Implementing Values Clarification and Attitudes Transformation Workshops in Pakistan. An assessment of progress and prospects

Transcription

1 Implementing Values Clarification and Attitudes Transformation Workshops in Pakistan An assessment of progress and prospects Aliya Rifaqat MA Jamie Menzel, MPH Marium Waqas MBBS Erin Pearson, MPH Ghulam Shabbir, MBBS, MPH Katherine Turner, MPH HEALTH ACCESS RIGHTS PAKISTAN

2 2015 Ipas. Cover photo: Ipas

3 IMPLEMENTING VALUES CLARIFICATION AND ATTITUDE TRANSFORMATION WORKSHOPS IN PAKISTAN: AN ASSESSMENT OF PROGRESS AND PROSPECTS Aliya Rifaqat, Jamie Menzel, Marium Waqas, Erin Pearson, Ghulam Shabbir, Katherine Turner EXECUTIVE SUMMARY In Pakistan, abortion is legal to save the life of the woman, but the law does not address the issues of rape, incest, and fetal abnormalities. Due to stigma surrounding abortion, the narrow legal grounds for abortion, and the lack of clarity in interpreting and implementing the law by both women and healthcare providers, an estimated 623,000 women were treated in public and private sector facilities for complications resulting from induced abortions in Pakistan in Ipas Pakistan launched Values Clarification and Attitude Transformation (VCAT) workshops in 2009 to address stigma-related barriers to abortion care that were initially for senior obstetriciangynecologists and faculty from teaching hospitals. From , Ipas Pakistan strengthened the capacity of their partners and conducted 39 VCAT workshops for 720 people including doctors, midlevel providers, NGO/CBO staff, health facility managerial and support staff, tutors, and government officials. To evaluate Ipas Pakistan s VCAT workshops in improving providers knowledge and attitudes pertaining to abortion and contraception, matched pre- and post-vcat workshop surveys were administered to 84 Ipas-trained clinical providers who attended VCAT workshops. The survey evaluated the providers knowledge and attitudes toward abortion and contraception. Differences in pre- and post-workshop answers were assessed using McNemar s test, and statistical significance was assessed at an alpha level of 0.05 for all analyses. In addition, 20 in-depth interviews were conducted with Ipas-trained providers to understand their perspectives on behavior change resulting from participation in the VCAT workshop. The interview transcripts were read and analyzed thematically. Analysis of the pre- and post-workshop survey data showed that Ipas-trained providers significantly increased their knowledge about both abortion and contraception by participating in VCAT workshops. Significantly more providers supported the provision of abortion services as permitted by law in Pakistan and could explain their personal values concerning abortion post-workshop. Analysis of the in-depth interview data showed that as a result of attending the VCAT workshop, most providers regarded provision of abortion services as a woman s right and reported that they began to treat their clients with more empathy. Providers also had an increased sense of professional responsibility to provide abortion care and, when needed, they reported providing referrals for safe abortion services. Overall, VCAT workshops have been successful in Pakistan in improving providers knowledge, attitudes and behaviors about abortion and abortion care. VCAT workshops are a promising approach for helping providers clarify their personal values about abortion and to improve care for women, especially in a conservative setting such as Pakistan. 1 P a g e

4 INTRODUCTION Context of abortion in Pakistan Pakistan has a population of 180 million people, making it the sixth most populous country in the world. According to the Pakistan Demographic and Health Survey, the total fertility rate is 3.8, which is a slight decrease (0.3 births) over the past six years (NIPS [Pakistan] and ICF International, 2013). Fertility preferences play an important role in estimating unmet need for contraception and the future fertility of a population. More than 50% of currently married women in Pakistan aged do not want another child, yet the contraceptive prevalence rate (CPR) in Pakistan is low (35%), and 20% of married women of reproductive age have an unmet need for contraception (NIPS [Pakistan] and ICF International, 2013). The current high level of unmet need for contraception, low contraceptive prevalence rate, and high level of unwanted and unintended pregnancies are key drivers of abortion in Pakistan. Abortion is legal in Pakistan to save the life of the woman or to provide necessary treatment (Pakistan Abortion Law revised -1997), but there is lack of clarity in interpreting and implementing the law by both women and healthcare providers. Due to this lack of clarity and stigma surrounding abortion, women often resort to clandestine and unsafe abortion procedures that result in death or adverse health consequences. Since poor women are those least able to obtain contraception and most likely to have unintended pregnancies, they are also more likely to resort to illegal abortion to achieve their fertility goals. The majority of women seeking abortion services in Pakistan are married, residents of rural areas, uneducated, poor and have five or more children (Sathar et al., 2013). A 2012 national study on postabortion complications conducted by the Population Council and Guttmacher Institute estimated that there were 2.2 million abortions in Pakistan with an annual abortion rate of 50 per 1,000 women (Sathar, Singh, Rashida, Shah & Niazi, 2014). This is an increase from the previous estimate of 27 per 1,000 women in In addition, an estimated 623,000 women in Pakistan were treated for complications resulting from induced abortion in public and private sector facilities in 2012 (Sathar et al., 2014). Given the strong evidence on the relationship between unsafe abortion and threats to women s health, the Government of Pakistan has ramped up efforts to reduce abortion-related morbidity and mortality. The October 2009 Karachi Declaration on Scaling up Maternal, Neonatal, Child Health and Family Planning Best Practices in Pakistan clearly pledges, along with the provision of contraception services, to ensure the inclusion of the practice of postabortion care in policies, guidelines, protocols and standards for health facilities at the national level (Government of Pakistan, 2009). As a result of advocacy work by Ipas Pakistan and its partners, the Society of Obstetricians and Gynecologists of Pakistan (SoGP), Pakistan Nursing Council (PNC), and the Department of Health (DoH) Punjab have committed training and resources toward PAC services (SoGP, 2015; DoH Punjab, 2013). Although policy commitments and training providers are important steps, they are often not enough to create change due to a variety of economic, social, and cultural factors, including stigma (Benson, Andersen, & Samandari, 2011). Without attitudes grounded in respect for women, providers may refuse to provide care or provide substandard care (Turner, Pearson, Andersen, & George, 2014). As the WHO recommends, In addition to skills training, participating in values-clarification exercises can help providers differentiate their own personal beliefs and attitudes from the needs of women seeking abortion services. (WHO, 2012). 2 P a g e

