BEREGA, Tanzania - A handwritten ledger at the hospital tells a grim story. For the month of January, 17 of the 31 minor surgical procedures here were done to repair the results of "incomplete abortions." A few may have been miscarriages, but most were botched operations by untrained, clumsy hands.
Abortion is illegal in Tanzania (except to save the mother's life or health), so women and girls turn to amateurs, who may dose them with herbs or other concoctions, pummel their bellies or insert objects vaginally. Infections, bleeding and punctures of the uterus or bowel can result, and can be fatal. Doctors treating women after these bungled attempts sometimes have no choice but to remove the uterus.
Pregnancy and childbirth are among the greatest dangers that women face in Africa, which has the world's highest rates of maternal mortality - at least 100 times those in developed countries. Abortion accounts for a significant part of the death toll.
Maternal mortality is high in Tanzania: for every 100,000 births, 950 women die. In the United States, the figure is 11, and it is even lower in other developed countries. But Tanzania's record is neither the best nor the worst in Africa. Many other countries have similar statistics; quite a few do better and a handful do markedly worse.
Eighty percent of Tanzanians live in rural areas, and the hospital in Berega - miles from paved roads and electric poles - is a typical rural hospital, struggling to deal with the same problems faced by hospitals and clinics in much of the country. Abortion is a constant worry.
Worldwide, there are 19 million unsafe abortions a year, and they kill 70,000 women (accounting for 13 percent of maternal deaths), mostly in poor countries like Tanzania where abortion is illegal, according to the World Health Organization. More than two million women a year suffer serious complications. According to Unicef, unsafe abortions cause 4 percent of deaths among pregnant women in Africa, 6 percent in Asia and 12 percent in Latin America and the Caribbean.
Reliable figures on abortion in Tanzania are hard to come by, but the World Health Organization reports that its region, Eastern Africa, has the world's second-highest rate of unsafe abortions (only South America is higher). And Africa as a whole has the highest proportion of teenagers - 25 percent - among women having unsafe abortions.
The 120-bed hospital in Berega depends on solar panels and a generator, which is run for only a few hours a day. Short on staff members, supplies and even water, the hospital puts a lot of its scarce resources into cleaning up after failed abortions.
The medical director, Dr. Paschal Mdoe, 30, said many patients who had had the unsafe abortions were 16 to 20 years old, and four months pregnant. He said there was a steady stream of cases, much as he had seen in hospitals in other parts of the country.
"It's the same everywhere," he said.
On a Friday in January, 6 of 20 patients in the women's ward were recovering from attempted abortions. One, a 25-year-old schoolteacher, lay in bed moaning and writhing. She had been treated at the hospital a week earlier for an incomplete abortion and now was back, bleeding and in severe pain. She was taken to the operating room once again and anesthetized, and Emmanuel Makanza, who had treated her the first time, discovered that he had failed to remove all the membranes formed during the pregnancy. Once again, he scraped the inside of her womb with a curet, a metal instrument. It was a vigorous, bloody procedure. This time, he said, it was complete.
Mr. Makanza is an assistant medical officer, not a fully trained physician. Assistant medical officers have education similar to that of physician assistants in the United States, but with additional training in surgery. They are Tanzania's solution to a severe shortage of doctors, and they perform many basic operations, like Caesareans and appendectomies. The hospital in Berega has two.
Abortions in Berega come in seasonal waves - March and April, August and September - in sync with planting and harvests, when a lot of socializing goes on, Dr. Mdoe said. He said rumor had it that many abortions were done by a man in Gairo, a town west of Berega. In some cases, he said, the abortionist only started the procedure, knowing that doctors would have to finish the job.
Dr. Mdoe said he suspected that some of the other illegal abortionists were hospital workers with delusions of surgical skill.
"They just poke, poke, poke," he said. "And then the woman has to come here." Sometimes the doctors find fragments of sticks left inside the uterus, an invitation to sepsis.
In the past some hospitals threatened to withhold care until a woman identified the abortionist (performing abortions can bring a 14-year prison term), but that practice was abandoned in favor of simply providing postabortal treatment. Still, women do not want to discuss what happened or even admit that they had anything other than a miscarriage, because in theory they can be prosecuted for having abortions. The law calls for seven years in prison for the woman. So doctors generally do not ask questions.
"They are supposed to be arrested," Dr. Mdoe said. "Our work as physicians is just to help and make sure they get healed."
He went on, "We as medical personnel think abortion should be legal so a qualified person can do it and you can have safe abortion." There are no plans in Tanzania to change the law.
The steady stream of cases reflects widespread ignorance about contraception. Young people in the region do not seem to know much or care much about birth control or safe sex, Dr. Mdoe said.
In most countries the rates of abortion, whether legal or illegal - and abortion-related deaths - tend to decrease when the use of birth control increases. But only about a quarter of Tanzanians use contraception. In South Africa, the rate of contraception use is 60 percent, and in Kenya 39 percent. Both have lower rates of maternal mortality than does Tanzania. South Africa also allows abortion on request.
But in other African nations like Sierra Leone and Nigeria, abortion is not available on request, and the figures on contraceptive use are even lower than Tanzania's and maternal mortality is higher. Nonprofit groups are working with the Tanzanian government to provide family planning, but the country is vast, and the widely distributed rural populations makes many people extremely hard to reach.
Geography is not the only obstacle. An assistant medical officer, Telesphory Kaneno, said: "Talking about sexuality and the sex organs is still a taboo in our community. For a woman, if it is known that she is taking contraceptives, there is a fear of being called promiscuous."
In interviews, some young women from the area who had given birth as teenagers said they had not used birth control because they did not know about it or thought it was unsafe: they had heard that condoms were unsanitary and that birth control pills and other hormonal contraceptives could cause cancer.
Mr. Kaneno said the doctors were trying to dispel those taboos and convince women that it was a good thing to be able to choose whether and when to get pregnant.
"It is still a long way to go," he said.