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AJRH Vol. 10 No. 3 REVIEW ARTICLE Global policy change and women’s access to safe abortion: The impact of the World Health Organization’s guidance in Africa Leila Hessini1, Eunice Brookman-Amissah2 and Barbara B. Crane3 ABSTRACT Along with governments from around the world, African leaders agreed at the International Conference on Population and Development (ICPD) in 1994 to address unsafe abortion as a major public health problem. At the five-year review of the ICPD, they decided further that health systems should make safe abortion services accessible for legal indications. Based on this mandate, the World Health Organization (WHO) developed norms and standards for quality abortion services, Safe Abortion: Technical and Policy Guidance for Health Systems, released in 2003. While abortion-related maternal mortality and morbidity remains very high in many African countries, stakeholders are increasingly using WHO recommendations in conjunction with other global and regional policy frameworks, including the African Union Protocol on the Rights of Women in Africa, to spur new action to address this persistent problem. Efforts include: reforming national laws and policies; preparing service-delivery guidelines and regulations; strengthening training programs; and expanding community outreach programs. This paper reviews progress and lessons learned while drawing attention to the fragility of the progress made thus far and the key challenges that remain in ensuring access to safe abortion care for all African women. (Afr J Reprod Health 2006; 10[3]:14-27) RÉSUMÉ Modification de la politique mondìale et l’accès par la femme à l’avortement sans danger: L’impact du conseil de l’Organisation mondiale de la santé en Afrique. Au cours de la Conférence Internationale sur la Population et le Développment (CIPD) en 1994, les leaders africains et les gouvernements partout dans le monde se sont mis d’accord pour s’occuper de l’avortement dangereux comme étant un problème majeur de la santé publique. Pendant la revue de cinq ans de la CIPD, ils ont decidé en plus que les systèmes de santé doivent rendre les services de l’avortement sans danger accessibles pour des indications lègales. Se fondant sur ce mandat, l’organisation mondiale de la santé (OMS) a élaboré des normes et des standards permettant de rendre des services de l’avortement de qualité, L’avortement sans danger: Les conseils technique et politique pour les systèmes de santé, publié en 2003. Alors que la mortalité et la morbidité liées à l’avortement restent très élevées dans plusieurs pays d’Afrique, les dépositaires d’enjeux se servent de la OMS conjointement avec d’autres cadres de la politique régionale et mondiale y compris le protocole de l’Union Africaine sur les Droits de la Femme en Afrique pour encourager une nouvelle action pour s’occuper de ce problème continuel. Les efforts comprement: la réforme des lois et des politiques nationales; la préparation des conseils et des réglements concernant la prestation de service; le renforcement des programmes de formation; et l’élargissement des programmes de l’information au niveau de la communauté. Cet article passe en revue le progrès et les leçons apprises tout en tirant l’attention sur la fragilité du procès fait jusqu’ici et les défis clé qui ne sont pas encore atteints pour assurer l’accès au services du soin de l’avortement sans danger pour toutes les femmes africaines. (Rev Afr Santé Reprod 2006; 10[3]:14-27) KEY WORDS: Abortion, postabortion care, maternal mortality, Africa, WHO, health policy 1Leila Hessini, Senior Policy Advisor, Ipas, P.O. Box 5027, Chapel Hill, NC 27514 USA. Tel: 919-967-7052. e-mail: [email protected]. 2Eunice Brookman-Amissah, Vice President for Africa, Ipas P.O. Box 1192, 00200 City Square, Nairobi, Kenya Tel:254-20-577239, 577422, Fax: 254-20-576198 e-mail: [email protected], 3Barbara B. Crane, Executive Vice President, Ipas, P.O. Box 5027, Chapel Hill, NC 27514 USA. Tel: 919-960-5566. E-mail: [email protected] Correspondence: Leila Hessini, Senior Policy Advisor, Ipas, P.O. Box 5027, Chapel Hill, NC 27514 USA. Tel: 919-967- 7052. E-mail: [email protected] Global policy change and Women’s access to safe abortion: The impact of the World Health Organization’s guidance in Africa 15 Introduction What challenges remain in advancing access Women in sub-Saharan Africa face the highest to safe abortion in Africa? risk of death and injury from abortion-related What more is needed to improve the enabling complications in the world, accounting for 60% environment? of the nearly 20 million cases of unsafe abortion In addition to reliance on secondary sources, globally each year.1 Tens of millions of women the interpretations and conclusions of this article of reproductive age today in Africa will are based on the authors’ own experiences and experience an unsafe abortion in their lifetimes. com- munications with a range of partners in the region as well as a set of qualitative interviews Globally, unsafe abortions claim the lives of at 8 least 68,000 women each year; 43% of these conduc-ted with selected African