Although abortion is technically legal in Zambia, the reality is far more complicated. Zambia has what has been called a “paper law” with numerous barriers to care at both the policy and implementation levels [1]. Unsafe abortion remains a very real problem - causing death and disability across the country. Although evidence on the incidence and consequences of unsafe abortion in recent years is scarce, numerous studies from the late 1990s identify the methods used across the country, such as ingesting toxins like detergent and inserting cassava sticks in the cervix [2–4]. While information and utilization of legal abortions is becoming more common, most experts feel that unsafe abortion is persisting [5–7]. Between 2003 and 2008 in Zambia’s major hospitals, almost one-third of all gynecologic admissions were due to complications of unsafe abortion, researchers estimated that 6 in every 1,000 of these women died as a result of their complications [8].
The impact of recent maternal health interventions on the incidence of unintended pregnancy and unsafe abortion remains unclear. Early childbearing is still very common, almost 60% of Zambian women have borne a child by age 19 [9]. Rural young women in poverty bear the brunt of morbidity from early childbearing, facing twice the risk of complications during pregnancy as older women and severely limited opportunities for continued education that help lift women and their families from poverty [9]. Regardless of education, socioeconomic status or place of residence, most Zambian women have more children than they originally wanted [9].
Until recently, legal abortion services have not been widely available in health centers or hospitals, compelling women to continue to turn to illegal providers and unsafe methods and confirming that just the existence of a law, with insufficient political will or guidance for implementation may not be effective in improving maternal health [6, 10–12]. Unsafe abortion – the termination of an unintended pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both – contributes to 8-13% of global maternal mortality [13, 14]. Although Zambia’s Maternal Mortality Ratio (MMR) declined in the preceding 7 years from 591 to 398 per 100,000 births in the 2014 Demographic and Health Survey, it remains high for the African continent; as many as 30% of these deaths could be the result of unsafe abortion according to an audit of maternal deaths at the University Teaching Hospital (UTH) in Lusaka [5].
Medical abortion (MA) using the World Health Organization’s recommended mifepristone and misoprostol combined regimen, is a highly effective method of pregnancy termination, with low complication rates up to and even after 9 weeks of gestation [15–17]. The use of medications offers women a non-surgical method of induced abortion, and has been proven to be highly acceptable to both clients and providers [18, 19]. Particularly in low-resource settings, with limited health care access and few trained surgical abortion providers, MA can increase safe abortion access, and decrease maternal morbidity and mortality associated with unsafe abortion by providing a safe and effective non-surgical option. However, at the time of this study, mifepristone was registered in only two African countries - Tunisia and South Africa; since 2009 only five additional African countries have registered mifepristone for importation - Zambia, Ghana, Mozambique, Ethiopia and Kenya [20]. Restrictive abortion laws, the expense of the medication, and reluctance by policymakers to shepherd mifepristone to broader markets and tackle policies necessary for wider distribution have contributed to few developing countries making this drug available.
In 2008, concerned with alarming maternal death rates and faced with daunting Millennium Development Goals (MDGs), the Ministry of Health (MOH) supported a national strategic assessment of unsafe abortion in the country. Findings revealed high demand for safe abortion in the country, the existing use of a wide variety of unsafe and traditional abortifacients, persistent high levels of provider stigma, logistical barriers to accessing safe abortion for women across the country and lack of specific provisions for youth [21]. On the heels of this assessment, Ipas, an international non-governmental organization (NGO) working in the field of reproductive health and rights, in collaboration with the Ministry of Health (MOH) and the University Teaching Hospital, conducted a comprehensive pilot project to introduce medical abortion (MA) with mifepristone and misoprostol in Zambia and to demonstrate a model for strengthening and scaling up safe abortion services to the extent allowed by the law. The project evaluation was designed using an implementation science model to document the factors and components that could be used to move a national comprehensive abortion care (CAC) program from limited to extensive service provision for replication in other parts of the continent.
This paper first describes the process and results of galvanizing access to medical abortion in an environment where abortion has been legal for many years, but provision of safe services has been severely limited. Secondly, results are presented to highlight the successes and the challenges of bringing medical abortion to an operationally complex context, a health system being rebuilt after enormous investment in HIV prevention and treatment, using implementation science to document the results of 2 years of implementation. Finally, these findings not only provide a case study of medical abortion in Zambia, but also offer important lessons and recommendations for expanding access to safe abortion in similar settings across Africa.
Establishment of legal abortion in Zambia
Although weak in implementation, Zambia has among the most liberal abortion policies of any Sub-Saharan African country. The Termination of Pregnancy (TOP) Act of 1972 permits abortion in Zambia under the following circumstances: the pregnancy causes risk to the life of the pregnant woman; risk of injury to the physical or mental health of the pregnant woman; risk of injury to the physical or mental health of any existing children of the woman, greater than if the pregnancy were terminated; or if there is substantial risk of fetal malformation. Moreover, the law states that if the continuance of a pregnancy would involve great risk, account may be taken of the pregnant woman's environment or of her age [22]. Further amendments to the Penal Code have allowed for abortion in cases of rape and incest.
