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Danish Ministry of Foreign Affairs
Report from the conference:
The conference gathered 50 delegates from 15 countries and gave them a possibility to critically assess what is known and what needs to be done to further advance midlevel health professionals as providers of comprehensive, high-quality abortion care.
The main objectives with the conference were 1) to review existing experiences, data and policies related to the provision of abortion care by midlevel providers (MLPs), 2) to discuss and evaluate facilitating factors and barriers to the involvement of MLPs in abortion care services, and 3) to draw up recommendations for future research, programmatic and policy activities in selected countries.
Focusing on objective 1, ten countries (Bangladesh, Zambia, India, Cambodia, Kenya, Mozambique, South Africa, Sweden, United States, and Vietnam) had prior to the conference written a country report, which highlighted the abortion situation in their respective countries. The country reports were presented and the individual country’s experiences were discussed.
Regarding objective 2 and 3 to further address the involvement of MLPs in abortion care service, discussions, focusing on facilitating factors as well as barriers to the involvement of MLPs, were carried out in smaller workgroups. The main issues raised during these discussions were used as an inspiration in drafting a set of recommendations focusing on how to advance the roles of MLPs in abortion care.
In conclusion, the conference offered a unique possibility for delegates with a sincere interest in addressing the problem of unsafe abortion to gather and discuss their experiences. It has also led to the establishment of a network "Expanding Access", which will create the possibility for further discussions and which will facilitate collaboration across country borders. The conference highlighted the need of making abortion service accessible and available at the most local level possible. To achieve this, MLPs should be involved and their scope of practice expanded to include services that are now provided mainly by physicians.
Framework of the conference
In many countries, however, abortion and abortion care are still inaccessible due to administrative, practical, and historical standards. Incomplete abortion has traditionally been treated by physicians in tertiary level hospitals, even though these sites are inaccessible to the vast majority of people in the developing world, particularly poor and rural women. Primary-level health facilities, which may be more conveniently located than hospitals, are likely to be staffed by a midlevel professional such as a midwife or clinical officer, but these providers are rarely trained, authorized, or equipped to provide abortion or postabortion care services. Consequently, in countries where abortion is legalised (e.g. Zambia and India) many women are still without access to safe legal abortion and are instead resorting to clandestine and unsafe procedures. In addition in countries where abortion is still restricted by law there is only limited access to qualified postabortion care service.
In order to bring abortion related services closer to women there seems to be a need of advancing the role of midlevel providers (midwives, nurses, clinical officers, physician assistants, family welfare visitors and others) in the management of abortion and postabortion care.
It was within this framework the conference: "Expanding Access: Advancing the role of Midlevel Providers in menstrual Regulation and Elective Abortion care" was held 2-6 December 2001, in South Africa. The conference was organised by Ipas (USA) and IHCAR (Sweden). Financial support was provided by Sida, NORAD, Danida, the David and Lucile Packard Foundation, and the Swedish Foreign Office.
The conference gathered 50 delegates from 15 countries to critically assess what is known and what needs to be done to further advance midlevel health professionals as providers of comprehensive, high-quality abortion care
The main objectives with the conference were:
Support from governmental level is crucial when discussing access expansion as well as advancing the roles of MLPs in abortion care, since it is often local laws and policies that regulate what training is available and what service MLPs can or are allowed to provide. An increasing number of governments have become committed to deal with the need of reproductive health services as well as the problem of unsafe abortion since the International Conference on Population and Development (ICPD) 1994. The presence of The prime minister of Government of Mozambique, Dr Pascoal Manuel Mocumbi as inaugural speaker at the conference, served as an example of a government which acknowledge the challenge of delegating responsibilities to MLPs in order to better address the problems associated with high levels of maternal morbidity and mortality.
In his speech, the prime minister emphasised that he saw the roles of midlevel providers in menstrual regulation (MR) and elective abortion care as part of the efforts underway worldwide to implement the ICPD commitments to reduce the maternal morbidity and mortality rates. He also stressed that lack of skilled attendants is one of the reason why developing countries account for high numbers of maternal deaths.
He then shared the experiences from Mozambique, where the number of abortion complications has fallen dramatically due to a pragmatic interpretation of the law, which allowed abortions to be performed at public hospitals in 1981. The ministry of health in Mozambique is paying great attention to MLPs role in illegal abortion, many MLPs are known to be practising illegal abortions and the ministry of health wants to improve MLPs performance in order to make these abortions safer.
