Evidence made the difference: From quasi-legal to safe and available abortion in Zambia Dr. Patrick Djemo, Acting Country Director, Ipas Zambia
Unsafe abortion in Zambia High maternal mortality estimated at 398 per 100,000 live births Continued reliance on unsafe abortion Relatively low use of contraception; high teenage pregnancy rate Termination of Pregnancy Act, 1972 Risk of death or injury to the pregnant woman Risk to existing children or fetus
Example: Zambia Termination of Pregnancy Act Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if he and two other registered medical practitioners, one of who has specialised in the branch of medicine in which the patient is specifically required to be examined before a conclusion could be reached that the abortion should be recommended, are of the opinion, formed in good faith--
The WHO Strategic Approach STAGE I STAGE II STAGE III Developing Scaling-Up Reproductive Health Challenges Strategic Assessment and Testing Programme Innovations Successful Interventions Policy & Programme Strengthening Improved Reproductive Health Status & Programmes
Findings from the WHO Strategic Assessment (2008) Findings Striking lack of knowledge about current laws No organized system for provision of safe abortion services no guidelines for services No formal practical training in medical/nursing schools, in-service training for PAC available only recently available Limited supply of MVA kits for trained PAC providers Strong cultural stigma against abortion leading to self-induction/clandestine providers Some use of misoprostol - no combined mife/miso product Recommendations Improve access to contraception to reduce need Re-introduce abortion at hospitals and health centers Train mid-level providers Develop national standards and guidelines Register medical abortion product Strengthen health systems Create public awareness regarding: Current laws and services Dangers of unsafe abortion and Negative health consequences of abortion stigma
Introducing abortion care through operations research & implementing assessment recommendations Develop national standards and guidelines (completed 2009) Train mid-level providers, in-service and preservice Register medical abortion products and improve MVA supplies Create public awareness regarding: Current laws and services Dangers of unsafe abortion Introduce and evaluate safe services to provide local evidence Continue to improve access to contraception
Piloting Comprehensive Abortion Care through operations research Operations research MA introduction pilot initiated in 2009 28 facilities in Lusaka and Copperbelt Province (7 hospitals, 21 health centers) Collaborating institutions: University Teaching Hospital (UTH) in Lusaka Ministry of Health Ipas Planned Parenthood Association of Zambia
Conceptual Framework for the OR study INPUTS OUTPUTS OUTCOMES IMPACT CBO training & support Clinical Intervention @ each site Supportive supervision Skills and knowledge needed to access safe abortion Social norms reflect reduced stigma Strong social networks and community intermediaries Women in community able to seek and receive safe abortion care and information Improved maternal health
OR Study achievements (2009-2011) Introduced abortion, and often PAC services, in 25 health facilities Trained more than 140 providers to offer CAC services Trained more than 20 clinical mentors Conducted over 125 community sensitization activities on the prevention of unsafe abortion and safe abortion access reaching over 36,000 people in 4 communities
OR Study achievements (2009-2011) Over 13,000 women received abortion care 80% of all procedures were PAC (n=10,881) 55% of all procedures were performed at UTH; 19% were performed in health centers 46% of clients left with a contraceptive method
When offered a choice most women chose MA
180 160 Increase in safe terminations (TOP), with PAC decline Lusaka health centers Total Quarterly Caseload Among 8 Lusaka Health Centers 69% TOP 140 120 100 80 60 TOP PAC 40 20 53% TOP 0 Jan-Mar 2010 Apr-Jun 2010 Jul-Sep 2010 Oct-Dec 2010 Jan-Mar 2011 Apr-Jun 2011 Jul-Sep 2011
Increased provision of safe and legal abortion services 2 separate donors funding abortion care Increased interest among NGOs and broader coalition of support
More informed proponents and opposition to legal abortion services More informed media and populace on abortion issues Proponents and opponents have decreased the evidence gap on abortion
Concluding observations It is feasible to implement safe abortion services in the public sector, including in primary health care facilities. Research is a valuable first step in promoting feasibility and acceptability of abortion service introduction. Zambian women overwhelmingly chose MA for first trimester TOP, given a choice of MA or MVA. Introducing MA is an important way to improve service acceptability for women and providers. The impact of community awareness-raising interventions is still in question; highly motivated providers can also increase awareness and confidence in services
Concluding observations Postabortion contraceptive acceptance remains an institutional challenge, still with better performance at health centers than hospitals Health centers will resist treating women with abortion complications, preferring to refer most PAC clients to hospitals Heated public and policy debates in Zambia continues on access to safe abortion and needs to be informed by public health evidence
Thank You! A special thank you to our hard-working abortion care providers Research funded by the Consortium for Research on Unsafe Abortion in Africa s principal donor - UKAid Current Zambia donors: Anonymous Prevention of Maternal Death from Unwanted Pregnancy