Transcript Applying the WHO Strategic Approach to Unsafe Abortion in
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.D
Senior Research and Evaluation Adviser for the Africa Region, Ipas
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Summary
Conceptual framework Global examples Location Background WHO Strategic Approach
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Conceptual framework
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Global experiences Applying the WHO Strategic Approach (Case studies)
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Methods
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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)
SRHR Challenge: Unsafe Abortion
WHO Strategic Approach
STAGE I STAGE II Developing and Testing Interventions STAGE III Scaling-Up to increase capacity and impact Improved policies, programmes, and health status Policy & Programme Strengthening
Strategic Approach: conceptual framework
RH Status, User Perspectives, Gender PEOPLE SERVICES Policies, Programmes, Access, Availability, Quality of Care TECHNOLOGY Availability, Characteristics Social, Cultural, Political and Resource Contexts
Countries applying the WHO Strategic Approach to abortion
AFRO
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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 chronology Locations of case studies
Generalities
Senegal
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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
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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 chronological Background
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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
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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.
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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
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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
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Government officials Representatives of international organizations NGO officials Politicians
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Parlimentarians, Regional Elected officials, Mayors Professionals and Ministries
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Health,
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Education, Judicial authorities, Police and Administrators Religious leaders, Youths Family and women’s affairs Community members
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Traditional authorities
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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
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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
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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?
Operational research Development/revision of standards and guidelines Harmonize training curricula with standards and guidelines Service delivery expansion Health provider training Strengthening quality of care, including introduction of new technologies (MVA and MA) Registration of mifepristone and misoprostol Technical support for legal reform
What has followed the strategic assessment?
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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
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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
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Manga fis
Malawi
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