5 Description of VCAT Ipas works globally to increase women s ability to exercise their sexual and reproductive rights and to reduce abortion-related deaths and injuries. Ipas seeks to expand the availability, quality and sustainability of abortion and related reproductive health services, as well as to improve the enabling environment. Ipas believes that no woman should have to risk her life or health because she lacks safe reproductive health choices. Abortion like other public health concerns that are related to sex, gender and sexuality, has engendered stigma and discrimination against those advocating for, seeking and providing services (Turner et al., 2014). As a result, different stakeholders influence and sometimes obstruct safe uterine evacuation/pac service delivery, access and quality. They are acting upon their personal values, beliefs and biases (Turner et al., 2014). Abortion values clarification and attitude transformation (VCAT) interventions engage stakeholders to facilitate provision of and access to abortion care. In Ipas VCAT interventions, trained facilitators lead diverse stakeholders through a process conducted in an emotionally safe environment in which they examine their personal values, attitudes and actions related to abortion (Turner & Chapman Page, 2008). The goal is to engage in honest, open-minded and critical reflection and evaluation of personally relevant abortion information and situations, and fully comprehend the harmful consequences of stigmatizing abortion and restricting access to abortion care (Turner & Chapman Page, 2008). The VCAT workshop activities used most frequently are Cross the Line, Four Corners and Why Did She Die? (Turner & Chapman Page, 2008). Cross the Line is often used as an ice breaker to bring participants views on abortion to the surface and address the connection between abortion and stigma. It helps participants understand how stigma affects people s diverse views and experience with abortion. In this activity, tape is used to create a line on the floor. All participants are asked to stand on one side of the line and then a statement is read aloud. For example, At some point in your life, you believed that abortion is wrong. If the statement applies to the participant s beliefs or experiences, she/he is asked to fully step to the other side of the line. There is no in between and participants must choose to fully cross the line. There are no right or wrong answers in this exercise, and participants are asked to discuss their choices. Four Corners is used to help participants come to a deeper understanding about their own and others beliefs about abortion; empathize with the underlying values that inform a range of beliefs, and consider how their beliefs affect societal stigma on abortion. In addition, for health-care providers this activity aids in understanding how personal beliefs can affect the provision of high-quality abortion services (Turner & Chapman Page, 2008). In this activity, four signs are used: Strongly agree, Agree, Disagree, and Strongly disagree. Each sign is placed in one corner or area of the room. Each participant is given a worksheet and asked to read each statement about abortion and circle the answer option (strongly agree, agree, disagree, strongly disagree) that best reflects their personal beliefs. For example, Abortion services should be available to every woman who wants them. When they are finished, participants are asked to stand in a circle, crumple their worksheet into a ball, and throw them into the middle of the circle. Each participant is then randomly handed a crumpled worksheet. For the remainder of the activity, they will represent the views on that worksheet. Each statement is then read aloud and people move to the appropriate corner or area of the room based on the response on their worksheet. After each statement, participants are asked to discuss with the other participants in their corner the strongest rationale for why people might hold that opinion. These are then shared with the entire group and discussed. 3 P a g e

