The Supreme Court on Monday, October 18 heard a case in which a local non-governmental organisation, Great Lakes Initiative for Human Rights and Development (GLIHD), sought to challenge two articles within the Penal Code regarding safe abortion. Article 72 of the law determining the jurisdiction of courts stipulates that any person, company or association with legal personality can petition the Supreme Court to declare a law unconstitutional if they have any interest. The government, through the Ministry of Justice, was the respondent in the case. The hearing was presided over by the Chief Justice and President of the Supreme Court, Faustin Ntezilyayo, who was heading a panel of four other Supreme Court Judges. The case Unlike previously when the final decision for a woman to have an abortion procedure was subject to a court ruling, in 2018, the law determining offences and penalties was changed, requiring only consultation between a woman and her doctor. However, the law still provides for specific circumstances under which abortion is legally permissible, for example in cases of rape, forced marriage, incest, or instances where the pregnancy poses health risks to the mother or the unborn child. In the petition, GLIHD, which works on issues of sexual and reproductive health and rights, digs into Articles Article 125 paragraph two and article 126 paragraph three of the Penal Code that state that an abortion must be performed by a medical doctor who by law, is someone who has at least a degree in medicine. The legal representative of GLIHD, Theophile Twizeyimana, told the court that they were seeking an amendment of these articles which he said exclude other trained healthcare providers such as nurses and midwives from providing safe abortion services. According to the structure set up by the government, health centres are only staffed by nurses and midwives and other support health care professionals as opposed to doctors. He explained that this means that health centres, which are the primary care facilities in the country and that are more accessible to many women and girls, particularly to those living in rural areas and low-income earners, are staffed with only mid-level providers. He reminded that General Practitioners and specialists that are by law, the only ones permitted to perform safe abortions are available only in district, referral and national hospitals that are usually located far away from some of the people that may need these services. “This definitely has severe impact on low income and rural women and adolescent girls. Due to their income level and geographical location, these women and girls are less likely to access safe abortion and as a result, they choose to resort to unsafe methods that put their lives at risk,” he argued. However, Senior State Attorney Specioza Kabibi, who was representing the State told the judges that safe abortion procedures cannot be performed at the health centre level to avoid failure to manage complications that may arise, like severe bleeding. “Managing severe bleeding which may result from performing an abortion can only be managed by facilities that have more resources in terms of expert doctors and the use of advanced equipment which are not available at health centres,” she said. She said that to ensure that abortion is safe and that such associated complications are managed, a medical doctor and a multidisciplinary team make a hospital a good setting for abortion. However, Twizeyimana reminded that according to the World Health Organization’s (WHO) Safe Abortion Guidance, any properly trained health care provider, including midlevel providers that are non-physicians, can safely provide abortion care. “For most abortions during the first trimester of pregnancy, there is no medical need to have the procedure performed by a medical doctor. This is because the provision and monitoring of first-trimester abortions and medical abortions is straightforward and does not require advanced technical skills, knowledge, or expensive equipment,” he said. ‘Friend of the Court’ Meanwhile, Health Development Initiative (HDI), a sexual and reproductive health rights advocacy organisation, appeared as ‘amicus curiae’ – a ‘friend of the court’ in the case. A ‘friend of the court’ is someone or an organisation that is not a party to a case who assists a court by offering information, expertise, or insight that have a bearing on the issues in the case. The Legal Representative of HDI, Christian Garuka, told the court that despite commendable legal progress, Rwanda is still facing many challenges in enforcing the law on safe abortion and ensuring access to safe and legal abortion for women and girls in practice. Garuka touched on the argument raised by the State on the health centre staff inability to handle complications from performing abortions. He referred to the Ministry of Health’s guidelines titled, “Expanding Access to Post-abortion Care Services: National Comprehensive Treatment Protocol for Post-abortion Care Services.” The guidelines, he explained, permit nurses, midwives, and medical assistants in Rwanda to provide post-abortion care, which is necessary medical care that is provided when a woman experiences complications from a usually unsafe abortion or when there was an incomplete abortion. “If a midwife or nurse can handle an incomplete abortion, why would they not be able to provide a safe abortion procedure?” he wondered. The numbers A report published by the Ministry of Health in 2019 indicates that the total number of registered medical doctors in Rwanda is 1,648. Only less than half of these are currently practising. 452 are practising in the public sector. The rest are either not actively practising or are employed in private or faith-based facilities. On the other hand, there are 15,050 registered nurses and midwives, making up 69 per cent of the entire health workforce in the country. Of these, 7,593 are employed in public health facilities. The verdict in the case will be delivered on November 19.