Rwanda Medical Journal / Revue Médicale Rwandaise June 2012, Vol.69 (2) 29 Only three years remain to reach the Millennium Devel- opment Goal targets. In Rwanda, as in most developing countries, the rate of decrease in maternal mortality is much slower than that needed to achieve the fifth Millen- nium Development Goal—a 75 percent reduction in the maternal mortality ratio by 2015 (UN 2011). To accelerate progress toward meeting this goal, developing countries need to address the key causes of maternal morbidity and mortality, including unsafe abortion. The precise level of abortion-related mortality in Rwanda is unknown. The World Health Organization (WHO) estimates that unsafe abortion accounts for one in six maternal deaths in Eastern Africa (WHO 2011). Only slightly more is known about morbidity caused by unsafe abortion. The only published research on this topic—a 2004 study of four health districts in Rwanda— estimated that 50 percent of obstetric complications were a consequence of spontaneous and induced abortion (Pearson and Shoo 2005). Abortion’s major contribution to maternal morbidity cases that reach health centers strongly suggests that abortion is an important women’s health concern in Rwanda and that additional empirical research on this topic is warranted. Setting and Background Abortion law remains restrictive in Rwanda—the proce- dure is only permitted to save a woman’s life or to pro- tect her physical health (Government of Rwanda 1980). Rwanda’s abortion law was put into effect in 1977 when the country enacted a new penal code. A woman seeking a legal abortion has to go through the demanding process of obtaining consent for the procedure from two doctors, which makes access to legal abortion extremely difficult even under the limited circumstances when it is allowed under the law. Prison sentences for women who obtain illegal abortions range from one to five years (Kanyesi- gye 2011), and the penalty for helping a woman to abort outside the legally sanctioned circumstances can be five to ten years (the penalty varies depending on the specifics of the case) (Kwizera 2011). Thus, many medical doctors refuse to provide abortion even when medically indicat- ed (Vyankandondera 2009). Many women turn to illegal abortion to terminate unwanted pregnancies, and some of these procedures are performed by untrained practi- tioners or under unhygienic conditions and may lead to severe morbidity or death. Abortion Incidence and Postabortion Care in Rwanda Paulin Basinga, Ann M. Moore, Susheela D. Singh, Elizabeth E. Carlin, Francine Birungi, and Fidele Ngabo Abortion is illegal in Rwanda except when necessary to protect a woman’s physical health or to save her life. Many women in Rwanda obtain unsafe abortions, and some experience health complications as a result. To estimate the incidence of induced abortion, we conducted a national sample survey of health facilities that provide postabortion care and a purposive sample survey of key informants knowledgeable about abortion conditions. We found that more than 16,700 women received care for complications resulting from induced abortion in Rwanda in 2009, or 7 per 1,000 women aged 15–44. Approximately 40 percent of abortions are estimated to lead to complications requiring treatment, but about a third of those who experienced a complication did not obtain treatment. Nationally, the estimated induced abortion rate is 25 abortions per 1,000 women aged 15–44, or approximately 60,000 abortions annually. An urgent need exists in Rwanda to address unmet need for contraception, to strengthen family planning services, to broaden access to legal abortion, and to improve postabortion care. (StudieS in Family Planning 2012; 43[1]: 11–20). Paulin Basinga is Senior Lecturer, Department of Community Health, and Francine Birungi is Assistant Lecturer, Department of Epidemiology and Biostatistics, School of Public Health, National University of Rwanda. Ann M. Moore is Senior Research Associate and Susheela Singh is Vice President for Research, Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY 10038. Elizabeth E. Carlin is a graduate student, Harvard University, and Fidele Ngabo is Director of Maternal and Child Health Unit, Ministry of Health, Rwanda. E-mail: amoore@guttmacher.org. Case Study REPRINT