Why abortion should be treated as an essential health service in humanitarian emergencies | On the front line | future planet



According to data from the World Health Organization, each year there are seven million hospitalizations due to complications related to unsafe abortion methods. For this reason, access to voluntary termination of pregnancy in humanitarian contexts should be considered a matter of public health, although unfortunately this is not how it is usually interpreted. Doctors Without Borders (MSF) knows first-hand the consequences of unsafe abortion. I personally know of numerous cases of women who have died trying to use sticks, pins, or hangers to terminate a pregnancy. Others ingest soap or laundry detergent, and some are poisoned by herbs or medications that are not indicated for this purpose.

We usually work in contexts where it is very common to receive women who have tried to have an abortion in a medical consultation, although they also go to the emergency services. This fact has a huge impact on our staff. Regardless of the reasons a person may have for terminating a pregnancy, the medical consequences of an unsafe abortion are always the same.

At MSF we have put a lot of effort into training our workers to understand that medical care to prevent unsafe abortions is based on medical ethics and the needs of patients. We started addressing the issue of safe abortion care more systematically in 2015. In 2016, when we did an internal study, we interviewed MSF midwives and found that for most of them, medical care for a safe abortion was already part of their daily lives, although this practice was not officially formalized in medical protocols. There have always been abortion requests in our projects and our staff always tried to help those women who asked us for help whenever they could, but it was from there that we decided to start providing this service in a more intentional way.

After formalizing the medical protocol and policy in 2015, we decided to introduce a one-day reflection workshop on abortion among the training our workers receive. The course is called Exploring Values ​​and Attitudes (EVA), which in Spanish translates as “exploring values ​​and attitudes”. It’s very short, but it has a huge impact on people’s awareness of their own values, their perspective on abortion, and the consequences their attitudes have on our patients’ access to health care.

Both personally and organizationally, we should not put up another barrier amidst the obstacles women already face when trying to terminate a pregnancy.

In the workshop we also explored the values ​​of MSF as an organization, and how personal values ​​can conflict with institutional ones. We have observed that there are many misunderstandings: for example, there are people who think that it is a dangerous activity that can have negative consequences for the safety of the mission, staff and patients. But actually providing this kind of care can have a very positive impact, especially when the community gets involved and participates in the discussions.

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In fact, people change their position drastically, although not necessarily from an individual point of view about themselves or what they think about this subject, because that can be a long road, but they do realize the important role that we play all of us who are part of MSF and understand that, both personally and organizationally, we should not put up another barrier amid the obstacles that women already face when trying to seek this type of care.

I remember the workshop we organized in Niger, on the border with Nigeria, and it still moves me. It was a very hostile and sensitive context, a place where a series of armed groups operate and terrorize the population, which inevitably made our staff afraid to provide care to women undergoing abortion. The next day, staff members put little notes of thanks and appreciation for coming to teach the workshop in my bag.

It was a very moving experience: in a single day we witnessed how much it is possible to influence people’s awareness. People realize that abortion is a problem that surrounds us, that affects our families and our communities. And after the workshop, they all come to the same conclusion: “Let’s not become an obstacle to care and create spaces for dialogue.” It is a transformative and very emotional personal experience.

Some people tell us that in school they were not taught anything about this subject. The only thing they were told is that it is prohibited. Our approach to the issue of abortion during the workshop is, for many, a breath of fresh air.

In the turbulent context of war, natural disasters or epidemics, various actions have been carried out to inform patients that abortion is a possible option. First of all, we talk often with the community about our activities; what we usually call health promotion activities. What we do is engage fully with the community and talk to people about their health issues and top concerns, and what services we can provide them.

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Then, we do an analysis of the mortality risks in the community and that leads us to easily address the issue of unsafe abortion, because it is a problem present in all societies. Sexual and reproductive health is very much integrated into MSF’s care, so we explained that safe abortion is a service we offer.

But in any case, as soon as we respond to an abortion request with safe and confidential care, and that person has a positive experience, the information is passed on by word of mouth.

To ensure that the woman who decides to have an abortion is safe, the issue of confidentiality is crucial. This is one of the reasons why women are very interested in the possibility of self-managed abortion at home when we tell them that this is one of the options they have. Patients tell us that it is easier for them to find the right time, place, and support person if they can self-manage termination of pregnancy at home. Keep in mind that sometimes the hospital environment is not very welcoming for them.

We must deconstruct that narrative that ensures that psychological care is an essential component of care for a safe abortion. My experience shows me that it is not necessary at all; it does not coincide in the least with what women say, ask for or need. I think the idea of ​​mandatory mental health care is much more reassuring to health providers than to patients.

If we want to reduce maternal mortality, we must respond without fail to the requests of women who want to abort

In our most recent experience, the women who usually come to our consultations, and who wait all day in the 40 degree sun, know very well what they want, so they are not really conditioned by ambiguity or doubts. In general, they come to our organization after a long and difficult search for medical attention. Therefore, if we listen to them and provide them with the care they request, they do not ask for any type of psychological support.

Relief is the most common emotion among people who finally decide to voluntarily terminate the pregnancy. Above all, at MSF we respond to advances in science, to the recommendations of the World Health Organization and to the protocols that have been established after having carried out many studies on this issue.

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It is interesting to point out that, when we participate in meetings of specialists, the discussions are based on facts, results, advances… And, therefore, we completely avoid the politicization of the subject. Right now we have a drug protocol that is extremely effective and simple, whether it’s eight weeks, 10, 12 or even 22. Depending on each case, it can also be later.

Therefore, our focus is more on how to improve abortion self-management than on knowing exactly how many weeks pregnant a woman is. It is true that the more advanced the pregnancy, the greater the risks, but if we want to reduce maternal mortality, we must without fail respond to the requests of women who want to terminate a pregnancy and provide them with the information they need to do so in a safe.

Self-managed abortion, MSF’s commitment

To increase access to safe abortion care, in 2017 MSF simplified its protocols for an abortion with pills and eliminated routine medical tests such as ultrasounds and blood tests. In MSF projects, safe abortion care is now essentially a conversation between two people during which accurate information is shared and pills are provided for the person to take home. Since they started with this new care model, the number of people they can serve has increased: from 781 in 2016 to more than 30,000 in 2020.

Many people prefer self-managed abortion for a variety of reasons, including greater privacy and confidentiality, more autonomy and control over the process, and easier access, especially if they live far from a facility that offers abortions. All that is needed for a safe abortion with pills are three elements: accurate information, quality medications, and mutual respect and trust.

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George Holan

George Holan is chief editor at Plainsmen Post and has articles published in many notable publications in the last decade.

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