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African Journal of Reproductive Health, Vol. 8, No. 1, April, 2004 pp. 37-42 Woman-Centred Safe Abortion Care in Africa Eunice Brookman-Amissah Correspondence: Eunice E. Brookman-Amissah, Vice-President for Africa, Ipas Africa Alliance, Rhapta Road/Mvuli Road Junction, Westlands, P.O. Box 1192-00200, Nairobi, Kenya, Tel: 254-2-4445900/4443557 (Office); Fax: 254-2-4449177; E-mail: brookmanae@ipas.or.ke Code Number: rh04007 Abstract Unsafe abortion in Africa affects not only women, but also their children, families and communities. To counter this extremely costly yet easily preventable problem, African nations must ensure that health systems are trained and equipped to help prevent unwanted pregnancy, to treat women in emergency situations, and to make safe abortion services available to the full extent of the law. One critical component of this process is comprehensive woman-centred care, an approach that emphasises access, choice and quality of services. This article examines this and the obstacles to safe abortion care, as well as how they can be overcome through broad-based partnerships. (Afr J Reprod Health 2004; 4[1]:37-42) Key Words: Abortion, women-centred care, partnerships, training, equipment, abortion, quality, access Résumé Le soin d`avortement centré sur la femme en Afrique. L`avortement à risque en Afrique n'affecte pas que les femmes, mais aussi leurs enfants, leurs familles et leurs communautés. Pour combattre ce problème extrêmement coûteux et pourtant facilement évitable, les nations africaines doivent s`assurer que des systèmes de santé sont formés et équipés pour aider à prévenir la grossesse non-désirée, à soigner les femmes en cas d`urgence et à rendre disponible des services d`avortement à risque selon la loi. Une partie critique de ce processus est le soin compréhensif centré sur la femme, une approche qui met l`accent sur le choix et la qualité de services. Cet article examine ce problème et les obstacles au soin d`avortement sans risque, aussi bien que la manière dont ils peuvent être surmontés à travers les collaborations à tendances très variées. (Rev Afr Santé Reprod 2004; 4[1]:37-42) Introduction It is an undeniable fact that abortion, both safe and unsafe, has always occurred and will continue to occur in every culture and society. It is inevitable that women will continue to experience unwanted pregnancies for widely varying reasons, including lack of birth control services, contraceptive failure and sexual assault. In response, we must aim to address all facets of the problem, from the provision of contraceptive services to preventing unwanted pregnancy, through the provision of high quality abortion care within the legal indications of individual nations and post-abortion care for unsafely procured abortions. A critical first step toward this goal was made at the 1994 Cairo International Conference on Population and Development (ICPD), when the problem of unsafe abortion§ was recognised as a public health concern of great magnitude. This recognition resulted in subsequent commitments by many ministries of health to ensure that post-abortion care (PAC) is part of national reproductive health programmes and services to reduce deaths related to unsafe abortion. Conference participants also agreed that health systems have the responsibility to ensure that abortion is safe in circumstances where it is legally indicated. §The World Health Organization defines unsafe abortion as "a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both." Five years later, in 1999, representatives from 18 African, Asian and Latin American countries met at an international conference in Mombasa, Kenya, to share best practices and to promote south to south exchanges for expanding PAC programmes on a broad scale. At that conference, one participant likened efforts to respond to the problem of unsafe abortion to the Sisyphean task of continuously mopping and remopping the floor without ever addressing the problem of the leaky faucet that floods the floor in the first place. In order to truly go beyond "mopping the floor" with regard to stemming unsafe abortion in Africa, we must adopt models of woman-cantered safe abortion care and hold our governments and health systems accountable to commitments made at ICPD and subsequent international consensus meetings. The consequences of unsafe abortion are myriad; they include not only death but also countless acute and chronic injuries. These consequences affect women, their children, families, the communities they live in and cause economic loss to the whole society. What can and should be done for these women when they need help? We need to adopt the mandates contained in recent international consensus documents, specifically paragraph 63(iii) of 1999's ICPD+5 programme of action. This section stipulates that, where abortion is not against the law, health systems should both train and equip health care providers and take other steps to ensure that abortion services are safe and accessible. In other words, governments and health systems are now charged with the responsibility to translate the policy commitments made at ICPD into the tangible provision of services. Fortunately, we now have guidelines in the form of the World Health Organization's new book titled Safe Abortion: Technical and Policy Guidance for Health Systems, which provides extensive practical information for implementing these exemplary standards of care. We also have regional organisations and partnerships like the International Planned Parenthood Federation Africa Region (IPPFAR) and the Regional Prevention of Maternal Mortality (RPMM) Network increasingly committing to provide safe abortion services. This article examines how African nations can uphold this commitment and ensure universal access to high quality reproductive health services. A critical component of this process is the introduction of