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Paschal Awah, Ph.D Senior Research and Evaluation Adviser for the Africa Region, Ipas

International Interdisciplinary colloquium: “Reduction of Maternal Mortality in sub-Saharan Africa: better understanding for better action” (Dakar, 13-16 Dec 2010) Applying the WHO Strategic Approach to Unsafe Abortion in Malawi and Senegal. Paschal Awah, Ph.D

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Paschal Awah, Ph.D Senior Research and Evaluation Adviser for the Africa Region, Ipas

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  1. International Interdisciplinary colloquium: “Reduction of Maternal Mortality in sub-Saharan Africa: better understanding for better action” (Dakar, 13-16 Dec 2010)Applying the WHO Strategic Approach to Unsafe Abortion in Malawi and Senegal Paschal Awah, Ph.D Senior Research and Evaluation Adviser for the Africa Region, Ipas

  2. Summary • Conceptual framework • Global examples • Location • Background • WHO Strategic Approach • Conceptual framework • Global experiences • Applying the WHO Strategic Approach (Case studies) • Methods • Findings • What has followed the strategic assessment • Ongoing actions • Recommendations • Conclusions International Interdisciplinary colloquium: “Reduction of Maternal Mortality in sub-Saharan Africa: better understanding for better action” (Dakar, 13-16 Dec 2010)

  3. WHO Strategic Approach STAGE I STAGE II STAGE III Strategic Assessment Developing and Testing Interventions Scaling-Up to increase capacity and impact Improved policies, programmes, and health status SRHR Challenge: Unsafe Abortion Policy & Programme Strengthening

  4. Strategic Approach: conceptual framework RH Status, User Perspectives, Gender PEOPLE SERVICES TECHNOLOGY Policies, Programmes, Access, Availability, Quality of Care Availability, Characteristics Social, Cultural, Political and Resource Contexts

  5. Countries applying the WHO Strategic Approach to abortion • AFRO • Ghana (2005); Zambia (2008); Malawi (2009); Guinea (2009); Senegal (2010) • EURO • Romania (2001); Moldova (2005); Macedonia (2007); Ukraine (2008); Russian Federation (2009); Kyrgyzstan (2011) • SEARO • Bangladesh (2002) • WPRO • Viet Nam(1997); Mongolia (2003)

  6. Conducting a strategic assessment • Preparation • Planning workshop • Team training • Fieldwork • Dissemination, generation of stakeholder consensus for action, donor engagement

  7. Map of Africa

  8. Strategic Approach chronologyLocations of case studies

  9. Generalities Senegal Malawi Population: 15,263,417 English Speaking Restrictive law Main religion: Christianity High maternal mortality: 807/100 000 live births Unsafe abortion: 24% Ratified all treaties and conventions relation to SRH Rights President Banda intends to set up a similar initiative in Malawi • Population: 12,534,228 • French speaking • Restrictive laws • Main religion: Islam • High Maternal mortality: 401/100 000 live births • Unsafe abortion: 3.6%, 50% of gynecological admissions at maternities • Ratified all treaties and conventions related to SRH Rights • Reproductive health law • BadjeuGon – President Wade’s Initiative

  10. Ratified International human rights agreements, promoting reproductive health for Senegalese and Malawian women • Several agreements ratified by Senegal and Malawi contradict the countries’ current policies and law on abortion notably: • Strategic Action 5.1.2 of the African Union Commission's Maputo Plan of Action (2006) which calls on governments to "Enact policies and legal frameworks to reduce incidence of unsafe abortion". • Article 14 of the Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa (2003), ratified by Senegal and Malawi in 2005

  11. Strategic Approach chronologicalBackground Senegal Malawi 2008 – Request of MOH at African Union MOH meeting Hope of generating a strategy to address what is certainly the most sensitive and neglected component of maternal mortality -- unsafe abortion. 2009 - Lilongwe Planning workshop 2009 – Strategic Assessment 2009 - Magnitude study • 2008 – Request of MOH at regional meeting in Bamako • Hope of generating a strategy to address what is certainly the most sensitive and neglected component of maternal mortality -- unsafe abortion. • 2008 - Sally Workshop • 2010 - Strategic Assessment

  12. Methods Senegal Malawi Field work (14 to 27 June 2009) by a team of 24 members representing governmental bodies, human rights groups and non- and inter-governmental organizations. • Field work (25 to 12 May 2010) by a team of 28 members representing governmental bodies (MOH), civil society and non- and inter-governmental organizations.

