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Reproductive Health

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Open Access 01-12-2017 | Research

Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia

Authors: Tamara Fetters, Ghazaleh Samandari, Patrick Djemo, Bellington Vwallika, Stephen Mupeta

Published in: Reproductive Health | Issue 1/2017

Abstract

Background

Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation.

Methods

An intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country’s abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships.

Results

After 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides.

Conclusions

These findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa.

Ngwena CG. Protocol to the African charter on the rights of women: implications for access to abortion at the regional level. Int J Gynaecol Obstet. 2010;110(2):163–6. doi:10.1016/j.ijgo.2010.04.013.CrossRefPubMed

Webb D. Attitudes to ‘Kaponya Mafumo’: the terminators of pregnancy in urban Zambia. Health Policy Plan. 2000;15(2):186–93.CrossRefPubMed

Koster-Oyekan W. Why resort to illegal abortion in Zambia? Findings of a community-based study in Western Province. Soc Sci Med. 1998;46(10):1303–12.CrossRefPubMed

Dahlback E, Maimbolwa M, Kasonka L, Bergstrom S, Ransjo-Arvidson A-B. Unsafe induced abortions among adolescent girls in Lusaka. Healthc Women Int. 2007;28(7):654–76.CrossRef

Macha S, Muyuni M, Nkonde S, Faundes A. Increasing access to legal termination of pregnancy and postabortion contraception at the University Teaching Hospital, Lusaka. Zambia Int J Gynaecol Obstet. 2014. doi:10.1016/j.ijgo.2014.03.010.PubMed

Leone T, Coast E, Parmar D, Vwalika B. The individual level cost of pregnancy termination in Zambia: a comparison of safe and unsafe abortion. Health Policy Plan. 2016. doi:10.1093/heapol/czv138.PubMed

Coast E, Murray SF. “These things are dangerous”: Understanding induced abortion trajectories in urban Zambia. Soc Sci Med. 2016;153:201–9. doi:10.1016/j.socscimed.2016.02.025.CrossRefPubMed

Likwa RN, Biddlecom A. Abortion statistics in Zambia: ‘A research brief for reproductive health programming, policy and research implications’. University of Zambia; 2009

Central Statistical Office (CSO) Zambia, Ministry of Health (MOH) [Zambia], International I. Zambia Demographic and Health Survey 2013-14. Rockville, Maryland, USA: Central Statistical Office, Ministry of Health, ICF International; 2014.

10.

Macha S, Muyuni M, Nkonde S, Faundes A. Increasing access to legal termination of pregnancy and postabortion contraception at the University Teaching Hospital, Lusaka, Zambia. Int J Gynaecol Obstet. 2014;126 Suppl 1:S49–51. doi:10.1016/j.ijgo.2014.03.010.CrossRefPubMed

11.

Institute G. Making Abortion Services Accessible in the Wake of Legal Reforms: A Framework and Six Case Studies. New York, NY, USA: Guttmacher Institute; 2012.

12.

Jewkes RK, Gumede T, Westaway MS, Dickson K, Brown H, Rees H. Why are women still aborting outside designated facilities in metropolitan South Africa? BJOG. 2005;112(9):1236–42. doi:10.1111/j.1471-0528.2005.00697.x.CrossRefPubMed

13.

World Health Organization. Safe abortion: technical and policy guidance for health systems. 2nd ed. Geneva: World Health Organization (WHO); 2012.

14.

Ganatra B, Tunçalp O, Johnston HB, Johnson BR, Gülmezoglu AM, Temmerman M. From concept to measurement: operationalizing WHO’s definition of unsafe abortion. Bulletin of the World Health Organization 2014; 92155.

15.

Honkanen H, Piaggio G, Hertzen H, Bártfai G, Erdenetungalag R, Gemzell-Danielsson K, Gopalan S, Horga M, Jerve F, Mittal S, et al. WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. BJOG. 2004;111(7):715–25. doi:10.1111/j.1471-0528.2004.00153.x.CrossRefPubMed

16.

