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.
Highlights
Abortion is technically legal in Zambia, the reality is far more complicated
Plain english summary abortion is legal in Zambia, very few women know they have the right to have an abortion or know where to seek this care
In this study routine statistics from more than 13,000 women were collected from health facilities and combined with survey data from women seeking abortions, trained health care workers and community members to illustrate the results of the national efforts to introduce and scale up abortion services
Summary
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. Evidence on the incidence and consequences of unsafe abortion in recent years is scarce, numerous studies from the late 1990s identify the methods used across the country, such as ingesting toxins like detergent and inserting cassava sticks in the cervix [2,3,4]. Between 2003 and 2008 in Zambia’s major hospitals, almost one-third of all gynecologic admissions were due to complications of unsafe abortion, researchers estimated that 6 in every 1,000 of these women died as a result of their complications [8]
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