Marie Stopes International Submission to the APPG on Population, Development and Reproductive Health Hearing: Abortion in the Developing World and the UK About MSI Marie Stopes International (MSI) is one of the world s leading providers of contraception and safe abortion services. Working across 37 countries, MSI services give women and girls the power to choose if and when they have children. In 2016, we provided 3.6 million safe abortion and post abortion care services and removed 17 policy restrictions that inhibited access to sexual and reproductive health services. MSI s contraception services prevented around 7.6 million unintended pregnancies and averted 4.8 million unsafe abortions in 2016 alone. Global context An estimated 22 million unsafe abortions take place each year, due to legal restrictions and other barriers that prevent women from accessing safe services. This results in millions of women experiencing complications and in tens of thousands of deaths. These are part of the 56 million induced abortions that occur annually, a number that has been growing each year since the early 1990s. Although a recent study from Guttmacher found that abortion rates in the developed world have declined significantly since 1990, they have not in the developing world. It is estimated that 40% of pregnancies worldwide are unintended, and of these, 50% result in abortion i. This risk to women in the developing world remains serious, with 214 million women not wanting to get pregnant but unable access modern contraception. While the right to abortion has been recognised in international development frameworks, such as the Sustainable Development Goals, and through continental mechanisms such as the Maputo Protocol, this has not translated to safe access. An estimated 90% of women of reproductive age in Sub-Saharan Africa continue to live in countries with abortion laws that restrict their access to safe and legal abortion. ii Each year, 183,000 women in Sub-Saharan Africa die from pregnancy-related causes, and at least 9% are directly caused by unsafe abortion. The elimination of unsafe abortion alone would reduce maternal mortality rates by 13% globally. iii The re-enactment and expansion of the Mexico City Policy by the United States government in January threatens to further exacerbate the situation. The policy means any international organisation that provides abortion services or advocates for policy reform regardless of how those services are funded is prohibited from receiving US Government funding. Organisations like MSI which support a woman s right to choose will therefore be unable to receive US funding to provide contraceptive services. Research from Ghana evaluating the impact of the policy between 1993 and 2001 found policyinduced budget shortfalls forced NGOs to cut services, reducing the availability of contraceptives in rural areas. The lack of contraceptives likely caused an observed 12 percent increase in rural pregnancies, ultimately resulting in about 200,000 additional abortions and between 500,000 and 750,000 additional unintended births iv. This reinstatement of the policy is likely to deny millions of women access to contraception and lead to an increase in unintended pregnancy and in unsafe abortion.
MSI estimates that, as a result of the policy, each year approximately 1.6 million fewer women across the developing world will have access to contraception from a trained MSI provider. Between 2017 and 2020, this could result in 6.5 million unintended pregnancies, 2.1 million unsafe abortions, and 21,700 maternal deaths. There are also growing challenges for progressing supportive international policy, with no consensus between member states on the proposed resolution at the 2017 Commission on Population and Development. This was only the second time the Commission has not reached a unanimous outcome and was in part due disagreement on the right to abortion. In addition, increased opposition to the realisation of women s SRH rights by anti-choice movements and fundamentalist religious groups is on the rise, with well-financed and organised campaigns. Current policy and legal environment Although most countries make some provision for abortion services, there are still high levels of restrictions in many. Restrictive laws do not however lead to fewer abortions, with data indicating that restrictive abortion laws in fact lead