What happens when the women you study need your help?

Across Benin and Togo, a team of young women researchers, working in partnership with Rutgers, the African Population and Health Research Center, the Association Béninoise pour la Promotion de la Famille, the Association Togolaise pour le Bien-Être Familial and the Population Council, spent months documenting how adolescent girls and women navigate unintended pregnancies and seek abortion care.

What they uncovered was a maze of dead ends. For the young researchers documenting these experiences, it became increasingly difficult to remain detached.

The maze women face: why a law alone cannot provide a way out

On paper, Benin and Togo look like two different worlds. In 2021, Benin reformed its Law on Sexual Health and Reproduction, establishing the most progressive legal framework for abortion in the francophone West African region. In Togo, by contrast, the law heavily restricts abortion. People are not aware of the law and healthcare workers have no clear guidelines on what is and isn’t permitted.

Yet when you look at what adolescent girls and women are experiencing, the difference is not always that clear cut.

In both countries, women with an unintended pregnancy often begin looking for help without telling anyone. Terrified of being judged, shamed or exposed, most adolescent girls and young women cannot ask their parents or an adult for advice. Instead, they rely on rumours, advice from friends or whatever “remedies” they encounter on informal markets or social media.

Even when women do go to a public health facility, they can still find that there is nowhere to turn. In Benin, for instance, researchers followed 15 health centres, nine of them public. Out of the nine public health centres only one had a healthcare worker who was willing to help women seeking safe abortion care under the new law. Legally, healthcare workers who conscientiously object are required to refer women somewhere else. In practice, almost none of them did. Most midwives either felt uncomfortable to offer a referral or simply didn’t know where safe care was available.

In Togo, where abortion is allowed under specific circumstances, health workers have received little guidance on the law and there is widespread fear and confusion. Most midwives believe abortion is completely forbidden, and their personal beliefs reinforce this. When women ask for help, they are frequently scolded and sent home.

Days or weeks later, many return in a critical condition.

This was the case for 17-year-old Ama. After an unsafe procedure, she arrived at the hospital at night, bleeding heavily. The midwives on duty refused to let her sit on the waiting room bench, complaining that they would get blood on the furniture. When they finally treated her, she was insulted and subjected to a manual vacuum aspiration procedure without any pain relief medication. This frequently happens, sometimes because pain relief medication is running low and saved for what staff considered “deserving” patients and sometimes as a form of punishment.

As one of the Togolese researchers recalled:

“I found myself questioning the way certain women were treated. In my view, you shouldn’t speak to someone like that. When someone is suffering, you must first listen to them, try to understand what they are going through and offer them support. Sometimes, when a woman arrived bleeding, some people immediately assumed she’d had an abortion, without necessarily trying to understand her story. That’s what made me question things.”

They spent long days inside crowded maternity wards, watching women wait up to eight hours just for a routine pre-natal care checkup. The midwives were often overwhelmed, facilities understaffed and researchers frequently pitched in to help with simple tasks, like weighing patients or organising medical charts.

Then the work became much more personal. In Togo, five women died from the complications of unsafe abortion during the fieldwork period.

Witnessing a woman arrive at the hospital in a critical condition and then lose her life was difficult to process for the researchers. As part of their fieldwork, they were asked to follow up – where possible – with the families to understand what had happened. Visiting homes in mourning meant sitting with grieving, angry families and partners, often arguing  over who was to blame.

For one young researcher who witnessed two women die within a short window, the emotional toll was overwhelming. “She arrived right at the door of the gynaecology ward and died before she could even be taken into the delivery room.”

Experiences like these can stay with researchers long after the study ends, which is why emotional support from the research team and professionals matters: “I knew I might come across cases of death during the work we were set out to do. But when I actually saw it with my own eyes, honestly, even today, I can’t say I’ve fully recovered. My superiors automatically referred me to a psychologist. In any case, made me feel better and really helped me get back on my feet.”

When doing nothing is not an option

What do you do when the medicine someone needs sitting in a cupboard down the hall, but none of the midwives gives it to them?

