Legalization Alone Does Not Guarantee Availability of Safe Abortion Services
Evidence shows that restrictive abortion laws contribute substantially to maternal illness and death from unsafe abortion, and, in the last two decades, 26 countries have expanded the conditions under which abortion is legal. While abortion law reform is a positive step toward improving women’s health, little comprehensive information has been available until now on how the laws have been implemented and what impact they have had on the provision of abortion services and women’s health. A new study, Making Abortion Services Accessible in the Wake of Legal Reform, examines the implementation and impact of legal reforms in six settings—Cambodia, Colombia, Ethiopia, Mexico City, Nepal and South Africa—and finds that expanding access to legal abortion does not in itself guarantee a decrease in unsafe procedures. The findings indicate that increasing safe abortion services following legal reform requires sustained commitment and dedicated human and financial resources.
The study compared outcomes in the five countries and Mexico City and identified key factors that determine how successfully abortion policy reform is implemented. These include: creating strategic campaigns to raise awareness among women and providers that the law has changed and that abortion is legal under certain conditions, developing clinical and administrative guidelines to standardize service delivery, and taking steps to ensure that providers have the necessary training and supplies.
While the six case studies highlight the need for women, health care providers, government agencies and other key stakeholders to understand the new law, the analysis found knowledge was often limited. Campaigns to publicize the new abortion laws, undertaken in all six settings, varied considerably in terms of scale and success. As a result, knowledge of new laws appeared to be inconsistent among both the public and health professionals in most settings. In Nepal, one reason identifed for the slow uptake of safe abortion services was the lack of awareness among women that the law had changed in 2002. In Cambodia, where the law changed in 1997, a 2005 survey of health faciliities found that 40% of medical staff in hospitals believed that abortion was still illegal. Knowledge of new laws appeared to be highest in Mexico City and Colombia, where there was robust media coverage leading up to the change in the law.
The study also found that the scope of medical and administrative guidelines for delivering the newly legal abortion services varied across the six settings. Comprehensive guidelines were widely available in Ethiopia and Colombia. In Ethiopia, the guidelines have likely contributed to improved provision of safe abortion services. In Colombia, however, the ongoing political opposition to changing the abortion law has created a hostile environment, making it difficult to implement the guidelines.
In the three lowest-income countries (Ethiopia, Cambodia and Nepal), weak health systems posed a significant challenge to the rollout of abortion services, but the study documented that successful strategies can be implemented even where health infrastructure is lacking. Training health workers to perform safe abortions was identified as an essential step toward ensuring the availability of safe services. After revising its abortion law, Nepal’s Ministry of Health worked with international NGOs to implement a carefully planned strategy to make safe services available, which included training public- and private-sector providers, and providing equipment. In Cambodia, Nepal and South Africa, efforts to establish safe abortion services benefited from authorizing and training midlevel providers, such as nurses and midwives, to perform abortions.
In addition to reviewing implementation, the report examined how law reform had affected women’s health. It found that in Ethiopia and Nepal, countries where abortion is now broadly legal within set gestational limits, evidence is beginning to demonstrate that fewer women are suffering from complications related to unsafe abortion. In South Africa, where the liberalized law has been in place the longest, the evidence suggests that abortion legalization led to a dramatic 91% decline in abortion-related maternal mortality in the six years following law reform. In Mexico City and Colombia, legal abortion services have not been available long enough to allow measurement of their impact.
The report also found that opposition to legal abortion can intensify following abortion law reform. The case studies showed that resistance to implementing the new law came from religious groups, health providers and conservative legislators. In Colombia, for example, the Catholic Church had assumed a largely hands-off role before the 2006 court decision that liberalized abortion, but its opposition intensified dramatically once the law was passed. The authors recommend that advocates, program planners and other stakeholders anticipate increased attacks by opponents of legal abortion after a law has changed and plan strategies to ensure that the new law is fully realized and protected.
Click here to read the the four-page summary of key findings: In Brief: Making Abortion Services Accessible In the Wake of Legal Reform. Click here to read the full report: Making Abortion Services Accessible in the Wake of Legal Reform.