Does supportive legislation guarantee access to pregnancy termination and postabortion care services? Findings from a facility census in Central Province, Zambia

Abstract

IntroductionZambia is one of the few countries in Africa to permit termination of pregnancy (TOP) on a wide range of grounds. However, substantial barriers remain to TOP and postabortion care (PAC).MethodsWe conducted a census of 153 facilities between March and May 2016. We defined facilities according to whether they met basic and/or comprehensive signal functions criteria for TOP and PAC. We linked our facility data to census data to estimate geographic accessibility under different policy scenarios.ResultsOverall, 16% of facilities reported they had performed a TOP and 39% performed a PAC in the last year. Facilities were twice as likely to use medical methods for TOP compared with surgical methods, and four times more likely for PAC. Considerably more facilities had performed TOP or PAC than met the basic or comprehensive signal functions criteria, indicating services were being performed in facilities below essential quality standards. Under current Zambian law for non-emergency scenarios, 21% of women in Central Province lived within 15 km of a facility with basic capability to provide TOP; if midlevel providers were trained to provide TOP, this would increase to 36%.ConclusionA supportive legislative framework is essential, but not in itself sufficient, for adequate access to services. Training midlevel providers, in line with WHO guidance, and ensuring equipment is available in primary care can increase accessibility of TOP and PAC. While both medical and surgical methods need to be available, medical abortion is a safe and effective method that can be provided in low-resource settings.

Treading the Thin Line: Pharmacy Workers’ Perspectives on Medication Abortion Provision in Lusaka, Zambia

“…Ministry of Health guidelines permit MA up to nine gestational weeks and manual vacuum aspiration up to 12 weeks (or 14 weeks under certain circumstances) (Government of Zambia 2017). However, Zambian women have limited access to safe, quality abortion care due to poor service availability (Ministry of Health 2009;Cresswell et al 2018), restrictive clinical regulations on who can provide care coupled with health worker shortages, health care provider refusal to offer abortion care (Freeman 2019), and poor awareness of abortion laws (Ministry of Health 2009; Coast 2016). One of the legal requirements for a woman to access an abortion is signatures of approval from three medical doctors, including a specialist, except in emergency cases (Government of Zambia 1972), which creates challenges in the context of severe health worker shortages (Prust 2019).…”

Comparing women’s financial costs of induced abortion at a facility vs. seeking treatment for complications from unsafe abortion in Zambia

“…16 In addition, some pharmacists have been trained to provide referral information to women seeking an abortion. 6,9,17 To reduce the risk that a woman and her family experience harmful financial consequences associated with an unsafe abortion, greater use of family planning and provision of safe abortion services through the dissemination of accurate and reliable information must be promoted in Zambia. Unsafe abortion not only places a woman at greater risk of severe health consequences but also has a negative economic consequence because of the costs associated with seeking CUA and the treatment or untreated effects of long-term health consequences.…”

“…2–5 In addition, negative social attitudes about abortion, and difficulties reaching facilities, inhibit women’s access to safe services. 4–6 Therefore, women take significant risks to terminate unwanted pregnancies. Zambia has an estimated maternal mortality ratio of 398 deaths per 100,000 live births, 7 with 30% estimated to be due to unsafe abortion.…”

“…A census of 153 facilities (hospitals and health centers) conducted in 2016 found that only 12% reported that they would be able to perform a medical or surgical first trimester abortion procedure. 6 Medical abortion (MA) using mifepristone and misoprostol was officially introduced in Zambia in 25 public health facilities in 2009. 2 Misoprostol is more accessible although not frequently used in health facilities in Zambia.…”

“…This work is part of a larger project which assessed women’s abortion-related behaviour in Zambia through a community-based household survey, 4 a policy analysis, an economic analysis of women’s abortion-related costs, an assessment of near-miss cases of abortion-related maternal mortality occurring in health facilities, 11 and an assessment of the capacity of health facilities to perform signal functions for abortion services. 6…”