HFHC-pathways-to-care-web

STRENGTHENING THE SRHR OF ADOLESCENT GIRLS AND YOUNG WOMEN

Pathways to Care

Enhancing Access to Safe Abortion for Adolescent Girls and Young Women

ENDLINE EVALUATION KNOWLEDGE PRODUCT

Her Future, Her Choice Pathways to Care: Enhancing Access to Safe Abortion for Adolescent Girls and Young Women

HFHC Final Endline Evaluation Report - Drivers of Change for Lasting Impact

Prepared by Lara Jean Cousins and Jennifer Sawyer for Oxfam Canada

Client: Oxfam Canada

November 2024

For more information and questions about this study, please contact: Jose Chacon, MEAL Officer jose.chacon@oxfam.org Oxfam Canada

Oxfam Canada

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ABOUT

HER FUTURE, HER CHOICE (HFHC)

The Her Future, Her Choice (HFHC) project (2019-2025), funded by Global Affairs Canada (GAC) and Oxfam Canada, sought to improve the sexual and reproductive health and rights (SRHR) of adolescent girls and young women (AGYW) in targeted districts of Ethiopia, Malawi, Mozambique, and Zambia, by directly addressing barriers that hinder access to SRHR. These barriers include harmful social norms, traditional practices, and taboos about gender and sexuality; lack of access to sexual and reproductive health (SRH) information and services; and AGYW’s lack of meaningful decision-making power regarding their health and sexuality. To address these barriers, HFHC partners undertook efforts around three interconnected areas:

1. engaging AGYW and community members to understand and transform discriminatory social norms, and strengthen AGYW agency;

2. enhancing the capacity of service providers and healthcare facilities to provide comprehensive SRH information and services; and

3. promoting change in SRHR-related legislative and policy frameworks.

STRENGTHENING THE SRHR OF ADOLESCENT GIRLS AND YOUNG WOMEN

pathways to care

ENHANCING ACCESS TO SAFE ABORTION FOR ADOLESCENT GIRLS AND YOUNG WOMEN

Over the course of the HFHC project, Oxfam and partners placed a strong emphasis on improving the provision and accessibility of safe abortion services for AGYW. This document shares Oxfam’s key learnings regarding how to increase access to and uptake of comprehensive abortion care (CAC) services, stemming from HFHC experiences, and illustrates that even across legally restrictive settings, there are ways to expand access to life-saving safe abortion and post-abortion care for women and adolescent girls.

SRHR and Safe Abortion

At their most basic level, sexual and reproductive health and rights (SRHR) involve peoples’ ability to exercise meaningful decision-making power over their health, bodies, and lives, as well as the wider social systems and enabling environment necessary for them to do so.1 Integral to ensuring SRHR, is ensuring the availability and accessibility of safe abortion and post-abortion care. As with other components of SRHR (such as access to contraceptives and comprehensive sexuality education), the right to legal, safe, and accessible abortion is grounded in numerous human rights recognized and protected under international law.2 When safe and legal abortion services are widely accessible, they lead to improved health outcomes for women and girls, including significant reductions in maternal mortality and morbidity. Yet of abortions occurring globally in 2010-2014, an estimated 45% of abortions (25 million) were still unsafe,3 due to various barriers in access to services, including legal restrictions.

1 Oxfam Canada (2020). Sexual and Reproductive Health and Rights Theory of Change. Retrieved 8 October 2024, from https://www.oxfam.ca/publication/sexual-and-reproductive-health-and-rights-theory-of-change/ .

2 Relevant international Human Rights treaties include but are not limited to: the International Covenant on Economic, Social and Cultural Rights (ICESCR); the International Covenant on Civil and Political Rights (ICCPR); the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT); the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW); the Convention on the Rights of the Child (CRC); and the Convention on the Rights of Persons with Disabilities (CRPD)); as well as the regional Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo Protocol). For examples of recommendations from Human Rights Bodies regarding the right to safe abortion, see World Health Organization (2022), Abortion Care Guideline Web Annex A. Key International Human Rights Standards on Abortion

3 Starrs et al (2018), Accelerate Progress – Sexual and Reproductive Health and Rights for All: Report of the GuttmacherLancet Commission

Ethiopia4

In 2005, Ethiopia revised its abortion laws and developed the first Technical and Procedural Guidelines in 2006 for expanding and implementing safer abortion care services, permitting abortion under a range of conditions. These include rape, incest, fetal impairment, when the pregnant woman’s health is at risk, if the pregnant girl is under 18 years old and faces mental or other health challenges, or in cases where a woman is unable to support a child due to economic hardship. Following these reforms and the expansion of comprehensive abortion care and other health interventions, the country saw a dramatic decrease in the maternal mortality rate from unsafe abortion, dropping from around 32% in 2006 to approximately 4% in 2018.

