uneOctober 2021 2018

IMAP Statement on Self-Care

Introduction care, away from a medicalized and provider- This statement has been prepared by the led approach, within a people-centred model International Medical Advisory Panel (IMAP) and which empowers individuals and is supported was approved in May 2021. by community collectives and social networks, however still backed-up by the healthcare system This statement supports IPPF’s commitment to whenever needed or required. This statement improving access to abortion care for all and also serves as an advocacy tool to create an to creating a supportive social, policy, and legal enabling environment for abortion self-care. environment for abortion by offering guidance and information on abortion self-care. This is an evidence-based approach that enables Understanding abortion self-care women, girls, and all people who have the Broadly speaking, self-care encompasses“the capacity to become pregnant1 to realize their ability of individuals, families and communities sexual and , prevent mortality to promote health, prevent disease, maintain and morbidity associated with , health, and to cope with illness and disability and overcome coercive legal restrictions and with or without the support of a healthcare inadequate health systems, while simultaneously provider”.i Self-care is not a new concept, nor challenging harmful social norms and patriarchal does it apply exclusively to abortion. Health structures. workers and health experts have been promoting and encouraging this approach for decades, and Guided by the existing evidence and even more so as technology increasingly supports practices, this statement provides practical more straightforward access to information, recommendations for IPPF Member Associations enabling individuals to make informed decisions and other sexual and reproductive health about their health and take control over stakeholders on how to manage abortion implementing specific health tasks.

1This document is inclusive of women and girls and all people who can become pregnant, including intersex people, transgender men and boys, and people with other gender identities that may have the reproductive capacity to become pregnant and have . For the purposes of this document, references to “women and girls” refer to all people who have the capacity to become pregnant. 1 IMAP Statement on

In the field of abortion, there is not a single non-discrimination, information, and the right way of defining self-care, yet, it is essential to to enjoy the benefit of scientific progress.iii acknowledge that many stakeholders associate ƒ People-centred: Providing options relevant to the concept primarily to self-administration of the individual’s needs, preferences, and lived medical abortion. With the increasing access to experiences supports people’s self-efficacy to highly sensitive pregnancy tests and availability control their lives and decisions and tackle of simple, safe, highly-effective abortion abortion stigma and the silencing that comes pills ( alone or and with it. misoprostol combined), more and more women ƒ Gender transformative: Every woman and and girls have the option of safely and effectively girl has the right to abortion, in a manner ending a pregnancy with or without the that respects their rights, autonomy, dignity, involvement of a health provider.ii and needs, taking their lived experiences and circumstances into account, placing the individual at the centre, enhancing their decision-making and control over their IPPF understands abortion lives, and challenging gender norms, roles, self-care as the right of women and and stereotypes that stigmatize women’s girls to lead, in part or entirely, their reproductive autonomy.iv abortion process, with or without ƒ Inclusiveness: All individuals who may need support from health providers2 an abortion must have access to care that considers their unique needs, irrespective of visible or invisible differences. ƒ Equity in health: All efforts should be made to address avoidable and unjust differences This usually includes the self-administration of in exposure to health risk factors, health medical abortion, but could also mean being in outcomes and their social and economic charge of other aspects of the abortion process, consequences, healthcare access, and capacity such as the post-abortion care or the decision of to finance care.v engaging (or not) other stakeholders throughout ƒ Quality: Care delivered should be in line with the process (i.e., abortion doulas;3 peers; the available evidence and the needs, values, pharmacists). and preferences of the clients, free of stigma and with compassion and empathy. Abortion self-care is underpinned by the following principles: Abortion self-care places women and girls firmly at the centre of the abortion process, as the ƒ Rights-based: Bodily integrity and autonomy key decision makers in control of their bodies. is a fundamental human right, central to However, multiple stakeholders can also play a sexual rights and gender and reproductive role in enabling and facilitating this approach, justice. People’s right to make autonomous by acting on three components of support for decisions about their own bodies and abortion self-care: a. Delivery of accurate and reproductive functions, is at the core of their accessible information; b. Access to quality fundamental rights to life, health, equality and and affordable medication; and c. Provision of supportive care:vi

2Individuals who face spontaneous abortions, incomplete abortion, and intrauterine foetal demise may also decide to lead – when considered safe and based on the specificities of the case – parts of the abortion process. 3Individuals trained to provide emotional, physical, and informational support, free of stigma, during and after an abortion procedure. 2 IMAP Statement on medical abortion

ƒ Women and girls have access to quality medical abortion pills, either misoprostol alone or a combipack of mifepristone and misoprostol. ƒ Women and girls have the conditions to implement the abortion with the desired level of privacy.

