Women who want an abortion prioritize social protection over medical security to escape the law and stigma. Can self-care be the answer?
Safe abortion and post-abortion care are essential health services. But until the publication in 2022 of new guidelines of the World Health Organization (WHO) on the definition of safe abortion was narrow. In the previous guidelines WHO, medical safety was the guiding principle for safe abortion. Safety, according to the WHO, referred to an abortion performed according to recommended methods, by a person with the required skills or in an environment that meets minimum medical standards, or both.
However, research shows that many girls and young women do not seek medical safety when seeking an abortion. They prioritize social protection. And this, regardless of the fact that they live in contexts where legislation is restrictive ou liberal. Women's priority is to avoid legal proceedings and social stigma.
Their need for discretion is one of the reasons women and girls continue to use unsafe abortion methods.
The latest guidelines take an approach more holistic. They go beyond an emphasis on medical safety to promote quality abortion care. These guidelines respect the right to non-discrimination and equal access to abortion services. But will this change make a difference for girls and young women living in rural areas or in countries where abortion laws are restrictive, and where social protection remains an imperative?
La social protection goes beyond physical health. It includes women's emotional and economic well-being, social status, reputation and relationships. In the context of abortion, this means being able to find an affordable provider, conceal the abortion and be protected from law enforcement agents.
We conducted a study in Kenya and Benin to learn more about what makes girls and young women feel safe (or not) when they want an abortion. In the two countries concerned, the rate of unwanted pregnancies and unsafe abortions is high. And abortion is socially frowned upon.
The study found that in these settings, social security is only achieved when abortion is performed discreetly.
We conducted an ethnographic study over a six-month period in urban and rural settings in Kilifi County (Kenya) and Atlantique Department (Benin). We observed girls and young women being recruited from health facilities and surrounding communities. We also conducted informal discussions and in-depth interviews.
Our study showed that women were aware of safe abortion methods such as medical abortion and surgical abortion in health facilities.
But for girls and women who wanted an abortion, health facilities were not the first choice. The reason being that discretion was not guaranteed. Care was offered in the maternity ward or in the emergency department, with no private space for procedures. In addition, women and girls feared being reported by providers or bumping into their neighbors in the facility. They were also confronted with psychological or physical violence from moralizing caregivers.
Instead, the girls and women in our study began their abortion journey by trying locally available, inexpensive alternative methods used to treat other conditions. These include herbal concoctions and high doses of antimalarials, painkillers, or antibiotics. This allowed them to conceal their abortion – but only temporarily. Most of the cases progressed to complications requiring urgent treatment or even resulting in death. In Benin, a study showed that almost half of the cases of women treated for post-abortion care were related to complications from unsafe abortions. In Kenya, nearly 30% of induced abortions resulted in complications treated in health facilities.
Where the conception of safety in women seeking abortion conflicts with the definition of public health, the solution may, in some contexts, be found in self-care.
Self-care for social protection
In recent years, and especially since the COVID-19 pandemic, the concept of self-care has been promoted in the field of public health. WHO defines self-catch supported as:
“the ability of individuals, families, and communities to promote health, prevent illness, maintain good health, and cope with illness and disability with or without the assistance of a health worker”
Abortion self-management involves the ability to self-manage one's abortion as much as desired. This includes access to information and access to abortion pills without a prescription. It also involves the use of digital platforms to facilitate access and use of abortion pills.
Research has shown a success rate of abortion self-care more than 93% in countries with a liberal and high-income system.
Self-management of abortion allows women and girls to be more discreet when they have an abortion and strengthens their autonomy and control. In theory, self-management of abortion could therefore offer social protection. It allows discretion, and could prevent interaction with unfriendly providers, or lack of privacy and the risk of arrest in health facilities.
In practice, however, it is very difficult to imagine how women and families who may not have their own mobile phone or smartphone or internet or the money needed to use these devices can have access to self-support.
Inequalities in digital access, gender, social class and literacy prevent many poor women and girls from accessing abortion self-care. For them, self-management of abortion is not yet the solution. Social protection around abortion could only be achieved through home abortion methods which can lead to serious complications. Efforts to increase accessibility to safe abortion should therefore be continued.
One possible avenue could be to invest in discreet abortion services user-centric, for example through intermediate leagues of health. However, there remains a need to address provider biases and community attitudes, and to ensure that authorities and law enforcement officials better understand existing laws and improve them where necessary.
The results of our study showed that partners, parents and community champions can also serve as intermediaries. Therefore, another avenue could be through gender transformative interventions. These would make it possible to involve male partners and other family members in abortion self-management interventions. Men are often involved in abortion journeys and often have better access to digital technologies. As long as they are well informed, they could support women seeking self-help.
Ramatou Ouedraogo, Associate Research Scientist , African Population and Health Research Center; Grace Kimemia, Research officer, African Population and Health Research Center, and Jonna Both, Researcher, Rutgers International