Saving Women’s Lives: The Potential of Medical Abortion in Africa

Jennifer Daw Holloway

Access to medical abortion could save tens of thousands of women in Africa each year, by providing a safe alternative to unsafe abortion and a treatment for incomplete abortion or miscarriage.

This is the first in a series of articles from Keeping Our Promise: Addressing Unsafe Abortion in Africa this week.

Just a few pills could save an African woman’s life. Certainly, with roughly 250,000 dead each year from pregnancy-related causes, the need is great. Two major causes of maternal death in the region, postpartum hemorrhage and incomplete abortion, can be prevented and treated with access to misoprostol, a known medication that has been available for decades. Misoprostol, with or without another medicine, mifepristone, is also used for safe abortion.

Isn’t it time that African women benefit from the same simple technology that women around the world have?

Experts at Keeping our Promise: Addressing Unsafe Abortion in Africa, a meeting taking place this week in Accra, Ghana, say yes. The entire conference, full of policymakers, providers, advocates, health system workers and NGOs, is focused on finding and sharing effective ways to reduce unsafe abortion. The promise of medical abortion in Africa features prominently here at the conference.

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“The advantages of these medicines are many,” according to Dr. Davy Chikamata, medical advisor for the Concept Foundation, Africa.

“Medical abortion is proven safe and effective,” says Chikamata, “offers a choice to women and providers, and increases access to safe care through public health centers in both urban and rural areas.”

For women with limited access to reproductive health care, particularly those in remote areas, medical abortion gives them a safe alternative to dangerous methods of abortion and a proven treatment for incomplete abortion or miscarriage.

Dr. Joachim Osur, senior training and service delivery advisor with Ipas Africa Alliance, agrees and says the provision of medical abortion technology in Africa is still in its infancy, citing a paucity of standards and guidelines, very little training and a host of myths about the drugs. In addition, most African countries have restrictive laws that limit safe abortion services—though we know these laws don’t prevent abortion, just women’s ability to make safe reproductive health choices. Fortunately, he notes, there are programs working in a number of countries to build capacity of the health systems and communities to make medical abortion more available.

The medicines aren’t yet widely available in all of Africa, and where they are the indications for use most likely don’t include abortion. Misoprostol is registered for some obstetric uses in Ethiopia, Ghana, Kenya, Madagascar, Malawi, Mozambique, Nigeria, Somaliland, Tanzania, Uganda and Zambia. Mifepristone is registered in South Africa, Tunisia and Zambia and in process in Ethiopia and Ghana.

But some countries have emerged as leaders in the provision of the medicines for abortion and post-abortion care. In Ethiopia, women can get medical abortion in the public sector, where most women seek health care. Within two years of launching mifepristone and misoprostol, roughly 45 percent of women seeking abortion choose medical abortion there in the sites where it is available. And in Zambia, notes Dr. Osur, the Ministry of Health has added medical abortion to the national standards and guidelines. In Nigeria, a study has demonstrated the feasibility of using misoprostol to treat incomplete abortion, and policymakers are expected shortly to endorse this as an approved method of providing post-abortion care.

Misoprostol isn’t just a back door for abortion. “Misoprostol is key to advancing access to safe abortion in the region,” says Traci Baird, director of Ipas’s medical abortion initiative, “and it’s also a safe, acceptable option for treating incomplete abortion and a number of other ob-gyn problems.”

Let’s face it, women seek abortion, “even if by making this choice they risk their health or lives,” says Annie Nturubika, with SOS Femme et enfant et Catastrophe in the Democratic Republic of Congo. Women in the DRC have been subject to rape on a massive, systematic scale. Many of them seek unsafe abortion and their stories are never told. Her work there demonstrates that when women are given accurate information about medical abortion they will choose it. In fact, in the last two years, its use has significantly increased in DRC, according to Nturubika.

Challenges remain. Registration and procurement issues must be resolved. Standards must be established. Providers—from community health workers to mid-level providers to gynecologists—must have accurate information and be trained to help women use the medicines safely and effectively. Health systems throughout Africa must make medical abortion a priority and commit to increase access.

These medicines have the potential to reduce the thousands of deaths and countless injuries caused by unsafe abortion and pregnancy-related complications in low-resource settings and even in restricted legal settings. “We have the evidence, the knowledge, and the technologies to keep our promises to African women—now we must create the will,” says Getachew Bekele, senior advisor, Marie Stopes International Ethiopia.