to an increase in unsafe abortion. The median rate of unsafe abortions in the 82 countries with the most restrictive abortion laws is up to 23 per 1000 women, compared with 2 per 1000 where there are less restrictive laws. Abortion-related deaths are more frequent in countries with more restrictive abortion laws than in countries with less restrictive laws (34 deaths per 100,000 childbirths as opposed to 1 or fewer per 100,000 childbirths). v In most contexts, services are restricted by excessive regulation and over-medicalisation. In Zambia, for example, a woman who meets the legal criteria for abortion must still obtain the signatures of three doctors before the procedure is permitted. With only 1,500 doctors in a country of 16.2 million people, it is almost impossible for Zambian women to access the safe services to which they have a right. MSI categorises its countries of operation into three typologies, to identify the varying levels of restrictions and the feasibility of safe access in the environment: Type Description Countries 1 High levels of restrictions These countries have some of the world s most restrictive laws where abortion is permitted only to save a woman s life. These policy restrictions combined with poverty, stigma and inaccurate perceptions of the true legal status of abortion make it challenging, if not impossible, for many women to access safe services within a safe gestational window, with devastating health outcomes for women and girls, including high levels of maternal mortality. Afghanistan, Bangladesh, Madagascar, Malawi, Myanmar, Nigeria, Papua New Guinea, Philippines, Senegal, Sri Lanka, Tanzania, Timor Leste, Uganda, Yemen, Zimbabwe 2 Medium levels of restrictions Countries are characterised by a more responsive stakeholder environment but the legal/policy and/or regulatory environment restricts access to safe abortion, and low levels of knowledge and implementation of policy further restrict access. 3 Low levels of restrictions Countries characterised by a policy and legal environment that enable provision of safe abortion care, and policy is Bolivia, Burkina Faso, Kenya, Mali, Niger, Pakistan, Sierra Leone, Zambia Cambodia, China, Ethiopia, Ghana, India, Mongolia, Nepal,
operationalised to a larger extent. However, continuing high levels of stigma, lack of awareness, cost barriers and some technical and legal challenges exist to providing and accessing safe services. Vietnam Much work is needed to ensure that progressive laws are implemented on the ground. In Ethiopia, abortion laws became less restrictive in 2005, but problems with access persist; it is estimated that 6 in 10 women who have an abortion experience serious complications and only about 14% of women having abortions receive the treatment they need. vi Appropriate, affordable services need to be made widely available to ensure that new laws succeed in reducing unsafe abortion. How women are accessing services: trends in medical and surgical abortion Medical abortion (MA) has revolutionised access to abortion in recent years, and health systems need to keep pace with increased availability in order to ensure women receive quality care. MSI service numbers over the last few years show that there has been a significant increase in MA while the number of surgical procedures has remained fairly constant. MA is increasingly available through pharmacies, with some women preferring it because it enables privacy, autonomy and a greater sense of control vii. Availability of MA drugs is thought to have reduced incidence and severity of complications from more dangerous methods of self-induced abortion. viii ix x There is some evidence it is also leading to a reduction in maternal mortality xi. Figure 1: MSI abortion services 2012-2016 In response to increased prevalence of counterfeit and ineffective drugs in pharmacies, high quality MA drugs need to be available. Improving access to information about medical abortion is also critical, as pharmacy workers rarely have adequate knowledge about correct use of MA, and do not adequately counsel women on how to take the drugs, what side effects to expect, and what to do in case of complications. WHO guidelines on health worker roles for safe abortion care, published in 2015, state that women can self-manage medical abortion when they have both a source of accurate information and access to a health care provider.
