After undergoing a back-room abortion as a 15-year-old, Isabel considers herself among the lucky ones. Ten years later, she has a healthy five-year-old son, while several of her friends will forever be unable to have children. Women in her neighborhood have lost their lives.

"I knew that something could happen to me," Isabel recalls, sitting on a plastic chair outside her home, "but I risked it."

In Mozambique, where abortion remains illegal under any circumstances, the government has come to regard the ravages of clandestine abortions as a major public health problem. According to the Ministry of Health, they are responsible for more than half of visits to obstetric and gynecological services nationwide, and more than 5,000 maternal deaths each year. The true number is probably much higher, since many women die without reaching a hospital or at a stage when they are not visibly pregnant.

“Around the world, clandestine abortion is a leading cause of maternal death, and one of the hardest to get good data on,” says Dr. Diederike Geelhoed, a physician with the International Centre for Reproductive Health (ICRH). “ The [World Health Organization] estimates that more than 5 million clandestine abortions occur annually throughout Africa, while only 100,000 abortions that take place in a safe, legal setting.

In March, the Mozambican legislature is expected to pass a bill that would revise the country’s draconian abortion law and legalize voluntary abortions in the first 12 weeks of pregnancy. In doing so, Mozambique would become the ninth African country to liberalize its abortion policy in the last decade. Since 2003, 28 countries have ratified an African Union protocol supporting the right to abortion in cases of rape, incest, or high-risk pregnancies. In these incremental changes, there may be signs of a continental shift.

At the Tete Provincial Hospital around the corner from Isabel’s home, Dr. Clemente Madeira, director of obstetric and gynecological services, regularly treats women suffering from complications following clandestine abortions. Many of them have drunk laundry detergent or bitter concoctions offered by traditional doctors or purchased pills from off-duty health workers. Many have hemorrhages, sepsis, and perforated uteruses, and face lifelong infertility or even death.

“The ones who lose their lives are the ones who delay their visits to the hospital,” Dr. Madeira says.

Abdul Carimo, who led the legal reform team that drafted the proposed law, argues that it will save lives. “Only by offering legal, controlled, sanitary means of abortion... will we be able to keep women from taking these risks,” he says.

It is a view that some officials here have held for more than 20 years. Mozambique’s current law is a legacy of the Portuguese colonial penal code, inherited at independence and unchanged since 1886. Though prosecutions are rare, it carries a sentence of up to eight years in prison for providers and pregnant women alike, and girls as young as 16 have been arrested for seeking to interrupt unwanted pregnancies.

In 1990, alarmed by by the country’s astronomical rates of maternal mortality – more than 1,000 women died for every 100,000 live births – the minister of health authorized first-trimester abortions in cases of rape, incest, and high-risk pregnancies. But the measure was limited to the country’s main hospitals and did not carry the force of law. According to Mr. Carimo, many doctors are unaware the decree exists, or object to performing abortions on moral grounds.

In practice, application of the decree varies widely, and its impact has been limited to two or three hospitals. In the capital, Maputo, women have long been able to obtain voluntary abortions in a quasi-legal setting, while in Tete, Madeira performs abortions only when a woman’s health is at risk.

Though it remains among the highest in the world, Mozambique’s maternal mortality rate has fallen by more than half in the last twenty years, aided by economic growth and the expansion of formal health services, such as care by professional midwives and growing access to family planning. Still, clandestine abortions continue.

Several health professionals at Tete suggested that adolescents bear the brunt of the complications that stem from unsafe abortions. Looking back on her own experience, Isabel said that she “knew nothing and didn’t use condoms.” It was only with her mother’s guidance that she used the relatively safer method of Cytotek, a drug used legally in several countries for medical abortions.

By contrast, Dr. Madeira said he often sees patients whose parents learn of their daughters’ abortions only when they bring them to the hospital. The Ministry of Health now includes information about the risks of unsafe abortion in a sex education program in secondary schools, and distributes family planning materials through "youth-friendly services" aiming to improve access among sexually active minors.

The pressures that cause teenage girls in Mozambique to seek abortions are probably growing: contraception use is still under 20 percent and adolescence in Mozambique is something of an emergent phenomenon. “Before, either you were a child, or you had your initiation, and you got married, and then you got kids,” Dr. Geelhoed explains. “Now you go to school, and if you get pregnant during school time, it’s very unlikely that you’ll be able to continue.”

Evidence from other countries suggests that legalizing abortion contributes directly to reducing maternal mortality. In the United States, rates of complications from abortion dropped dramatically in the four years following Roe v. Wade; in Romania, maternal mortality fell by two-thirds following the ouster of dictator of Nicolas Ceausecu, who outlawed abortion and contraception.

In moving towards legalization, the Mozambican government is hoping to replicate the experience of its neighbor South Africa, where legalized abortion contributed to a 91 percent drop in the maternal mortality rate over five years in the 1990s. Yet the examples of South Africa and Zambia, another of Mozambique’s neighbors, have also shown that the widespread social stigma continues to fuel clandestine abortions even after legalization.

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Mozambique’s proposed law would require a referral from two doctors, and parental authorization for minors. For a procedure that is most often performed by midwives and nurses under a veil of secrecy, it remains to be seen just how much will change.

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