In order to improve the situation further in Mozambique, the prime minister suggested more readily available contraception and extension of hospital-based services for pregnancy termination to district and rural hospitals throughout the country. The government of Mozambique is working on making MR and elective abortion care available for all women. In order to achieve this in a cost effective way, emphasis was put on the need of training of MLPs.
Objective 1, Review of existing experiences, data and polices related to the provision of abortion care by MLPs
The conference offered an opportunity for country representatives from 15 different countries with quite diverse abortion laws, ranging from supportive to prohibitive, to share and discuss their experiences in relation to abortion service and post abortion care. They had prior to the conference written a country report, which highlighted the situation in their respective countries. Each of these reports were presented at the conference and the individual countries experiences were discussed in plenum.
The presentation of country reports was divided in to three themes or sessions: Access to abortion service, Quality of abortion care, and Health systems and policy strategies.
Session 1 Access to abortion services by midlevel providers
In this first session focus was placed on the involvement of MLPs in elective abortion care and post abortion care as mean to enhance access to abortion service. Experiences from Mozambique, Vietnam and Kenya were shared.
Mozambique Expanding access when resources are scare and doctors few
Mozambique is quite a unique example; according to the law induced abortion is only legal in order to preserve the woman’s physical or mental health. However, in spite of the law, the government has addressed the problem of complications from unsafe abortions, by allowing public hospitals to offer abortion care and allowing space for comparative studies on illegal and legal abortions to be carried out. Prosecutions of persons who have been involved in illegal abortion are extremely rare and providers are discussing openly the issue of induced abortion. It can be argued that in spite of the law, an illegally induced abortion has become a decriminalized intervention in Mozambique. Many women, however, still fear the law and avoid attending the public hospitals to have an induced abortion. Instead they resort to clandestinely abortions, which often are performed unsafely.
The government prioritizes on a cost-benefit basis, aiming at reducing the high rates of morbidity and mortality at minimal costs. The cost of training doctors is ten times or more than that of training MLPs, in addition doctors tend to move away from rural areas. To address these economical and staffing constraints, great emphasis are placed on role of MLPs, also when it comes to offering safe abortion services. In addition the Ministry of Health is aiming at creating conditions, which may improve MLPs performance, e.g. by making medical methods for pregnancy termination easily available.
Viet Nam: Decentralization of abortion services: Midwives & assistant doctors providing abortion care
Abortion has been legal and available on request in Vietnam since 1960. The country has one of the highest abortion rates in the world, an estimated 40-50 percent of all pregnancies are terminated by an induced abortion. The high number of induced abortions are due to mainly three factors i) counseling and provision of contraception is limited, ii) postabortion counseling is inadequate resulting in many repeat abortions, iii) the cost for an induced abortion is often lower than the cost of contraceptives.
In order to increase access to abortion care, private providers were in 1989 permitted to perform induced abortion and in 1993 midwives and assistant doctors were allowed to perform abortions up to six weeks of gestation. Consequently abortion services in Vietnam are now widely available.
There are still some factors, however, which limits Vietnamese women’s access to safe abortion care: i) Equipment for abortion services are not available in all health facilities, especially not at the communal level, ii) The quality of abortion service in the private sector is not well controlled, resulting in unsafe abortions performed by unskilled providers, iii) the midwives and assistant doctors are often trained inadequately and there is a need of refreshing their knowledge and skills from time to time.
Kenya: Expanding access to abortion services through postabortion counseling and linking public and private providers
The Kenyan law restricts abortion except to save the life of the woman. As a consequence of the law, unsafe clandestine abortions are common and women suffering complications constitute a significant proportion of the gynecology ward admissions. In order to address the problem of unsafe abortions, post abortion care (PAC) services have increasingly become available, although mainly at referral hospitals in urban areas.
As part of the government’s overall plan to decentralize health care management, the Kenyan Ministry of Health has in the past decade allowed the licensing of MLPs for private practice. As a result the number of private health facilities has increased dramatically. Midwives working in primary health care and maternity/nursing homes are responsible for a wide range of reproductive health services and in 1997 their duty responsibilities were expanded to also include PAC service. The midwives performance as PAC providers has been tested in several pilot projects. The evaluation of these projects has demonstrated that MLPs could offer PAC services efficiently, competently, and save women’s life. The results have been incorporated in the Ministry of Health’s 1997-2010 Reproductive Health Strategy, which calls for an expansion of the role of MLPs, notably in PAC.
In spite of the well-documented effect of involving MLPs in PAC services, the service is only available in five of the countries eight provinces. In addition PAC services is mainly available at referral level. In order to also make PAC service available for women living in communities in the semi-urban and rural areas, there is need of involving and training MLP in these areas in performing PAC service.