Commentary Abortion

It’s Time for an Abortion Renaissance

Charlotte Taft

We’ve been under attack and hanging by a thread for so long, it’s been almost impossible to create and carry out our highest vision of abortion care.

My life’s work has been to transform the conversation about abortion, so I am overcome with joy at the Supreme Court ruling in Whole Woman’s Health v. Hellerstedt. Abortion providers have been living under a very dark cloud since the 2010 elections, and this ruling represents a new day.

Abortion providers can finally begin to turn our attention from the idiocy and frustration of dealing with legislation whose only intention is to prevent all legal abortion. We can apply our energy and creativity fully to the work we love and the people we serve.

My work has been with independent providers who have always proudly delivered most of the abortion care in our country. It is thrilling that the Court recognized their unique contribution. In his opinion, after taking note of the $26 million facility that Planned Parenthood built in Houston, Justice Stephen Breyer wrote:

More fundamentally, in the face of no threat to women’s health, Texas seeks to force women to travel long distances to get abortions in crammed-to-capacity superfacilities. Patients seeking these services are less likely to get the kind of individualized attention, serious conversation, and emotional support that doctors at less taxed facilities may have offered.

This is a critical time to build on the burgeoning recognition that independent clinics are essential and, at their best, create a sanctuary for women. And it’s also a critical time for independent providers as a field to share, learn from, and adopt each other’s best practices while inventing bold new strategies to meet these new times. New generations expect and demand a more open and just society. Access to all kinds of health care for all people, including excellent, affordable, and state-of-the-art abortion care is an essential part of this.

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We’ve been under attack and hanging by a thread for so long—with our financial, emotional, and psychic energies drained by relentless, unconstitutional anti-abortion legislation—it’s been almost impossible to create and carry out our highest vision of abortion care.

Now that the Supreme Court has made it clear that abortion regulations must be supported by medical proof that they improve health, and that even with proof, the burdens can’t outweigh the benefits, it is time to say goodbye to the many politically motivated regulations that have been passed. These include waiting periods, medically inaccurate state-mandated counseling, bans on telemedicine, and mandated ultrasounds, along with the admitting privileges and ambulatory surgical center requirements declared unconstitutional by the Court.

Clearly 20-week bans don’t pass the undue burden test, imposed by the Court under Planned Parenthood v. Casey, because they take place before viability and abortion at 20 weeks is safer than childbirth. The federal Hyde Amendment, a restriction on Medicaid coverage of abortion, obviously represents an undue burden because it places additional risk on poor women who can’t access care as early as women with resources. Whatever the benefit was to late Rep. Henry Hyde (R-IL) it can’t possibly outweigh that burden.

Some of these have already been rejected by the Court and, in Alabama’s case, an attorney general, in the wake of the Whole Woman’s Health ruling. Others will require the kind of bold action already planned by the Center for Reproductive Rights and other organizations. The Renaissance involves raising an even more powerful voice against these regulations, and being firm in our unwillingness to spend taxpayer dollars harming women.

I’d like to entertain the idea that we simply ignore regulations like these that impose burdens and do not improve health and safety. Of course I know that this wouldn’t be possible in many places because abortion providers don’t have much political leverage. This may just be the part of me that wants reproductive rights to warrant the many risks of civil disobedience. In my mind is the man who stood in front of moving tanks in Tiananmen Square. I am yearning for all the ways to stand in front of those tanks, both legal and extralegal.

Early abortion is a community public health service, and a Renaissance goal could be to have early abortion care accessible within one hour of every woman in the country. There are more than 3,000 fake clinics in this country, many of them supported by tax dollars. Surely we can find a way to make actual services as widely available to people who need them. Of course many areas couldn’t support a clinic, but we can find ways to create satellite or even mobile clinics using telemedicine to serve women in rural areas. We can use technology to check in with patients during medication abortions, and we can provide ways to simplify after-care and empower women to be partners with us in their care. Later abortion would be available in larger cities, just as more complex medical procedures are.

In this brave new world, we can invent new ways to involve the families and partners of our patients in abortion care when it is appropriate. This is likely to improve health outcomes and also general satisfaction. And it can increase the number of people who are grateful for and support independent abortion care providers and who are able to talk openly about abortion.