6 Why Did She Die? features a case study that highlights the sociocultural context around a woman s unwanted pregnancy and abortion decision (Turner & Chapman Page, 2008). This case study from the Ipas VCAT toolkit was adapted for the Pakistani context and is presented in the text box below. In this exercise, participants are confronted with the tragic consequences that can result when access to safe, legal abortion services is restricted and are asked to articulate their personal or professional responsibility to prevent deaths such as the one in the story. After reading the story, participants are led in a facilitated discussion in response to the question Why did she die? Some of the discussion questions are: Who do you think is responsible for her death and why?, What could have been done to prevent her death? and What information and resources may have helped her avoid this situation? For more complete information on VCAT activities, please refer to Abortion Attitude Transformation: A Values Clarification Toolkit for Global Audiences (Turner & Chapman Page, 2008). Why Did She Die? Nasreen was the eldest daughter of her family. She was intelligent and hard-working. Even though Nasreen worked hard at home helping her mother, school was her top priority. She always came first in her class, and she was the pride and joy of her family and village. Nasreen was allowed to go to university. It was her first time in a big city, and she found it difficult to make new friends. But slowly that changed, and she settled into her new environment. Nasreen continued to study diligently and made sure she was at the top of her class. Her professors were very proud of her and took special interest in her. They encouraged her to pursue her professional dreams. After graduation, Nasreen joined a professional firm and sent money home to pay school fees for her younger brothers and sisters. She became the breadwinner for her extended family. She met and fell in love with a colleague at work, Jamal, and they were planning to marry. At first Jamal was gentle and loving, but gradually that began to change. He became distant and unkind to Nasreen. Nasreen soon discovered that Jamal had a wife. When she discovered this, she told Jamal that their relationship was over. Jamal became very angry and forced her to have sex. He knew that she wasn t using contraception. As he pushed her out the door, he declared, I know that when you become pregnant, you will return to me. Four months later, after feeling sick for quite a while, Nasreen went to a free clinic. When she returned for the results, she was shocked to discover that she was, in fact, pregnant. Nasreen had always had an irregular menstrual cycle and had never been taught the symptoms of pregnancy. She determined that there was no way she would go back to Jamal. When she inquired at the clinic about terminating the pregnancy, the doctor looked at her with disgust and refused to answer her questions. Nasreen went to another clinic to ask about terminating the pregnancy, but they turned her away also saying she was too far along. Nasreen felt afraid and was too ashamed to tell anyone in her family about the rape and pregnancy. She felt that no one would help her, and she became desperate. She tried drinking a toxic mix of household chemicals that she had heard from her friends would terminate a pregnancy. She tried inserting sticks into her cervix. She became terribly sick and developed a painful infection, but was still pregnant. Eventually, after trying all of these things, Nasreen took her own life. 4 P a g e

7 Overview of VCAT in Pakistan Ipas Pakistan launched VCAT workshops in 2009 to address stigma-related barriers to abortion care. Initially, workshops were for senior obstetrician-gynecologists and faculty from teaching hospitals, and were conducted in conjunction with clinical trainings on MVA and misoprostol use for PAC. Senior management from several of Ipas Pakistan s service delivery partners were also included in these initial workshops. Over time, demand for VCAT workshops increased among these service delivery partners (greenstar Social Marketing, Marie Stopes Society and Rahnuma Family Planning Association of Pakistan), and Ipas Pakistan began conducting VCAT workshops for partner organization staff in addition to including a VCAT component in all Ipas clinical trainings. The Ipas VCAT toolkit was adapted by reducing the number of questions in some activities and making the language simpler to understand and culturally appropriate. Pakistan-specific reproductive health content was added to sensitize participants and to explain Pakistan s abortion law and explore Islamic perspectives. Additional contraception content was added to activities to help providers clarify their views on a woman s right to choose when she uses contraception and which method she uses. The VCAT facilitators debrief after each day of the workshop and discuss challenges and lessons learned. Based on these discussions and feedback from participants, the VCAT activities are adapted after each workshop to better meet the needs of the participants. The Ipas Pakistan VCAT workshops are two days in length and typically consist of participants per workshop. They are conducted as standalone activities in a space away from the participants workplaces so they are able to fully concentrate during the workshop. Initially, Ipas Pakistan conducted VCAT workshops for providers prior to their clinical trainings, but switched to providing them after their clinical trainings due to Pakistan s restrictive setting. Partner and Program Progression Since 2011, Ipas Pakistan in collaboration with its local partner, Association for Mothers and Newborns (AMAN), has conducted 39 VCAT workshops in two regions (Sindh and Punjab) for 720 people including doctors, midlevel providers, NGO/CBO staff, health facility managerial and support staff, tutors and government officials (Table 1). AMAN is a non-political, non-sectarian, non-profit voluntary welfare organization that was established to improve maternal and newborn health. In addition to VCAT workshops, AMAN conducts emergency obstetric and neonatal care courses and advocacy sessions on misoprostol with national stakeholders. Table 1. Number of VCAT workshops and attendees from Fiscal Year Number of VCAT Number of Ipas-trained Total Number of Workshops Clinical providers Attendees TOTAL P a g e

