Global policy change and women's access to safe abortion: the impact of the World Health Organization's guidance in Africa/Changement de la politique mondiale et acces de la femme a l'avortement sur: l'impact des orientations de l'Organisation Mondiale de la Sante en Afrique.

• Author: Hessini, Leila

Along with governments from around the world, African Leaders agreed at the International Conference on Population and Development (ICPD) in 1994 to address unsafe abortion as a major public health problem. At the five-year review of the ICPD, they decided further that health systems should make safe abortion services accessible for Legal indications. Based on this mandate, the World Health Organization (WHO) developed norms and standards for quality abortion services, Safe Abortion: Technical and Policy Guidance for Health Systems, released in 2003. While abortion-related maternal mortality and morbidity remains very high in many African countries, stakeholders are increasingly using WHO recommendations in conjunction with other global and regional policy frameworks, including the African Union Protocol on the Rights of Women in Africa, to spur new action to address this persistent problem. Efforts include: reforming national laws and policies; preparing service-delivery guidelines and regulations; strengthening training programs; and expanding community outreach programs. This paper reviews progress and lessons learned white drawing attention to the fragility of the progress made thus far and the key challenges that remain in ensuring access to safe abortion care for all African women.

Women in sub-Saharan Africa face the highest risk of death and injury from abortion-related complications in the world, accounting for 60% of the nearly 20 million cases of unsafe abortion globally each year. Tens of millions of women of reproductive age today in Africa will experience an unsafe abortion in their Lifetimes. Globally, unsafe abortions claim the Lives of at Least 68,000 women each year; 43% of these women are African. In addition to premature deaths, hundreds of thousands of African women who seek unsafe abortions each year experience severe complications: uterine perforation, chronic pelvic pain, haemorrhage and secondary infertility. They also face trauma, stigmatisation and isolation from families and communities as a result of unwanted pregnancies and unsafe abortions. Recent national-level studies in Kenya, Uganda, and Nigeria document the high numbers of women presenting with complications from unsafe abortions in public health facilities, and are indicative of the region-wide burden of ill-health caused by unsafe abortion. The consequences fall especially heavily on young women and girls; nearly 60% of women who have unsafe abortions are under the age of 25. Taken together, the data on unnecessary deaths and illnesses from unsafe abortions point to a public health crisis, a social injustice and a violation of women's human fights and dignity.

"In recent decades, international understanding of the basic civil, social and economic rights with which all people are born has deepened and been progressively articulated in international covenants, treaties, and other instruments. Such agreements create a solid basis for real improvements in people's lives, as ratifying nations commit themselves to uphold the rights enumerated therein, including by adjusting laws and policies."

Challenges In advancing access to safe abortion in Africa

However, while progress is being made at global and regional levels, introduction and scale-up of safe abortion services in many African countries faces numerous challenges. The grim realities facing all health and development efforts in the region are the stagnation, and, in many cases, deterioration, of health systems. Facilities are increasingly overwhelmed by HIV/AIDS and other infectious diseases and are coping with significant annual attrition in trained health workers. The shortage of contraceptives across the African continent is alarming. In 2005, 20-35% of all married women between the ages of 15-49 lacked access to effective methods thus contributing to high rates of unintended pregnancies. Numerous obstacles to the provision of abortion services exist including:

* Barriers to involving midlevel health providers in safe and Legal abortion services--with limited trained medical doctors, majority of eligible women easily access the services of midlevel providers.

* Negative provider attitudes--although they have the necessary skills in clinical protocols for abortion care, majority of them lack the knowledge on national abortion laws and how to interpret them using diverse perspectives. Others are reluctant to provide or refer services on religious grounds.

* Insufficient supplies of technologies--health-care providers with skills in abortion-related care are often unable to offer these services due to lack of the appropriate medical equipment e.g. the manual vacuum aspiration (MVA) technology that offers a major advantage in the management of abortion complications and provision of early abortion in all types of health care settings, including low-resource primary health care centers. MVA allows for abortion services to be provided safely on an outpatient basis in decentralized Locations and by midlevel providers. MVA is registered or on commodity lists in many African countries, although procurement is still not reliable.

* Women's inability to access services--Even if services are available in health facilities, many women do not have the power and resources to access and utilize the services. Groups most Likely to encounter barriers include adolescents, unmarried women, women living outside of urban centers, and women who are displaced or refugees.

* Lack of political will and resources--Mobilizing political will to implement supportive policy statements and commit adequate resources are the biggest immediate challenges. The lack of a concerted response and an unequivocal position by a number of international agencies and bilateral donors in support of intergovernmental commitments is troubling. The anti-choice position of the U.S. government accounts for hesitation by...