Malawi5

Malawi has the most restrictive abortion legislation of the four HFHC countries, where safe, legal abortion is only permitted in cases to save the pregnant woman’s life. Interpreting and applying this exception, moreover, remains a significant challenge in Malawi, with many service providers being uncertain or afraid of providing safe abortion care even when legally permitted, for fear of being criminally prosecuted. As a result, most abortions in Malawi are undertaken in unsafe conditions, with complications from abortions having been estimated to cause 6-18% of maternal deaths.6 A Termination of Pregnancy Bill, which would expand legal access to safe abortion, was presented in Parliament in 2017, but debate over the draft law was suspended in 2021,7 and the Bill still has yet to be passed. Access to safe abortion continues to be highly restricted, with strong ongoing opposition to any attempts to expand the country’s legislative grounds for abortion.

4 Center for Reproductive Rights, The World’s Abortion Laws: Ethiopia

5 Center for Reproductive Rights, The World’s Abortion Laws: Malawi

6 https://www.guttmacher.org/fact-sheet/abortion-malawi

Mozambique8

Until 2014, safe abortion was permitted in Mozambique only to save the life of the pregnant woman and to preserve her physical health. Thanks to the advocacy efforts of women’s rights and civil society organizations, a less restrictive abortion law was approved and signed into law in 2014. The new abortion law, along with Mozambique’s revised penal code, allows women to electively terminate their pregnancies during the first 12 weeks, in cases of rape during the first 16 weeks, and in limited circumstances such as fetal abnormality, up to 24 weeks. Many communities, however, remain unaware of the current legal status of abortion, or that this service can be accessed for free at health clinics, meaning that unsafe abortion remains a leading cause of maternal mortality in the country.

Zambia9

Zambia’s Termination of Pregnancy Act allows abortion under specific conditions, such as preserving the pregnant woman’s physical or mental health, or in cases of rape or incest. The legislation, however, imposes requirements that can be difficult to meet. For example, a pregnant woman seeking abortion must first obtain approval from three medical practitioners, which creates a significant barrier, especially in rural areas, where finding even one doctor can be a considerable challenge.10 In this context, 30% of maternal deaths are estimated to result from unsafe abortion.11

Irrespective of their differing legislative contexts, HFHC partners in all four countries have achieved notable successes in promoting comprehensive abortion care services, and improving the health and wellbeing of women and girls, as well as their ability to claim their rights.

Ana’s storya

7 The Termination of Pregnancy Bill proposes expanding legal access to safe abortion care to include cases of risk of harm to the physical and mental health of the pregnant woman, incest, rape or sexual assault, and fetal impairment. Southern Africa Litigation Centre (2021), Malawi’s Obligation to Enact the Termination of Pregnancy Bill

8 Center for Reproductive Rights, The World’s Abortion Laws: Mozambique; Ipas (2020), In Recent Penal Code Review, Mozambique Recognizes Legal Right to Abortion

9 Center for Reproductive Rights, The World’s Abortion Laws: Zambia

10 In cases of emergency and where three doctors are not accessible (e.g. in rural areas), this requirement may be waived, and women may only need to procure the approval of one doctor.

