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This is the published version of a paper published in The Lancet Global Health.
Citation for the original published paper (version of record):
Cleeve, A., Oguttu, M., Ganatra, B., Atuhairwe, S., Larsson, E C. et al. (2016) Time to act-comprehensive abortion care in east Africa.
The Lancet Global Health, 4(9): e601-e602
http://dx.doi.org/10.1016/S2214-109X(16)30136-X
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Time to act—comprehensive abortion care in east Africa
Inaccessible sexual and reproductive health carecontinues to be a major obstacle to women’s health and a violation of their rights.1 Access to comprehensive
abortion care—comprising induced abortion and post-abortion care, including contraceptive services2—is
fundamental to avert preventable maternal mortality and morbidity.1,3 In east Africa, abortion rates have not
declined since 1990 and about 2·7 million abortions are estimated to occur annually in this region.4 The vast
majority of these abortions are unsafe, making them a major cause of maternal mortality and morbidity. A workshop was organised in Kampala, Uganda, in March, 2016, to address the challenges of implementation and expansion of access to comprehensive abortion care in east Africa. Workshop participants included researchers from teaching institutions and health-care providers from Kenya, Uganda, and Sweden, members of the Uganda Ministry of Health, WHO, the International Federation of Gynecology and Obstetrics working group on the prevention of unsafe abortion, representatives of non-governmental organisations and aid organisations, and journalists. Although the workshop focused on Uganda and Kenya, delegates also presented research from Tanzania and Rwanda. Here we summarise key action points needed to speed up implementation and expand access to comprehensive abortion care in east Africa, as identifi ed by the workshop delegates.
Kenya and Uganda have restrictive abortion laws dating from the time of British rule. In both countries the constitution and penal code are not harmonised, leaving room for ambiguous interpretation of the legal environment.5,6 Standards and guidelines on reduction
of morbidity and mortality due to unsafe abortion were developed by the respective ministries of health
in Kenya in 2012,7 and in Uganda in 2015.8 These
standards and guidelines were an expansion of existing national policies and standards and the 2012 WHO Technical Guidance on Safe Abortion,9 supported by the
constitutions. However, the standards and guidelines were withdrawn in Kenya in December, 2013, and in Uganda in January, 2016, because of disagreements between stakeholders regarding their content. Absence of clear standards and guidelines specifi c to comprehensive abortion care leaves vital questions on health-care access and provision—such as roles,
eligibility, and responsibility—unanswered. At the time of the workshop, discussions between the Ugandan Ministry of Health and stakeholders were ongoing, including eff orts to bring religious leaders who opposed the standards and guidelines to the table. Meanwhile, in Kenya, the withdrawal of the standards and guidelines was being petitioned in court by civil societies.
Delegates emphasised the urgent need for a consensus regarding the standards and guidelines among stakeholders in Kenya and Uganda. In addition, a common interpretation of the legal environment was considered crucial, and therefore the constitution and penal code would need to be harmonised in both countries. In east Africa, the shortage of health-care providers trained in comprehensive abortion care is severely restricting women’s access to care, and thus updated in-service comprehensive abortion-care training and quality pre-service training is imperative. Eff orts to expand access to comprehensive abortion care through task sharing or shifting should also be prioritised, as they have been shown to be safe, eff ective, and highly acceptable to women.10 The harm reduction
model, already in use within some settings in east Africa, was acknowledged as an important strategy to prevent unsafe abortions. The delegates also emphasised the opportunity for prevention of unintended pregnancies, which comprehensive abortion care entails. However, quality improvement of contraceptive services is needed to increase use of eff ective methods and ensure informed decision making. Quality comprehensive abortion care is also dependent on factors such as availability of misoprostol and eff ective contraceptives, known to be heavily aff ected by stock-outs in Kenya and Uganda within public facilities. Stock-outs at national dispensaries are unacceptable and should be addressed alongside the control of counterfeit misoprostol. Sensitisation and support for misoprostol and addressing of misconceptions at community, health-care, and decision-making levels were recognised as central to the implementation process.
Young women in particular struggle to access comprehensive abortion care, and delegates stressed that stigma and insuffi cient youth-friendly services across the east African region both need to be addressed. Abortion stigma continues to restrict comprehensive
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abortion-care access and impair the quality of existing services, highlighting the need for stigma reduction measures such as values clarifi cation. Comprehensive abortion-care providers were described as sometimes perpetuating stigma but also as targets of stigma and police harassment. Local human rights organisations providing legal support—and increasing awareness of the right to health—therefore play an important role in the move towards universal comprehensive abortion-care access. For implementation to be successful, faith-based organisations, civil society organisations, and the media should be engaged. Advocates for change need to come together, creating alliances and networks, and campaigning for the right to safe, high-quality sexual and reproductive care. Finally, comprehensive abortion care should be advocated as an indivisible component of women’s sexual and reproductive health care and rights, and a crucial strategy in reduction of gender inequality and social inequity.
*Amanda Cleeve, Monica Oguttu, Bela Ganatra, Susan Atuhairwe, Elin C Larsson, Marlene Makenzius, Marie Klingberg-Allvin, Mandira Paul, Othman Kakaire, Elisabeth Faxelid, Josaphat Byamugisha,
Kristina Gemzell-Danielsson
Department of Women’s and Children’s Health (AC, ECL, MK-A, KG-D) and Department of Public Health Sciences/Global Health (MM, EF), Karolinska Institutet, Stockholm, Sweden; Kisumu Medical and Education Trust, Kisumu, Kenya (MO); WHO, Department of Reproductive Health and Research, Geneva, Switzerland (BG); Department of Obstetrics and Gynecology, Mulago Hospital, and Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda (SA, OK, JB); Department of Women’s and Children’s Health/IMCH,
Uppsala University, Akademiska University Hospital, Uppsala, Sweden (ECL, MP); WHO Center for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden (AC, KG-D); School of Nursing, College of Health Sciences, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya (MM); and School of Education, Health and Social Studies, Dalarna University, Falun, Sweden (MK-A)
amanda.cleeve@ki.se
We declare no competing interests. BG is employed by WHO. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affi liated. The Swedish Research Council funded this workshop. The funding source were not involved in the workshop design, content, organisation, or any other aspect pertinent to the workshop or this article. We thank all the workshop participants for their contributions.
Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-CD license.
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