The World Health Organization recommends that up to 12 weeks gestation, individuals can self- administer mifepristone and misoprostol medication without the direct supervision of a health provider.viii

An important condition for safety of self- induced abortion is the ability to self-determine Abortion self-care: safe, effective, wanted! gestational age. Evidence has shown that Emerging research suggests that abortion outside women, in different contexts, geographies, the medical setting is an overall safe, effective, socio-economic, and educational levels, are and wanted way to end a pregnancy. reasonably good at estimating gestational age based on their last menstrual period (LMP), Safety without the need for a physical examination or The safest environment for self-managed an ultrasound.ix Some women in specific personal abortion is one where: or medical conditions may have challenges estimating gestational age, in which case they ƒ Women and girls’ health literacy is supported. may benefit from clinic or laboratory support. That is, their capacity to obtain, process, and understand evidence-based health Recommended resources: for more information on information, explore their options, ask critical the evidence supporting self-administered medical abortion and questions about their choices, and actively protocols, see the following WHO guidelines: participate in decisions and tasks concerning their care. • Health worker roles in providing safe abortion care ƒ Medical care is accessible when chosen and and post-abortion contraception https://www.who. needed, with referral mechanisms in place for int/reproductivehealth/publications/unsafe_abortion/ women to access in-clinic care, including in abortion-task-shifting/en/ case of complications or for complementary • Medical Management of Abortion https://www.who.int/ services.vii reproductivehealth/publications/medical-management- abortion/en/

3 IMAP Statement on medical abortion

Effectiveness information on how to safely self-manage The statement is aimed at service providers, an abortion — are deeply appreciated advocates, programme staff, managers and by women who self-administer medical volunteers in IPPF Member Associations and abortion and may provide the technical the secretariat, and other SRHR and women’s information and emotional support that can organizations. ensure safe, complete abortions with few or no complications.xv Similarly, research has A recent systematic scoping review of peer found that community-based distribution of reviewed research found that studies reporting misoprostol – which enables abortion self-care on self-managed medication abortion reported – can safely and effectively support abortion high-levels of effectiveness.x care.xvi ƒ IPPF, as a global service provider and leading The effectiveness of specific self-care abortion advocate of sexual and reproductive health interventions has also been documented by care, pledges to uphold its commitment to recent studies: providing gender‑sensitive and rights‑based comprehensive abortion care to all, and to ƒ Most women and girls who self-manage their working in partnership with others to ensure abortions facilitated through pharmacies that the conditions and structures are in place report high effectiveness without surgical to help women access safe abortion in the interventions and are willing to use this way that works best for their lives. service again if need be. The challenge with this model is with regard to the quality of the information provided by pharmacists, especially related to timing and dosing of the Abortion hotlines and websites medication (usually, misoprostol). Therefore, have been shown to be highly more work needs to be done in terms of equipping pharmacists and drug sellers with effective in facilitating self- the correct information.xi xii managed abortions, as most ƒ A study conducted in showed that women do not present any services provided under a model known as complications nor require surgical “the harm reduction model” – in which intervention after taking the providers offer evidence and rights-based information and care before and after an abortion pills. These information abortion, to the extent allowed by the hubs have proved to have a positive law, and women and girls self-manage the impact on access to safe abortion procedure itself, in other words, taking the for women, both in legal as well as abortion pills – contributed to a reduction in legally restricted contexts.xvii in maternal mortality.xiii A study conducted at the Buguruni Health Centre in Tanzania – which adapted the harm reduction model to the local context – showed that these type Often, a wanted alternative of services are feasible and acceptable, and Evidence suggests that in some settings as much could provide an opportunity to reduce unsafe as 70% or 80% of abortions are self-managed.xviii abortion.xiv In legally or socially restrictive settings, or for ƒ Research also indicates that accompaniment those living in humanitarian settings, abortion groups – networks of activists/volunteers/ self-care may not always be the preferred option, peers which provide people with step-by-step but the only available option.

