Challenges and opportunities from using abortion harm reduction and value clarification and attitude transformation engagements for safe abortion advocacy in Uganda

The World Health Organization defines unsafe abortion as a procedure for termination of a pregnancy done by an individual who does not have the necessary training (skills) or in an environment not conforming to minimal medical standards [1]. Despite scientific advances in provision of safe abortion at the primary care level, the persistently high unsafe abortion burden and resultant high burden of complications are a major cause of maternal death, morbidity and disability, as well as being a substantial cost to women, families, and health systems [2, 3]. While rates of unintended pregnancy have declined worldwide [4] with increasing access to and use of contraception likely contributing to these trend [5], some countries have persistently high rates. For instance, the estimated unintended pregnancy rates ranged from 11 (80% uncertainty interval: 9 to 13) in Montenegro to 145 (131 to 159) in Uganda per 1000 women aged 15–49 years [6]. Also, while the global unintended pregnancy rate declined between 1990 and 94 and 2015–19, the proportion of unintended pregnancies that end in abortion increased in countries where abortion is restricted, leading to stagnation in the global average abortion [5]. For instance, in countries that restricted abortion, the proportion of unintended pregnancies ending in abortion increased in every 5-year period, with a cumulative increase of 39% between 1990 and 94 and 2015–19, while the abortion rate increased by 82% [5].

An estimated 35 abortions occurred annually per 1000 women aged 15–44 years worldwide in the period 2010–14, which was 5 points less than 40 in 1990–94 [7]. Adjusting for population growth, the annual number of abortions worldwide increased by 5.9 million from 50.4 million in 1990–94 (48.6 to 59.9) to 56.3 million (52.4 to 70.0) in 2010–14 [7]. From 1990 to 2008, WHO used indirect estimation techniques to determine the incidence of abortion, both in countries with restrictive laws and in countries with more permissive laws in which many abortions occurred illegally and clandestinely [8], and all were labelled as unsafe abortions. Ganatra et al. [8] propose an approach in which they replace this dichotomous classification of abortion safety (unsafe versus safe abortion) with a three-tiered classification (safe, less safe, and least safe) which approach permits a nuanced description of the spectrum of varying situations that constitute unsafe abortion, and which also rhymes with the increasingly widespread replacement of dangerous, invasive methods with use of misoprostol outside formal health systems in legally restricted contexts [8]. Through using a model-based approach that caters for multiple factors that systematically affect abortion safety, this classification offers advantage of explicitly aligning both the operational estimation of safety categories with WHO’s conceptual definition of unsafe abortion and the technical standards of care outlined in WHO guidelines [8]. Of the estimated 55.7 million abortions that occurred worldwide each year between 2010 and 14, 30.6 million were safe, 17.1 million were less safe, and 8.0 million were least safe, making an estimated 25.1 million (45·1%), with 24.3 million (97%) of these in developing countries [8]. The proportion of less safe abortions was significantly higher in developing countries than developed countries (49.5% vs. 12.5%), and was also higher in countries with highly restrictive abortion laws than in those with less restrictive laws [8].

Pathways to abortion-related complications and effective care to prevent or mitigate them are complex in different contexts [9], necessitating a multipronged context-informed advocacy strategy that targets multiple predicting factors and stakeholders. Stakeholders’ understanding of the root causes and contextual factors related to unsafe abortion and challenges related to accessing safe abortion and abortion-related care is critical to ending abortion-related morbidity and mortality [9, 10]. Individuals’ personal experiences and relationships are interconnected within the broader context of their lives (such as gender, traditions and culture) [9]. Unmet need for family planning highlights a gap between women’s reproductive desire to avoid pregnancy and contraceptive behaviour [11]. Contraception is key to enabling couples and individuals exercise the right to decide freely and responsibly the number and spacing of their children. However, some women want to avoid unintended pregnancy yet do not use any contraceptive method, possibly because they do not have access to contraceptives or prefer not to use them for various reasons [11]. Deterring factors include ignorance about the methods, fear of side effects, gender-based violence, myths and misconceptions, high cost of methods [11]. Besides, even those using contraception may do so imperfectly, inconsistently or experience method failure. Other root causes for unintended pregnancy include low self-esteem, lack of autonomy, poverty and lack of women empowerment. Inequalities in accessing abortion-related care, are compounded by multiple individual characteristics including age, marital status, education level and inequitable gender relations [9, 12‐14]. Indeed, women experience multiple, intersecting inequalities in both the risk factors for unwanted pregnancy (such as the negative traditional gender power relations and sociocultural factors) and the deficits in the healthcare system that hinder or delay access to abortion-related care [9, 13‐18].