Furthermore the involvement of MLPs in providing PAC service may also raise an opportunity to expand service provision to safe abortion services when the legal constraints are removed.
Session 2 Quality of abortion care: from client and health system perspectives, what are the roles of midlevel providers in improving abortion care
This session focused on MLPs role in improving quality of abortion care. South Africa, Bangladesh, and Sweden are all countries where MLPs role in abortion care and MR have been acknowledged and were the acknowledgement has increased the quality of care offered, especially in terms of accessibility. However, in spite of supportive laws and the involvement of MLPs in abortion care and MR, South Africa and Bangladesh still have problems in providing all women with access to safe abortion and MR and thus unsafe abortions are still a frequent problem in these countries.
South Africa: Successes and challenges in quality of care
The Termination of Pregnancy Act was introduced in South Africa in 1997, permitting termination of pregnancy upon request of the woman up to and including 12 weeks of gestation. This implies that all women in South Africa, irrespective of age, socio-economic status, race or location could have access to early, safe and legal termination of pregnancy.
When implementing the law, activists, policymakers and health care providers recognized that a liberal law alone did not guarantee the creation of high quality abortion services accessible to all women. Therefore steps were taken to allow registered midwives to provide abortion and post abortion care services.
In theory induced abortion should be available at primary health care level all over the country. In practice, however, the majority of legally induced abortions are performed at secondary centers located in urban areas. Since the service is still not easily accessible for all women, illegally induced abortions are still a prevailing problem in South Africa.
Four year after the implementation of the new act, different evaluation studies were performed. The conclusions of these studies were that there still was an unmet need of access to safe, legal abortions. In order to meet this need, it has been suggested that more MLPs should be trained in performing pregnancy terminations and the service should increasingly be offered at primary health care level. In addition there also seems to be a need of changing the judgmental views on abortion (negative attitudes from hospital management as well as colleagues). Hence, it is anticipated that greater acceptance of abortion among health managers, providers and community members will help assuring women access to safe, induced abortion.
Bangladesh: Access to menstrual regulation in low resource settings: Family Welfare Visitors as service providers
In Bangladesh, induced abortion is restricted by law and is only permitted to save the life of the pregnant woman. Despite the restrictive law, however, MR is available as a public health measure to reduce the number of unsafe abortions. According to the law, MR is considered a part of the family planning program and as such should be available for all women. Currently 8,000 doctors and 6,500 MLPs have been trained on MR. MR can be performed by vacuum aspiration, within eight weeks of gestation, on an out patient basis by a trained MLP. In the 9-12 week period, only doctors are allowed to perform MR.
Family welfare visitors (FWV) are an important provider of MR services, especially in the rural areas. They work on household level in villages. Each FWV serves a population of 5,000-6,000 and they provide family planning and antenatal care by organizing satellite clinics.
In spite of the widespread availability of MR services, utilization of MR remains low and unsafe abortions is still a predominant problem. There are different reasons for this, firstly, MR is not discussed openly and many women are not aware of their legal rights to have a pregnancy terminated by MR. Secondly, many women are not aware of the fact that MR performed by an MLP is only available up to 8 weeks of gestation. If the woman is pregnant above 8 weeks, the procedure has to be performed by a doctor, who works in larger centers at district level, making the service less accessible to rural women. It has been documented that nearly one-third of women seeking MR service are rejected, mainly because they were pregnant above 8 weeks of gestation.
In Bangladesh, significant access to termination of pregnancy has been achieved despite illiberal laws. Most actors and advocates are content with current MR regulations. Improved quality and accessibility of MR are the issues to be addressed in Bangladesh rather than the legality of abortion service.
Sweden: Medical abortion by midwives; consequences for quality of care
According to the Swedish Abortion Act from 1974, a woman is entitled to have a pregnancy terminated until the end of 18th week of pregnancy without stating any reason for it, provided she is living in Sweden and the abortion is performed at a public hospital by a qualified medical doctor.
In Sweden, the vast majority, 93%, of induced abortions are first trimester abortions. In 1999, 36% of all first trimester abortions were medically induced, whereas the rest were performed by vacuum aspiration. In theory only physicians are allowed to perform abortion, however nurse midwives have increasingly become involved in counseling and care during medical abortions and in some areas they are also delegated the right to administer the drugs. Programs for management of medical abortion have now been developed and in most areas the care has gradually been converted from doctors to nurse midwives. Of about 5000 midwives in maternal health, an estimated 200-300 is today providing medical abortion and/or post abortion care.
