CONCEPTUAL
FRAMEWORK FOR COMMUNITY INTERVENTIONS
AIMED AT INCREASING DIRECT ACCESS TO SEXUAL REPRODUCTIVE HEALTH AND REPRODUCTIVE RIGHTS’ SERVICES
Introduction
Accesstosafeabortion,meansthatabortionservicesareaffordable,available,freeof coercion, stigma or discrimination, youth friendly, not biased, without bureaucracy, and not influenced by traditional, cultural, and religious beliefs. Access to Safe Abortion is an important issue for all women because it allows them to enjoy their right to decide on their body and health, to control their childbearing and bodily integrity, to achieve their plans and visions, to end unwanted pregnancies, to space births and to save their lives. Abortion affects all women everywhere. Discussing such an important matter needs everyone’s collaboration. The advocacy initiative presented here is part of an international movement that grants to advocate for selfmanaged abortion an important role in guaranteeing women access to safe abortion
Background
Generation Initiative for Women and Youth Network, with the support from Women Help Women, launched Strengthening Activists for Medical Abortion (SAMAN) project in Lagos in 2017 and it was renewed in 2019 for a two year project by Amplify Change Strengthening grant. One of the main objectives of the project it to develop a conceptual framework to challenge laws that criminalize community interventions, aimed at increasing direct access to safe abortion and challenging stigma, discrimination, attitudes and laws, conducted by women’s groups and community health providers. Therefore, the SAMAN project aims to improve women’s health and empowerment by expanding the role of activists to ensure access to safe abortion information as well as post abortion care and contraception, applying a human right’s framework. SAMAN adjusts and expands strategies to local Nigerian context, informed by lessons learned and innovations SAMAN project enables women to exercise their right to reproductive choice and the ability to control their own fertility. This in turn empowers women to participate equally with their male counterparts in the nation’s affairs, and exercise their social, political and economic rights, both in their homes and communities. SAMAN enables women to access information and abortion services, enhance women’s ability to decide on a personal matter as important as making a choice whether or not to bear a child or whether to get pregnant or not which is essential to women’s human rights and has direct implications for the achievement of SDG 5 on gender equality target 6 i , The International Conference on Population and Development(ICPD) with the objective of promoting women's health and safe motherhood; and, on the basis of a commitment to women's health and well-being, to reduce greatly the number of deaths and morbidity from unsafe abortion. In other words, the conception framework has increased direct access to misoprostol, reflecting the continued respect for women’s health and autonomy. SAMAN hasstrengthened actions and interventions that increase direct access to
safe abortion with pills by women’s groups and community health providers and has also convened human rights lawyers who have helped to frame discussions challenging laws that criminalize those community interventions. The objective of this document is to create a conceptual framework to challenge laws that criminalize community interventions that increase direct access to abortion pills by women’s groups and community health workers
TheLocalContext
According to our grassroots experience in Nigeria and Cameroon, feelings and opinions about abortion in the communities are complex. Abortion is a taboo and a silenced topic in our environment. Even when there are National Guidelines on Safe Termination of Pregnancy in Nigerian on Legal Indications that support Medicalization of Abortion in the cases in which abortion is authorized, it is still highly politicized and policed by the state Activists for safe abortion in Nigeria and Cameroon work under very restricted regulatory environments, which in turn lead to discriminatory attitudes from community health delivery channels and the broader public towards women who want access to safe abortion. In addition to this, bureaucratic procedures in reaching policy makers, allied with victimization and criminalization of activists, limit abortion advocacy efforts for effective attitudinal and policy change. GIWYN’s focus countries are Nigeria in West Africa and Cameroon in Central Africa. It is estimated that each year 6,000 Cameroonian women die as a result of pregnancy related issues and abortion can be performed legally only in cases of medical necessity or rape. In Nigeria, abortion is permitted on legal grounds only to save the life, that is, when the life of the woman is at risk or in case of fetal impairmentii. More recently, in 2017, according to Performance Monitoring and Accountability (PMA 2020) survey data, the annual incidence of likely abortions in Nigeria was 41.8 per 1000 women in the age of 15-49, approximately 1.8 million abortions per year. More than 6 out of 10 abortions were considered least safe, and 11% of women experienced complications for which they sought Post Abortion Care (PAC) at a healthcare facilityiii. Most poor and rural women seek abortion care from unskilled providers, experiencing serious complications or death. The WHO (2015) reported that community health activists are essential in advancing access to information, but activists often face harassment.
Medical Abortion
According to the WHO recommendations, women themselves have an important role to play in managing their own health through self-assessment and selfmanagement approaches in contexts where access toappropriateinformation and to health services is limitediv. Such health directions lead to medical abortion methods (abortion with pills), that is the use of pharmaceutical drugs (only
Misoprostol or Mifepristone and Misoprostol combined) to terminate a pregnancy. These medications are available and the combinations are included in the World Health Organization’s (WHO) essential model medicine. In this regard, illegal abortion need not be equivalent to unsafe abortion. Unsafe abortion occurs annually due to restrictive laws against performing an abortion. This situation demands deepening public debate and knowledge about medical abortion to challenge laws that criminalize community interventions, led by women’s groups and community health workers, which increase direct access to safe abortion.