stakeholders. An women are African.2 In addition to premature appendix provides information on abortion laws deaths, hundreds of thousands of African in Africa. women who seek unsafe abortions each year experience severe complications: uterine perfo- Global and regional policies – paving ration, chronic pelvic pain, haemorrhage and the way for national action secondary infertility.3 They also face trauma, “In recent decades, international understanding of the stigmatisation and isolation from families and basic civil, social and economic rights with which all communities as a result of unwanted pregnancies people are born has deepened and been progressively and unsafe abortions. Recent national-level studies articulated in international covenants, treaties, and other in Kenya, Uganda, and Nigeria document the instruments. Such agreements create a solid basis for high numbers of women presenting with real improvements in people’s lives, as ratifying nations complications from unsafe abortions in public commit themselves to uphold the rights enumerated therein, including by adjusting laws and policies.’’9 health facilities, and are indicative of the region- wide burden of ill-health caused by unsafe Modest efforts to address unsafe abortion have abortion.4,5,6 The consequences fall especially been underway in Africa for nearly two decades, heavily on young women and girls; nearly 60% with a primary focus on improving the capacity of women who have unsafe abortions are under the of public health systems to provide postabortion age of 25.7 Taken together, the data on unnecessary care (PAC) – a package of interventions that deaths and illnesses from unsafe abortions point to includes treatment of complications and provision a public health crisis, a social injustice and a of postabortion contraception and other violation of women’s human rights and dignity. reproductive health services.10 PAC programs This article examines the responses to unsafe were initiated or expanded in a number of abortion in Sub-Saharan Africa, with a special countries following global agreement at the focus on how guidance for health systems International Conference on Population and released by the World Health Organization in 2003 Development (ICPD) to address the health has increased recognition of governments’ consequences of unsafe abortion as a key obligations to provide safe services for legal component of comprehensive programs for indications and has contributed to greater efforts reproductive health and rights. At the ICPD, to make services available. The article addresses governments agreed that: “In all cases, women four central questions: should have access to quality services for the Have global and regional policies addressing management of complications arising from unsafe abortion made any difference for women? abortion.11 The ICPD Programme of Action What progress is being made at the national (PoA) further states that postabortion counseling, level? education and family-planning services should be African Journal of Reproductive Health Vol. 10 No.3 December, 2006 16 African Journal of Reproductive Health an integral part of PAC services to avoid repeat should be accessible.19 With this mandate, the abortions. World Health Organization gathered experts in A year later at the Fourth World Conference 2000 to develop guidance for national health on Women in Beijing, the Platform for Action systems. Among the key recommendations were called for governments to consider reviewing the following: 12 punitive abortion laws. Most abortion laws in • Vacuum or electric aspiration, and medical Africa are derived from the former laws of abortion, are the preferred methods of abortion Belgium, England, France and Portugal and are in the first 12 and 9 weeks of pregnancy. 13 quite restrictive. Some countries in the region • Safe abortion services should be available at did expand legal indications for abortion between all levels of the health system, including the 1994 and 2003, allowing for abortions in cases primary health care level. of pregnancies resulting from rape or incest, • Midlevel providers including nurses, midwives foetal impairment or threats to women’s health. and clinical officers, should play a role in These include Benin, Burkina Faso, Chad, Guinea abortion counselling, service provision and 14 and Mali. Ethiopia legalized abortion for a range referrals. 15 of indications in 2004. • Health systems should eliminate as many A major breakthrough was adoption of the barriers as possible, such as required Choice on Termination of Pregnancy (CTOP) ultrasounds, waiting periods, and multiple Act in South Africa in 1996. South Africa’s signatures by committees.20 abortion law is considered a model as it recognizes: i) a women’s right to have an abortion The guidance, based on the latest clinical with no restrictions in the first trimester; ii) allows evidence, was developed with great care and midlevel providers to perform early abortions; attention to the relevant ethical and policy and iii) gives women, not husbands or guardians, considerations.
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