We can tailor our services to learn which women may benefit from additional time or counseling and give them what they need. And we can provide abortion services for women who own their choices. When a woman tells us that she doesn’t believe in abortion, or that it is “murder” but she has to have one, we can see that as a need for deeper counseling. If the conflict is not resolved, we may decide that it doesn’t benefit the patient, the clinic, or our society to perform an abortion on a woman who is asking the clinic to do something she doesn’t believe in.

I am aware that this last idea may be controversial. But I have spent 40 years counseling with representatives of the very small, but real, percentage of women who are in emotional turmoil after their abortions. My experience with these women and reading online “testimonies” from women who say they regret their abortions and see themselves as victimized, including the ones cited by Justice Kennedy in the Casey decision, have reinforced my belief that when a woman doesn’t own her abortion decision she will suffer and find someone to blame for it.

We can transform the conversation about abortion. As an abortion counselor I know that love is at the base of women’s choices—love for the children they already have; love for their partners; love for the potential child; and even sometimes love for themselves. It is this that the anti-abortion movement will never understand because they believe women are essentially irresponsible whores. These are the accusations protesters scream at women day after day outside abortion clinics.

Of course there are obstacles to our brave new world.

The most obvious obstacles are political. As long as more than 20 states are run by Republican supermajorities, legislatures will continue to find new ways to undermine access to abortion. The Republican Party has become an arm of the militant anti-choice movement. As with any fundamentalist sect, they constantly attack women’s rights and dignity starting with the most intimate aspects of their lives. A society’s view of abortion is closely linked to and mirrors its regard for women, so it is time to boldly assert the full humanity of women.

Anti-choice LifeNews.com contends that there have been approximately 58,586,256 abortions in this country since 1973. That means that 58,586,256 men have been personally involved in abortion, and the friends and family members of at least 58,586,256 people having abortions have been too. So more than 180 million Americans have had a personal experience with abortion. There is no way a small cadre of bitter men with gory signs could stand up to all of them. So they have, very successfully so far, imposed and reinforced shame and stigma to keep many of that 180 million silent. Yet in the time leading up to the Whole Woman’s Health case we have seen a new opening of conversation—with thousands of women telling their personal stories—and the recognition that safe abortion is an essential and normal part of health care. If we can build on that and continue to talk openly and honestly about the most uncomfortable aspects of pregnancy and abortion, we can heal the shame and stigma that have been the most successful weapons of anti-abortion zealots.

A second obstacle is money. There are many extraordinary organizations dedicated to raising funds to assist poor women who have been betrayed by the Hyde Amendment. They can never raise enough to make up for the abandonment of the government, and that has to be fixed. However most people don’t realize that many clinics are themselves in financial distress. Most abortion providers have kept their fees ridiculously and perilously low in order to be within reach of their patients.

Consider this: In 1975 when I had my first job as an abortion counselor, an abortion within the first 12 weeks cost $150. Today an average price for the same abortion is around $550. That is an increase of less than $10 a year! Even in the 15 states that provide funding for abortion, the reimbursement to clinics is so low that providers could go out of business serving those in most need of care.

Over the years a higher percent of the women seeking abortion care are poor women, women of color, and immigrant and undocumented women largely due to the gap in sexual health education and resources. That means that a clinic can’t subsidize care through larger fees for those with more resources. While Hyde must be repealed, perhaps it is also time to invent some new approaches to funding abortion so that the fees can be sustainable.

Women are often very much on their own to find the funds needed for an abortion, and as the time goes by both the costs and the risk to them increases. Since patients bear 100 percent of the medical risk and physical experience of pregnancy, and the lioness’ share of the emotional experience, it makes sense to me that the partner involved be responsible for 100 percent of the cost of an abortion. And why not codify this into law, just as paternal responsibilities have been? Perhaps such laws, coupled with new technology to make DNA testing as quick and inexpensive as pregnancy testing, would shift the balance of responsibility so that men would be responsible for paying abortion fees, and exercise care as to when and where they release their sperm!