8 VCAT Trainer Profile #1: I am a doctor and have been working in public health since Prior to attending a VCAT workshop, I wasn t aware of the high abortion rate in Pakistan and the consequences of unsafe abortion. I used to assume that only unmarried women sought induced abortions, but the experiences usually shared by participants were eye-opening for me. I believe that VCAT has impacted my personality in a positive way. After going through the VCAT process, the majority of my conflicting ideas have changed. VCAT answered 80% of my questions about this sensitive issue, while the remaining 20% were resolved when I became a trainer myself. I was able to exchange ideas with other participants and co-facilitators. I believe that after attending the VCAT workshop myself and facilitating so many other VCAT workshops, I have gained a lot of experience and knowledge on this issue that has made me confident enough to become a strong advocate. The VCAT workshop starts with ground breaking sessions during the first half of day one, which includes introduction and icebreakers. This is followed by activities, such as Cross the Line and a session on Pakistan s reproductive health scenarios explaining Pakistan s law and sensitizing the participants on the topic of abortion. Afterward, sessions related to individual beliefs and values are carried out through interactive discussions. Lastly, the story Why Did She Die? is shared which has always proved to be an effective sensitizer and thought provoking exercise for the participants. I should share a story of a service provider who wanted to resign from her organization because of some religious reservations, but after day one of the workshop, she took her resignation back and said that she is serving humanity. Another participant shared that he no longer feels ashamed to be associated with an abortion provider organization. I consider such stories as the biggest achievements of VCAT. METHODS To evaluate the outcomes of Ipas Pakistan s VCAT workshops in improving providers knowledge and attitudes pertaining to abortion care, matched pre- and post-workshop surveys were conducted among the 84 Ipas-trained clinical providers who attended VCAT workshops. The pre- and postworkshop survey was adapted from the Ipas VCAT toolkit to conform to the adapted Ipas Pakistan VCAT curriculum (Turner & Chapman Page, 2008). The Ipas VCAT toolkit included behavioral intention questions, but these were not included in the Pakistan version of the survey. The survey was developed in English and translated to Urdu. Depending on the choice of the participant, the written surveys were completed in English or Urdu. The pre-workshop survey was completed at the beginning of each workshop, and the post-workshop survey was completed on the last day of the workshop. Upon completion of each workshop, the paper surveys were delivered to the Ipas Pakistan office where they were entered using EpiData software. Two domains were assessed by the survey: knowledge and attitudes. Five multiple choice knowledge questions evaluated the providers knowledge about statistics on unsafe abortion, contraceptive use, and the abortion law. Ten attitude questions were asked on a four-point Likert scale and evaluated the providers willingness to discuss abortion with colleagues, family, and friends and their attitudes toward the legality and provision of abortion. The responses to each knowledge question were classified into correct or incorrect for analysis. Missing data was included in the incorrect category since it was assumed that a participant did not know the correct answer to the question if she or he left the question unanswered. For both the pre- and post-workshop surveys, we present the proportion classified as correct and incorrect. The responses to each attitude question were classified into positive or negative for analysis. For both the pre- and post-workshop surveys, we present the proportion classified as positive and negative. Differences in pre- and post-workshop survey answers were assessed using McNemar s test for matched pairs. Statistical significance was assessed at an alpha level of 0.05 for all analyses. Statistical analyses were conducted using Stata version P a g e