Medical abortion is the termination of a pregnancy through the use of pillsv. The medicines used for medical abortion are called Mifepristone and Misoprostol. These pills cause a process similar to a natural miscarriage. Medical abortion is often also called “abortion with pills” or “medication abortion. Self-managed medical abortion, in turn, is the use of abortion pills to end a pregnancy outside established medical settings. Self-managed abortion may also be called “selfinduced abortion,” “self-administered abortion,” “self-sourced abortion” or “home abortion”. Provided people have correct information, self-managing an abortion in early pregnancy has proven safe and effective and is common throughout the world. Information about self-managing abortion safely has empowering potential as it aids women in protecting their lives and health; yet speaking about it can be a challenge. Providing information about and access to medical abortion is related to healthcare, human rights, reproductive justice, empowerment and stigma reduction. Nonetheless, deploying a human rightsbased approach can be at times challenging in our context, because groups such as children or adolescents are not viewed as having rights. Affirming then the rights of children and adolescents should is an important part of the advocacy work., In light of this, GIWYN integrates different advocacy frameworks in relation to medical abortion to accommodate such groups.
Frameworks for Discussing Abortion
Framework Description
Public Health Abortion must be seen as a public health issue, because unsafe abortion contributes to maternal mortality and morbidity, which can be prevented if safe abortion is available.Arguments for community activism in this frame are based on safety and prevention and should be articulated by presenting scientific evidence of the health impacts of both safe and unsafe abortion
Right to Information
Article 19 of the Universal Declaration of Human Rights states that "Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers”.*Article 39 of the Constitution of the Federal Republic of Nigeria (1999) protect access to information: “Every person shall be entitled to freedom of expression, including freedom to hold opinions and to receive and impart ideas” theAfrican Charter on Human and People’s Rights?Article 9:
Every individual shall have the right to receive information.
Every individual shall have the right to express and disseminate his opinions within the law Therefore, the right to information – which means the right to seek, receive and share freely information and ideas without the interference of the state – protects women, activists and healthcare providers who disseminate and publicize information about access to safe abortion.
Harm Reduction
The framework highlights strategies to reduce harm and preserve health in situations where policies and practices are barriers that stigmatize and drive common human activities underground. The harm reduction approach recognizes that taking abortion medicines at home with support is safer than obtaining illegal abortion procedures, and that if abortion is going to happen anyway, then it should be made as safe as possible.
Many safe abortion programs in countries with restrictive access to abortion are based on a harm reduction approach.
Human Rights
The focus is on abortion access as a human right. As such, this right is derived from a series of other human rights guaranteed by national constitutions and laws and regional and international human rights convenants. They include the right to life, to survival, to security and to sexuality; the right to non-discrimination; the right to right to make decisions about one’s sexual and reproductive life, including the freedom to choose maternity; the right to the highest attainable standard of health and to enjoy the benefits of scientific progress; the right to be free from cruel, inhuman and degrading treatment; the right to privacy and confidentiality; and the right to health information and education. Lack of access to safe abortion and contraception is thus a violation of human rights.All women have the right to choose to end or to continue a pregnancy as they see fit.
Reproductive Justice
This framework repositions reproductive rights in a political context, by acknowledging the intersecting negative impact class, gender, race and sexual oppressions Therefore, reproductive justice expands our understanding of reproductive rights and health to include bot the woman’s right to end a pregnancy and
to have children and raise them with dignity and support. Reproductive justice demands us to recognize and fight oppression as a means to attain sexual freedom and autonomy. Lack of access to abortion is linked to systemic marginalization as disadvantaged communities experience the most challenges to access, while at the same time being the target of population control and obstetric violence. Access to abortion is therefore a matter of justice and ethics as well as of overcoming structural inequalities. Stigma Reduction There is shared belief that abortion is wrong and/or morally unacceptable within a community or society. In Nigerian context, stigma is manifested on multiple levels: from media and public debate, through institutions, legal regulations, community and personal beliefs, and self-judgment. In this context, to struggle for the right to safe access to abortion also entails fighting against the multiple forms of stigma attached to it, by demonstrating that abortion is a common event of women’s lives and women are capable of deciding for themselves.
Empowerment and autonomy
To empower means to give the power and authority. It requires trust and respect for people’s autonomy and choices. Empowerment fights stigma, promotes women’s rights and power. The discourse on empowerment uses sex-positive and abortion-positive language while promoting all existing options, as it is always up to each person to decide what is right for them. Directly providing women with access to products and reliable information empowers both those who share the knowledge and those who receive it. It is a way of concretizing bodily and reproductive autonomy.
Lessons Learned
In addition to framing arguments to support activism on the ground , language and discussion should clarify individual values, positive ideas, vision, and respect for individuals.
