Research priorities to support evidence-informed policies and advocacy for access to safe abortion care in sub-Saharan Africa.

A key obstacle to advocacy efforts to promote legal and policy reforms that ensure women's and girls' access to comprehensive abortion care (CAC) is the lack of relevant and timely evidence. This commentary outlines a research agenda-setting initiative that identified research priorities to support evidence-informed policy and advocacy for CAC access in sub-Saharan Africa (SSA). It involved three phases: 1) a landscape analysis; 2) research agenda co-creation with stakeholders, and 3) a validation exercise on research priorities. Overall, the priority evidence needs included 1) estimating the incidence and magnitude of unsafe abortion and related costs; 2) examining the role of abortion laws and policies in facilitating or inhibiting access to CAC; 3) developing and documenting successful approaches for addressing societal barriers to the provision of CAC, and fostering a more inclusive and liberal abortion environment, and 4) documenting practice-based evidence on the provision of legal abortion services as well as for advocating for CAC. Various stakeholders, including researchers, policymakers, civil society organizations, and funding agencies, will find the agenda useful as they engage, at different levels, for the full domestication and implementation of forward-looking commitments on access to CAC in SSA.

Introduction

Twenty-six years after the International Conference on Population and Development in Cario in 1994, which identified comprehensive abortion care (CAC) as a high priority for the reduction of maternal morbidity and mortality, unsafe abortion remains a significant public health problem globally, but particularly in sub-Saharan Africa (SSA). Three in four abortions that occur in SSA are unsafe, with an estimated 680 deaths per 100,000 abortion-related complications.[1] Abortion-related deaths contribute close to 10% of maternal deaths in SSA, a region with the highest global maternal mortality ratios.[2] Also, an estimated 1.6 million women are treated for unsafe abortion-related complications yearly in SSA.[2]

The magnitude of unsafe abortion in SSA is predicated on the restrictive legal, policy, service, and cultural contexts of abortion.[2] An estimated 93% of women of reproductive age in Africa live in countries with restrictive abortion laws.[3] Even in settings where national laws permit abortion under limited circumstances, gaps exist between laws and actual practice, with only a few women able to navigate the complex processes required to obtain safe and legal abortions.[4,5] Moreover, provider unwillingness, negative attitudes, and abortion-related stigma at all levels continue to deny women and girls access to safe abortions.

Most African countries have signed and ratified the Maputo Protocol, which protects women’s and girls’ reproductive rights and recognises abortion, under specific conditions, as a human right.[6,7] The Protocol offers an entry point for advocating for progressive abortion laws and policy change and promoting access to CAC, including safe abortion and quality post-abortion care. However, successful advocacy should be premised on robust and relevant evidence. To galvanise discussions on the evidence needed for advocacy, the African Population and Health Research Center (APHRC) facilitated the co-creation of a regional research agenda, articulating relevant priority areas for abortion research.

Process of agenda co-creation

Even though abortion research continues to grow in SSA, existing research is concentrated in a few countries in the region. It also lacks the inputs of key stakeholders advocating for progressive abortion policies. As such, our co-created research agenda aimed to identify the evidence most urgently required by regional and sub-regional actors to advance their policy engagement and advocacy for the domestication of continental commitments on access to CAC.

The co-creation process encompassed a series of steps that we broadly categorised into three phases: (1) landscape analysis, (2) co-creation workshop, and (3) validation. The landscape analysis phase began with a scoping review of research on abortion to identify critical evidence gaps. In addition to reviewing the literature, we also mapped out 78 key government, civil society, academic, and technical partners working on abortion and sexual and reproductive health and rights (SRHR) in SSA. In Phase 2, we invited the stakeholders identified through the mapping process to participate in a two-day co-creation workshop held in October 2019. Fifty stakeholders from 37 institutions from Burkina Faso, Eswatini, Ethiopia, Kenya, Malawi, Rwanda, Senegal, South Africa, Tanzania, Zambia, and Zimbabwe participated in the workshop. Phase 3 involved a validation process where the emerging research priorities were clarified, and opportunities to operationalise the research agenda explored through an iterative engagement with partners.

Advocacy and research priorities of the new agenda

The co-created agenda identifies key policy advocacy priorities and evidence needs to support that advocacy. It also highlights suggested research methods and tools to use in generating evidence to facilitate effective advocacy.