9 In addition to this quantitative data collection and analysis, 20 in-depth interviews were conducted with Ipas-trained clinical providers in April and May of The providers chosen to be interviewed had attended a VCAT session between six months and two years prior to their interview. A semistructured in-depth interview guide was developed in English and was translated into Urdu. The indepth interview guide covered the following topics: personal feelings about abortion, professional responsibilities regarding abortion, topics that still need clarification after the workshop, topics they would like to learn more about as a result of the workshop, and how their ideas about abortion have changed. The in-depth interviews were conducted in Urdu and lasted approximately one hour. Interviews were tape recorded, transcribed, and translated to English. The transcripts were read and analyzed thematically by question. VCAT Trainer Profile #2: I am a consultant gynecologist. I have been associated with VCAT trainings since Additionally, I work as a trainer with MVA and other fields of gynecology. Prior to attending a VCAT workshop, I took abortion as an immoral act and considered it as a wrong practice from both a social and an Islamic point of view. After VCAT, I experienced a vivid change in my views. I admire all components of the workshop. I would denote Why Did She Die? as the most influential activity. After VCAT, I think of myself as a better human being and feel more comfortable while discussing abortion. My professional life has also been influenced in a positive manner. I have stopped being judgmental about my clients, and I refer certain cases when I realize it to be against my values. I believe VCAT leaves a promising impact on its trainers as well as its trainees. Therefore, I suggest that this training should also be held for teachers and rural communities in order to propagate awareness in society. I would like to disclose a story of a doctor who wanted to quit her job because of her personal beliefs. After attending the VCAT workshop, she took her resignation back. VCAT trainings have proved to be effective as they help individuals clarify their ideas, and they have received praise from a variety of attendees. I would like to suggest that VCAT requires a serene environment to discuss and ponder. It is a time consuming activity so the duration needs to be extended while taking the quality of the training and expense into consideration. FINDINGS FROM MATCHED PRE- AND POST-VCAT WORKSHOP SURVEYS Table 2 presents the knowledge pre- and post-workshop survey data for the 84 Ipas-trained clinical providers. For all five knowledge questions, significantly more providers knew the correct answers on the post-workshop survey when compared to the pre-workshop survey. For the abortion-related knowledge questions, 86% of providers who incorrectly answered the question about the legality of abortion in Pakistan pre-workshop answered it correctly post-workshop (p<0.001). Additionally, nearly all (97%) of the providers who did not know the prevalence of abortion in Pakistan preworkshop answered the question correctly post-workshop (p<0.001), and half (51%) of the providers who did not know unsafe abortion s contribution to maternal mortality in Pakistan pre-workshop answered the question correctly post-workshop (p<0.001). In regard to contraception, 46% of providers who did not know that if all contraceptive methods were used perfectly all of the time there would still be unintended or unwanted pregnancies pre-workshop answered the question correctly post-workshop (p=0.002). Finally, 61% of providers who did not know the contraception prevalence rate in Pakistan pre-workshop knew post-workshop (p<0.001). 7 P a g e

10 Table 2. Pakistan VCAT knowledge pre- and post-workshop survey data for Ipas-trained clinical providers (n=84) Post-workshop Correct Incorrect Pre-workshop n (%) n (%) p-value 1 It is estimated that there are over 890,000 induced (elective) abortions a year in Pakistan. (Correct answer: True) <0.001 Correct 47 (92) 4 (8) Incorrect 32 (97) 1 (3) If all contraceptive users were to use methods perfectly all the time, there would not be any unintended or unwanted pregnancies. (Correct answer: False) Correct 20 (71) 8 (29) Incorrect 26 (46) 30 (54) Abortion is illegal in Pakistan. (Correct answer: False) <0.001 Correct 24 (86) 4 (14) Incorrect 48 (86) 8 (14) In Pakistan, unsafe abortion accounts for an estimated of maternal deaths. (Correct answer: 5%) 2 <0.001 Correct 4 (40) 6 (60) Incorrect 38 (51) 36 (49) The contraceptive prevalence rate (CPR) in Pakistan is. (Correct answer: 10-30%) 3 <0.001 Correct 20 (80) 5 (20) Incorrect 36 (61) 23 (39) 1 P-values associated with McNemar's test for paired data. 2 At the time the pre- and post-test surveys were administered the correct answer was 5%, but this has changed and currently the correct answer is 6%. 3 At the time the pre- and post-test surveys were administered the correct answer was 10-30%, but currently the correct answer is 30%. Table 3 presents the attitude pre- and post-workshop survey data for the 84 Ipas-trained clinical providers. For three of the ten attitude questions, significantly more providers expressed a positive attitude on the post-workshop survey when compared to pre-workshop survey. For the following statements, all providers (100%) who answered negatively pre-workshop answered positively postworkshop: I support the provision of abortion services as permitted by law in Pakistan. (p=0.001), I can clearly explain my personal values concerning abortion. (p<0.001), and I can respectfully explain values concerning abortion that conflict with mine. (p=0.003). For the other seven attitude questions, we did not see a statistically significant increase in positive attitudes. For some questions, this was due to the high proportion of positive attitudes pre-workshop. This is expected since these are trained providers who are already, in general, supportive of abortion prior to attending the VCAT workshop. The vast majority of providers retained positive attitudes between the pre- and postworkshop survey with the exception of two attitude statements: I feel empathy for women who have experienced abortion and I feel very conflicted about abortion. This may have been due to misunderstanding the question if it was asked in English. 8 P a g e

