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Overcoming inaction and increasing access to safe abortion care: MSF experience

On International Womens Day, Claire Fotheringham, Manisha Kumar, and Catrin Schulte-Hillen of Médecins Sans Frontières discuss recent efforts to improve access to safe abortion care worldwide.

At least  22 800 women and girls die each year as a result of unsafe abortion. Another seven million are hospitalised due to related complications.  The vast majority—97%—of unsafe abortions occur in resource-poor settings. But working in women’s health, as part of an organisation committed to reducing maternal mortality and morbidity, there’s a paradox that’s hard to ignore: unsafe abortion is the only cause of maternal death that is almost entirely preventable, but it may be the most intractable.

Médecins Sans Frontières/Doctors Without Borders (MSF) is a medical humanitarian organisation committed to action. At our core, we provide direct medical care. From 2013-2017, MSF assisted over 1.1 million deliveries, including nearly 107,000 caesarean sections. But when it came to providing safe abortion care, something was different.  Despite treating the consequences of unsafe abortions daily all around the world, we weren’t adequately responding on this issue.

This was at odds with an explicit organisational commitment by MSF to providing safe abortion care. By 2004, we had a clear policy. We passed numerous internal resolutions and motions.  We had qualified medical staff ready to provide this care and had the necessary medications in our projects. Why was this not translating into action?

By 2015 we identified several key barriers, including: abortion-related stigma and social norms, myths and misconceptions, lack of clinical knowledge, concerns about legal constraints, and fears about security and community acceptance.

A small team was established to design a comprehensive approach aimed at overcoming these barriers.  This Task Force developed a strategy with six components: (1) an “Exploring Values and Attitudes” (EVA) Workshop; (2) clinical trainings; (3) meetings with local actors; (4) threat and risk analysis; (5) implementation strategy; and (6) data collection. The Task Force piloted this strategy through field support visits to 10 MSF projects in sub-Saharan Africa.

Implementing this strategy taught us a lot about what works to improve access to safe abortion care. And while each component is important, the Task Force’s assessment of ‘lessons learned’ at the 2-year timepoint concluded that the first one, the EVA workshop, was the key to overcoming our organisational inertia. By starting with a dialogue about values and attitudes, we were able to create a shift on an issue where we had seen a roadblock for a very long time.

Fortunately, other organizations had realized this before. For support in the initial rollout of EVA we collaborated with Ipas, a leading nonprofit organisation dedicated to increasing access to contraception and safe abortion care worldwide.  We adapted their toolkit on values clarification and attitude transformation (VCAT) to our contexts to create the EVA workshop.

The EVA workshop is a full-day event where individuals engage in honest, open-minded, and critical reflection regarding safe abortion care. The goal of the workshop is for people to look internally at their own values and how they impact their attitudes and actions regarding abortion. We invited everyone to participate in the workshops, including headquarters and field staff, national and international staff, sceptics and supporters alike–not only doctors and midwives but also project managers, pharmacists, guards, communications, cleaners, administrators and drivers.

From 2016-2018, we conducted over 130 EVA workshops in over 25 countries, with more than 2300 MSF staff participating.

The EVA workshop was so vital because it created a space for open dialogue about abortion—an issue that is often difficult to talk about. Through this group reflection process, we were able to learn about different people’s perspectives and better understand the medical need for safe abortion care. Staff told personal stories about the impact of unsafe abortion on their mothers, sisters, friends, colleagues, and even themselves. This set the tone and paved the way for MSF to approach safe abortion care in a whole new way.

The Task Force seems to have led to substantive long-lasting change. Two years after a field support visit to put the Task Force comprehensive approach in place, each of those 10 pilot projects is now systematically providing safe abortion care. At the same time, the Task Force has catalysed action throughout the entire organisation—MSF has seen a significant increase in provision of abortion care over the past two years. And every one of these safe abortions was an unsafe abortion prevented. We plan to publish further about these experiences and the lessons learned.

At the same time, there’s still work to be done. We know our limits. No single organisation can meet the global need for safe abortion care. But we are convinced that if organisations look within, they can mobilise to provide a more effective response to unsafe abortion.

Worldwide, one in four pregnancies end in induced abortion. It is a common experience in many women’s lives. Yet a heavy stigma remains and keeps women suffering in silence. On this International Women’s Day we call upon our fellow health workers around the world to help break this silence. It is by speaking out and sharing our stories that we can make a difference in the lives of women and girls around the world.


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About the authors:

Claire Fotheringham is an obstetrician/gynaecologist and medical advisor with MSF based in Sydney, Australia. 

Manisha Kumar is an Amsterdam-based family medicine physician and serves as Coordinator of MSF’s Task Force supporting the implementation of safe abortion care.

Catrin Schulte-Hillen is a midwife working with MSF’s International Office in Geneva. She headed MSF’s Reproductive Health and Sexual Violence Care Working Group and since 2016 has led the MSF Task Force on safe abortion care.



Feature image: Women in a Bambuti camp in eastern Democratic Republic of Congo, where MSF conducted an anthropological study on unwanted pregnancy and abortion. DorisBurtscher/MSF

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