Faúndes A, Fiala C, Tang OS, Velasco A. Misoprostol for the termination of pregnancy up to 12 completed weeks of pregnancy. Int J Gynaecol Obstet. 2007;99 Suppl 2:S172–7. doi:10.1016/j.ijgo.2007.09.006.CrossRefPubMed

17.

Kapp N, Whyte P, Tang J, Jackson E, Brahmi D. A review of evidence for safe abortion care. Contraception. 2013;88(3):350–63. doi:10.1016/j.contraception.2012.10.027.CrossRefPubMed

18.

Swica Y, Chong E, Middleton T, Prine L, Gold M, Schreiber CA, Winikoff B. Acceptability of home use of mifepristone for medical abortion. Contraception. 2012;88(1):122–7. doi:http://dx.doi.org/10.1016/j.contraception.2012.10.021.

19.

Winikoff B, Dzuba IG, Chong E, Goldberg AB, Lichtenberg ES, Ball C, Dean G, Sacks D, Crowden WA, Swica Y. Extending Outpatient Medical Abortion Services Through 70 Days of Gestational Age. Obstet Gynecol. 2012;120(5):1070–6. doi:10.1097/AOG.0b013e31826c315f.PubMed

20.

Gynuity Health Projects [http://gynuity.org/resources/info/list-of-mifepristone-approvals/]. Accessed 02 Feb 2017.

21.

Ministry of Health, Ipas. Strategic Assessment of Policies, Programs and Research Issues Related To Prevention Of Unsafe Abortion In Zambia. Lusaka, Zambia: Ministry of Health, Ipas; 2008.

22.

Government of the Republic of Zambia. Termination of Pregnancy Act. Ministry of Legal Affairs; 1972.

23.

Ministry of Health. Standards and guidelines for reducing unsafe abortion morbidity and mortality in Zambia. Lusaka, Zambia: Ministry of Health; 2009. p. 51.

24.

Likwa RN, Whittaker M. The characteristics of women presenting for abortion and complications of illegal abortions at the University Teaching Hospital, Lusaka, Zambia: an explorative study. Afr J Fertil Sexual Reprod Health. 1996;1(1):42–9.

25.

Warriner IK, Wang D, Huong NTM, Thapa K, Tamang A, Shah I, Baird DT, Meirik O. Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomised controlled equivalence trial in Nepal. Lancet. 2011;377(9772):1155–61. doi:10.1016/s0140-6736(10)62229-5.CrossRefPubMed

26.

Otsea K, Baird TL, Billings DL, Taylor JE. Midwives deliver postabortion care services in Ghana. Carrboro, NC: Ipas; 1997.

27.

Ngo TD, Park MH, Free C. Safety and effectiveness of termination services performed by doctors versus midlevel providers: a systematic review and analysis. Int J Womens Health. 2013;5:57–17. doi:10.2147/ijwh.s39627.

28.

UNFPA. The State of the World’s Midwifery - Delivering Health, Saving Lives. New York, NY: UNFPA; 2011.

29.

Bradley J, Sikazwe N, Healy J. Improving abortion care in Zambia. Stud Fam Plann. 1991;22(6):391–4.CrossRefPubMed

30.

World Health Organization (WHO). Safe Abortion: technical and policy guidance for health systems. 1st ed. Geneva, Switzerland: World Health Organization (WHO); 2003. p. 112.

31.

Kaseba C, Phiri D, Camlin C, Sanghvi H, Smith T, Chibuye P, Folsom M. The Situation of Postabortion Care in Zambia: An assessment and recommendations. Research Triangle Park, NC: POLICY Project; 1998.

32.

Hart G, Macharper T. Clinical aspects of induced abortion in South Australia from 1970-1984. Aus N Z J Obstet Gynaecol. 1986;26(3):219–24.CrossRef

33.

Sims P. Abortion as a public health problem in Zambia. J Public Health Med. 1996;18(2):232–3.CrossRefPubMed

34.