11 Lubeya et al (2022), Magnitude and Determinants of Unsafe Abortion among Zambian Women Presenting for Abortion Care Services: A Multilevel Analysis

Ana says peer educators and trained health service providers saved her life: Teenager Ana, who had taken a job as a maid to help support her family, was one day raped by the homeowner. Soon after she began feeling unwell, showing signs of early pregnancy, and returned to her family home to recover from what she had gone through. While at home, she heard from a Pathfinder International peer educator that the nearby Health Centre was offering free comprehensive abortion services. The peer educator also told her that she could choose whether to disclose the situation to her family or not. She decided to tell her aunt, who accompanied her to the health facility for testing. Ana was devastated when the service provider confirmed that she was pregnant, and she vehemently declared that she did not want the pregnancy. Immediately, the counselor referred her to the youth-friendly space unit with service providers trained in Comprehensive Abortion Care (CAC), where she was able to obtain a medical abortion. She was also tested twice for HIV and found she was negative for the virus. Before leaving the facility, she received additional SRH counselling and a contraceptive implant. Ana credits the peer educator for pointing her in the right direction and has vowed to participate in similar programs in the future. “Thank God, my service providers, and my peers,” she said, “since you have saved my life.” (20202021 Annual Report)

a Real names and identifying information have been changed to protect peoples’ privacy and safety.

a Real names and identifying information have been changed to protect peoples’ privacy and safety.

HOW DO WE EXPAND ACCESS TO SAFE ABORTION AND POST-ABORTION CARE FOR WOMEN AND GIRLS?

ADDRESS ABORTION STIGMA, AND DISPEL RELATED MYTHS AND MISINFORMATION

Abortion stigma plays a significant role in how comprehensive abortion care is marginalized socially, medically, and legally around the world. It creates a major barrier to legalizing or decriminalizing abortion, putting guidelines for safe and legal abortion into practice, as well as to making abortion information, services, and medications available and accessible.12 It also perpetuates myths and misinformation around abortion, inhibiting both the provision and uptake of safe abortion services. Abortion stigma remains pervasive across the four HFHC countries, reinforced by deeply rooted religious beliefs, cultural attitudes, and patriarchal gender norms and stereotypes. As a result, women and adolescent girls who seek safe abortion services often face severe judgment, blame, rejection, and isolation from their communities, along with hostile attitudes from service providers. Many women and girls thus avoid talking about abortion altogether, and are often driven to seek unsafe alternatives.

In light of this, HFHC partners focused on community education to shift public perceptions and reduce abortion stigma. In Mozambique, for example, where widespread cultural and social stigmas continue to limit access despite the revised abortion law, HFHC partners undertook various awareness-raising initiatives to educate the public about safe abortion, leveraging the country’s legal framework to promote safer abortion methods. Partners engaged in radio programs to foster debates about abortion, featuring service providers who shared accurate public health and legislative information, with the aim of dismantling myths and cultural taboos that perpetuate unsafe abortion practices. Teachers were trained to deliver comprehensive sexuality education that covers safe abortion, and HFHC partners organized discussion panels at schools to address issues such as safe abortion, HIV/AIDS, STIs, adolescent pregnancies, and SRHR. Partners also facilitated community dialogues and trainings involving men, boys, parents, guardians, and the community at large. These sessions, organized in coordination with various sectors, helped clarify misconceptions, address stigma, and mobilize support for access to safe abortion. The involvement of community and religious leaders in these trainings has been crucial in reducing stigma and bias surrounding abortion, as these leaders started disseminating information about the abortion services available at local facilities, and addressing the issues of isolation and discrimination faced by those seeking these services. Community leaders have also begun referring cases of adolescents and young women who need safe abortion services to health facilities. AGYW who participated in discussion sessions have also begun to share information about safe abortion services with their peers, emerging as transformational leaders. In turn, health workers at HFHC project sites in Mozambique have reported seeing an increase in uptake of safe abortion services, as well as a decrease in cases of young women seeking healthcare for complications due to unsafe abortion. Over the five years of the project, the number of women and girls in Mozambique who received safe abortion and post-abortion care rose dramatically from 615 cases in the first year to 2,291 cases by the fifth year, marking a 273% increase.

12 Sorhaindo and Lavelanet (2022), Why Does Abortion Stigma Matter? A Scoping Review and Hybrid Analysis of Qualitative Evidence Illustrating the Role of Stigma in the Quality of Abortion Care

STRENGTHEN THE CAPACITIES OF HEALTHCARE PROVIDERS AND HEALTH FACILITIES TO OFFER

COMPREHENSIVE ABORTION CARE

In addition to working with communities to reduce abortion stigma, HFHC partners recognized that central to improving the provision of safe abortion and/or post-abortion care, was strengthening health facilities and healthcare providers’ capacities to provide this lifesaving care. Over the course of the project, there were institutional challenges to meeting the demand for SRH services, including supply chain issues, weak inventory management, a persistent lack of available SRH commodities and equipment at health facilities, and a lack of adequately trained staff to provide comprehensive abortion care.

