Sister Agatha Bwalya pushes open a grubby door to reveal a teenage girl naked from the waist down, lying on a bed, her legs drenched in blood. The girl's attempted abortion has gone wrong, and she drifts in and out of consciousness as nurses hurriedly prepare her for emergency surgery.
A second young woman is lying in the treatment room of the busy gynaecology emergencies ward at the University Teaching hospital in Lusaka, Zambia. "I was five months pregnant and I just started bleeding," says Florence, 19, swaddled in coarse woollen blankets despite the 30C heat. "I got a taxi with the baby's father. It took about an hour, I was really scared because there was a lot of blood."
Bwalya says nearly all the women who come here deny what has really happened. "They say the abortion was spontaneous, like a miscarriage," she says. "However, when we examine them we find things like sticks and sharp objects in their vaginas. They try to perforate the uterus, to get the foetus out, but often lacerate the cervix along the way, so many bleed heavily or leave tissue in the womb which becomes infected."
A third girl limps in. Natasha is 18 and arrived this morning when her 19-week pregnancy ended. When questioned, she averts her gaze and quietly repeats the familiar line: "I just started bleeding." All three girls are nervous and ask not to be named in full.
Unsafe abortion is a serious problem in Zambia. National figures do not exist, reflecting the low status of the issue, but research suggests thousands die every year attempting to terminate their pregnancies. These deaths account for 30% of an excessively high maternal mortality rate of 591 deaths per 100,000 live births. Girls and young women under 19 years old account for a staggering 80% of these deaths.
The Ministry of Health, unavailable for interview due to the presidential election taking place at the time of writing, acknowledges it must act fast to achieve Millennium Development Goal 5, to improve maternal health by 2015. While it published guidelines to confront the problem in June 2009, these have not been accompanied by a national action plan.
"Without tackling unsafe abortion, it will be impossible to reduce maternal mortality," explains Dr Stephen Mupeta, a gynaecologist and clinical services manager at Marie Stopes International in Zambia, an NGO that provides reproductive healthcare. "Abortion is actually legal under the Termination of Pregnancy Act of 1972 but very few people know about it. It's not just the general public either; health providers and even lawyers don't have all the information."
In desperation, girls attempt secret abortions using horrifying methods, from inserting knitting needles and turkey basters into their vaginas, to drinking laundry bleach and jumping off stairs on to their stomachs.
Ironically, the abortion law is one of the most liberal in sub-Saharan Africa and allows the procedure if the pregnancy risks the mother's physical or mental wellbeing. Yet it requires three doctors' signatures, almost impossible in a country with one doctor per 8,333 people (compared with one doctor per 435 people in the UK).
Some health clinics offer medical abortions for pregnancies up to nine weeks. Any pregnancies beyond that length, or "incomplete" abortions, must go to hospital for manual vacuum aspiration, a common technique that uses suction to complete the abortion process.
Zambians do not receive free healthcare, and prices for an abortion range from £1.30, following a referral from a doctor, to £29 in a private clinic. Some charities offer subsidised services in rural clinics and compounds. Youth worker Tracy Chiyabi, 22, of Youth Vision, believes that even when girls can afford the safe option, they are faced with a barrage of obstacles. "In African culture, people don't talk with their parents about sex because it's taboo," she says. "If your parents find out you're pregnant or want an abortion, they'll chase you out of the house.
"When you go to a clinic, there might be someone there who knows your mother, aunty or neighbour, and they'll tell on you. The people working there scorn girls who want an abortion. So girls would rather do it somewhere else, somewhere private."
Chiyabi believes this stigma stems from religion. "Zambia is a Christian nation, not a secular state, and society sees abortion as a sin because it's like killing a person," she says.
Zambia is 85% Christian, which includes Roman Catholic and Protestant, with evangelical churches on the increase in recent years. Catholicism is absolute in its opposition to abortion, labelling it "unchristian" and calling for the Termination of Pregnancy Act to be repealed.
Meanwhile, some Protestants permit abortion in exceptional cases – if the life of the mother is at risk – though Reverend Lucas Mwale, president of the Council of Churches, warns against increasing access. "We should be aware that liberalising abortion may lead to many more unnecessary cases. Girls mustn't be allowed to think: 'It's OK to get pregnant because I can just have an abortion', because that compromises the sanctity of human life."
But some Christians believe they can retain religious integrity while advocating elective abortion, and are attempting to change the way society perceives it.
"As well as providing services, we have to change people's mindsets," says Felicia Sakala, country director of Ipas, an organisation dedicated to preventing maternal deaths. "... When a woman has decided she wants to get rid of a pregnancy then she has really made up her mind, whatever you say she will procure it, so you may as well make it safe."
Sakala was a midwife for 30 years and has worked on highly contentious issues such as gender-based violence and HIV (which currently affects 14.3% of Zambians). She believes abortion should be approached in a similar way, by bringing it out of the shadows. "Everyone knows someone who has had an unsafe abortion; three of my daughters' friends have died from it," she says. "So, whether we are mothers, grandmothers or sisters, we need to start talking about it, to challenge the stigma. We've been silent for too long and the longer we stay silent, the more women will die."