11 Table 3. Pakistan VCAT attitude pre- and post-workshop survey data for Ipas-trained clinical providers (n=84) Post-workshop Positive Negative Pre-workshop n (%) n (%) p-value 1 I support the provision of family planning and contraceptive services in Pakistan Positive 47 (84) 9 (16) Negative 6 (32) 13 (68) The issue of abortion is of little importance to me Positive 41 (87) 6 (13) Negative 4 (13) 28 (88) I support the provision of abortion services as permitted by law in Pakistan Positive 55 (95) 3 (5) Negative 18 (100) 0 (0) I would feel comfortable talking with my closest friends about abortion care. Positive 60 (94) 4 (6) Negative 12 (100) 0 (0) I can clearly explain my personal values concerning abortion. Positive 60 (98) 1 (2) <0.001 Negative 16 (100) 0 (0) I feel very conflicted about abortion Positive 20 (57) 15 (43) Negative 13 (41) 19 (59) I feel empathy (compassion/understanding) for women who have experienced abortion Positive 42 (78) 12 (22) Negative 9 (41) 13 (59) I can respectfully explain values concerning abortion that conflict with mine Positive 50 (96) 2 (4) Negative 14 (100) 0 (0) I feel comfortable advocating for safe abortion care Positive 67 (97) 2 (3) Negative 5 (100) 0 (0) All women should have access to safe, comprehensive abortion care Positive 66 (96) 3 (4) Negative 6 (86) 1 (14) Note: For each attitude question, respondents missing either pre- or post-workshop data were excluded from the analysis for that question. 1 P-values associated with McNemar's test for paired data. 9 P a g e

12 VCAT Trainer Profile #3: I have been working in the field of sexual and reproductive health for the last 25 years and have been facilitating VCAT trainings for more than ten years. I believe that VCAT should be a requirement for service providers before they practice. In my opinion, professional responsibility should be a priority over personal views. The VCAT workshop improved my confidence level and helped me understand the framework, participant s values, empathy, alternatives, internal and external barriers, motivation, behaviors, attitudes and performance. After attending the VCAT workshop, my life changed. I can now talk confidently about abortion with others. I try my best to keep women s condition parallel with family and community wellbeing. I would like to reveal my thoughts regarding the impact of VCAT. I have divided the attitudinal change as a result of VCAT into five phases: 1) obstruction, 2) tolerance, 3) motivation, 4) acceptance, and 5) action and performance. In my opinion, the motivational phase has two further phases. First is to clarify personal values and second is safe service provision or referral. I suggest that VCAT should be applied in a practical way. Tools should be provided to differentiate between personal and professional responsibilities and proper follow-up should be conducted to examine training impacts on service providers. FINDINGS FROM IN-DEPTH INTERVIEWS WITH VCAT PARTICIPANTS The 20 Ipas clinical trainees who participated in in-depth interviews shared the changes that occurred in their values, attitudes and actions as a result of attending the VCAT workshop. Overall, participants interviewed reported being impacted in a positive way. During the interviews, several major themes emerged: Respect for women s rights and empathy for women Prior to the VCAT workshop, a few providers considered abortion a sin and murder. Additionally, some participants considered abortion an illegal act. Women who visited them wanting abortion services were told that they should continue the pregnancy and were turned away. One provider shared that she considered abortion a wrong-doing religiously, medically and legally. She thought that abortion was a result of ignorance of contraception methods. Moreover, she felt that if she or other service providers performed induced abortions in the case of rape they would be viewed negatively by their community. After attending the VCAT workshop, she reports that she now interacts with her clients in a polite and considerate manner, and she treats postabortion care cases and refers induced abortion cases. After participating in the VCAT workshop, a majority of the providers agreed that it is the right of every woman to have access to safe abortion care. As one provider stated, It is not illegal, and it s the right of every woman that she can have safe abortion. In addition, most of the providers stated that they should remain non-judgmental and must not criticize the woman s personal life and her decision to have an abortion. One provider shared, We should not be judgmental and should develop empathy and help the patient by doing it ourselves or by safe referrals. A few of the providers shared that even though they do not agree with abortion personally, they can show respect for both the women they serve and their decision to have an abortion. As one provider stated, I may not agree with patient s action, but I can respect her feelings. 10 P a g e

