International Interdisciplinary colloquium: “Reduction of Maternal Mortality in sub-Saharan

Africa: better understanding for better action” (Dakar, 13-16 Dec 2010)

Applying the WHO Strategic Approach to Unsafe Abortion in Malawi and Senegal

Paschal Awah, Ph.DSenior Research and Evaluation Adviser for the

Africa Region, Ipas

Summary• Conceptual framework• Global examples• Location• Background• WHO Strategic Approach

– Conceptual framework– Global experiences

• Applying the WHO Strategic Approach (Case studies)– Methods– Findings

• What has followed the strategic assessment• Ongoing actions• Recommendations• Conclusions

International Interdisciplinary colloquium: “Reduction of Maternal Mortality in sub-Saharan Africa: better understanding for better action” (Dakar, 13-16 Dec 2010)

WHO Strategic Approach

Strategic Assessment

Policy & Programme Strengthening

Developing and Testing

Interventions

Scaling-Up to increase

capacity and impact

STAGE I

SRHRChallenge:

Unsafe Abortion

Improved policies,

programmes, and health

status

STAGE II STAGE III

Social, Cultural, Political and Resource Contexts

PEOPLE

SERVICES TECHNOLOGYAvailability,

CharacteristicsPolicies, Programmes,

Access, Availability, Quality of Care

RH Status, User Perspectives, Gender

Strategic Approach: conceptual frameworkStrategic Approach: conceptual framework

Countries applying the Countries applying the WHO Strategic Approach WHO Strategic Approach

to abortionto abortion

AFRO– Ghana (2005); Zambia (2008); Malawi (2009); Guinea (2009); Senegal

(2010)EURO– Romania (2001); Moldova (2005); Macedonia (2007); Ukraine (2008);

Russian Federation (2009); Kyrgyzstan (2011)SEARO– Bangladesh (2002)

WPRO– Viet Nam(1997); Mongolia (2003)

Conducting a strategic assessment• Preparation• Planning workshop • Team training• Fieldwork• Dissemination, generation of stakeholder

consensus for action, donor engagement

Map of Africa

Strategic Approach chronologyLocations of case studies

GeneralitiesSenegal

• Population: 12,534,228 • French speaking• Restrictive laws• Main religion: Islam• High Maternal mortality: 401/100

000 live births• Unsafe abortion: 3.6%, 50% of

gynecological admissions at maternities

• Ratified all treaties and conventions related to SRH Rights

• Reproductive health law• Badjeu Gon – President Wade’s

Initiative

Malawi• Population: 15,263,417 • English Speaking• Restrictive law• Main religion: Christianity• High maternal mortality:

807/100 000 live births• Unsafe abortion: 24%• Ratified all treaties and

conventions relation to SRH Rights

• President Banda intends to set up a similar initiative in Malawi

Ratified International human rights agreements, promoting reproductive health for Senegalese and

Malawian women

• Several agreements ratified by Senegal and Malawi contradict the countries’ current policies and law on abortion notably:

– Strategic Action 5.1.2 of the African Union Commission's Maputo Plan of Action (2006) which calls on governments to "Enact policies and legal frameworks to reduce incidence of unsafe abortion".

– Article 14 of the Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa (2003), ratified by Senegal and Malawi in 2005

Strategic Approach chronologicalBackground

Senegal• 2008 – Request of MOH at

regional meeting in Bamako• Hope of generating a

strategy to address what is certainly the most sensitive and neglected component of maternal mortality -- unsafe abortion.

• 2008 - Sally Workshop• 2010 - Strategic Assessment

Malawi• 2008 – Request of MOH at African

Union MOH meeting• Hope of generating a

strategy to address what is certainly the most sensitive and neglected component of maternal mortality -- unsafe abortion.

• 2009 - Lilongwe Planning workshop

• 2009 – Strategic Assessment• 2009 - Magnitude study

Methods

Senegal• Field work (25 to 12

May 2010) by a team of 28 members representing governmental bodies (MOH), civil society and non- and inter-governmental organizations.

Malawi• Field work (14 to 27

June 2009) by a team of 24 members representing governmental bodies, human rights groups and non- and inter-governmental organizations.

Methods

Senegal• In-depth interviews and

focus discussions conducted among 785 people in all regions in the northern, central and southern regions in urban and rural areas.

• Sampling• Purposive using the

snowball approach

• Analysis: Thematic

Malawi• In-depth interviews and

focus discussions conducted among 485 people in 10 districts in the northern, central and southern regions in urban and rural areas.