Women as moral agents have the right to decide about their fertility. Their decision must be respected because only a pregnant person can know whether to carry the pregnancy to term and has the right to make the decision.Women should be allowed to choose the type of health care that will best meet their needs and situation when they decide to safely end their pregnancy within or outside the established medical community. As with all medical processes, abortion must be safe, legally and medically .
Therefore public safety and health policy should be based on sound scientific evidence, not ideology. Women and girls should have access to information, we believe information is power.Abortion with pills is safe.
Activists, community health providers and pharmacists are obligated to promote evidence-based information that shows the safety of the medical abortion process in Nigeria and Cameroon. This will promote ethical Commitment to a just Society, equality and human rights.
It is moral and just for women to take control over their own life and to empower others to do so. Women who receive information are more empowered to take decisions over their lives and know how to advocate for the rights of others.
Those who help them show resistance against oppressive systems and restrictive laws. Restrictive laws and censorship are harmful and lead to unsafe abortions.
Where the state and public system fails to support women and girls, they must help each other to stay safe and healthy. Community health workers and activists promote human rights by supporting access to information and expanding access to safe methods.
In Nigeria and Cameroon ,it is beneficial to introduce the principle of empowerment andreinforcing autonomy in the abortion advocacyforintegration and collectiveness , Empowerment play a key role in enabling women including adolescents to make rightful decision concerning their health and body . Therefore, there is also a collective empowerment at the community level , along with individual activists . These include local organizations, groups, community health care providers, community health care extension workers pharmacy workers, professionals, politicians and individuals who are ensuring that women get the accurate information they require to enable them access safe abortion with pills by themselves, Activists at the community level play a key role in increasing and improving access to safe abortions using the following strategies
Community activists are feminists who work within the community, navigating through the restrictive environment to create positive institutional, cultural changes and behavioral changes in favor of women. They develop national and international networks and forming alliances across movements
References
i United Nations (2019) The Sustainable Development Goals 5: Achieve gender equality and empower all women and girls.( Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences)
ii Federal Ministry of Health, (2018) National guidelines on safe termination of pregnancy . Abuja Nigeria
iii PMA 2020 Abortion Survey Results: Nigeria
iv World Health Organization ( 2015). Health worker roles in providing safe abortion care and post-abortion contraception.
v Women Help Women” Talking about Abortion
Coalition members reports on implementation of conceptual framework for community interventions on increasing direct access to Medical Abortion
bylessonslearned
National Coalition for Reproductive Justice Members (NCRJ) Organizations is one of the beneficiaries of the project .This Coalition is made up of community activists and feminists who work within the community, navigating through the restrictive environment to create positive institutional, cultural and behavioral changes in favor of women. They develop national and international networks and form alliances across movements.
The coalition in their respective organizations have introduced the conceptual framework according to the agenda of their organization such as
the framework of empowerment and reinforcing autonomy and Right to Information in their abortion advocacy for integration and collectiveness , Empowerment play a key role in enabling women to make rightful decision.
The following are their reports:
Names of Organizations Organizations’ Report
ZACHIDACARE
Joined NCRJ in 2011, she has been educating community women who come for antenatal care on their sexual and reproductive health rights. Most of these women patronize Traditional Birth Attendants (TBA’s) and give them infot,ation Miso pills and Hotline numbers have been successfully introduced to these TBA’s to enable them save more lives.
MOTHERandCHILD INITIATIVE
Became a member of NCRJ 2014 . we have been adapting the conceptual framework using harm reduction and reinforcing autonomy focusing on house on house advocacy. We speak to women and girls on their sexual and reproductive rights and the use of pill for safe managed abortion. One of our advocacy tools is the Hotline stickers which are being distributed to these women and girls for them to get more information
SARAHCARE
WOMENEMPOWERING WOMENINITIATIVE (WEWIN)
Through GIWYN’s trainings and seminars SARAH CARE has been empowered by to disseminate information on the use of misoprostol for safe abortion to TBA’s, use of contraceptives and family planning methods
WEWIN has been able to penetrate women in the rural communities. Educating them on their rights, counseling women on the dangers of domestic violence, visiting hospitals with advocacy materials like pills samples to women receiving antenatal care to talk to them about contraceptives and hotline stickers for those that need more information on self-medical abortion.
ADEBANJOADEBAYO WELFARE FOUNDATION(AAWF
WorkcutsacrossbothLagosandOsunstatesThepartnershipwe hadwithGIWYNhasmadeusto
Understand that women are indeed important in our society. We refer women who need access to call the Hotline.
Trust and Care Foundation Trust And support foundation was founded in 2015 as a community based situated organization situated in a semi-rural area, formerly known as Trust and care initiative with aim of reducing and ensuring women and young girls have access to sexual reproductive right information and services, gender based violence, right of all women in various spheres of life and working to achieve SDG goal 5.
During the lock down in Nigeria, TASF witnessed a rise in abortion services and family planning services.
A total of 34 women came for abortion services within the first trimester and second trimester.
25 women received information on family planning service. TASF achieved this through community member’s referrals, and Patent right medicine store popularly known as Chemist.