In spite of the millions of women who have chosen abortion through the ages, many women still feel alone. I wonder if it could make a difference if women having abortions, including those who received assistance from abortion funds, were asked to “pay it forward”—to give something in the future if they can, to help another woman? What if they also wrote a letter—not a bread-and-butter “thank you” note—but a letter of love and support to a woman connected to them by the web of this individual, intimate, yet universal experience? This certainly wouldn’t solve the economic crisis, but it could help transform some women’s experience of isolation and shame.

One in three women will have an abortion, yet many are still afraid to talk about it. Now that there is safe medication for abortion, more and more women will be accessing abortion through the internet in some DIY fashion. What if we could teach everyone how to be excellent abortion counselors—give them accurate information; teach them to listen with nonjudgmental compassion, and to help women look deeper into their own feelings and beliefs so that they can come to a sense of confidence and resolution about their decision before they have an abortion?

There are so many brilliant, caring, and amazing people who provide abortion care—and room for many more to establish new clinics where they are needed. When we turn our sights to what can be, there is no limit to what we can create.

Being frustrated and helpless is exhausting and can burn us out. So here’s a glass of champagne to being able to dream again, and to dreaming big. From my own past clinic work:

At this clinic we do sacred work
That honors women
And the circle of life and death.

Analysis Law and Policy

What Monday’s Supreme Court Decision Means in the Fight for Abortion Rights

Jessica Mason Pieklo

Monday's decision striking two provisions of Texas' HB 2 doesn't just threaten similar laws nationwide; it could be the basis for finally stemming the onslaught of anti-science abortion restrictions in the states.

Read more of our coverage of Whole Woman’s Health v. Hellerstedt here.

Abortion rights advocates have insisted, since the beginning of the fight over targeted regulation of abortion providers (TRAP) laws, that despite anti-choice lawmakers’ claims to the contrary, the evidence proved these restrictions harmed rather than advanced patient safety. On Monday, the U.S. Supreme Court finally listened.

Monday’s decision in Whole Woman’s Health v. Hellerstedtwhich struck as unconstitutional Texas’ requirements in HB 2 that all doctors performing abortions in the state have admitting privileges at a nearby hospital and that all clinics meet the same requirements as stand-alone surgical centers—is not just a win for advocates and patients in Texas. It produced an opinion that has the potential to turn back the seemingly endless wave of restrictions from the states and to reinforce abortion as a fundamental right.

First things first. Whole Woman’s Health is a data-heavy opinion, and there is probably no better justice to pen one than Justice Stephen Breyer. The man seems to live for statistical analysis. He may offer up rambling hypotheticals during oral arguments, but his written opinions are more often than not grounded in data.

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The reason this matters is that both the conservatives on the Roberts Court and their supporters in the Fifth Circuit have tried their damnedest for years to sidestep piles and piles of facts. Such as the fact that in 2013, the year Gov. Rick Perry (R) signed HB 2 into law, the number of Texans who traveled out of state to have an abortion increased to 681, a jump Rewire reported as amounting to more than the previous four years combined. Conservatives also tried to explain away the fact that prior to the implementation of HB 2, there were 41 facilities providing abortion services in the state; by the end of 2013, 16 of those facilities had either stopped providing abortion services or closed altogether. And they tried to manipulate the legal standard governing how courts review abortion restrictions to do so. Justice Breyer, his liberal colleagues, and even noted abortion rights skeptic Justice Anthony Kennedy finally put a stop to all that nonsense. Here’s how.

When upholding the Texas abortion restrictions, the Fifth Circuit relied heavily on a line of reasoning in Gonzales v. Carhartthe 2007 Supreme Court case that upheld the so-called federal partial-birth abortion act. As part of that decision, the Court ruled that when there is a question of scientific or medical uncertainty, legislators could essentially pick a side they agree with and draft laws accordingly. We’ve all witnessed what happened next. Anti-choice lawmakers in the states went bananas concocting abortion restrictions with not much more than a hand-wave that those restrictions were grounded in science and designed to advance patient safety. The Fifth Circuit Court of Appeals took that ruling one step further in the fight over HB 2 and ruled that once legislators announce their justification for an abortion restriction, there was little, if anything, the federal courts could do to second-guess that reasoning.

Not so, the Court ruled Monday. “The statement [by the Fifth Circuit] that legislatures, and not courts, must resolve questions of medical uncertainty is also inconsistent with this Court’s case law,” Breyer wrote. “Instead, the Court, when determining the constitutionality of laws regulating abortion procedures, has placed considerable weight upon evidence and argument presented in judicial proceedings” holding that the “Court retains an independent constitutional duty to review factual findings where constitutional rights are at stake.”