One young researcher in Benin wrote about her frustration after seeing boxes of safe medical abortion pills locked away in a public health centre while midwives refused to prescribe them:

“What really upset me was that I’d been working at two public health facilities where the supplies were available, but the service [safe abortion with abortion pills] wasn’t. The healthcare providers would take pleasure in saying that the abortion pills would just stay in the cupboards until they expired and whoever donated them could come and check on them. When you see this raw reality and realise that the staff themselves are causing women to end up in these terrible situations, it makes you angry. Sometimes it got on my nerves so much I just had to get on my motorbike and leave.”

Some midwives working in public health facilities, who routinely refused to help women or give them referrals, began doing something unexpected: they started pointing women toward the young researchers, knowing they had contact numbers for NGO helplines and safe clinics.

Research on a sensitive, life-threatening issue raises difficult questions about to what extent the researcher can remain a relatively distant observer, and when inaction is likely to contribute to harming vulnerable people.

“When you see a woman who is refused abortion care and who, no matter what, is going to have an abortion even, if it is through clandestine methods, and you know she can die because of the cases of death that we had already found out about… there is no point in not guiding her and leaving the woman like that.”

While the team’s ethical protocol included the obligation to refer in case of emergency, the team did not expect to be given this role systematically in the Benin health setting given the legal reform. Discussions with the full research team made the choice clear: the guiding principle of “do no harm” meant they could not stand by when a life was on the line. When a woman came to a clinic asking for safe legal abortion care and was turned away, or referred to the young researchers they would give her information on available helplines and NGO’s. Doing so didn’t jeopardise the study. They carefully documented the reality of seeking abortion care in a public facility, while also making sure the women’s lives were protected.

When a woman was shaking in a clinic after taking heavy medicine on an empty stomach, a young researcher bought her a hot breakfast. When another woman was slipping into critical condition from blood loss and the clinic had run out of blood, the research team used project emergency funds to pay for a blood transfusion from another centre. And when a woman died, they contributed to the family’s bereavement expenses to support them through the funeral.

The researchers saw these actions as an inherent part of their work and ethical conduct. But they also knew that the field work had an end date and that after they left, women would continue to face many of the same barriers. This concern became an important topic in the research dissemination dialogues with health care providers and civil society organisations in both countries. The researchers and their partner organisations used these discussions to explore practical solutions, including how to ensure that health workers understood their responsibility to refer women and knew where to refer them for safe care. The discussions also prompted reflection on the conscientious objection clause: some health care providers said they would no longer stigmatise women and would “refer women as it should be”, while a few expressed openness to providing abortion care within the legal framework.

What the research showed

This kind of in-depth ethnographic research can show what the numbers often miss: what happens when a law meets real life, what adolescent girls and women encounter when they seek abortion care.

Benin’s 2021 legal amendment was a major step forward. More than half of the women in the Benin study were ultimately able to access a safe abortion, a clear improvement from the situation before the reform.

Changing the law is essential but also only the beginning. In Togo, the lack of clear guidelines and the fear and stigma surrounding abortion continue to drive women towards unsafe options. In Benin, despite the more progressive law, some healthcare  providers still refuse care or refuse to make referrals, leaving women to turn to informal and unsafe practices instead. A law that exists on paper cannot protect anyone if the health clinic doors remain shut.

The young researchers who carried out these studies did not just sit down and collect interviews. They stood alongside women as they tried to get through barriers.

These researchers did not enter the field without their own questions. Some initially wondered whether abortion was even a subject that could be discussed openly in Togo. Reflecting on why she applied to join the team, one young researcher in Togo recalled that she initially wondered whether the project was even possible or necessary:

“Before this study, I wondered whether talking about abortion was really necessary in our country. Did people really need to discuss it?

Now, after seeing what happens in the health clinics, I really saw women [with abortion complications] suffering. Their pain had a deep impact on me. And I realised that it was necessary. It was necessary.”