Ensuring a continuum of quality care While the rise of MA is expanding access, it is increasingly apparent that there need to be measures in place to ensure quality and a continuum of care. Through our experience providing abortion services to millions of women, MSI sees three essential aspects to ensuring women access safe services and quality care: 1) Increasing knowledge of safe methods Even with the increasing availability of safe services and products, MSI teams are seeing that women continue to use unsafe methods and providers to induce abortion. Women lack reliable information sources about rights, entitlements, and options. Evidence from Kenya xii shows poor knowledge of safe methods, while a study from Nepal shows that knowledge of where to obtain an abortion is lower among poorer women with low levels of education. xiii It is therefore vital that women s knowledge of safe methods and where to find them increases, through: Delivering information directly to women so they know how to use MA drugs Communications campaigns targeting women and gate-keepers such as partners, religious leaders, parents and traditional leaders Building up referral mechanisms to reliable providers 2) More safe access points Women often lack access to safe options due to policy, clinical, legal, cost, cultural and social restrictions. To ensure women have access to a safe service, the number of safe access points for services needs to be increased, by: Using different types of access points effectively to respond to different needs, including clinics, pharmacies, and youth friendly facilities Removing cost barriers that prevent women from accessing a choice of services Advocating to remove restrictions and barriers to access 3) Ensuring quality With unreliable and unsafe methods increasingly available, women need safe and tailored options, meaning excellent clinical care and counselling, quality products, and a client-centred approach based on their rights. It is vital to: Support providers so that they ensure a quality service, counselling and care Increase availability of high quality, effective MA products, and advocate for regulatory controls which protect quality Registering quality MA products and ensuring they are procured by ministries of health The importance of contraception and post-abortion family planning Ensuring access to comprehensive choice of contraceptive services is the best way to mitigate against unsafe abortion. Women and girls should be able to make their own decisions about their sexual and reproductive health, supported by the necessary information, services, and supplies. As
noted above, we estimate that MSI s contraceptive services averted 4.8 million unsafe abortions in 2016 alone. Contraceptive information and services must be made available in post-abortion counselling as a key component of quality safe abortion care and post-abortion care. Fertility returns within two weeks of an abortion, and to enable women to prevent future unintended pregnancies, a full range of contraceptive methods should be made available with client-centred counselling. Providers need to be mindful however that women are often not ready to make a decision about contraception on the day of procedure. Therefore mechanisms that provide continuous support to women post-abortion are essential, for example mobile technologies. The UK s role in reducing unsafe abortion The UK is a global leader on family planning and recognises how access to modern contraception mitigates against unsafe abortion. This framing is significant, as it acknowledges the reality of unsafe and backstreet methods and looks to reduce the risks by enabling women to make decisions about if and when to have children through family planning. Alongside this, the UK makes an important recognition that contraception is not always accessible and that safe abortion services, where legal, reduce recourse to unsafe abortion and therefore save lives. DFID should be commended for this perspective, acknowledging that contraception is the best means to mitigate the disastrous effects of unsafe abortion, but that safe abortion services are an essential part of a comprehensive approach to sexual and reproductive health and maternal health. The government s renewed pledge of 225m per year to family planning xiv is therefore encouraging but needs to be monitored closely to ensure it gives women choice and that access to comprehensive services becomes a reality. Case studies Protecting progressive legislation in Zambia In 2016, Zambia held a referendum on a new constitution. Article 15 of the proposed Bill of Rights stated that Every person has the right to life which begins at conception and if passed would prohibit safe abortion and some modern methods of contraception. This would undermine the gains that Zambia has made in reproductive health. Unintended pregnancy is already a major cause of maternal deaths in Zambia, with an estimated 30% of maternal deaths attributed to unsafe abortion (Ministry of Health, 2010). To support local and national efforts to protect women s rights, civil society segmented the different audiences and different NGOs led on engaging different constituents. Marie Stopes Zambia partnered with the Zambia Medical Association, Safe Abortion Action Group and the Zambia Youth Platform to lead awareness raising activities in the Western Province. These targeted traditional leaders, local media, and youth and women s community organisations to raise awareness of Article 15 and its potential implications for medical services and SRHR. The multi-faceted approach was vital, with women and youth leaders mobilising their constituencies to vote no, and the Zambia Youth Platform playing a vital role in reaching youth.