Justice Breyer put that last part in italics just to drive home that yes, when it comes to the fundamental right to abortion, the federal courts are not simply rubber stamps for state lawmakers.

With that point made clear, Breyer then laid out—basically in a listicle—the number of places the Fifth Circuit got its review of the data wrong as to the effect of admitting privileges on the availability of reproductive care. It’s an impressive list that goes on for pages and includes “[a] collection of at least five peer-reviewed studies on abortion complications in the first trimester, showing that the highest rate of major complications including those complications requiring hospital admission—was less than one-quarter of 1%” as “[e]xpert testimony to the effect that complications rarely require hospital admission, much less immediate transfer to a hospital from an outpatient clinic.”

There’s more, but Breyer summed it up nicely: “In our view, the record contains sufficient evidence that the admitting-privileges requirement led to the closure of half of Texas’ clinics, or thereabouts. Those closures meant fewer doctors, longer waiting times, and increased crowding.”

Moving on to those claims made by attorneys for the State of Texas that the ACS provisions in particular advanced patient safety, Justice Breyer dropped some more data bombs. “Nationwide, childbirth is 14 times more likely than abortion to result in death, but Texas law allows a midwife to oversee childbirth in the patient’s own home,” Breyer wrote.

Colonoscopy, a procedure that typically takes place outside a hospital (or surgical center) setting, has a mortality rate 10 times higher than an abortion. The mortality rate for liposuction, another outpatient procedure, is 28 times higher than the mortality rate for abortion. Medical treatment after an incomplete miscarriage often involves a procedure identical to that involved in a nonmedical abortion, but it often takes place outside a hospital or surgical center. And Texas partly or wholly grandfathers (or waives in whole or in part the surgical-center requirement for) about two-thirds of the facilities to which the surgical-center standards apply. But it neither grandfathers nor provides waivers for any of the facilities that perform abortions.

How good does it feel to hear the Supreme Court call shenanigans on lawmakers who insist the best way to protect the health and safety of patients is by making comprehensive reproductive health care impossible to access? Probably as good as it feels to hear the Supreme Court shut down in the same opinion all the nonsense from abortion rights opponents claiming rogue provider Dr. Kermit Gosnell is proof positive that all abortion providers are dangerous predators that require the kind of regulation advanced in HB 2. “Gosnell’s behavior was terribly wrong. But there is no reason to believe that an extra layer of regulation would have affected that behavior,” Breyer wrote. “Determined wrongdoers, already ignoring existing statutes and safety measures, are unlikely to be convinced to adopt safe practices by a new overlay of regulations. Regardless, Gosnell’s deplorable crimes could escape detection only because his facility went uninspected for more than 15 years.”

Breyer went on: “Pre-existing Texas law already contained numerous detailed regulations covering abortion facilities, including a requirement that facilities be inspected at least annually. The record contains nothing to suggest that H. B. 2 would be more effective than pre-existing Texas law at deterring wrongdoers like Gosnell from criminal behavior.”

And: scene.

Immediately, Monday’s decision means that similar TRAP restrictions in other Fifth Circuit states like Louisiana are likely to be found unconstitutional. In states like Missouri or Kansas, it’s too soon to tell how the decision will affect those kinds of laws, but advocates are no doubt looking into that issue right now given the opening Monday’s decision creates.

And importantly, it makes it much more difficult for anti-abortion lawmakers to advance additional restrictions like “dismemberment bans” without being able to scientifically prove those laws actually advance patient care. These are laws that would effectively criminalize surgical abortions pre-viabilty, and are anti-abortion lawmakers’ latest attempts to cut off access to abortion while claiming to advance patient safety.

This is why Whole Woman’s Health v. Hellerstedt has the potential to reach far beyond TRAP laws in the fight for comprehensive reproductive health care. Finally, we’ve got a Supreme Court decision that demands facts over rhetoric and data over belief, and doesn’t fall into the “difficult decision that people disagree on” false equivalence. Monday’s decision is a clear, data-driven defense of the importance of access to comprehensive reproductive health care and an affirmation of abortion as a fundamental right. And that kind of defense has been a long time coming.