By Sara Jerving
Including abortion in universal health coverage was one of the main messages emerging from the Women Deliver conference this week in Kigali, Rwanda.
The conference, which ends Thursday, showcased stories of countries that have expanded access, and speakers called for abortion to be treated as a simple medical procedure.
“If you cannot legalize or you cannot access safe abortion, I think you’ll never have equitable health care,” Dr. Sangeeta Kaushal Mishra, a health secretary at Nepal’s Ministry of Health and Population, told the audience.
Three out of 4 countries penalize women for seeking abortion care, according to Dr. Bela Ganatra, head of the World Health Organization’s prevention of unsafe abortion unit. And where it is criminalized, unsafe abortions lead to complications that are a leading cause of maternal deaths and morbidities.
Governments that have rolled back access, such as the United States, often dominate the global conversation around abortion services. But the Women Deliver conference highlighted that abortion is a common health intervention in many countries and how the global health system largely considers it as simply a medical procedure.
Advances in science have made abortions simple, inexpensive, and easy to integrate into public health systems, they said. They also emphasized that the only way for a country to truly have universal health care is when abortion services are legal and provided in a country at no cost. The conference highlighted stories of countries that have expanded access, such as Nepal and Colombia.
Countries expanding access
Nepal was one of the countries in the spotlight. Mishra, the health secretary, told the audience about how the country gradually expanded access to abortion starting in 2002. Before then, over half of maternal deaths in the country’s major hospitals were attributed to unsafe abortions.
Sabine Shrestha, the executive director of Nepal’s Forum for Women, Law and Development, said that in a landmark legal case in 2009, the country’s Supreme Court interpreted access to abortion as an integral part of the right to sexual and reproductive health.
Since 2017, all abortion services in public sector hospitals have been free for patients. Mishra said that establishing the link between maternal mortality rates and illegal abortions has been an effective strategy to push for access in the country.
The conference also focused on Benin, which adopted one of the most liberal abortion laws in Africa in 2021. Legislators voted to decriminalize abortion under most circumstances up to 12 weeks of gestation — including if the pregnancy “is liable to aggravate or cause a situation of distress that is incompatible with the woman’s or unborn child’s interest in the following areas: education, economic situation, career or social well-being.”
Jean-Pierre Wangbe, head of the legal unit at Benin’s Ministry of Health, said during the conference that concerns around women dying from backstreet abortions pushed the government to amend the law. There are still barriers to access and the government does not budget enough financing for sexual and reproductive health services.
Colombia was also on showcase. Dr. Ana Cristina Gonzalez, the pioneer of the Causa Justa movement, which has worked to eliminate abortion as a crime, told audience members how Colombia worked to expand access. In 2022, Colombia’s Constitutional Court decriminalized abortion up to 24 weeks of pregnancy, and Gonzalez said that this ruling allowed advocates to push to also ensure health care providers guarantee access to these services.
Simple and safe, but hard to access
WHO has worked on abortion since 1967, when the World Health Assembly, its decision-making body, recognized the issue as a public health problem. A global reproductive health strategy including abortion was endorsed by member states and WHO in 2004. It provides guidelines that synthesize the evidence on how health care workers can provide safe abortions.
In medical school, abortion is taught as a medical procedure, said Dr. Angela Akol, director of Ipas Africa Alliance, a Nairobi-based NGO that trains safe abortion providers and supports health clinics that offer abortion services.
“It’s a no-brainer for a health worker to perceive it as health care because that’s what it is. Even the word miscarriage doesn’t exist in medicine; it’s abortion,” Akol said. “We frequently prefer to approach it from a public health perspective because unsafe abortion is a major killer.”
Over time the procedure has become easier, said WHO’s Ganatra. While it was once a major hospital-based intervention, now it’s a simple primary health care-level intervention that can be provided by a wide range of health workers and can be easily and cheaply integrated into health infrastructures, she said.
“The science has advanced so much that the interventions that we need are simple, safe, primary health care-level and can very easily be adopted by countries,” Ganatra said.
Self-managed abortion, which involves taking pills independently with guidance, gives women and girls the opportunity to access services in their privacy and convenience, said Dr. Sarah Onyango, senior technical adviser of self-care at Population Services International. Evidence shows it’s safe, effective, and empowers women, she said, and doesn’t negate the role of the health system — women still need to be connected to health systems to receive care and support if needed.
Countries with health insurance schemes and functional public health systems should provide access to abortion services as part of primary health care, said Salima Namusobya, senior regional director for Africa at the Center for Reproductive Rights, a global legal advocacy organization focused on advancing reproductive rights.
“As long as it remains outside of the public health care system, then we cannot achieve universal access,” she said.
The health providers and ministries her organization works with focus on the evidence around maternal mortality, she said, which drives them toward expanding access.
“We are not going to fight maternal mortality, for example, without directly confronting that issue of having access to safe and legal abortion,” Namusobya said.
Funders were also at the conference telling attendees how they are using their development assistance to expand access. The Swedish International Development Cooperation Agency works to ensure abortion is included in universal health care systems and integrated into national health care plans as a free service, said Sarah Thomsen, the agency’s lead policy specialist for health and sexual and reproductive health.
Even when the procedure is legal, supportive environments need to be created to ensure people are accessing the services — a view echoed by conference speakers.
While Ghana has relatively favorable laws and policies, stigma and opposition still limit access, said Esi Asare Prah, the advocacy and donor relations manager in Ghana for MSI Reproductive Choices, an international NGO that provides contraception and safe abortion services. She said that misinformation, for example, means young people can go through their schooling falsely thinking abortion is illegal.
“The ambiguity in communicating abortion services and the lack of information that perpetuates ignorance about safe abortion services are some of the key barriers to accessing services,” Prah said.
It’s important to leverage systems beyond the traditional health systems, such as telemedicine, she said. She also suggested that countries leverage school systems to not only deliver reproductive health educational information but also serve as a referral system with school clinics that can make connections to facilities that provide care.