Signs of progress in the ‘complicated reality’ of abortion in Zambia
Abortion is legal in Zambia, but as the authors of a new study note, “the reality is far more complicated.” Very few women know they have the right to have an abortion or know where to seek this care. Unsafe abortions have caused unnecessary deaths in Zambia, even among women who have the right to a safe and legal abortion.
With the goal of introducing and scaling up abortion services in Zambia, the Ministry of Health, the University Teaching Hospital and Ipas created a two-year intervention to introduce medical abortion (abortion with pills) and to address the lack of understanding and implementation of the national abortion law.
The study, published in the journal Reproductive Health, used an implementation science model to evaluate the intervention and glean findings from it. It concludes that the project, which helped more than 13,000 women get care, could serve as a national model for other countries seeking to bring safe and legal abortion services to scale. The study was carried out by researchers at Ipas, the Zambia School of Medicine, and the University of North Carolina, Chapel Hill.
Tamara Fetters, a senior research advisor for Ipas and the study’s lead author, says the Zambia experience offers important lessons for other countries. “It shows that you can successfully tackle a difficult issue by involving a wide range of local stakeholders and using evidence to guide policymaking,” she says.
The intervention involved the provision of comprehensive abortion care services in 28 public health facilities (seven hospitals and 21 health centers) over a two-year period, August 2009 to September 2011. It focused on three main areas:
- Building health worker capacity in public
facilities and introducing medical abortion. Ipas and partners trained
128 providers to provide treatment for unsafe abortion (postabortion
care) and to provide safe and legal abortion services at low or no cost.
Medical abortion and manual vacuum aspiration (MVA) supplies were
provide to each site.
- Working with pharmacists to provide improved
information on medical abortion. Pharmacy workers were trained to
respond in a more compassionate manner, to provide more accurate
information, and to provide referral information to women seeking safe
- Engaging with communities to increase knowledge of abortion services and rights through stronger health system and community partnerships. Planned Parenthood of Zambia (PPAZ) and several community-based organizations conducted outreach activities—including radio and community theater projects – to provide community members with information about the abortion law. By speaking more openly about the need for reproductive choices in Zambia, they hoped to reduce abortion stigma.
Results and ongoing challenges
By the end of the intervention, 25 sites had provided abortion services, providing care for more than 13,000 women. All providing facilities had managers supportive of continuing legal abortion services, and the percentage of pharmacists at neighboring pharmacies offering misoprostol for purchase increased from 19 percent to 47 percent. By the end of the project, there was more attention being paid to safe abortion issues on a national level and more research on abortion. In addition, 25 of the original 28 intervention sites are still providing care where services are technically provided free or at low cost.
However, Fetters says, the evaluation revealed an ongoing problem with stigma on both the provider and client sides. While a majority of providers trained during the intervention said they personally supported the provision of abortion services, in 80 percent of the facilities, there were other health personnel who said they would oppose expansion of abortion services. In addition, just 11 of the 28 facilities had the same intake procedures for abortion as for other services, suggesting that abortion was still being treated as a “different and more shameful kind of service” than other medical care.
“In too many instances, abortion is not seen as an integral part of maternal health care,” says Fetters. “More effort is needed at the community level to address abortion stigma and, within the public health system, more work is needed to integrate abortion services into the rest of the services.”
Important roles for pharmacists and mid-level providers
The study shines light on the important roles that mid-level providers (such as midwives) and pharmacists can play in helping to provide and scale up abortion services. The study found that mid-level providers can be successfully trained to provide safe abortion care and recommends that the Zambian law be amended to allow them to provide services without physicians’ signatures.
It also found that pharmacists can be “partners in the provision of medical abortion.” By the end of the intervention period, all of the participating pharmacists and pharmacy workers agreed that they should provide information on safe abortion to women who request it. In addition, the percentage offering to sell abortion pills or provide women with information about medical abortion increased from 46 percent to 66 percent of mystery client interactions over the course of the intervention.
While the study found that the intervention had improved access to abortion care, Fetters and her co-authors say that much more work remains to be done to ensure that levels of care remain high, that access continues to grow and that the deep-rooted stigma hindering women’s access to care is replaced with concern for putting women’s lives first.
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