4 IMAP Statement on medical abortion

A robust body of qualitative studies show that self-care. A concrete example is in the context abortion self-care is often a wanted alternative of the COVID-19 pandemic, as women and for some women; because it is affordable, it girls have seen their mobility restricted, implies reduced transportation needs, ease of affecting their capacity to access facility-based scheduling, earlier intervention in the pregnancy, abortion care. privacy, reduced stigma, sense of control, comfort, and easier access for people with restricted mobility (e.g. from refugees to people Recommendations for Member with disabilities).xix xx xxi xxii Associations and other organizations on how to support abortion self-care What abortion self-care is not ƒ Abortion self-care is not an approach that 1. Transform policy and legislation to create an removes the duty of care away from the enabling environment for abortion self-care as formal health system. The formal health part of a supportive health system for abortion system must facilitate access to information, care. services, commodities, and referrals, as ƒ Advocate with governments to remove needed and wanted, within the national legal abortion from the penal code and end criminal and policy framework. penalties for women who self-manage their ƒ Abortion self-care is not an approach driven abortion process. by the aim of reducing costs for the health ƒ Advocate to ensure that national regulations system. While it is true that studies on self- and guidelines explicitly integrate self- care interventions highlight their potential managed abortion as a legitimate and to save resources both for users and the permissible pathway to abortion care. healthcare system,xxiii abortion self-care should ƒ Work with governments to ensure the be strongly guided by a people-centred availability and accessibility of quality medical approach and existing evidence on its safety abortion products with the inclusion of and effectiveness. mifepristone and misoprostol in policy and ƒ Abortion self-care is not an approach that service guidance documents, lists of essential undermines or eliminates advocacy efforts medicines, and procurement catalogues. to expand legal access to abortion. The ƒ Advocate for medical abortion products to be decriminalization of abortion is still essential to free or subsidized for poor and marginalized ensure that all individuals can realize the right populations. to a safe and dignified abortion, on their own ƒ Advocate for the withdrawal of unnecessary terms and informed by the values and needs regulations on the provision of medical most important to them, and to guarantee abortion products, and advocate for over-the- that health workers can perform their duty of counter sale of medical abortion drugs. care without fear of prosecution. ƒ Work with governments to expand access ƒ Abortion self-care is not an approach limited to generic formulations of medical abortion to legally restricted settings or humanitarian products and promote public-sector availability settings. However, in such settings, it can and competitive pricing in the private play a significant role in increasing access, marketplace, including innovations in retail- reducing mortality and morbidity associated market options, such as bundling pregnancy to unsafe procedures, and transforming tests and medical abortion products.xxii negative abortion narratives and stigma. ƒ Advocate for eradicating censorship of Even in contexts with legal, quality, and online evidence-based abortion information comprehensive services widely available, some to improve individuals’ ability to make safe women and girls may prefer or need abortion choices in any place and any context.

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ƒ Advocate for the implementation of service ƒ Generate safe spaces for dialogue between delivery strategies that eliminate access health workers and groups leading the barriers for women and girls who decide conversation on and implementation of to involve health providers in the abortion abortion self-care, to discuss challenges and process. Self-care can be complemented with, opportunities for collaboration. for example, task sharing to mid-level health ƒ Engage students of health-related professions workers or with telemedicine guided clinical or in dialogues around self-care. This contributes emotional support, supervision, or counselling. to long-term change, gradual transformation of the provider-client relationship, and de- 2. Improve knowledge and attitudes around medicalization of issues that, while health- abortion self-care and catalyse sociocultural related, have the potential to be managed change by creating positive narratives and social outside the health system. movements to remove stigma. ƒ Educate the medical community about ƒ Develop public campaigns to increase health the safety and effectiveness of abortion literacy regarding abortion care and to inform self-care, in order to reduce unnecessary individuals about their right to manage their clinical concern, overmedicalization and care, based on the available evidence and overtreatment of clients, and stigmatization within the restrictions of their legal context. or criminalization of women seeking abortion Information should be made available in local care. languages and in a format that supports ƒ Support community engagement initiatives the needs/information-seeking practices of that could help to build trust in the systems/ overlooked populations, such as women with structures that enable and facilitate abortion disabilities, refugees, indigenous women, and self-care, i.e. work with community leaders sex workers, among others. and local media to ensure they are supportive ƒ Develop positive messaging and narratives of locally-led accompaniment groups. on abortion self-care, including response to ƒ Participate in forums that aim to catalyse concerns or opposition to abortion self-care sustainable social change for women and from a range of actors. This could include normalize and facilitate abortion self-care. developing factsheets to address common myths and misconceptions, and using 3. Implement person-centred, on-demand models evidence and rights-based arguments to of care that support and enable an individual counter opposition. throughout an abortion self-care experience. ƒ Include content on agency, abortion self- ƒ Through collaboration with legal experts, care, abortion stigma as part of evidence- assess your legal framework to understand based comprehensive sexuality education how the regulatory framework supports or programmes and outreach to young people. restricts abortion self-care initiatives. Any ƒ Implement participatory processes to restrictions should be understood in order to gather the stories of individuals who have create risk mitigation strategies while, at the experienced abortion self-care, as well as of same time, supporting women and girls in those who have played a role in enabling and their abortion process. facilitating abortion self-care. Disseminate ƒ Map existing interventions that enable or these stories in relevant spaces. limit abortion self-care in your geographical ƒ Engage partner organizations, including areas of operation. Avoid duplication of feminist groups, professional bodies of efforts by partnering with other like-minded health providers, and nursing and medical stakeholders. institutions, to create a diverse network of ƒ Review your organization’s existing champions for abortion self-care. strengths, initiatives, and models of care