Abortion-related care-seeking can be understood as a process that responds to changing circumstances and experiences [9]. Patients’ delay to seek care, or healthcare providers’ delay to provide due quality timely abortion care (due to denial or refusal to provide women abortion-related counseling and services, partly due to abortion stigma), are some of the contributing factors to morbidity from abortion complications [9, 10, 17‐19]. Advocacy that involves progressively changing national and international laws, policies, and patient management guidelines, coupled with the increasing decriminalization of abortion [10, 20‐22] are some of the strategies in which access to safe abortion care may be promoted (to the highest standards of care and to the full extent allowable by law). Advocacy to provide data that informs strategies and or interventions is key to improvement in abortion policy and practice [23]. Additionally, targeted advocacy to provide access to the continuum of care from prevention of unintended pregnancy to management of abortion complications has potential to reduce abortion-related morbidity and mortality. To achieve this goal, there is need for advocacy targeting the different stakeholders who may influence behaviors that improve access to services or reduce abortion stigma, necessitating assessment of how advocacy targeting the different stakeholders may influence these behaviors. The objective of this paper is to share experiences and lessons learnt about using value clarification and attitude transformation (VCAT) and abortion harm reduction (AHR) as the advocacy theoretical frameworks for advocacy engagements in Uganda.

The abortion values clarification and attitude transformation (VCAT) is an intervention grounded in the Transtheoretical Model [24], which posits that an individuals’ beliefs influence their attitudes, and these attitudes then influence their motivations and intentions to enact specific behaviors in line with their held beliefs. Values play a critical role in determining how people make decisions and ultimately act [25]. Through VCAT, audiences engage in honest, open-minded and critical reflection and evaluation of personally-relevant abortion information and situations related to abortion practices or management, including the underlying factors which constitute the root causes of abortion.

Abortion harm reduction (AHR) is an evidence-based public health and human rights framework that prioritizes strategies to reduce harm and preserve health in situations where policies and practices prohibit, stigmatize and drive common human activities underground. The principles of AHR (neutrality, humanism and pragmatism) present a conceptual legal and ethical framework for comprehensive abortion care, where services can be provided for primary, secondary or tertiary prevention of abortion complications that cause death, through strategies and practices that address abortion related harms [26‐28].

Scaling up an intervention refers to expanding or replicating pilot or small-scale projects to reach more people and/or broaden the effectiveness of an intervention to a national level or to even more countries. Scaling up refers to “deliberate efforts to increase the impact of successfully tested health interventions so as to benefit more people and to foster policy and program development on a lasting basis” [41]. In the context of our findings, scale up refers to expanding advocacy among different stakeholders to seek commitments to increase access to SRH services (along the abortion trajectory) and eventually reduce abortion-related deaths, via strategies that include increased access to safe abortion. The scalability of an intervention is influenced by its effectiveness, the likely reach and adoption of the intervention, the likely costs of implementing at a larger scale, the acceptability and fit of the intervention within the local policy context [42]. Scaling up recognizes that different pathways may be used to achieve replication, adoption, adaptation or reach of an intervention [43].

Our abortion harm reduction and value clarification and attitude transformation intervention are credible in that they are derived from public health strategies of primary, secondary and tertiary prevention of illness (which is our context is prevention of mortality from abortion-related complications). The intervention is inclusive, and identifies roles for different players among the key stakeholders to provide the continuum of care, while addressing the factors in the abortion trajectory from the root causes of unintended pregnancy to management of abortion complications and linkage to other reproductive health services. Increasing access to safe abortion is a key component of the strategies. Besides, through VCAT, different stakeholders are encouraged to adapt empathetic values and attitudes, and address professional and personal vale conflicts, so as to provide care/services that provide the continuum of comprehensive abortion care. The support for change is likely to be high. The scaleup model has advantage over existing practices in that it expands options for increased access to safe abortion and addresses both the contributory factors for unintended pregnancy and the abortion complications that lead to abortion mortality and morbidity. Additionally, through advocacy, the intervention can be adapted to different abortion care contexts, irrespective of the existing legal and regulatory framework.

The framework for scaleup of the harm reduction intervention recommended is the one suggested by Barker et al. [44] which describes three core components: “a sequence of activities that are required to get a program of work to full scale, the mechanisms that are required to facilitate the adoption of interventions, and the underlying factors and support systems required for successful scale-up”. The four steps in the sequence include the first step: Set-up, which prepares the ground for introduction and testing of the intervention that will be taken to full scale. Our findings have partly covered this step. In the context of our intervention, the step involves sustained advocacy about the need to reduce abortion-related morbidity and mortality, through changing the abortion narrative from abortion being a medical problem to being a public health problem, where different players can identify definite roles along the abortion trajectory. The second step, Developing the Scalable Unit, an early testing phase, where results of the intervention are disseminated to seek opinions and recommendations (from diverse stakeholders) that inform scale up at a bigger level. The third step, Test of Scale-up, will test the intervention in a variety of settings and among the diverse stakeholders who potentially have a role along the abortion trajectory (from unintended pregnancy to death from abortion complications) and who represent different contexts that will be encountered in practice. The last step, Go to Full Scale, will enable replication or adaptation of the intervention among different stakeholders and different settings/contexts.