HFHC partners used several strategies to strengthen the institutional capacity of health facilities. To address issues of abortion medication stockouts, for example, in Mozambique partners improved supply chain policies, trained inventory management teams, and implemented monitoring and evaluation systems. Ethiopia, in turn, is characterized by a decentralized system for distributing SRH supplies, which ensures that public health facilities have a distribution hub within reasonable distances (e.g. 50-200 km) to facilitate their access to the necessary medications and commodities. These hubs, however, are not always fully operational, due to humanitarian crises such as the recent Tigray conflict13 causing severe disruption and damaging infrastructure. Pathfinder International thus worked with government actors to strengthen the supply distribution system, helping stock regional distribution hubs and distribute supplies directly to facilities during field visits. Pathfinder also provided mentorship regarding commodity management to better ensure that all facilities receive the necessary materials and that stock levels are maintained effectively.

Across Ethiopia, Mozambique, Malawi, and Zambia, moreover, partners have placed a strong emphasis on training healthcare providers to separate personal beliefs from professional responsibilities. All four countries have implemented Values Clarification and Attitude Transformation (VCAT) training to support

A community health worker in Mozambique helps increase access to free, safe abortion in her community:

Dina works as an Agente Polivante Elemental (a community health worker) at a Health Center in Mozambique. Even though Mozambique changed its laws to guarantee free and safe abortion a few years ago, Dina says she, along with most other people in her community, did not know about the changes. “I never talked about it in my counselling for pregnancy options,” she says. “I thought you had to pay...and also thought that service could only be provided in the health facility in town”—a trip most young women don’t have the resources to make. Her understanding changed completely when she attended a training session with Pathfinder International. “In the training I not only learnt about the circumstances and timeframe in which you can have an abortion,” Dina says, “but I also learnt that we do not have to pay and that our health facilities in the rural areas also provide safe abortion.” Now, she has started telling others in her community about SRH services and getting them up to date with the laws about abortion. Her work is already paying off. She has already begun referring women, including 16-yearold Jacinta, who was able to have a free, safe abortion in a health facility near her home. “Today I feel happy supporting many other women,” Dina says. (HFHC annual report 2020-2021).

service providers in clarifying their values around abortion, address associated stigma, improve providers’ understanding of abortion and relevant legislation, and ensure compassionate abortion and/or postabortion care. These VCAT training initiatives contributed significantly to the provision of quality services, improved patient outcomes, and built confidence in the healthcare system.

“We’ve also seen a reduction in illegal abortions and unsafe abortions […] the people now have the information and they are able to go and access the abortion and other services from the health facility unlike in the past.”

— SAFAIDS, HFHC PROJECT PARTNER, ZAMBIA.

Additionally, partners provided ongoing clinical mentoring, training, and supervision to healthcare providers, including regular site visits and constructive feedback to enhance clinical skills and practices. In Ethiopia, this work has included a focus on expanding access to selfmanaged medical abortion,14 through the inclusion of medical abortion in the recently endorsed National SelfCare Initiatives for RMNCAYH-N Interventions. Whereas in Zambia, while many service providers were comfortable with offering medical abortion, they felt less equipped to offer surgical abortion procedures. Mentorship programs and follow-ups thus provided opportunities for additional practice, and strengthened related skills and confidence among providers. In turn, partners have seen visible changes related to the provision of safe abortion services. For example, at the start of the project, surgical abortion was only available in one out of four project districts in Zambia. Now, clients in all project districts in Zambia have access to surgical abortion. Similarly in Mozambique, while surgical abortion was not available in any of the project districts at the outset of the project, clients in all HFHC project districts now have access to this service. Implementing mobile health clinics and outreach services, and establishing referral networks between healthcare facilities and community-based organizations, has also improved the uptake and accessibility of comprehensive abortion care services in remote areas.

Luyando’s Journey to Safe Abortion Access and Becoming a Peer Educator:

Luyando, a teenage girl from Zambia was 8 weeks pregnant but had not told anyone. She was in the process of preparing for college but came from a povertystricken home, unable to support both herself and a child. She lived in with her mother and was deeply concerned about her future.