The 1972 TOP Act of Zambia contained cumbersome requirements that had to be instituted before a termination could be performed [1]. The TOP Act did not reference gestational limits for an abortion but the MOH later issued regulations for provider authorization through viability (28 weeks of gestation) [23]. The onerous regulations were established under the guise of safeguarding against potential abuses of the law. To this end the law stated that a doctor’s decision to perform an abortion had to be co-signed by two other physicians, one of whom had to be a specialist, before the procedure could be initiated. The law also stipulated that only licensed physicians could perform the procedure and only in facilities designated by government as might be considered appropriate in the United Kingdom but were unrealistic in Zambia where health infrastructure, training and physicians were in short supply. Unfortunately, the regulations now codified in the law, essentially created an impossible standard for implementation [1]. With fewer than 2 physicians for every 10,000 people in the country, even when women have a willing and skilled provider, many women, especially in rural areas, are forced to seek unsafe abortions because they can’t navigate the health system and get the permissions required to have a legal abortion in time to terminate their pregnancies [8, 24]. The Zambian law eliminated any role for midlevel providers - health care workers such as nurses, midwives and medical officers, who have a more restricted scope of practice than physicians - in abortion care without a new law or ministerial guidance overriding it. African midlevel health workers currently provide most of the induced or postabortion care in Africa [25–28].
Abortion access in Zambia, 1970s-2000s
Although Zambia’s TOP Act was ratified in 1972, very little was done in the post-legalization era to inform the public or improve access to services. The law itself was passed quietly, and was not followed by technical guidance to facilitate implementation; even today, most legislators and judges are unclear about the nuances of the TOP Act [11]. Furthermore, dilation and curettage remained the outdated standard of abortion care for much of the three decades following the passage of the Act, well after the World Health Organization (WHO) technical guidance on abortion technologies recommended manual vacuum aspiration (MVA) and medication for induced abortion. In the early 1990s limited training for legal terminations was introduced in the country with the material support of NGOs and with USAID support. [5, 29–31] However, due to lack of funding and sustainable support from the government, exhaustive resource and infrastructure needs and a loss of health workers during the early years of the AIDS crisis, access to legal abortions never devolved past the University Teaching Hospital (UTH), by the mid 1990’s the UTH was the only facility providing induced abortion services in the country [29, 31, 32].
In the 1990s, due to persistent lack of access to contraceptive methods, and virtually no health system support for abortion provision, women continued to suffer the consequences of unsafe abortions. Alarmingly, many of these procedures were unlawfully performed by untrained providers or traditional practitioners, who benefited from women’s lack of knowledge regarding legal abortion and their inability to access licensed care [33].
In this milieu, some efforts were made to improve access to PAC services. In 1992, the Zambian government restructured the health care system to be more decentralized, moving human and material resources to the purview of the districts. At the same time, the reforms introduced an “essential package” of health care services aimed at addressing the most pressing needs of Zambians. Reproductive health was highlighted under the new reforms, and USAID and Zambian government partners assessed the situation for improving post-abortion care in the country [31]. The introduction and decentralization of safe abortion and PAC services was suggested using manual vacuum aspiration, a technology and service which requires the same skill set as the provision of induced abortion, to eliminate the outdated use of dilatation and curettage in the country. The assessment team did not make strong recommendations about the TOP Act that has hindered access to TOP in rural areas where most care is provided my midwives and nurses and physicians are uncommon [31].
Unfortunately, the timing of PAC reforms coincided with the most devastating period of the HIV epidemic in Zambia. During the 90s the epidemic in Zambia peaked at 16.5% HIV prevalence in the general population, which significantly impacted the population in all conceivable ways. The spread of the disease devastated the health care work force, as doctors, nurses and even policy makers across the country succumbed to their illnesses [34]. The epidemic itself - and the resultant thinning of human resources for health – as well as the restructuring and resources required to rapidly scale up voluntary counselling and testing for HIV, prevention of mother-to-child transmission efforts and antiretroviral treatment throughout the country, shifted the focus of health care towards basic efforts to sustain the population, leaving little for other initiatives.
2008 strategic assessment of unsafe abortion
In the new millennium, attention in Zambia was refocused on improving maternal health outcomes, largely due to the Millennium Development Goals. Zambia was tasked with reducing deaths from 591 to 162 per 100,000 live births by 2015 [35]. Although that goal was ultimately proven to be beyond reach, the increased attention to maternal health spurred a renewed examination of unsafe abortion issues.
In response to this problem, in 2008 the Zambian government and Ministry of Health (MOH) recruited a diverse multidisciplinary team of Zambian policymakers, Ipas and WHO representatives to participate in an assessment on unsafe abortion based on the WHO Strategic Assessment approach to strengthening reproductive health services [36]. Members of the strategic assessment team are responsible for maintaining continuity in the process that begins with the assessment and leads to testing interventions and scaling-up policies. Team members came from a range of organizations and reflected a diversity of perspectives on issues related to abortion and reproductive health, including, University of Zambia Senior Lecturers; programme managers; service-delivery providers; health and social science researchers; women’s health advocates; and external facilitators with experience using the WHO Strategic Assessment Approach.
Findings of the Strategic Assessment concluded that because gynecologists are only available at general and central hospitals, many women from rural areas must travel great distances to access reproductive health services [21]. Negative staff attitudes toward abortion further discouraged women from seeking safe services even in the limited places where these services were presumably available. These issues are exacerbated amongst adolescents, who face additional stigma accessing safe abortion, lack of areas in facilities specifically for adolescents, and lack of information on services [2, 24, 31, 37].
The recommendations stemming from the strategic assessment called for the scale-up of medical abortion and the training of midlevel providers for MVA provision to improve access and availability as well as the standard of care and called for better education and training programs on abortion for the health workforce. Additionally, participants saw the need for improved understanding of the public on their rights regarding abortion. Finally, they noted that the lack of national guidelines, which were finally drafted for the first time in 2009, on abortion hindered progress on scale-up of safe abortion across the country [21].