How can innovation help increase access to self-managed medical abortion in Sub-Saharan Africa?

Increasing access to safe abortion reduces maternal mortality and disability. However, currently, 45% of all abortions globally are unsafe and are a catastrophic public health problem, accounting for up to 13% of preventable maternal deaths worldwide and causing hundreds of thousands of survivors to live with preventable long-term complications.

The World Health Organization states that in the first 12 weeks of pregnancy, a medical abortion can safely be self-managed by the pregnant person outside of a health care facility (e.g., at home), in whole or in part, and with access to quality medicines, accurate information and the support from a trained health worker (if needed).

At Women Deliver 2023 in Kigali, sexual and reproductive health experts discussed the opportunities and considerations required to strengthen increasing access to self-managed medical abortion (SMMA) in sub-Saharan Africa in a session co-hosted by Options Consultancy Services, FIGO, the Mama Network, Grand Challenges Canada, the Hewlett Foundation and MSI Reproductive Choices. Here, we share key insights that emerged from this discussion.

1. Increasing access to SMMA is complex and sensitive work, but keep going: progress is possible.

In July 2023, after significant advocacy efforts by organisations such as the Kenya Sexual and Reproductive Rights and Health Sector (which the Kenya Obstetrical and Gynaecological Society is a member of), the Kenyan Ministry of Health updated their Kenya Essential Medicines List of 2019 to enable oral and per vaginal tablets of Mifepristone and Misoprostol to be more readily available,at diverse health facilities. For example this now includes at the primary health centre level. This is a progressive step as prior to this the availability of the Combipack Mifepristone/Misoprostol was restricted to District hospitals only.

To achieve this, health advocates and women’s rights organisations used advocacy messaging that was accessible for decision-makers, by demystifying clinical evidence which illustrated that SMMA is safe and effective up to 12 weeks of pregnancy.

It is important to make the scientific facts and figures accessible. We also linked access to safe abortion care with other issues that governments listen to. We told them that they were losing voters one by one by not addressing unsafe abortion and that we wanted our government to follow through on what they agreed under the Maputo Protocol. It’s important to keep being persistent.

– Dr Carolyne Odula - Obstetrician and Gynaecologist, International Federation of Gynaecology and Obstetrics (FIGO).

2. Embrace tech, without forgetting to reach those who have no access to it

Shifting to telemedicine is another effective approach to increasing access to safe abortion.

MSI, who undertook this shift in Ghana, stressed that COVID provided valuable lessons in how to reach women and girls in a crisis situation.

They found that there was huge demand for the service and that it presented an opportunity to reach a much wider audience: 88% of MSI’s Ghana’s telemedicine clients were completely new and a third reported that they had no other option to access safe abortion services other than through telemedicine.

It’s important to keep in mind that not everyone has access to technology whether that’s a phone or the internet.  But coming up with innovative ideas to reach women and girls through multiple platforms and channels has proven effective. Speaking 1:1 with women at community level and coming up with fun ways to share info with women – from stickers in toilets and public transport to community radio are just some examples according to the MAMA Network, an African regional network of grassroots organisations - that mobilises activists on medical abortion (MAMA).

Turning to newer and more popular social media platforms to spread the word about abortion services has two benefits as it reaches young people who actually use them while older people who tend to oppose abortion don’t tend to be on them, according to MSI whose TikTok video on telemedicine got 30k views and had people openly talk about abortion in the comments.

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3. Design innovative approaches to SMMA with and for her

Using a human-centred design approach to better understand women and girls’ needs is key.

“Through a ‘human-centered design’ approach, we engaged girls in sub-Saharan Africa to truly understand from their perspective and circumstances what girl-approved care meant. The outcome of this process was an innovative programme based on integrated model that was co-designed with the girls,” explains Kimani Karuga, Public Health Specialist at Options, where he managed the organisation’s Supporting adolescents to access integrated sexual and reproductive health services’ (Safire) programme. "Our integrated model consisted of three pathways: reaching girls with accurate information, community engagement focusing on creating a stigma-free conducive social environment, and providing quality services through a network of trained, supervised and supported private sector vendors and referral centres."

We also worked with a cohort of near-peers – slightly older girls, called ‘Big Sisters’ who acted as confidants, educators, and referral agents. This was a game changer. On the supply side, we learnt that although restrictive legal and regulatory environments distort the MA commodity market, programmes can get private sector providers to lower the prices and make commodities affordable with the right value proposition.

One of the biggest challenges in expanding access to SMMA for innovators is also ensuring diversity and inclusivity, as funders like Grand Challenges Canada (GCC), have found.

“You might have an innovation available in a common language, but communities who don’t speak that language can’t access [the innovation],” found Michelle Cruickshank, Senior Portfolio Manager, OPTions Initiative for GCC.

If you provide text-heavy information, then your innovation is not accessible to communities with low literacy rates. Additionally, not everyone has access to mobile devices. Innovators we work with at Safe Nest, are using really innovative approaches to address these challenges by using images instead of text to give directions, and ensuring people have access to devices, by loaning them a device for the time they need that access. Many innovators have also started to use audio or voice-over to give directions [for SMMA] for those who live with visual impairments. It’s so important to think about inclusivity amongst everything else.

4. Keep tackling abortion-related stigma and lack of trust

We must tackle abortion-related stigma among providers to ensure that women and girls consider abortion services safe and use them, said Dr Carolyne Odula.

You can’t have healthcare providers sitting on the fence on this issue. We need to clarify our values across the board as healthcare providers – and leave our personal views at home. We have to provide the service in a non-judgemental, gentle way, and if you can’t provide the (abortion) service, you must refer the woman or girl in a timely way.

Convincing decision-makers that we can trust women to use SMMA in the same way that we trust them to give medicine to their children, even when they are non-literate, and that it is effective is also key.

While challenges in increasing access to SMMA in sub-Saharan Africa remain, promising innovations have emerged that have proven effective in expanding access to women and girls in need. But to achieve progress, we must provide girls with accurate information, quality medicines and support from trained health workers, if needed. But most of all, we must trust women and put the power over their bodies and futures back in their hands.