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and consider how they can be adapted to provide person-centred care for a woman to integrate components of support for self-managing an abortion. abortion self-care. For example, a strong network of community health workers could be leveraged to create an accompaniment Special consideration should be network for abortion self-care. An existing made when supporting abortion hotline model or telemedicine service could be adapted to include a dedicated team self-care to vulnerable groups, providing information and support for women including very young adolescents; undertaking abortion self-care. women with disabilities; sex ƒ Based on the outcomes of mapping and workers; women subject to gender- assessment work, develop interventions to based violence; transgender or provide on-demand support for individuals who choose abortion self-care through trans men; and women subject to innovative approaches, considering the three human trafficking. main components of support for self-care: • Delivery of accurate and accessible information on abortion and, particularly, ƒ Clinical, psychosocial, and protection services on medical abortion (dosage, regimen, must be available for vulnerable groups to contraindications, side effects, and address other sexual and reproductive health signs of complications). Strategies may needs before, during, or after their abortion. include hotlines, peer provision, websites, ƒ Collect data on the safety, effectiveness, and or referral to other reliable sources of acceptability of self-care interventions to information and support. improve programming and support advocacy • Access to quality medical abortion pills. efforts. This can include operational research Strategies may include digital prescriptions, on how to improve women’s experience of partnership with pharmacists, and sending self-managed abortion, how to overcome pills by post or dispensed by community barriers and challenges to facilitating health workers. abortion self-care, and the contribution • Providing supportive care during the of abortion self-care to reducing abortion self-care process. Strategies may include stigma, increasing self-efficacy, and catalysing adaptation of clinical protocols to ensure sociocultural change. readiness to meet the needs of a woman at any point in her abortion process; provision 4. Recommendations on abortion self-care during of on-demand abortion counselling when the COVID-19 pandemic and humanitarian crises. requested; and setting up referral networks ƒ Ensure that supply chains that support in case of doubts or for treatment of the distribution of abortion pills remain complications, post-abortion care, or other operational. relevant services, as needed. ƒ Build alliances with humanitarian actors for ƒ Strengthen the capacity of your organization the delivery of medical abortion supplies to undertake abortion self-care programming. and contraceptives, as well as accurate and For example, update institutional policies and comprehensive information on the use of guidelines on abortion to include self-care, abortion pills. conduct values clarification exercises for staff ƒ Accelerate the development of digital and volunteers at all levels to build support initiatives focused on providing evidence- and commitment for abortion self-care, and based information on abortion and provide training for health providers on how abortion-related services, to ensure women´s