comprehensive woman-centred care, a pragmatic approach to meeting the needs of individual women that emphasises access, choice and quality of services. Finally, we will examine various obstacles to universal access, including barriers to safe abortion care and how those obstacles can be overcome through partnerships involving health care providers, legal experts, policymakers, non-governmental organisations, faith-based and women's groups, and others. It is society's responsibility to safeguard the health of African women, and everyone has a role to play. The Mandate of Paragraph 63(iii) A trio of international conferences that took place in the 1990s-the 1994 Cairo conference, the 1995 Beijing Fourth World Conference on Women, and the 1999 ICPD+5 five-year review-resulted in the creation of important consensus documents that examine various aspects of women's health. Each document progressively elaborated upon women's rights with regard to reproductive health and safe abortion and challenged us to make services available to women on an equitable basis. The most recent and explicit directive comes from the 1999 United Nations General Assembly review of the implementation of commitments made at the 1994 ICPD conference, commonly known as ICPD+5. At that session, governments agreed in paragraph 63(iii) of the resulting programme of action that in circumstances where abortion is not against the law, health systems should train and equip health service providers, and take other measures to ensure that abortion is safe and accessible. This international mandates commit us not only to ensue that PAC services are made available to African women, but also that our health systems should take responsibility for training and equipping health care providers. Furthermore, they should take additional necessary measures to guarantee safe, accessible abortion services as indicated by law. Often when we refer to "health systems," we equate it with the ministries of health and their traditional public sector facilities. In many African countries, however, non-governmental organisations (NGOs) and other private sector entities are major providers of health services. These institutions include private sector systems and individual clinics, NGO facilities, informal and traditional providers, and community-based partnerships. In order to ensure broad scale consistent access to safe abortion care, we must enlist the leader- ship and cooperation of each of these stakeholders in serving women's reproductive health needs.
The Importance of Woman-Centred Care To truly meet the needs of African women, we must introduce and reinforce the concept of woman-centred abortion care, a comprehensive approach that addresses the varying factors influencing a woman's individual medical and psychological needs, her personal circumstances, and her actual ability to access services. There are multiple aspects to comprehensive abortion care. These include health system services that provide thorough psychosocial assessment and counselling, clinical care, and contraceptive counselling and services. But it is not sufficient that these high quality services merely exist; women must also be able to access and use them appropriately. Therefore, the approach also takes into account broader aspects related to access. For example, we must address the time and distance required to reach services, trans-portation and other logistic hurdles, the affordability of services, cultural and social obstacles, and women's ability to pay. We also need to ensure an effective referral system The provision of high quality counselling services helps the woman clarify her feelings and emotions, identify her needs, and ensure that she has adequate information to make well-informed decisions without the imposition of the counsellor's personal opinions. The woman should have information on her options for dealing with an unwanted pregnancy including carrying the pregnancy to term, or if she opts for termination, the procedures available to her. Very importantly, each woman's needs should be met in a holistic, non-judgmental and confidential manner. This is essential for fostering trust and confidence, which enable her to use the services appropriately. With regard to clinical care, there is need to ensure that the safest most appropriate technologies for uterine evacuation are available for the treatment of unsafe abortion or for safe elective abortion. These technologies include vacuum aspiration and pharmacological or medical agents such as misoprostol and mifepristone. Wherever possible, providers should offer the woman a choice of methods for uterine evacuation so that she can choose the method that best suits her particular needs. Additional areas of clinical care include the appropriate use of pain management and follow-up care. Thirdly, contraceptive counselling and services are essential to any comprehensive abortion care effort. In the case of PAC and elective abortion, the woman can begin using most contraceptive methods immediately following her treatment. The woman should be offered a range of methods to choose from and which she is likely to use successfully. Finally, the woman's contact with the health system when receiving abortion care is an ideal time to address other reproductive health and related needs she may have. This may be her sole opportunity to access such services as screening for cervical cancer or HIV/AIDS and sexually transmitted infections or addressing social issues such as domestic violence or exploitation. These services may be provided at the facility where she receives care or by referral to another facility. Essential Elements for High Quality Services Training Paragraph 63(iii) of the ICPD+5 review mandates us to train appropriate providers to provide services. The uneven distribution of trained health care providers within countries, including the high concentration of physicians in urban areas, stymies