April 2012 Making Abortion Services Accessible in the Wake of Legal Reforms: A Framework and Six Case Studies HIGHLIGHTS n This report examines the processes that followed passage of abortion law reforms in Cambodia, Colombia, Ethiopia, Mexico City, Nepal and South Africa and identifies a frame- work of activities that are essential to successfully implement less restrictive abortion laws. n Essential activities include strategic publicity of the change in the legal status of abortion; formulation and dissemination of detailed medical guidelines for the provision of legal procedures; introduction of legal abortion services; and development of data collection and monitoring systems to evaluate the level, quality and impact of these new services. n Campaigns to publicize the new abortion laws were undertaken in most of the six settings, but the scale and success of the dissemination efforts varied considerably. n The existence, scope and public availability of guidelines also vary across settings. The most comprehensive and widely available guidelines exist in Ethiopia and Colombia. n Limited health service infrastructures in all setttings have challenged the rollout of abortion services. Rollout has been relatively successful in South Africa, Ethiopia and Nepal, partly due to the support of international nongovernmental organizations. n The revised law in South Africa has been followed by a dramatic reduction in abortion-related maternal deaths. Some evidence suggests the incidence of abortion-related complications has declined in Ethiopia and Nepal. The narrow terms of the change in Colombia’s law preclude a notable impact on the incidence of abortion or related outcomes. Impact in Mexico City and Cambodia cannot yet be reliably assessed. n Other activities often required for successful implementation of new laws include establishing mechanisms for financing safe services and developing adequate responses to resistance to the new law. n Successful implementation of abortion law reform can take years, and requires ongoing commitment from government, providers and advocates for women’s health and rights. CONTENTS Introduction .................................................................................................. 3 Initiatives to Reform Abortion Laws .................................................. 3 Overview of Reform in Six Settings ................................................... 4 About This Report ................................................................................. 4 South Africa ......................................................................................9 A. The Country Setting ......................................................................... 9 April 2012 B. Legal Grounds for Abortion Under the Revised Law .................. 9 C. Guidelines and Their Dissemination ........................................... 10 Making Abortion Services Accessible in D. Creation, Availability and Uptake of Safe Abortion The Wake of Legal Reforms: A Framework Services ........................................................................................... 10 And Six Case Studies E. Impact of the Revised Law ............................................................ 11 Ethiopia ........................................................................................................ 14 Guttmacher Institute A. The Country Setting ....................................................................... 14 B. Legal Grounds for Abortion Under the Revised Law ................ 15 C. Guidelines and Their Dissemination ........................................... 15 D. Creation, Availability and Uptake of Safe Abortion Services ........................................................................................... 15 ACKNOWLEDGMENTS E. Impact of the Revised Law ............................................................ 16 Susheela Singh, Gilda Sedgh, Akinrinola Bankole and Mexico City ................................................................................................. 17 Rubina Hussain, all of the Guttmacher Institute, contributed A. The State Setting ............................................................................ 17 to this report, which was edited by Susan London, inde- B. Legal Grounds for Abortion Under the Revised Law ................ 18 pendent consultant. C. Guidelines and Their Dissemination ........................................... 18 D. Creation, Availability and Uptake of Safe Abortion The authors are also grateful for the extensive comments Services ........................................................................................... 19 offered by the following colleagues who reviewed the E. Impact of the Revised Law ............................................................ 21 manuscript: Jillian Henderson, University of California, San Colombia ...................................................................................................... 22 Francisco; Margaret Hoffman, University of Cape Town; A. The Country Setting ....................................................................... 22 Giselle Carino, Manuelle Hurwitz and Carrie Tatum, Interna- B. Legal Grounds for Abortion Under the Revised Law ................ 22 tional Planned Parenthood Federation; and Tamara Fetters C. Guidelines and Their Dissemination ........................................... 22 and Saba Kidanemariam, Ipas. Special thanks are also due D. Creation, Availability and Uptake of Safe Abortion to Alyssa Tartaglione and Michelle Eilers for their help with Services ........................................................................................... 23 data collection and preparing the manuscript. E. Impact of the Revised Law ............................................................ 24 This report was made possible by grants from the Dutch Nepal ............................................................................................................ 27 Ministry of Foreign Affairs and the John D. and Catherine T. A. The Country Setting ....................................................................... 27 MacArthur Foundation. B. Legal Grounds for Abortion Under the Revised Law ................ 27 C. Guidelines and Their Dissemination ........................................... 28 The Guttmacher Institute gratefully acknowledges the D. Creation, Availability and Uptake of Safe Abortion general support it receives from individuals and founda- Services ........................................................................................... 28 tions—including major grants from The William and Flora E. Impact of the Revised Law ............................................................ 30 Hewlett Foundation, The David and Lucile Packard Founda- Cambodia..................................................................................................... 32 tion and the Ford Foundation—which undergirds all of the A. The Country Setting ....................................................................... 32 Institute’s work. B. Legal Grounds for Abortion Under the Revised Law ................ 32 C. Guidelines and Their Dissemination ........................................... 32 D. Creation, Availability and Uptake of Safe Abortion Services . 32 E. Impact of the Revised Law ............................................................ 33 Conclusions ................................................................................................ 36 Key Findings ......................................................................................... 36 Public Awareness of Changes in the Law ................................................. 36 Guidelines and Their Dissemination ........................................................... 36 © Guttmacher Institute, 2012 Creation and Uptake of Safe Abortion Services ...................................... 36 Suggested citation: Guttmacher Institute, Making Abortion Impact of the Revised Law ........................................................................... 37 Services Accessible in the Wake of Legal Reforms: Additional Insights .............................................................................. 38 A Framework and Six Case Studies, New York: Guttmacher Safe Abortion Service Costs ........................................................................ 38 Institute, 2012, <www.guttmacher.org/pubs/abortion- Role of International Stakeholders in Implementation Efforts ............... 38 services-laws.pdf>. Countering Resistance to Reform ............................................................... 39 Recommendations .............................................................................. 39 www.guttmacher.org References .................................................................................................. 41 Introduction Induced abortion* has been legal on broad grounds in meetings of reproductive rights activists; advocacy cam- most of the industrialized world† since the early 1970s or paigns using mass communications to mobilize public longer. However, the legal status of abortion in the devel- opinion; coalition building; and the development of innova- oping world is mixed, and interpretation of existing laws tive, human rights–based litigation strategies. varies. As of 2008, 47% of women of childbearing age in Although successful campaigns to revise abortion laws the developing world lived in countries that banned the or penal codes are well documented, somewhat