7 IMAP Statement on medical abortion

reproductive choices are not undermined as a Acknowledgements result of circumstances that limit their mobility We would like to express our appreciation to Marcela Rueda Gomez and Josephine Mugishagwe Recommended resources from IWORDS Global and Rebecca Wilkins for • Her in charge - Medical abortion and women’s lives - A drafting this statement, and to Dr France Anne call for action https://www.ippf.org/resource/her-charge- Donnay, Professor Kristina Gemzell Danielsson, medical-abortion-and-womens-lives-call-action Dr Raffaela Schiavon, Professor Oladapo Alabi • IPPF’s Medical Abortion Commodities Database http:// Ladipo, Professor Michael Mbizvo, and Professor medab.org/ Hextan Yuen Sheung Ngan for providing technical • Self-care interventions communications toolkit https:// input and guidance as the lead reviewers. We are www.who.int/reproductivehealth/self-care-interventions/ also grateful to Seri Wendoh, Karthik Srinivasan, WHO-Self-Care-SRHR-Comms_Kit.pdf Manuelle Hurwitz, IPPF Programme Directors and • WHO consolidated guideline on self-care interventions other IPPF Member Association and Secretariat for health: sexual and reproductive health and rights colleagues for their input and review of this https://www.who.int/reproductivehealth/publications/ document. Finally, we gratefully acknowledge self-care-interventions/en/ the support from IPPF’s International Medical • Evidence-based information websites: www. Advisory Panel (IMAP): Dr Ian Askew, Anneka womenonweb.org, www.womenhelp.org, www. Knutsson, Dr France Anne Donnay, Professor safe2choose.org. Kristina Gemzell Danielsson, Dr Raffaela Schiavon, Professor Oladapo Alabi Ladipo, Professor Michael Mbizvo (Chair), Janet Meyers, and Professor Hextan Yuen Sheung Ngan for their valuable and timely guidance and reviews offered during the development process.

Who we are The International Planned Parenthood Federation (IPPF) is a global service provider and a leading advocate of sexual and reproductive health and rights for all. We are a worldwide movement of national organizations working with and for communities and individuals

IPPF 4 Newhams Row London SE1 3UZ United Kingdom

tel: +44 20 7939 8200 fax: +44 20 7939 8300 email: [email protected] www.ippf.org

UK Registered Charity No. 229476

Published June 2021

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(2016) ‘Provision of html (Accessed: 23 April 2021). harm-reduction services to limit unsafe abortion in Tanzania’, iv International Planned Parenthood Federation (2017) Gender International Journal of Gynecology and Obstetrics, 136, pp. 210- Equality Strategy. Available at: https://www.ippf.org/resource/ippf- 214 doi: 10.1002/ijgo.12035 2017-gender-equality-strategy (Accessed: 21 April 2021) xv Zurbriggen R., Keefe-Oates B., Gerdts C. (2018) v World Health Organization (2021) Social determinants of ‘Accompaniment of second-trimester abortions: the model health. Available at: https://www.who.int/health-topics/social- of the feminist Socorrista network of Argentina’, Elsevier determinants-of-health#tab=tab_3 (Accessed: 21 April 2021) Incorporated, 97 (2), pp. 108-115 doi: https://doi.org/10.1016/j. vi Pizzarossa L., and Nandagiri R. 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(2020) ‘Self-managed abortion: A systematic so much more than a provisional solution for times of pandemic’, scoping review’, Best Practice & Research Clinical Obstetrics & Sexual and Reproductive Health Matters, 28(1) doi: https://doi.org Gynaecology, 63, pp. 87-110 doi: https://doi.org/10.1016/j. /10.1080/26410397.2020.1779633 bpobgyn.2019.08.002 xxi Baiju N. et al. (2019) ‘Effectiveness, safety and acceptability xi Stillman M, et al. (2020) ‘Women’s self-reported experiences of self-assessment of the outcome of first-trimester medical using misoprostol obtained from drug sellers: a prospective abortion: a systematic review and meta-analysis’, BJOG, 126, pp. cohort study in Lagos State, Nigeria’, BMJ Open, 10(e034670), 1536-1544 doi: http://dx.doi.org/10.1111/1471-0528.15922 pp. 1-10 doi: http://dx.doi.org/10.1136/bmjopen-2019-034670 xxii Moseson H., et al. (2020) ‘Self-managed abortion: A systematic xii Tamang A., Puri M., Lama K., Shrestha P. (2014) ‘Pharmacy scoping review’, Best Practice & Research Clinical Obstetrics & workers in Nepal can provide the correct information about using Gynaecology, 63, pp. 87-110 doi: https://doi.org/10.1016/j. mifepristone and misoprostol to women seeking medication to bpobgyn.2019.08.002 induce abortion’, Reprod Health Matters, 22 (44 Suppl 1) ,pp. xxiii Remme M., et al. (2019) ‘Self-care interventions for sexual and 104-15 doi: https://doi.org/10.1016/s0968-8080(14)43785-6 reproductive health and rights: costs, benefits, and financing’, BMJ, 365 (l1228), doi: doi: https://doi.org/10.1136/bmj.l1228

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