women's access to reproductive health services. Furthermore, in Africa, we have very few physicians compared to nurses and midwives. For these reasons, it is essential to train midwives and other cadres of community-based health care providers to provide high quality services. Many midwives and other mid-level providers have solid reproductive health skills that can be augmented to include abortion care. Experience from numerous countries shows that with appropriate training and supervision, nurses, midwives and other non-physician providers can readily become proficient in using manual vacuum aspiration (MVA) to treat incomplete abortion and to perform early abortions. Such training has proved to be a valuable strategy for expanding women's access to life-saving care. For example, in Ghana, while the majority of the population lives in rural areas, an estimated 90% of doctors live in the country's two largest cities. A three-year operations research project carried out by Ipas, the Ghana Ministry of Health, and the Ghana Registered Midwives Association showed that midwives could be trained to provide high quality PAC services at private maternity homes, public health centres, and public district hospitals.1 In South Africa, the 1997 Choice on Termination of Pregnancy Act authorises trained professional midwives to perform abortions throughout the first trimester. This provision is crucial in the process of expanding and decentralising abortion services to district hospitals and rural health clinics. In addition, appropriate pre-service training for doctors and nurse-midwives can help achieve sustainable high quality abortion care by ensuring that new providers enter the field already equipped with the skills they need to practice. Meanwhile, in-service and on-the-job training is also needed to introduce and establish services until abortion care is routinely integrated into pre-service training. We must continue to expand the array of training options available to both public and private sectors to promote quality of care. Very importantly, we also need to have in place policy and systems changes that support practice by trained and skilled personnel. The impact of unsafe abortion on already strapped health systems continues to be a widespread problem. The treatment of women suffering from complications of unsafe abortion takes up beds, blood, medicines, personnel and other valuable commodities. These emergency care costs, including the cost in human lives and disability, could be substantially reduced if safe elective services were available for women who need them. As referred to earlier, there is also a need to train private sector providers, which have become a valuable and indispensable partner as we work to decentralise services, and as health care restructuring continues to play out in many African countries. For instance, it is estimated that in Kenya the private sector provides 40% of health services and are the sole providers in some remote regions.2 There are examples of successful private sector efforts worthy of emulation. For instance, in rural Kenya, the Kisumu Medical and Educational Trust (KMET) trains private practitioners to provide comprehensive reproductive health services. The rural communities in which KMET works suffer from poor transportation, a dearth of medical equipment and supplies, lack of running water or electricity, and dilapidated health facilities. Despite this, KMET has managed to reduce unwanted pregnancy and maternal mortality rates in each of the communities where it has worked. It has accomplished this to a large degree by working with various community stakeholders to address each issue in ways that could be sustained by the community itself in the long term.
Equipping We need to address other factors that pose barriers to high quality PAC and elective abortion care. Unsafe abortion is the easiest cause of maternal mortality that we must prevent and eliminate. There are modern technologies that can help women make safe well-informed choices throughout their reproductive lives; yet contraceptive prevalence rates continue to be shockingly low in the region. Women in East, Central and West Africa have the highest total fertility rate in the developing world, with approximately six children per woman; MVA and other safe uterine evacuation technologies continue to be underutilised due to various logistics and other cumbersome procedures. There is need to mainstream these instruments so that they are considered in the same category as the sharp curette and any other surgical instruments. We also need to ensure a functional distribution channel for these technologies especially in the public sector. In Tanzania, for example, government health officials found that some public providers who had been trained to use MVA reverted to using the more dangerous method of sharp curettage because they lacked a sustainable channel through which MVA instruments could be procured. In response, the Ministry of Health added MVA to its official procurement list, making it possible for public facilities to have regular access to the instruments.3 Reproductive health programmes and services have very often been faced with the situation of "no product, no programme" due to frequent stock outs especially of family planning commodities. We must work to achieve sustainable affordable access to appropriate reproductive health technologies including MVA at the most decentralised level possible in both public and private sectors. We must engage ministries of health to develop and implement policies supporting the sustainable procurement, supply and distribution of reproductive health technologies needed for the prevention of unwanted pregnancy and for abortion care in both public and private sectors. Finally, we must expand technological options for abortion care, including medical abortion, in countries where this is feasible so that women have additional choices.