The conditions in Sweden have been favorable in terms of involving nurse midwives more active in medical abortions. This is due to the fact that nurse midwives with special training since many years have been the main providers of contraceptive service in Sweden and they are used to prescribe oral contraception and insert IUDs.
Regarding the quality of care, abortion services offered by midwives have been of high quality and have been well received by the women. Midwives are trusted by the women, they are willing to listen and easy to reach in case of complications. Midwives have also since long been involved in IEC (information, education, communication), which is an advantage when they are counseling and providing care in relation to medical abortion. In addition midwives, who are providing medical abortions, have actively chosen to be involved in abortion care, it can therefore be expected that they consist a highly motivated and devoted group of providers.
Session 3 Health systems and policy strategies: overcoming barriers to MLPs providing abortion services
The third session focused on how various barriers towards the involvement of MLPs in abortion services could be overcome. An extension of the cadres of healthcare providers who can offer abortion care requires individuals and groups like midwives, physicians, women’s health activists, NGOs, community members and others who work for and motivate a change in the established policy and practice. In this session experiences from Zambia, India and USA were presented.
Zambia: Bridging the policy – service delivery gap?
Zambia has one of the most liberal laws on abortion in Sub-Saharan Africa. According to the law of 1972, termination of pregnancy is allowed for health and socio-economic reasons. However there is a requirement of signatures from three physicians and one of them has to be a specialist in a branch related to the patient’s reason for seeking abortion, e.g. if a woman is seeking abortion for socioeconomic reasons, a psychiatrist has to sign the application form. Since there are only very few psychiatrists in Zambia and since they are mainly situated in larger cities, the effect of these requirements is that most Zambian women, in spite of the law, in reality are with out access to safe legal abortions. In addition there is virtually no debate in Zambia on the issue of induced abortion and most women are not aware of their legal rights to have an induced abortion. As a consequence many women are resorting to illegal and often unsafe interventions.
The authorities have acknowledged the problem of unsafe abortions and PAC services are increasingly being offered to women who are admitted to the hospital with complications after having had an illegally induced abortion. Nurse/midwives were in 1997 allowed to provide vacuum extraction on post abortion patients, and at present they contribute significantly in the PAC service offered to patients with incomplete abortion. They are, however, not entitled to perform termination of pregnancies.
Suggested means to be used in bridging the policy-service delivery gab is to lobby for a review of the act of pregnancy termination in order to make the intervention more accessible. This could be achieved by reducing the number of doctors needed to sign, by allowing other health care providers to perform abortion and by allowing private hospitals to perform abortion. In addition, Zambian women, health care providers and communities should be made more aware of the abortion act, and lastly more MLPs should be trained to provide PAC including vacuum extraction.
India: Strategies to advance midlevel provision of elective abortion services
The medical termination of pregnancy act was enacted by the parliament in 1971. It allows termination of pregnancies, which results from rape or contraceptive failure. By this act the government intended to reduce the incidence of unsafe abortion and the consequently high maternal morbidity and mortality. However abortions providers are limited to highly trained physicians who tend to be inaccessible to rural women. In addition the quality of care offered is often poor. The women are often met by negative attitudes from the providers, they fear loss of confidentiality, and they often feel they are pressed to use contraception after the abortion. Thus, 30 years after the legislation, an estimated 90 percent of women seeking abortion are resorting to illegal abortions, often performed unsafely by unskilled providers and under unhygienic circumstances.
To address the problem of unsafe abortions, initiatives are discussed and underway. They focus on decentralizing abortion services, advancing MLPs role in elective abortion care, improve confidentiality, and decrease the providers negative attitude. In addition, the legality of abortion should be passed on to the women. It was emphasized that NGOs, mass media, midwives- and physicians organizations etc. might play a critical part in gaining the necessary support from policymakers in order to make them change the law and enhance MLPs role in abortion service.
USA: Building professional support: Clinicians for Choice
In the US, induced abortion has been legal on request since 1973, however women’s access to abortion have since the law came into force been the target of religious and political conservatism and politicians have been under intense pressure to remove or erode abortion rights. As a consequence of this pressure, there are currently different obstacles, mainly the cost of the abortion and distance to the providers, which hindrance easy access to induced abortion. Since state monies pay for only 14 percent of abortions in US, the individual woman has to rely on private insurance polices or have to raise the money her self if she wants to have an unwanted pregnancy terminated by an induced abortion. In addition many women will have to travel a considerable distance to have an induced abortion, since the majority of abortions are performed in private clinics, in which abortion service comprise >50 percent of the clinic visits. These clinics are situated in urban or semi-urban areas, which implies that women from non-metropolitan areas have difficult access to the service. Another factor that also influence access to abortion in a negative direction, is that the number of providers has been decreasing during the past two decades.