• Sampling• Purposive using the

snowball approach

• Analysis: Thematic

Research participants• Government officials• Representatives of international organizations • NGO officials• Politicians

– Parlimentarians, Regional Elected officials, Mayors• Professionals and Ministries

– Health, – Education, – Judicial authorities,– Police and Administrators– Religious leaders,– Youths– Family and women’s affairs

• Community members– Traditional authorities– Initiators– TBAs– Sex workers– Women– Men– Adolescents

Findings

“An ongoing dialogue about unsafe abortion has started. The taboo on

this issue has been finally lifted”

Strategic assessment dissemination workshop

Senegal Malawi

Keys Findings• There is a high rates of:

– Rape, incest, unwanted pregnancies and infanticides• High rates of unsafe abortions

“When a woman decides that she does not want a pregnancy, she will do anything to terminate that pregnancy”

(Key informant in the South Malawi)• High rates of maternal deaths resulting from unsafe

abortions• The Abortion Law is the major barrier to access to safe

abortion• The misunderstanding of religious text is another barriers

to safe abortion

Key findings

• SRH services (PAC/FP/YFS/EC) are not adequately set up• Irrespective of the restrictive Law on abortion, abortion is widely

practiced in most places visited in Senegal and Malawi• Women, especially poor and young women don’t have access to

and or Information on SRH (Contraception/Safe Abortion)“If you are poor, your voice is nothing. Pregnancy is a death

sentence to the poor people. We are looking for change. Rich or poor, we should have access to abortion. If government liberalized the abortion law, our girls would be in school.”

Interview with four tribal authorities, Southern Region of Malawi

• There is a high ignorance of the full extend of the existing law

Keys Findings• Women are not empowered to autonomously make

Informed Reproductive Health Choices (Inequality in decision making)

• A majority of communities want revisions of the Abortion Laws to include rape and incest

Ils l’acceptent maintenant. Les femmes doivent être sensibilisées sur l’existence de l’avortement légal, c’est un pas vers l’autorisation de l’avortement. La procédure est lourdes il faut l’alléger, il faut donc responsabiliser les médecins pour facilité l’avortement thérapeutique. (Autorité judiciare, Senegal)Si la grossesse n’a pas atteint la 13éme semaine, l’interruption volontaire de grossesse peut être réalisée. (Leadeur communautaire, Dakar)C’est assez délicat, donc à manier avec prudence. Pour le viol et l’inceste, on pourrait l’autoriser ; En dehors je ne suis pas d’accord. Une autorité à Dakar

Key findings

• There is no concept of safe abortion – All abortions happening are unsafe because of the law and because of the ignorance of application of the provision to safe a woman’s life when it is in danger.

International Interdisciplinary colloquium is Monday, November

15th,2010

What usually follows a strategic assessment?What usually follows a strategic assessment?

Operational researchDevelopment/revision of standards and guidelinesHarmonize training curricula with standards and guidelinesService delivery expansionHealth provider trainingStrengthening quality of care, including introduction of new technologies (MVA and MA)Registration of mifepristone and misoprostolTechnical support for legal reform

What has followed the strategic assessment?

Senegal• Holding of an advocacy

workshop• Formation of a taskforce• Development of plans of

action

Malawi• Formation of an advocacy

group• Training of Journalist on

advocacy• Development of a plan of

action

Recommendations

• Revise the abortion laws to harmonise with its international treaty agreements under the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa which states “ Protect the health of a women by providing safe abortion services in case of sexual assault, rape, incest and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus ”

Recommendations• Revise the Standards and guidelines so that

Comprehensive Abortion Services can be implemented to the full extent of the law in harmony with the National SRH&R Policy.

• Training, mentoring and support supervision of health services providers to provide comprehensive FP and abortion services within the full extent of the law.

Ongoing actions

Senegal

• Taskforce will carry the agenda of informing women and adolescents and policy makers on setting up comprehensive RH services

Malawi

• Coalition for Prevention of Unsafe Abortion being established (hosted by WILSA)

• COPUA will push for reform of the law, based on ratification of the Maputo Protocol

• Improve procurement and distribution of MVA and misoprostol for emergency treatment of abortion complications

International Interdisciplinary colloquium: “Reduction of Maternal Mortality in sub-Saharan Africa: better understanding for better action” (Dakar, 13-16 Dec 2010)

General conclusion• International treaty agreements on human rights signed

and ratified by Senegal and Malawi are unknown at community level, technical level and even among most policymakers.

• These treaty agreements often conflict with national laws and norms on sex, contraception, pregnancy and abortion.

• The Protocol on the Rights of Women in Africa has the strongest statement on safe abortion, and is the international agreement in greatest conflict with Senegal and Malawi current laws on termination of pregnancy.

General conclusion• Many countries have successfully reduced

abortion-related mortality through revising and liberalizing their abortion laws and providing good access to safe, comprehensive abortion services.

• Revision of the current law on termination of pregnancy is required for achieving the ultimate goal of eliminating unsafe abortion and its related morbidity and mortality in Senegal and Malawi.

Acknowledgement

• I acknowledge WHO for producing this model and Dr Ronnie Johnson and Peter Fajans (all of WHO) for their previous presentations of this model

• Ipas acknowledges the involvement of WHO and UNFPA in the planning and support of the strategic assessments in both Senegal and Malawi

Senegal

•Manga fisMalawi

•Zikoma