As Uganda marks International Safe Abortion Day on September 28, the country’s abortion debate continues to sit between the law, women’s need for reproductive health care and the realities of what happens when someone reaches a health facility.
Globally, the day is being used to renew calls for access to safe abortion and to draw attention to the health, economic and social consequences when women and girls cannot obtain the care they need.
At a recent SHE & Rights session held ahead of World Contraception Day and International Safe Abortion Day, speakers argued that the discussion should move beyond whether services exist on paper to whether women can actually reach and afford them.
For Uganda, that distinction is particularly important.
The country has a restrictive legal framework around abortion, while health facilities continue to provide care for women experiencing complications following abortion. The result is a complicated health landscape in which the legal debate and the need for clinical care exist alongside each other.
Shobha Shukla, Coordinator and Host of SHE & Rights and Executive Director of CNS, said access to safe abortion should be considered part of sexual and reproductive health care.
“We demand accessible, safe, legal and stigma-free abortion care for all,” she said. “Safe abortion is – essential AND lifesaving – sexual and reproductive healthcare and a fundamental human right.”
She linked access to abortion with reproductive freedom, gender equality and the right to health.
But the experience of accessing reproductive health care is shaped by more than laws.
Nawmi Naz Chowdhury, Executive Director of the Women’s Global Network for Reproductive Rights, said consultations conducted by the organisation had repeatedly highlighted the gap between rights and actual access.
“One of the key messages that has come across very strongly from the regional and global consultations of WGNRR is the need to translate rights into actual access, particularly when it comes to access to safe abortion and abortion care,” she said.
She identified a range of barriers, including shortages of trained providers and medicines, weak referral systems, administrative requirements, cost, geographical inequalities, stigma and misinformation. She also said people may lack information about what services are available and how to navigate health systems.
Those barriers are relevant to Uganda, where access to health services can vary considerably according to location and resources.
The question, therefore, is not only whether a woman has a legal right to a particular service. It is also whether she can find a trained health worker, obtain the medicines she needs, afford transport and care, and reach a facility capable of managing complications.
The cost of unmet need
Dr Elizabeth Sully, Director of International Research at the Guttmacher Institute, used the SHE & Rights session to make a broader case for investment in sexual and reproductive health.
The Guttmacher Institute’s Adding It Up 2024 report examines the need, costs and potential impact of investing in sexual and reproductive health services across 128 low- and middle-income countries.
Sully said the analysis looks at three questions: the gaps in coverage, what it would cost to meet those needs, and the health and economic returns from investment.
“It’s more than just about the health benefits,” Sully said. “It is not just about surviving when we make these investments in sexual and reproductive health but also what it means for women being able to thrive.”
The report’s figures presented during the session were for Asia and should not be applied directly to Uganda. They nevertheless illustrate the broader investment argument.
In Asia, Sully said, an additional US$12.4 billion a year would be needed to meet sexual and reproductive health needs, equivalent to US$2.74 per person. The analysis estimates that the investment could reduce unintended pregnancies by 26%, maternal deaths by 65% and newborn deaths by 62%.
Sully said every additional dollar invested in family planning and contraceptive care could save US$1.97 in pregnancy-related and newborn care costs.
The Guttmacher Institute has also developed a Safe Abortion Calculator to examine the potential costs and health benefits associated with investment in safe abortion care.
The argument is that investment in reproductive health should not be viewed only as a cost to health systems, but also in terms of the health and economic consequences of failing to meet people’s needs.
Where the money goes
Riju Dhakal, Programme Officer at the Asian-Pacific Resource & Research Centre for Women, brought financing into the discussion.
“We cannot let sexual and reproductive health and rights be exclusive of the different developmental priorities,” she said, arguing that reproductive health must also be considered alongside poverty, economic justice and other development challenges.
Dhakal said official development assistance for sexual and reproductive health and rights had fallen by 46% between 2024 and 2026, while governments were increasingly talking about domestic financing.
Her question was whether commitments made at international and regional meetings are reflected in national budgets.
“We have four concrete asks,” she said, including localising the numbers, tracking investment pledges, checking whether commitments appear in approved budgets and applying a human rights lens.
“Behind every dollar of investment there are lives, there are women and girls who could not get contraception, who could not get safe abortion care or maternal care this year,” Dhakal said.
For Uganda, that raises a practical question: how much is being budgeted for the reproductive health services women need, and how much of that money reaches the health facilities where services are provided?
Law is only part of the story
Jane Nyanjom, Associate Director of Advocacy and Partnership at Reproductive Health Network Kenya, said the African experience shows why the legal framework cannot be considered separately from service delivery.
“When we look at safe abortion, there is a distinction between what we have in law and what is there in reality,” she said.
Her comments were made in the context of Kenya, but the distinction between legislation and what people experience when they seek care is relevant to the wider African debate.
Nyanjom identified access, affordability and awareness as major gaps, particularly for adolescents and young people.
For Uganda, these questions are particularly important for women and girls living far from health facilities and for those who face financial or social barriers to care.
Chowdhury said reproductive freedom requires more than a legal provision.
“True reproductive freedom requires more than just the legal right to choose,” she said. It also requires structural, economic and geographical access, including commodities, trained providers, emergency care and sustainable financing.
That is where the abortion debate becomes a health-system question.
A woman experiencing complications does not encounter the law in the abstract. She encounters a health worker, a health facility, a referral system, medicines and equipment, and the cost and distance involved in reaching care.
The quality of that response can determine whether an abortion complication becomes a manageable medical problem or a life-threatening emergency.
Shukla said attacks on bodily autonomy and reproductive rights are occurring in different parts of the world, but the session also emphasised the need to protect health and reproductive rights through functioning systems and investment.
For Uganda, International Safe Abortion Day therefore provides an opportunity to look beyond the polarised debate over abortion and ask a more immediate health question: when women need reproductive health care, are the services, medicines, information, trained health workers and referral systems available to them?
The answer lies not only in what is written in law, but also in what happens when a woman walks through the doors of a health facility.
