A learning agenda for abortion stigma: recommendations from the Bellagio expert group meeting.

Stigma discredits individuals, communities, and institutions and marks them as inferior. The stigma surrounding abortion plays a critical role in its social, medical, and legal marginalization around the world. Based on the existing field of knowledge, in June 19, 2012, researchers, practitioners, and advocates from 11 countries participated in an intensive meeting on abortion stigma to refine a conceptual framework for abortion stigma and set a future learning agenda to guide research and programmatic efforts to address abortion stigma.

Developing a scale to measure stigmatizing attitudes and beliefs about women who have abortions: results from Ghana and Zambia.

The objective of this research was to explore the context of abortion stigma in Ghana and Zambia through qualitative research, and develop a quantitative instrument to measure stigmatizing attitudes and beliefs about abortion. Ultimately, we aimed to develop a scale to measure abortion stigma at the individual and community level that can also be used in the evaluation of stigma reduction interventions. Focus group discussions were conducted in both countries to provide information around attitudes and beliefs about abortion. A 57-item instrument was created from these data, pre-tested, and then administered to 531 individuals (n = 250 in Ghana and n = 281 in Zambia). Exploratory factor analyses were conducted on 33 of the original 57 items to identify a statistically and conceptually relevant scale. Items with factor loadings > 0.39 were retained. All analyses were completed using Stata IC/11.2. Exploratory factor analysis resulted in a three-factor solution that explained 53% of the variance in an 18-item instrument. The three identified subscales are: (i) negative stereotypes (eight items), (ii) discrimination and exclusion (seven items), and (iii) potential contagion (three items). Coefficient alphas of 0.85, 0.80, and 0.80 for the three subscales, and 0.90 for the full 18-item instrument provide evidence of internal consistency reliability. Our Stigmatizing Attitudes, Beliefs, and Actions scale captures three important dimensions of abortion stigma: negative stereotypes about men and women who are associated with abortion, discrimination/exclusion of women who have abortions, and fear of contagion as a result of coming in contact with a woman who has had an abortion. The development of this scale provides a validated tool for measuring stigmatizing attitudes and beliefs about abortion in Ghana and Zambia. Additionally, the scale has the potential to be applicable in other country settings. It represents an important contribution to the fields of reproductive health, abortion, and stigma.

Facilitating women's access to misoprostol through community-based advocacy in Kenya and Tanzania.

OBJECTIVE: To explore the feasibility of educating communities about gynecologic uses for misoprostol at the community level through community-based organizations in countries with restrictive abortion laws. METHODS: In 2012, the Public Health Institute and Ipas conducted an operations research study, providing small grants to 28 community-based organizations in Kenya and Tanzania to disseminate information on the correct use of misoprostol for both abortion and postpartum hemorrhage. These groups were connected to pharmacies selling misoprostol. The primary outcomes of the intervention were reports from the community-based organizations regarding the health education strategies that they had developed and implemented to educate their communities. RESULTS: The groups developed numerous creative strategies to reach diverse audiences and ensure access to misoprostol pills. Given the restrictive environment, the groups attributed their success to having addressed the use of misoprostol for both indications (abortion and postpartum hemorrhage) and to using a harm reduction approach to frame the advocacy. CONCLUSION: This initiative proves that, even where abortion is legally restricted and socially stigmatized, community-based organizations can publicly and openly share information about misoprostol and refer it to women by using innovative and effective strategies, without political backlash. Furthermore, it shows that communities are eager for this information.

Early pregnancy detection by female community health volunteers in Nepal facilitated referral for appropriate reproductive health services.

BACKGROUND: Female community health volunteers (FCHVs) are a possible entry point for Nepali women to access timely reproductive health services at the village level. This evaluation assessed the success of a pilot program that trained FCHVs in early pregnancy detection using urine pregnancy tests (UPTs), counseling, and referral to appropriate antenatal, safe abortion, or family planning services. METHODS: Between July 2008 and June 2009, the program trained 1,683 FCHVs from 6 districts on how to provide UPTs and appropriate counseling and referral; 1,492 FCHVs (89%) provided follow-up data on the number of clients served and the type of services provided. In addition, the program conducted in-depth interviews with selected FCHVs and other reproductive health service providers on their perceptions of the program. RESULTS: Of the FCHVs with follow-up data, 80% reported providing UPTs to women in the 8-month follow-up period. In total, they conducted 4,598 UPTs, with a mean number of 3.1 tests per FCHV. Among the women with a negative pregnancy test (47%), FCHVs provided 24% of them with oral contraceptive pills and 20% with condoms; referred 10% for other contraceptive services; and provided contraceptive counseling only to 46%. Among the women with positive pregnancy tests (53%), FCHVs referred 68% for antenatal care and 32% for safe abortion services. CONCLUSIONS: Providing FCHVs with the skills and supplies required for early pregnancy detection allowed them to make referrals for appropriate reproductive health services. Results of this evaluation suggest that community health workers such as FCHVs are a promising channel for early pregnancy detection and referral. As the intervention is scaled up, the focus should be on ensuring service availability and awareness of available services, UPT supply, and creating viable options for record keeping.