  13. Methods Senegal Malawi In-depth interviews and focus discussions conducted among 485 people in 10 districts in the northern, central and southern regions in urban and rural areas. Sampling Purposive using the snowball approach Analysis: Thematic • In-depth interviews and focus discussions conducted among 785 people in all regions in the northern, central and southern regions in urban and rural areas. • Sampling • Purposive using the snowball approach • Analysis: Thematic

  14. Research participants • Government officials • Representatives of international organizations • NGO officials • Politicians • Parlimentarians, Regional Elected officials, Mayors • Professionals and Ministries • Health, • Education, • Judicial authorities, • Police and Administrators • Religious leaders, • Youths • Family and women’s affairs • Community members • Traditional authorities • Initiators • TBAs • Sex workers • Women • Men • Adolescents

  15. Findings“An ongoing dialogue about unsafe abortion has started. The taboo on this issue has been finally lifted”

  16. Strategic assessment dissemination workshop Senegal Malawi

  17. Keys Findings • There is a high rates of: • Rape, incest, unwanted pregnancies and infanticides • High rates of unsafe abortions “When a woman decides that she does not want a pregnancy, she will do anything to terminate that pregnancy” (Key informant in the South Malawi) • High rates of maternal deaths resulting from unsafe abortions • The Abortion Lawis the major barrier to access to safe abortion • The misunderstanding of religious text is another barriers to safe abortion

  18. Key findings • SRH services (PAC/FP/YFS/EC) are not adequately set up • Irrespective of the restrictive Law on abortion, abortion is widely practiced in most places visited in Senegal and Malawi • Women, especially poor and young women don’t have access to and or Information on SRH (Contraception/Safe Abortion) “If you are poor, your voice is nothing.Pregnancy is a death sentence to the poor people. We are looking for change. Rich or poor, we should have access to abortion. If government liberalized the abortion law, our girls would be in school.” Interview with four tribal authorities, Southern Region of Malawi • There is a high ignorance of the full extend of the existing law

  19. Keys Findings • Women are not empowered to autonomously make Informed Reproductive Health Choices (Inequality in decision making) • A majority of communities want revisions of the Abortion Laws to include rape and incest Ils l’acceptent maintenant. Les femmes doivent être sensibilisées sur l’existence de l’avortement légal, c’est un pas vers l’autorisation de l’avortement. La procédure est lourdes il faut l’alléger, il faut donc responsabiliser les médecins pour facilité l’avortement thérapeutique. (Autorité judiciare, Senegal) Si la grossesse n’a pas atteint la 13éme semaine, l’interruption volontaire de grossesse peut être réalisée. (Leadeur communautaire, Dakar) C’est assez délicat, donc à manier avec prudence. Pour le viol et l’inceste, on pourrait l’autoriser ; En dehors je ne suis pas d’accord. Une autorité à Dakar

  20. Key findings • There is no concept of safe abortion – All abortions happening are unsafe because of the law and because of the ignorance of application of the provision to safe a woman’s life when it is in danger. International Interdisciplinary colloquium is Monday, November 15th,2010

  21. What usually follows a strategic assessment? • Operational research • Development/revision of standards and guidelines • Harmonize training curricula with standards and guidelines • Service delivery expansion • Health provider training • Strengthening quality of care, including introduction of new technologies (MVA and MA) • Registration of mifepristone and misoprostol • Technical support for legal reform

  22. What has followed the strategic assessment? Senegal Malawi Formation of an advocacy group Training of Journalist on advocacy Development of a plan of action • Holding of an advocacy workshop • Formation of a taskforce • Development of plans of action

  23. Recommendations • Revise the abortion laws to harmonise with its international treaty agreements under the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa which states “ Protect the health of a women by providing safe abortion services in case of sexual assault, rape, incest and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus ”

  24. Recommendations • Revise the Standards and guidelines so that Comprehensive Abortion Services can be implemented to the full extent of the law in harmony with the National SRH&R Policy. • Training, mentoring and support supervision of health services providers to provide comprehensive FP and abortion services within the full extent of the law.

  25. Ongoing actions Senegal Malawi Coalition for Prevention of Unsafe Abortion being established (hosted by WILSA) COPUA will push for reform of the law, based on ratification of the Maputo Protocol Improve procurement and distribution of MVA and misoprostol for emergency treatment of abortion complications • Taskforce will carry the agenda of informing women and adolescents and policy makers on setting up comprehensive RH services International Interdisciplinary colloquium: “Reduction of Maternal Mortality in sub-Saharan Africa: better understanding for better action” (Dakar, 13-16 Dec 2010)

  26. General conclusion • International treaty agreements on human rights signed and ratified by Senegal and Malawi are unknown at community level, technical level and even among most policymakers. • These treaty agreements often conflict with national laws and norms on sex, contraception, pregnancy and abortion. • The Protocol on the Rights of Women in Africa has the strongest statement on safe abortion, and is the international agreement in greatest conflict with Senegal and Malawi current laws on termination of pregnancy.

  27. General conclusion • Many countries have successfully reduced abortion-related mortality through revising and liberalizing their abortion laws and providing good access to safe, comprehensive abortion services. • Revision of the current law on termination of pregnancy is required for achieving the ultimate goal of eliminating unsafe abortion and its related morbidity and mortality in Senegal and Malawi.

  28. Acknowledgement • I acknowledge WHO for producing this model and Dr Ronnie Johnson and Peter Fajans (all of WHO) for their previous presentations of this model • Ipas acknowledges the involvement of WHO and UNFPA in the planning and support of the strategic assessments in both Senegal and Malawi

  29. Senegal Malawi Zikoma • Manga fis

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