Key policy advocacy goals

The agenda co-creation process identified key policy advocacy goals at both the regional and sub-regional levels. At the regional level, an overarching policy advocacy goal is to nurture a renewed openness to explicitly raising the need for access to CAC as part of relevant Africa-wide women- and girl-focused policy initiatives and campaigns. Eastern, Southern, and Western Africa all have regionally specific instruments that focus on SRHR. Thus, the advocacy priorities for the sub-regions focus on these instruments. For the Eastern Africa Community sub-region, civil society organisations highlighted the importance of garnering support for the implementation and domestication of Gender Equality, Equity and Development bills. The Southern Africa sub-region’s advocacy goal is to push for the implementation of the Southern African Development Community’s Regional SRHR strategy (2019–2030). For West Africa, the priority is for the Economic Community of West African States to formulate and adopt sub-regional frameworks that enshrine access to safe, legal abortion, in alignment with the Maputo Protocol.

Priority evidence needed to help advance key policy advocacy goals

Three key evidence gaps emerged as critical and requiring urgent production to support the policy processes and opportunities highlighted during this workshop. First, researchers and funders should prioritise abortion incidence and magnitude studies for all SSA countries, particularly where no such studies exist. Second, researchers and funders should quickly generate evidence on the effect of progressive and permissive abortion laws and policies in reducing maternal deaths. The third priority evidence need is on successful approaches and sound practices pursued in Africa and other regions for positively engaging and garnering support from religious and traditional leaders on access to safe abortion and post-abortion care. This evidence is critical but lacking in the literature.

The incidence, magnitude, and costs of unsafe abortion

The need for studies on the scope and costs of unsafe abortion was consistently highlighted for the region and sub-regions. While some countries have recent studies on the incidence of abortion and abortion-related mortality, there is a need for research on the scope and cost of the problem in countries where evidence is acutely lacking. More specifically, there is a need for up-to-date national estimates of the incidence and spectrum of costs and opportunity costs (to individuals, families, and health systems) of unsafe abortion and criminalisation of abortion in all countries for which no data exist. Researchers should also estimate the costs of providing universal access to safe abortion compared to the economic and social costs (and opportunity costs) of unsafe abortion, the cost of treating unsafe abortions, and of unintended pregnancies carried to term.

Understanding the role of progressive laws and policies

In addition to the quantifiable data on unsafe abortions, there should be cross-country case studies on the extent to which progressive national policy and legalisation of abortion have translated into comprehensive access for women at the continental level and in Southern and East Africa. These studies can examine the role of progressive laws and policies in driving maternal morbidity and mortality changes. Additionally, these studies should look into the nature and role of policy in other sectors and key service and social contextual factors, including providers’ conscientious objection, in shaping policy translation into practice.

Successful approaches for addressing societal barriers to the provision of CAC and fostering inclusive access to legal abortion care

Also needed is documentation of sound practices and effective strategies, as pursued in Africa or other regions of the global South, to positively engage and garner support from religious and traditional leaders on access to safe abortion and post-abortion care. This type of research may assess and review how values, beliefs, and interests influence attitudes towards safe abortion among religious, cultural and community leaders, and the interventions needed to foster supportive attitudes. Documentation and assessment of sound practice in the provision of legal abortion services are also relevant. However, each sub-region in Africa had its own set of research needs related to providing legal abortion services. As a matter of urgency in the West Africa region, research that evaluates the effect of task-shifting programs on improving access to safe abortion services is needed. In East Africa, research on the knowledge, practices, and attitudes of health-care workers toward provision of safe abortion services, and how their knowledge and attitude affect their ability to deliver CAC services, is also needed.

Research approaches for better evidence uptake

The agenda co-creation process outlined research approaches, tools, and methods to facilitate effective advocacy. Principally, the development and use of comparative studies – meaning those that would show how countries compare in relevant indicators – may be compelling to decision-makers. Other cross-cutting approaches include documenting and packaging cases of unsafe abortion and the consequences, in stories for varying audiences. These types of personal stories, highlighting the human impact of unsafe abortion, are a useful tool in advocacy. There are several online tools for using personal stories in advocacy, which researchers working on abortion in SSA can draw from to make their research useful for advocacy. As a research method, participatory research that includes women, men, and civil society organisations is also critical. Such research should be collaborative in study design, operationalisation, and dissemination, allowing for better uptake of the evidence.

Ways forward

The co-created research agenda pinpoints evidence needs that are relevant for advancing policy engagement and advocacy to enhance access to CAC in SSA. Strengthened collaboration among researchers, civil society organisations, policymakers, and other key stakeholders in planning and implementing abortion studies that address these priorities can accelerate the uptake of scientific evidence in policy formation in SSA.