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

Abstract

BackgroundAlthough 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.MethodsAn 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.ResultsAfter 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.ConclusionsThese 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.

Does supportive legislation guarantee access to pregnancy termination and postabortion care services? Findings from a facility census in Central Province, Zambia

“…Medical abortion (which in Zambia may be either using mifepristone and misoprostol in combination or misoprostol alone) was introduced to Zambia in 2009 14 and is already the more frequently used method of both TOP and PAC. This is an important development since medical abortion is a safe and effective method of service delivery that can be provided discreetly and conveniently to women, with fewer physical barriers than surgical services (such as manual vacuum aspiration or dilation and evacuation, depending on gestation), and has the potential to reduce maternal mortality from unwanted pregnancy.…”

“… 13 Within health facilities, conscientious objection, lack of training, high staff turnover and stigma all present further barriers to care. 14 15 …”

Implementing and expanding safe abortion care: An international comparative case study of six countries

“…8 Several articles describe specific difficulties in guaranteeing equitable access to services in South Africa, Zambia, and India, and the interventions designed to address these problems. [9][10][11] Comprehensive reviews of a single country's program, including health system level implementation steps, successes, and difficulties exist for India, 12 Mexico City, 13 and South Africa, 14 but there are no comparative data to guide future program implementation. A recent five-country case study developed to inform the WHO guideline on task sharing found limited documentation of the implementation processes undertaken.…”

“…One multicountry report did offer a framework for the successful implementation of abortion services; it relied primarily on a review of published and “grey” literature although it included some interviews with key informants . Several articles describe specific difficulties in guaranteeing equitable access to services in South Africa, Zambia, and India, and the interventions designed to address these problems . Comprehensive reviews of a single country's program, including health system level implementation steps, successes, and difficulties exist for India, Mexico City, and South Africa, but there are no comparative data to guide future program implementation.…”

Setting the research agenda for induced abortion in Africa and Asia

“…The availability of medical induced abortion has revolutionized the way abortion services are provided, and has improved access to abortion. In low‐resource settings with few trained surgical providers, medical abortion provides a safe and effective non‐surgical option . Medical abortion drugs are widely available from pharmacies and drug sellers; even in restrictive settings, medication such as misoprostol can be purchased over the counter for other indications and used to induce an abortion .…”