Simpson A, Bond V. Narratives of Nationhood and HIV/AIDS: Reflections on Multidisciplinary Research on the HIV/AIDS Epidemic in Zambia over the Last 30 Years. J South Afr Stud. 2014;40(5):1065–89. doi:10.1080/03057070.2014.946222.CrossRef

35.

United Nations Development Programme UND. Millenium Development Goals: Progress Report Zambia 2013. Lusaka: UNDP; 2013.

36.

Fajans P, Simmons R, Ghiron L. Helping public sector health systems innovate: the strategic approach to strengthening reproductive health policies and programs. Am J Public Health. 2006;96(3):435–40.CrossRefPubMedPubMedCentral

37.

Basnet I, Clapham S, Shakya G, McCall M. Evolution of the postabortion care program in Nepal: the contribution of a national safe motherhood project. Int J Gynaecol Obstet. 2004;86(1):98–108. doi:10.1016/j.ijgo.2004.03.014. discussion 185.CrossRefPubMed

38.

Hendrickson C, Fetters T, Mupeta S, Vwallika B, Djemo P, Raisanen K. Client-pharmacy worker interactions regarding medical abortion in Zambia in 2009 and 2011. Int J Gynaecol Obstet. 2016;132(2):214–8. doi:10.1016/j.ijgo.2015.07.008.CrossRefPubMed

39.

Zambia Ministry of Health, Zambian University Teaching Hospital, Ipas. Introducing medical abortion in public health care facilities in Zambia: Operations Research in facilities and their catchment populations. Lusaka: Ipas Zambia; 2013.

40.

Fetters T, Raisanen K, Mupeta S, Malisikwanda I, Vwalika B, Osur J, Dijkerman S. Using a harm reduction lens to examine post-intervention results of medical abortion training among Zambian pharmacists. Reprod Health Matters. 2015;22(44 Suppl 1):116–24. doi:10.1016/s0968-8080(14)43794-7.CrossRefPubMed

41.

Ipas. Global annual monitoring data from Zambia. 2015.

42.

Campbell OM, Aquino EM, Vwalika B, Gabrysch S. Signal functions for measuring the ability of health facilities to provide abortion services: an illustrative analysis using a health facility census in Zambia. BMC Pregnancy Childbirth. 2016;16:105. doi:10.1186/s12884-016-0872-5.CrossRefPubMedPubMedCentral

43.

Parmar D, Leone T, Coast E, Murray SF, Hukin E, Vwalika B. Cost of abortions in Zambia: A comparison of safe abortion and post abortion care. Glob Public Health. 2017;12(2):236–49. doi:10.1080/17441692.2015.1123747.CrossRefPubMed

44.

Cresswell JA, Schroeder R, Dennis M, Owolabi O, Vwalika B, Musheke M, Campbell O, Filippi V. Women's knowledge and attitudes surrounding abortion in Zambia: a cross-sectional survey across three provinces. BMJ Open. 2016;6(3):e010076. doi:10.1136/bmjopen-2015-010076.CrossRefPubMedPubMedCentral

45.

Owolabi OO, Cresswell JA, Vwalika B, Osrin D, Filippi V. Incidence of abortion-related near-miss complications in Zambia: cross-sectional study in Central, Copperbelt and Lusaka Provinces. Contraception. 2017;95(2):167–74. doi:10.1016/j.contraception.2016.08.014.CrossRefPubMed

46.

Zambia To. Govt ‘Aborts’ Marie Stopes. In Times of Zambia. Lusaka, Zambia: Times of Zambia; 2012.

47.

Geary CW, Gebreselassie H, Awah P, Pearson E. Attitudes toward abortion in Zambia. Int J Gynecol Obstet. 2012;118(Supp 2):S148–51.CrossRef

Title: Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia
Authors: Tamara Fetters
Ghazaleh Samandari
Patrick Djemo
Bellington Vwallika
Stephen Mupeta
Publication date: 01-12-2017
Publisher: BioMed Central
Published in: Reproductive Health / Issue 1/2017
Electronic ISSN: 1742-4755
DOI: https://doi.org/10.1186/s12978-017-0289-2

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Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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