SAFAIDS, in partnership with Oxfam Zambia, provided training on SRHR to AGYW in Zambia to equip them with accurate SRHR information and skills. Among the participants in one such training was Luyando. During the training, Luyando learned about safe abortion and other SRH services, giving her the knowledge and confidence to seek help. After the training, Luyando reached out to a healthcare provider who facilitated the sessions, and explained that she was 8 weeks pregnant and wanted to access a safe abortion. She was advised to come to the clinic, where she was provided with counselling, safe abortion, post-abortion care, HIV testing and contraceptives on discharge. Luyando was relieved to discover that these services were free. She has since become a peer educator, actively linking other girls in her community to SRH services, including safe abortion and contraceptive access. (Zambia 2024 success stories)

REMEMBER, THERE’S POWER IN NUMBERS

To make inroads on a stigmatized issue like safe abortion, civil society actors cannot go it alone. Increasing access to comprehensive abortion care requires a collective, collaborative approach. This is especially true for achieving advances in legislative frameworks, where easing legislative restrictions requires the work of many. In this vein, HFHC partners in Malawi have been active members of the Coalition for the Prevention of Unsafe Abortion (COPUA), advocating for the Termination of Pregnancy Bill. Oxfam Malawi has also supported research in collaboration with COPUA members to generate more evidence on the impact of unsafe abortion on AGYW. The research, facilitated by stakeholders including the Ministry of Health, partner organizations, and journalists, has helped bolster the Termination of Pregnancy Bill and other safe abortion advocacy efforts in the country. Oxfam and partners have also funded local communitybased organizations (CBOs), as an important strategy for strengthening the number of allies, and advancing community advocacy, research, and programming on safe abortion. This sub-granting process involves partnerships with various international NGOs, local NGOs, and AGYW-led community-based organizations, with the aim of ensuring that organizations with the best understanding of local contexts and effective communication strategies help disseminate accurate information on SRHR and comprehensive abortion care (CAC) within their communities. AGYW are also increasingly sharing SRHR information within their communities, taking leading roles in high-profile forums, engaging gatekeepers and members of parliament, and publicly advocating for safe abortion in various ways, including through radio programs and public rallies. These youth SRHR champions have played a pivotal role in communicating sensitive issues around SRHR and abortion, and partners have seen substantial improvements in media coverage and public awareness due to their efforts.

A young woman receives live-saving post abortion care

in Malawi

In Balaka District, Chisomo was divorced and in her mid-twenties, noticed something unusual during her pregnancy. “During the third month, I started bleeding heavily. After two days, a relative told me to go to the hospital. At the hospital, I was asked if I had taken any pills to which I said no. The service provider confirmed that I had a miscarriage and assisted me accordingly. All the pain stopped, and I returned home in good health.” HFHC partner the Family Planning Association of Malawi (FPAM) has been training service providers in the area on post-abortion care (PAC). Nandumbo Health Facility in Balaka District is one of the facilities whose service providers were trained. Alinafe, a Nurse Midwife Technician at the facility, said before this training, they had no service provider specialized in PAC. The facility now has five service providers trained in PAC and who are able to assist women in PAC, as they did in the case of Chisomo. Alinafe says cases of unsafe abortions are a challenge in the community since his health facility alone sees two to three clients per week seeking PAC services. But Chisomo’s s story shows that proper training among health providers can give women the care they need. (Annual Report 2021-2022)

HFHC partners in Zambia have made similar inroads in expanding access to safe abortion care through collaborating with other stakeholders, where for example in 2023 the Ministry of Health, in consultation with stakeholders including Planned Parenthood Association of Zambia (PPAZ), revised the Standards and Guidelines for Comprehensive Abortion Care (CAC). These standards and guidelines have replaced the current 2017 standards and adapted the World Health Organization (WHO) 2022 Abortion Care Guidelines to the Zambian context, in the aim of ensuring quality service provision that conforms to Zambian laws, while making CAC services available, accessible, and affordable to clients. This includes provision of information, abortion management (including for different clinical indications), and post-abortion care (including follow-up care, treatment of complications, and post-abortion contraception).