Conceptualising abortion stigma.

Abortion stigma is widely acknowledged in many countries, but poorly theorised. Although media accounts often evoke abortion stigma as a universal social fact, we suggest that the social production of abortion stigma is profoundly local. Abortion stigma is neither natural nor 'essential' and relies upon power disparities and inequalities for its formation. In this paper, we identify social and political processes that favour the emergence, perpetuation and normalisation of abortion stigma. We hypothesise that abortion transgresses three cherished 'feminine' ideals: perpetual fecundity; the inevitability of motherhood; and instinctive nurturing. We offer examples of how abortion stigma is generated through popular and medical discourses, government and political structures, institutions, communities and via personal interactions. Finally, we propose a research agenda to reveal, measure and map the diverse manifestations of abortion stigma and its impact on women's health.

Abortion and Islam: policies and practice in the Middle East and North Africa.

This paper provides an overview of legal, religious, medical and social factors that serve to support or hinder women's access to safe abortion services in the 21 predominantly Muslim countries of the Middle East and North Africa (MENA) region, where one in ten pregnancies ends in abortion. Reform efforts, including progressive interpretations of Islam, have resulted in laws allowing for early abortion on request in two countries; six others permit abortion on health grounds and three more also allow abortion in cases of rape or fetal impairment. However, medical and social factors limit access to safe abortion services in all but Turkey and Tunisia. To address this situation, efforts are increasing in a few countries to introduce post-abortion care, document the magnitude of unsafe abortion and understand women's experience of unplanned pregnancy. Religious fatawa have been issued allowing abortions in certain circumstances. An understanding of variations in Muslim beliefs and practices, and the interplay between politics, religion, history and reproductive rights is key to understanding abortion in different Muslim societies. More needs to be done to build on efforts to increase women's rights, engage community leaders, support progressive religious leaders and government officials and promote advocacy among health professionals.

Global policy change and women's access to safe abortion: the impact of the World Health Organization's guidance in Africa.

Along with governments from around the world, African leaders agreed at the International Conference on Population and Development (ICPD) in 1994 to address unsafe abortion as a major public health problem. At the five-year review of the ICPD, they decided further that health systems should make safe abortion services accessible for legal indications. Based on this mandate, the World Health Organization (WHO) developed norms and standards for quality abortion services, Safe Abortion: Technical and Policy Guidance for Health Systems, released in 2003. While abortion-related maternal mortality and morbidity remains very high in many African countries, stakeholders are increasingly using WHO recommendations in conjunction with other global and regional policy frameworks, including the African Union Protocol on the Rights of Women in Africa, to spur new action to address this persistent problem. Efforts include: reforming national laws and policies; preparing service-delivery guidelines and regulations; strengthening training programs; and expanding community outreach programs. This paper reviews progress and lessons learned while drawing attention to the fragility of the progress made thus far and the key challenges that remain in ensuring access to safe abortion care for all African women.

Global progress in abortion advocacy and policy: an assessment of the decade since ICPD.

The 1994 International Conference on Population and Development (ICPD) Programme of Action represented a positive step toward legitimising abortion as a component of basic reproductive health services. This paper reviews how the ICPD principles and recommendations have been applied in the past decade toward increasing women's access to affordable, safe and legal abortion services. It examines advocacy efforts to increase understanding of abortion among policymakers and the public, policy and action at the global level, progress made in national-level policies and services, and obstacles encountered. Research and advocacy are helping to break the silence globally about unsafe abortion, and there is an emerging global movement supporting women's right to safe abortion. A great deal has been accomplished in the ten short years since ICPD, in spite of serious setbacks in some countries and continuing obstacles. A synthesis of public health and rights-based approaches, and strategic partnerships with other social justice movements are called for, as a foundation for effective legal reform efforts and to ensure that women have access to safe abortion services.

The power dynamics perpetuating unsafe abortion in Africa: a feminist perspective.

Tens of thousands of African women die every year because societies and governments either ignore the issue of unsafe abortion or actively refuse to address it. This paper explores the issue of abortion from a feminist perspective, centrally arguing that finding appropriate strategies to reclaim women's power at an individual and social level is a central lever for developing effective strategies to increase women's access to safe abortion services. The paper emphasises the central role of patriarchy in shaping the ways power plays itself out in individual relationships, and at social, economic and political levels. The ideology of male superiority denies abortion as an important issue of status and frames the morality, legality and socio-cultural attitudes towards abortion. Patriarchy sculpts unequal gender power relationships and takes power away from women in making decisions about their bodies. Other forms of power such as economic inequality, discourse and power within relationships are also explored. Recommended solutions to shifting the power dynamics around the issue include a combination of public health, rights-based, legal reform and social justice approaches.