Time to act—comprehensive abortion care in east Africa
Authors: Amanda Cleeve, Monica Oguttu, Bela Ganatra, Susan Atuhairwe, Elin C Larsson, Marlene Makenzius, Marie Klingberg-Allvin, Mandira Paul, Othman Kakaire, Elisabeth Faxelid, Josaphat Byamugisha, Kristina Gemzell-Danielsson
Journal: The Lancet Global Health (2016)

Inaccessible sexual and reproductive health care continues to be a major obstacle to women's health and a violation of their rights.1Faúndes A Unsafe abortion—the current global scenario.Best Pract Res Clin Obstet Gynaecol. 2010; 24: 467-477Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar Access to comprehensive abortion care—comprising induced abortion and post-abortion care, including contraceptive services2IpasElements of comprehensive abortion care.http://www.ipas.org/en/What-We-Do/Comprehensive-Abortion-Care/Elements-of-Comprehensive-Abortion-Care.aspxGoogle Scholar—is fundamental to avert preventable maternal mortality and morbidity.1Faúndes A Unsafe abortion—the current global scenario.Best Pract Res Clin Obstet Gynaecol. 2010; 24: 467-477Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 3Erdman JN DePineres T Kismodi E Updated WHO guidance on safe abortion: health and human rights.Int J Gynaecol Obstet. 2013; 120: 200-203Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar In east Africa, abortion rates have not declined since 1990 and about 2·7 million abortions are estimated to occur annually in this region.4Sedgh G Bearak J Singh S et al.Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends.Lancet. 2016; 388: 258-267Summary Full Text Full Text PDF PubMed Scopus (382) Google Scholar The vast majority of these abortions are unsafe, making them a major cause of maternal mortality and morbidity. A workshop was organised in Kampala, Uganda, in March, 2016, to address the challenges of implementation and expansion of access to comprehensive abortion care in east Africa. Workshop participants included researchers from teaching institutions and health-care providers from Kenya, Uganda, and Sweden, members of the Uganda Ministry of Health, WHO, the International Federation of Gynecology and Obstetrics working group on the prevention of unsafe abortion, representatives of non-governmental organisations and aid organisations, and journalists. Although the workshop focused on Uganda and Kenya, delegates also presented research from Tanzania and Rwanda. Here we summarise key action points needed to speed up implementation and expand access to comprehensive abortion care in east Africa, as identified by the workshop delegates. Kenya and Uganda have restrictive abortion laws dating from the time of British rule. In both countries the constitution and penal code are not harmonised, leaving room for ambiguous interpretation of the legal environment.5Center for Reproductive RightsBriefing paper: a technical guide to understanding the legal and policy framework on termination of pregnancy in Uganda. Center for Reproductive Rights, New York2012Google Scholar, 6Hussain R In brief: unintended pregnancy and abortion in Kenya. Guttmacher Institute, New York2012Google Scholar Standards and guidelines on reduction of morbidity and mortality due to unsafe abortion were developed by the respective ministries of health in Kenya in 2012,7Kenya Ministry of Medical ServicesStandards and guidelines for reducing morbidity & mortality from unsafe abortion in Kenya. Kenya Ministry of Medical Services, Nairobi2012Google Scholar and in Uganda in 2015.8Uganda Ministry of HealthReducing maternal and mortality from unsafe abortion in Uganda: standards and guidelines. Uganda Ministry of Health, Kampala2015Google Scholar These standards and guidelines were an expansion of existing national policies and standards and the 2012 WHO Technical Guidance on Safe Abortion,9WHOSafe abortion: technical and policy guidance for health systems. World Health Organization, Geneva2012Google Scholar supported by the constitutions. However, the standards and guidelines were withdrawn in Kenya in December, 2013, and in Uganda in January, 2016, because of disagreements between stakeholders regarding their content. Absence of clear standards and guidelines specific to comprehensive abortion care leaves vital questions on health-care access and provision—such as roles, eligibility, and responsibility—unanswered. At the time of the workshop, discussions between the Ugandan Ministry of Health and stakeholders were ongoing, including efforts to bring religious leaders who opposed the standards and guidelines to the table. Meanwhile, in Kenya, the withdrawal of the standards and guidelines was being petitioned in court by civil societies. Delegates emphasised the urgent need for a consensus regarding the standards and guidelines among stakeholders in Kenya and Uganda. In addition, a common interpretation of the legal environment was considered crucial, and therefore the constitution and penal code would need to be harmonised in both countries. In east Africa, the shortage of health-care providers trained in comprehensive abortion care is severely restricting women's access to care, and thus updated in-service comprehensive abortion-care training and quality pre-service training is imperative. Efforts to expand access to comprehensive abortion care through task sharing or shifting should also be prioritised, as they have been shown to be safe, effective, and highly acceptable to women.10Klingberg-Allvin M Cleeve A Atuhairwe S et al.Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial.Lancet. 2015; 385: 2393-2398Summary Full Text Full Text PDF Scopus (32) Google Scholar The harm reduction model, already in use within some settings in east Africa, was acknowledged as an important strategy to prevent unsafe abortions. The delegates also emphasised the opportunity for prevention of unintended pregnancies, which comprehensive abortion care entails. However, quality improvement of contraceptive services is needed to increase use of effective methods and ensure informed decision making. Quality comprehensive abortion care is also dependent on factors such as availability of misoprostol and effective contraceptives, known to be heavily affected by stock-outs in Kenya and Uganda within public facilities. Stock-outs at national dispensaries are unacceptable and should be addressed alongside the control of counterfeit misoprostol. Sensitisation and support for misoprostol and addressing of misconceptions at community, health-care, and decision-making levels were recognised as central to the implementation process. Young women in particular struggle to access comprehensive abortion care, and delegates stressed that stigma and insufficient youth-friendly services across the east African region both need to be addressed. Abortion stigma continues to restrict comprehensive abortion-care access and impair the quality of existing services, highlighting the need for stigma reduction measures such as values clarification. Comprehensive abortion-care providers were described as sometimes perpetuating stigma but also as targets of stigma and police harassment. Local human rights organisations providing legal support—and increasing awareness of the right to health—therefore play an important role in the move towards universal comprehensive abortion-care access. For implementation to be successful, faith-based organisations, civil society organisations, and the media should be engaged. Advocates for change need to come together, creating alliances and networks, and campaigning for the right to safe, high-quality sexual and reproductive care. Finally, comprehensive abortion care should be advocated as an indivisible component of women's sexual and reproductive health care and rights, and a crucial strategy in reduction of gender inequality and social inequity. We declare no competing interests. BG is employed by WHO. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. The Swedish Research Council funded this workshop. The funding source were not involved in the workshop design, content, organisation, or any other aspect pertinent to the workshop or this article. We thank all the workshop participants for their contributions.