WHEN IT COMES TO SHIFTING LEGISLATIVE FRAMEWORKS, BE IN IT FOR THE LONG GAME

Over the course of the project, one of the main challenges impeding the delivery of comprehensive abortion care has been unsupportive or restrictive abortion policies. In countries that lack supportive safe abortion policies, the range of safe abortion services offered to AGYW was limited, whereas in countries with supportive policies, partners reported a substantial increase in the ability to offer CAC, and considered this to be one of the key successes of the project. SRHR programming should thus have dedicated, ongoing resources focused on policy change, in order to foster more supportive policy environments for comprehensive abortion care.

Shifts in legislative and/or policy frameworks, however, take time. They require an ongoing, holistic approach to abortion advocacy, as well as the use of various entry points to create more enabling conditions. In Malawi, for example, legislative reform has been slow due to strong opposition from religious and cultural groups, a lack of political will, and the perpetuation of misconceptions and misinformation surrounding abortion. However, following over 10 years of tireless advocacy from COPUA members, there have recently been some promising developments. These include additional conditions under which pregnant women can access abortion, such as cases of incest or gynecological issues that put a woman’s life at risk. Community awareness efforts are ongoing, including translating the Termination of Pregnancy Bill into local languages and providing grants to youth organizations to undertake advocacy for abortion policy reform. The COPUA network also continues to actively advocate for the Termination of Pregnancy Bill, aiming to present it during the next parliamentary session along with more community-sourced evidence regarding why it needs to be passed, and has a case registered in the High Court, where COPUA is suing the Minister of Health as part of its strategy to push for the passage of the Bill.

“You know how advocacy is; it’s a long process, but we are hoping to one day [get the bill passed].”

–

FPAM, HFHC PROJECT PARTNER, MALAWI.

4 OECD DAC Network on Gender Equality (GenderNet) (2016). Donor support to southern women’s rights organizations: OECD Findings; P. Domingo et al (2015). Women’s Voice and Leadership in Decision-Making: Assessing the evidence.

5 Alethea Desrosiers et al (2020). A Systematic Review of Sexual and Reproductive Health Interventions for Young People in Humanitarian and Lower-and Middle-Income Country Settings; UNFPA (2022). My Body, My Life, My World Operational Guidance: Module 1 – ASRHR; UNFPA (2022). My Body, My Life, My World Operational Guidance: Module 3Comprehensive Sexuality Education

the area

Managing opposition, moreover, particularly from religious figures, has been another significant aspect of partners’ work, where partners and COPUA coalition members have organized meetings to address opposition attacks on safe abortion access, with representatives from various organizations, faith groups, youth champions, legal groups, media, and government staff. Moving forward, HFHC partners aim to build political support among parliamentarians, strengthen partnerships with SRHR and women’s rights organizations, and increase community awareness and mobilization efforts, particularly in rural areas where unsafe abortion practices remain prevalent. They are also focusing on engaging university and college students, who have shown strong support for the Bill. Overall, HFHC safe abortion advocacy efforts, campaigns, and community engagement have laid a strong foundation for future successes in promoting safe abortion and improving SRH outcomes in Malawi.

“A LUTA CONTINUA”: THE STRUGGLE CONTINUES

The experiences of HFHC partners in these four countries underscore the importance of continued awareness-raising, capacity strengthening, partnership, and advocacy to address barriers and enhance access to safe abortion and postabortion care services. These efforts are crucial for reducing maternal mortality, promoting comprehensive SRH care across diverse contexts, and upholding the rights of AGYW.

FAQS/FOR FURTHER READING

Interested in learning more about safe abortion and related care? Check out the resources below.

• What is Surgical Abortion?

- International Planned Parenthood Federation, What is Surgical Abortion and How Does it Work?

• What is Medical Abortion?

- How to Use Abortion Pill, Medical Abortion

• How to Use Medication to Self-Manage an Abortion at Home?

- How to Use Abortion Pill, Safe at Home Abortion Instructions

• How to Find Information About Abortion Services?

- Safe2Choose, Unwanted Pregnancy? We Can Support You.

• What are International Best Practices Regarding Abortion Care?

- World Health Organization (2022), Abortion Care Guideline

• What are Human Rights Standards on Abortion?

- World Health Organization (2022), Abortion Care Guideline Web Annex A. Key International Human Rights Standards on Abortion.