Ensuring Universal Access Our goal must be to provide universal access to high quality sustainable and comprehensive abortion care services. "Universal access" guarantees that all reproductive health services a woman might need are available and accessible geographically and financially, and that other cultural and social barriers are addressed. Comprehensive reproductive health services for women involve many institutions and cadres in the community who all have an important role to play. At the most basic level, community-based workers and distributors can provide women with contraceptives to prevent unwanted pregnancy and regulate their fertility. The local pharmacy can dispense emergency contraception. A victim of rape can receive counselling from a local women's group, which can help her access needed services like emergency contraception or HIV prophylaxis, or to have safe legal termination. In all situations, if a needed service does not exist where a woman first turns for help then there should be mechanisms in place for appropriate and timely information and referral.
Overcoming Obstacles through Partnerships "Other measures," as specified in the ICPD+5 mandate, includes advocacy at the national level for ensuring that abortion care resources receive adequate priority and allocations as an integral part of safe motherhood and other reproductive health programmes. Policies, standards and guidelines must be in place for service delivery. "Other measures" includes, to a large degree, the health system and related policies required to support adequate services and to address the barriers identified earlier that deny access to women including conscientious objection by providers. "Other measures" also includes measuring our progress toward implementing comprehensive woman-centred abortion care. In many settings, baseline assessments may be necessary to first assess the current status of existing services. Communities and facilities can then work to implement woman-centred abortion services that draw on models from other countries such as South Africa, and that incorporate best practices from other regions, as appropriate. As part of this process, health systems and facilities must also strive to integrate the monitoring and evaluation of abortion care with existing systems for the monitoring of other reproductive health programmes and services. While all this may seem like a daunting task, unsafe abortion is a major public health and societal issue in Africa. Everyone has a role to play, from the high-ranking government official in Addis Ababa to the adolescent in Nairobi's Kibera slum. There are numerous things we can do as individuals and as institutions. For example, parliamentarians can initiate reviews of existing laws that criminalise abortion and monitor their government's adherence to international commitments like ICPD+5. Health policymakers can work to eliminate medically unnecessary obstacles that prevent women from obtaining legal abortion services. Health care providers can learn and educate their peers about the circumstances under which abortion is permitted in their country, and can learn appropriate clinical skills for providing safe services. Legal experts can identify legal barriers that impede women's access to safe abortion services and help draft legislation that supports women's health and rights. Women's advocates can educate women about the dangers of unsafe abortion and lobby for positive legal, policy and service delivery changes. Donors can direct additional funds to prevent unsafe abortion and encourage other donors to support this neglected issue. Journalists can spur and inform public debate by writing balanced accurate features on unsafe abortion and its effect on women and their families and communities. Leaders or members of faith-based groups can educate community members about the wide range of beliefs within religions regarding reproductive health and rights. Leaders or members of youth groups can educate their peers about ways to prevent unwanted pregnancy, the dangers of unsafe abortion, and the indications under which abortion is permitted in their locale.
Conclusion We are at a critical juncture with regards to the human and reproductive rights of African women. We can ride on the momentum generated by the urgency of the Millennium Development Goal of reducing maternal mortality by three quarters by the year 2015- an impossible task unless we address unsafe abortion. We must call upon our African governments to uphold commitments under numerous international agreements to address unsafe abortion effectively. We must ensure that health systems are trained and equipped to help prevent unwanted pregnancy, to treat women in emergency situations, and to make safe abortion services available to the full extent of local and national laws. We must involve a broad range of community stakeholders in guaranteeing that high quality services exist, that women can make well-informed choices with regard to options, and that they are not impeded in their ability to access those services. By adopting these measures, we can make a tangible long-lasting difference in the lives of millions of African women. References
© Women's Health and Action Research Centre 2004 |
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