” she said.

Because Planned Parenthood must operate within the legal confines of the countries in which it works, the organization cannot provide abortions in Liberia. But like other public and private facilities in the country, it is permitted to offer post-abortion care: counseling, manual vacuum aspiration and antibiotics following cases of botched abortion, and contraception for future use.

“Some girls have permanent damage, to the point where they require surgical removal of the uterus,” said Hodges.

‘Blood Coming, Coming’

Philip*, a nurse, says he has performed about 40 secret abortions at his drugstore in the Monrovia slum of West Point, a poor community that has one of the highest teenage pregnancy rates in Liberia. Sitting among boxes of paracetamol and diapers, he recounts the procedure, though he is scant on specific medical detail.

“I used something they call a speculum to open up the cervix,” he said. “Then I’d use another instrument, a long thing, to enter inside. I’d see if anything bloodstained would be coming out. After that I’d take a syringe with liquid and then the blood would be coming, coming, the whole day.”

Philip said a doctor taught him the procedure when he worked as a nurse at a hospital. Eventually, Philip left to open his own drugstore, offering the procedure for $60, along with malaria tests and blood pressure screening. He eventually stopped providing the service for moral reasons, believing it to be sinful.

“I don’t like spoiling the belly anymore, and it can also be dangerous,” he said. “One time a girl came to see me after taking country herbs, bleeding all over the floor. Some of them can be scared to talk, and by the time they find a car to go to a clinic, they can fall off [die].”

Stigma and Knowledge

Because the stigma around abortion is so high, many girls and women make like Mamie and simply “close their mouth” after undergoing the procedure, fearing moral judgment from their partners, families or communities. This means they often don’t seek clinical help until it’s too late.

“Many young women die like that,” said Nelly Cooper, director of the West Point Women for Health and Development Organization. “Most of the time the herbs are not effective, or the girls get into severe pain and there’s no good medication or no good doctor around that will be able to save their life.”

Cooper’s volunteers work to create awareness around sexual and reproductive health. She said that an inequitable lack of access to information about contraceptive methods is fueling the number of unsafe abortions, putting the lives of women and girls at risk.

“Many parents don’t realize that the sexual education we are giving their daughters is important,” she said. “They say things like, ‘My daughter has to work, so she’s not going over there.’ And those girls are the ones that are getting pregnant.”

Because of the Trump administration’s reinstatement and expansion of the Global Gag Rule, Liberian gynecologists employed by the country’s Ministry of Health – which receives extensive funding from USAID – were unable to comment on the prevalence of unsafe abortion. The rule prevents global health providers from providing family planning services or USAIDfunding if they provide, discuss or even mention abortions to their patients. Subsequently, many international health NGOs in Liberia are afraid of even mentioning “the A-word” for fear of losing funding.

But for women’s reproductive health advocates like Hodges and Neeplo, their stance is clear.

“It’s a right and a choice,” Neeplo said. “And they should leave it to us as women to say, ‘I want this, or I don’t want this.’”

* Name has been changed.