Focusing on MLPs involvement in abortion service, the law varies throughout the states, MLPs are only allowed to perform surgical abortion in two states, whereas they often are involved in medical abortions, although some states prohibit MLPs from dispensing mifepristone (interpretating this as "performing an abortion").
In the US there is a need for greater involvement of MLPs to solve the problem of difficult access to induced abortion. In order to help achieve this goal, a network, Clinicians for Choice, has been established. It consists of pro-choice clinicians who are active in education and outreach within professional organizations. They work with medical, physician assistant, and nursing schools in developing and presenting abortion care curricula. The goal of the organization is to expand the cadre of support beyond those already dedicated to the issue and to advocate for abortion as one aspect of the continuum of reproductive health services to which women have a right, in the US and in every nation around the world.
Objective 2, Evaluation of facilitating factors and barriers to the involvement of MLPs in abortion care services
In order to further address the involvement of MLPs in abortion care service, discussions were carried out focusing on facilitating factors as well as barriers to the involvement of MLPs in abortion care. These discussions took place in plenum where the experiences from the various countries were discussed as well as different solutions to the problems raised.
The participants were then divided in to six workgroups. Each workgroup were asked to focus on one of six different themes; i) Necessary skills for high quality abortion care, ii) Service delivery requirements, iii) Quality of care from the client perspective, iv) Health systems policies and regulations governing the training and practice of MLPs, v)Policies governing existing or potential abortion service delivery sites, and vi) Involvement of local community stakeholders in linking women to safe abortion services. The workgroups were given a discussion guide and asked to work from that. The experience gained from the various country reports as well as the participant’s own experiences were drawn on and lively and fruitful discussions took place in each workgroup. The main issues raised during the discussions in the workgroups were then shared and further discussed in plenum.
Objective 3, to draw up recommendations for future research, programmatic and policy activities
The issues raised by the various workgroups were used as an inspiration in drafting a set of recommendations focusing on how to advance the roles of MLPs in abortion care within four different disciplines: Research, Policy, Training/education and Service delivery. In addition a set of recommendation were drafted regarding four different themes: Expanding access to abortion services in restrictive settings, Medical abortion, Value clarification, and Developing the network.
Recommendations for the four disciplines: Research, Policy, Training/education and Service delivery
Recommendation regarding the four themes: Expanding access, Medical abortion, Value clarification, Education, and developing the network
Value Clarification Education (VCE)
Developing the Network
The conference offered a unique possibility for delegates with a sincere interest in addressing the problem of unsafe abortion to gather and discuss their experiences. It has led to the establishment of a network "Expanding Access", which will enhance the possibility for further discussions and which will facilitate collaboration across country borders.
In order to address the problem of unsafe abortion, there is a need of making abortion service accessible and available at the most local level possible. To achieve this, MLPs should be involved and their scope of practice expanded to include services that are now provided mainly by physicians. The MLPs scope of practice in relation to abortion care, however, has to be adapted to the legal situation of abortion. Hence in countries, where abortion is illegal, MLPs should be trained in providing post abortion care, which includes post abortion counseling, emergency treatment, and family planning service. In countries where abortion is legal, MLPs should be trained to perform high quality induced abortions, including post abortion family planning.
There is also a need of operational research focusing on the effect of: i) Advancing the role of MLPs in relation to abortion care, ii) Improvement of accessibility to abortion care, and iii) Increased quality of care. Such research might provide evidence that can be of use in influencing the policy makers to work for better access to safe abortion.
Danida and other donor agencies can play a significant role in reducing the number of complications and maternal death associated with unsafe abortion by supporting the training of MLPs and the establishment of abortion care at more local level. On a smaller scale, support to research projects aiming at documenting the effect of expanding access and advancing the role of MLPs in abortion care might play a role in facilitating better access to safe abortion or better treatment of complications.
Support from Danida and other Nordic donor agencies regarding the aspect of unsafe abortion has become more necessary since President Bush reinstated the so-called "Mexico City Policy" in January 2001. According to the statement, the US government policy will disqualify foreign NGOs from receiving US-family planning funding if they provide counselling on abortion, provide safe legal abortion service or participate in political debate surrounding abortion. The results of the policy will be more unintended pregnancies, more unsafe abortions, and more maternal and child deaths, Consequences, which are in strict opposition to the recommendations stated at ICPD in 1994.
By supporting the Ipas/IHCAR partnership and the recently established network "Expanding Access" in future, Danida may contribute in reducing the number of unsafe abortions and the associated high maternal mortality.