13 Professional responsibility The VCAT workshop reminded providers of their professional responsibilities and duties regarding abortion. Most of the providers interviewed expressed feeling an increased sense of responsibility to provide abortion services along with appropriate guidance and counseling to the women they serve. Two of the providers shared their thoughts: My ideas about abortion have changed because my responsibility is superior to my personal beliefs and VCAT will introduce awareness and improvement in woman s health services; therefore providers will be able to decrease the rate of unsafe abortions and will also be able to respect the right of a mother s life and her choice of conduct. A few of the providers interviewed did not agree with providing abortion services prior to the VCAT workshop and would discourage women who came to them from seeking abortion care. After attending the VCAT workshop, many of these providers understood the need to separate their personal values from their professional responsibilities. As one provider stated, My ideas about abortion have changed because I will consider dealing with access of induced abortions also and providing them health care services postabortion care is right of every woman. Provision and referral for safe abortion services In addition to having an increased sense of professional responsibility after the VCAT workshop, providers also reported some improvements they made in their provision of and referral for safe abortion services. Some of the providers improved their interpersonal communication skills through participation in the VCAT workshop, which has improved their relationships with their patients. Prior to the VCAT workshop, providers were often rigid and harsh toward women seeking induced abortion, but after the workshop they reported listening to their patients carefully and empathetically, understanding the reasons compelling them to seek an abortion. Most providers emphasized the importance of providing high quality abortion services to all women. Almost all of the providers interviewed stated that they would provide referrals for women if they could not provide abortion services themselves. As one provider stated, Provide services to patient, counsel and give treatment. If not done by myself, then refer to safe hands to provide abortion services. Another provider disclosed that prior to the VCAT workshop she turned away an unmarried woman who was seeking care for an infection after going to an unsafe abortion provider. She said that she now felt terrible about her past actions. As she shared, I believe that saving human life is most important religious practice. After attending the VCAT workshop, there were still a few providers who were uncomfortable providing induced abortion services to women because they felt these women were responsible for their situation. One provider stated, How to help out those girls who themselves make their lives miserable. Also a few of the respondents reported that their attitude had only improved toward women who are compelled by certain circumstances, such as rape, to seek an abortion. In addition to providers stigmatizing women for having abortions, they also feared being stigmatized themselves as abortion providers. Some providers expressed that they are worried about their reputation in the community due to social and cultural stigma if they were to begin providing induced abortion services. As one participant shared, I am afraid of bad reputation. 11 P a g e

14 Islam and abortion A few providers were still conflicted about providing abortion services after the VCAT workshop because they continued to be constrained by their Islamic values. As a few of the providers shared, Still conflicts are there dealing with PAC. and Can t fully apply due to my religious constraints. I still have religious barriers. In contrast, the VCAT workshop clarified the Islamic view of abortion for some participants. It was expressed that abortion would not be considered a sin if it was carried out during early pregnancy and in accordance with the patient s needs. As one participant stated, My ideas about abortion have changed because it is not related to religion. One of the areas where many providers were lacking clarity and wanted to explore further after the VCAT workshop was how Sharia and Islamic views related to abortion. Two providers shared their view on this: I want to explore abortion s Islamic point of view and the practices going on in the Islamic world. and I want to explore the conflict regarding law, religion and culture. Influential VCAT activities During their interviews, some providers mentioned specific VCAT activities that were particularly meaningful to them and helped them to better understand topics related to abortion. A few of the activities mentioned often by the providers were: Nasreen s story ( Why Did She Die? ), Four Corners, and Cross the Line. As two providers shared, My ideas about abortion have changed because of workshop exercises, especially Why Did She Die? and Four Corners. and Nasreen s story made me realize that no other women should die like Nasreen due to our non-professional behavior. Providers were also moved by the personal stories shared by their fellow participants, and they reflected on these during the workshop. References to the Quranic verses, Fatwas from Islamic scholars, and ayahs from the Quran also inspired the providers during the workshop. VCAT Trainer Profile #4: I am a doctor. I have been affiliated with VCAT as a trainer since When I started practice in obstetrics and gynecology in 1994, I had biased views regarding abortion. I thought of it as a wrong practice. The VCAT helped in clarifying my views regarding abortion and provided me with awareness from both perspectives of law and Islamic teachings. I learned that survival of the patient should be the priority. After VCAT, I started to advise and support women who wanted to terminate their pregnancies. I try my best to do everything I can to aid my patients so that they may not fall in the wrong hands. I admire three activities which help inspire the participants: 1) Why Did She Die?, 2) Four Corners which builds a sense of empathy, and 3) emphasizing the idea that the participant s responsibility is more significant than his/her personal beliefs. The VCAT workshop has brought a massive change in my day-to-day clinical management. Now in addition to providing services, I also counsel my patients on contraceptive methods. I would like to share some of my suggestions regarding VCAT. In my opinion, the scope of workshop needs to be broadened and issues should be projected via mass media since the availability of service providers and coverage needs to be increased. Additionally, stakeholders should be involved including parliamentarians, representatives and media personnel. 12 P a g e