Despite counter-campaigns by the ruling Patriotic Front and the Catholic Church, which claimed that a yes vote would eliminate abortion in Zambia, the activities of MSZ and partners helped to influence a no vote, protecting the rights of women in Zambia. Increasing abortion access for women in Zimbabwe The Termination of Pregnancy Act in Zimbabwe only permits abortion to save a woman's life or in the case of rape or incest. Even so, law-makers and the judiciary often block access to services for rape survivors by failing to interpret the law in the way it was intended and to grant the necessary official permissions required to access abortion services. MSI s Zimbabwe programme, Population Services Zimbabwe (PSZ), has been working closely with the Zimbabwe Women Lawyers Association (ZWLA) to challenge this, and both improve the implementation of the current law, and to advocate for law reform in the future. In Harare region there has been a 100% increase in permissions granted for abortion services for survivors of rape. A series of consultations led by PSZ with lawmakers and law enforcers highlighted the challenges they faced interpreting the existing legislation. In response, our programme and ZWLA have developed a checklist designed to support them through this process to ensure the current law is correctly interpreted, and that the right of rape survivors to demand abortion services is fulfilled. Advocacy by doing has helped successfully make the case for the law reform in the future. The Law Development Commission of Zimbabwe has agreed to support a process to revise the Termination of Pregnancy Act. Supporting providers Lack of willing providers is one of the unseen barriers restricting women s access to quality services and care. To better support clinical staff, Marie Stopes Kenya delivers the Provider Share Workshop, a facilitated group workshop designed to offer safe abortion/post abortion care workers a safe space for discussing the unique rewards and burdens of their work. Workshops rely on narrative storytelling and arts-based methods and are led by experienced, trained facilitators who do not have dayto-day work relationships with participants. The workshops allow participants to give voice to experiences that they normally remain silent about; they offer participants support and connection to others, and reduce isolation. Although feelings of social support, judgment and discrimination did not immediately change, the workshop has positive effects: The evaluation of provider share workshops found reduced experiences of stigma, improvements in providers attitudes towards women seeking abortion, and reductions in provider burn-out which included reduced emotional exhaustion and feelings of depersonalization. The workshop also increased the willingness of participants to engage in legal advocacy related to safe abortion Providers includes all staff involved in abortion provision i.e. clinicians, receptionists and care assistants. Reducing the stigma faced by providers is vital to ensuring sustainable access to quality abortion services. While the Provider Share Workshop helps to support providers, similar and ongoing efforts are needed across the health system.
i Sedgh, Gilda, Susheela Singh, and Rubina Hussain. "Intended and unintended pregnancies worldwide in 2012 and recent trends." Studies in family planning 45.3 (2014): 301-314. ii Guttmacher Institute, Abortion in Africa, 2016 Available https://www.guttmacher.org/fact-sheet/factsabortion-africa iii World Health Organization, Unsafe abortion: global and regional estimates of incidence of unsafe abortion and associated mortality in 2008. (2011). iv http://poppov.org/~/media/poppov/documents/events/6thannconf/jones-2011-mexico-city-fertility.ashx v Haddad, L. B., & Nour, N. M. (2009). Unsafe Abortion: Unnecessary Maternal Mortality. Reviews in Obstetrics and Gynecology, 2(2), 122 126 vi Guttmacher Institute, Making Abortion Services Accessible in the Wake of Legal Reforms: A Framework and Six Case Studies, 2012 vii Lie, Mabel LS, Stephen C. Robson, and Carl R. May, Experiences of abortion: a narrative review of qualitative studies, BMC Health Services Research 8.1 (2008): 150. viii Miller S, Lehman T, Campbell M, Hemmerling A, Anderson S, Rodriguez H, Gonzalez W, Cordero M, Calderon V. Misoprostol and declining abortion-related morbidity in Santo Domingo, Dominican Republic: a temporal association. BJOG 2005; 112: 1291 1296. ix Sherris J, Bingham A, Burns M, Girvin S, Westley E, Gomez P. Misoprostol use in developing countries: results from a multicountry study. Int J Gynecol Obstet 2005; 88(1): 76-81. x Harper C, Blanchard K, Grossman D, Henderson J, Darney P. Reducing maternal mortality due to elective abortion: Potential impact of misoprostol in low-resource settings. Int J Gynecol Obstet 2007; 98(1):66 9. xi Baggaley R, Burgin J, Campbell O. The potential of medical abortion to reduce maternal mortality in Africa: what benefits for Tanzania and Ethiopia? PloS one 2010; 5(10): e13260. xii Izugbara, C., et al. High profile health facilities can add to your trouble : Women, stigma and un/safe abortion in Kenya. Social Science & Medicine 141 (2015): 9-18. xiii Thapa, S., et al. Women's knowledge of abortion law and availability of services in Nepal. Journal of biosocial science 46.02 (2014): 266-277. xiv https://www.gov.uk/government/news/uk-to-save-a-womans-life-every-90-minutes-by-increasing-familyplanning-support