15 CONCLUSIONS AND LESSONS LEARNED In Pakistan, VCAT workshops have been successful in improving providers knowledge, attitudes, and behaviors pertaining to abortion and abortion care. The greatest improvement was seen in the providers knowledge between the pre- and post-workshop surveys. One of the questions with the greatest increase in correct responses between the pre- and post-workshop surveys was about the legality of abortion in Pakistan. This demonstrates that even though abortion is legal to save the life of the woman in Pakistan many providers are unaware of the law, and VCAT sessions can help increase this understanding. Even though there was an overall improvement in knowledge, there were still some providers who answered knowledge questions correctly pre-workshop but then answered them incorrectly post-workshop. This shows that there are still gaps in knowledge that need to be reinforced during and after the VCAT workshops. More modest improvements were seen in the providers attitudes between the pre- and post-workshop surveys, which is expected because attitudes may be less pliable than knowledge with short interventions. VCAT was most successful in shifting attitudes in support of the provision of abortion services as permitted by law in Pakistan and being able to clearly explain one s values concerning abortion. Individuals who leave VCAT workshops with positive attitudes may be the most likely to provide, support and advocate for abortion. In contrast, nearly half of the providers left the VCAT workshop still feeling conflicted about abortion. This is not surprising since the VCAT workshops are attempting to change a lifetime of internalized messages about abortion in a short period of time. This is an indication that follow-up with providers after the VCAT workshop is necessary. Participation in VCAT workshops also had a positive impact on reported provider behaviors. The indepth interviews showed that most providers regarded provision of abortion services as a woman s right and reported treating their clients with more empathy after the VCAT workshop. The majority of providers also had an increased sense of professional responsibility to provide abortion care and, when needed, reported providing referrals for safe abortion services. A few providers still expressed objections to providing PAC services even though PAC is a medically-necessary intervention, and it would be a violation of their professional and ethical responsibilities to refuse or delay PAC. This indicates their high level of discomfort with any abortion-related procedures and the amount of attitudinal transformation that is needed for them to increase their comfort initially with PAC, and then with induced abortion. We expect this type of change to be gradual, and for changing attitudes to occur along a continuum. In addition to increased provision of abortion services and referrals, several providers also reported that they began to provide contraceptive counseling to women after the VCAT workshop. All of these reported positive shifts in behavior lead to improved abortion care for women in Pakistan. RECOMMENDATIONS Based on these findings and overall experiences with VCAT workshops over the past five years, the following recommendations are made: Changes to VCAT curriculum Add more content to the VCAT curriculum pertaining to: Islam and abortion, abortion law in Pakistan, induced abortion, abortion for women who have been raped, social barriers to abortion services and how to mitigate them, and contraception. With midlevel providers, use the Urdu VCAT materials. 13 P a g e

16 A list of sites providing abortion/postabortion care and contraception services should be distributed to all the participants along with the VCAT materials for PAC and contraception referral. An group should be created for the VCAT participants for networking, follow-up discussions, sharing experiences, and any further needs about technical resources. Expanding VCAT participation VCAT workshops should include a mixed group of participants, including doctors, nurses, midwives, and non-clinical providers. This allows the participants to gain insight into other areas of work. The VCAT curriculum should be adapted for use with policy makers, community leaders, media personnel, NGOs/CBOs, mid-level management, medical students, teachers and youth leaders for social behavior change. VCAT workshops should be conducted for providers in areas having feudal systems, rigidity, and cultural stereotypes and for new medical school graduates. VCAT workshops should be conducted prior to PAC trainings for junior level service providers and should include facility department heads, senior management, and administrative staff. For sustainability of VCAT, TOTs should be conducted for service delivery organizations. This will allow them to conduct their own trainings internally. 14 P a g e

17 REFERENCES Benson, J., Andersen, K., & Samandari, G. (2011). Reductions in abortion-related mortality following policy reform: Evidence from Romania, South Africa and Bangladesh. Reproductive Health, 8, 39. Department of Health Punjab. (2013). Essential Package of Health Services for Primary Health Care in Punjab. Accessed online March 26, 2015, at %20Package%20on%20Health%20Services%20(EPHS).pdf Government of Pakistan. (2009). Karachi declaration on scaling up MNCH-FP best practices in Pakistan. Ministry of health and Ministry of population welfare. National Institute of Population Studies (NIPS) [Pakistan] and ICF International. (2013). Pakistan Demographic and Health Survey Islamabad, Pakistan, and Calverton, Maryland: NIPS and ICF International. Pakistan Penal Code (Act XLV of 1860), Chapter XVI, S. 338A-C. Sathar, Z.A., Singh, S., Rashida, G., Shah, Z.H., & Niazi, R. (2014). Induced abortions and unintended pregnancies in Pakistan. Studies in Family Planning, 45(4), Sathar, Z.A., Singh, S., Shah, Z.H., Rashida, G., Kamran, I., & Eshai, K. (2013). Post-abortion care in Pakistan: A national study. Islamabad, Pakistan: Population Council. Society of Obstetricians & Gynaecologists of Pakistan (SOGP). (2015). SOGP Policy Position Paper on Access to Reproductive Health Care Services. Turner, K.L. & Chapman Page, K. (2008). Abortion Attitude Transformation: A Values Clarification Toolkit for Global Audiences. Chapel Hill, NC, Ipas. Turner, KL, Pearson, E, Andersen KL, & George, A. (2014). Values clarification to improve abortion knowledge, attitudes and intentions: Global evaluation results. Manuscript submitted for publication. World Health Organization (WHO). (2012). Safe abortion: Technical and policy guidance for health systems. Second edition. Geneva: WHO. 15 P a g e

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