IPAS Women's Reproductive Health and Access to Safe Abortion Training l IFMSA Manual

IPAS WOMEN'S REPRODUCTIVE HEALTH AND ACCESS TO SAFE ABORTION TRAINING A one day experience

IPAS women's reproductive health and access to safe abortion training

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IFMSA Imprint Laura Lalucat García-Valdés (SCORA-Director) Egle Janusonyte (Liaison Officer for SRHR) Hochem Smaali (SCORA Development Assistant for Capacity Building)

Layout Design Asmaa Atef (PRC Team)

Publisher

International Federation of Medical Students’ Associations (IFMSA)

The International Federation of Medical Students’ Associations (IFMSA) is a non-profit, non-governmental organization representing associations of medical students worldwide. IFMSA was founded in 1951 and currently maintains 136 National Member Organizations from over 126 countries across six continents, representing a network of 1.3 million medical students.

IFMSA envisions a world in which medical students unite for global health and are equipped with the knowledge, skills and values to take on health leadership roles locally and globally, so to shape a sustainable and healthy future.

IFMSA is recognized as a nongovernmental organization within the United Nations’ system and the World Health Organization; and works in collaboration with the World Medical Association.

International Secretariat: c/o IMCC, Norre Allé 14, 2200 Kobenhavn N., Denmark

Email: gs@ifmsa.org Homepage: www.ifmsa.org

This is an IFMSA Publication

Notice

© 2020 - Only portions of this publication may be reproduced for non political and non profit purposes, provided mentioning the source.

All reasonable precautions have been taken by the IFMSA to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material herein lies with the reader.

Disclaimer

Contact Us

vpprc@ifmsa.org

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This publication contains the collective views of different contributors, the opinions expressed in this publication are those of the authors and do not necessarily reflect the position of IFMSA. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the IFMSA in preference to others of a similar nature that are not mentioned.

Some of the photos and graphics used in this publication are the property of their respective authors. We have taken every consideration not to violate their rights.

Contents

Introduction

The Trainings

www.ifmsa.org

The Sessions • • • • • •

Introduction.

Abortion ABCs. A new perspective on abortion. reason why?

Four Corners.

Access denied: Human rights and abortion.

• Why did she die?

• The quest for safe abortion.

• Comprehensive abortion care.

• Wrap Up and Closing session.

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INTRODUCTION

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About the Guide THIS GUIDE takes you into a one day journey throughout

the maternal health and access to safe abortion thematic. It is the result of laborious work done by SCORA members in order to provide you with extensive and detailed content in a shorter time frame. This way, within a shorter version, its aim is to make the capacity building more accessible and reach out to all interested members in our National Member Organisations.

The guide is intended to be used by facilitators who have had prior comprehensive training in sexual and reproductive health and rights as well as prior experience in planning and facilitating workshops. They should be knowledgeable about and comfortable with the topic of abortion.

To adequately prepare for workshops, we encourage facilitators to: • • •

Review all the activity instructions and tools.

Read or watch all the core resources.

Use the pre and post-assessment in order to receive IFMSA certification.

For any inquiry please don't hesitate to contact the SCORA Capacity Building Development Assistant by email: da.scora@ifmsa.org.

For further information don’t hesitate to review the IPAS manual accessible here.

Other related opportunities: •

Program enrollment: IFMSA Programs are centralized streams of activities, which are organized by IFMSA National Member Organizations (NMOs) and IFMSA internationally. IFMSA Programs address problems within a specific field that we as medical students and global health advocates stand up for while connecting local, national and international activities and opportunities that contribute to the final outcome.

All IFMSA Programs connect the work of NMOs locally and nationally with the IFMSA vision and mission.

The Programme on Maternal Health and Access to Safe Abortion can support your advocacy efforts through the Programme Coordinator by: I. Assisting you in organising activities related to the theme and focus areas of the program.

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II. Supporting you with resources and feedback to organise international, regional and local activities and campaigns.

III. Helping you enrol your projects and reporting your activities with IFMSA programs.

IV. Develop with you evaluation plans for activities and campaigns.

V. Connecting you with activity coordinators around 136 countries.

The Programme Coordinator on Maternal Health and Access to Safe Abortion is only an email away: maternalhealth@ifmsa.org Feel free to contact anytime! •

Ipas workshop: Women's Reproductive Health and Access to Safe Abortion: a three days training that aims to increase IFMSA members' awareness of, experiences with and ability to effectively advocate for women and adolescent’s reproductive health, especially safe abortion. The focus of this workshop is to advance the development of a network of safe abortion advocates within the Federation.

The training covers several related topics; for example: human, sexual and reproductive rights; abortion laws and policies; barriers to access care, including stigma; safe abortion methods; and identification and referral of women with abortion-related complications.

Should you want to check when next Ipas trainings are hold, email da.scora@ifmsa.org.

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THE TRAINING

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The Training GOAL: To build participants’ capacity and commitment to take action for safe abortion.

OBJECTIVES: By the end of the workshop, participants will be able to: • • • • • • • •

Demonstrate increased respect for women seeking abortion and support for abortion rights; Articulate how their own personal perceptions and attitudes may affect their work on abortion; Describe how unsafe abortion affects women and societies; Articulate how human rights support access to safe abortion; Describe the relationship between gender discrimination and abortion; Describe different barriers that affect women’s and adolescents’ access to safe abortion care; Identify different strategies to improve access to safe abortion care, and explain which of these strategies future health professionals are well-suited to implement; Describe essential elements of woman-centred comprehensive abortion care, including counselling and safe methods for abortion.

Agenda:

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Morning for knowledge

Abortion as a human Right

Abortion and me

Abortion ABCs

4 Corners

The quest for safe abortion

A new perspective on abortion

Access denied: Human rights and abortion

Comprehensive abortion care

Reasons why ?

Why did she die?

Closing and evaluation

THE SESSIONS

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Session 1: Introduction DESCRIPTION: It is essential to start the training with sufficient time to get to understand the aim of the training, align expectations and to get to know each other in order to build a comfortable environment.

GOALS: By the end of this activity, participants will be able to: • • •

Understand the goals and objectives of the training.

Articulate their hopes and fears about the training, particularly concerning the topic of abortion.

Be at ease in a comfortable environment.

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Know the workshop objectives and the agenda.

EXPECTED TIME : 30

minutes

MATERIALS: • • •

Flipcharts Pens Envelops

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Markers

PROPOSED ACTIVITIES : • •

• • •

•

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Introducing the trainers and the workshop agenda.

Setting Ground Rules for the training: brainstorming on which basic principles that should be respected during the overall training (for example, respect each other’s opinions, avoid side talks, reach out for help when needed…).

Sharing Hopes and Fears.

Introducing what a safe space is and how it will be ensured during the training.

Transforming expectations into learning objectives: summarize participant's expectations into learning objectives by asking them to write down individually what they want to learn through the training using the SMART objectives method. Trainers can collect the learning objectives and by the end of the training, give them back to participants to check to which extent those were fulfilled.

Ice breakers and getting to know each other's activities.

Session 2: Abortion ABC's DESCRIPTION : Before we begin working to reduce abortion stigma with community groups, we must build a common understanding about abortion that is grounded in fact. It is also helpful to build a shared awareness of the variety of experiences participants have had with abortion in their communities. This can serve as the basis for a richer understanding of the social and cultural forces that shape our attitudes about abortion and unwanted pregnancies.

As a foundation for subsequent sessions, this one offers facts about abortion and introductory activities to help build a common understanding.

GOALS : By the end of this activity, participants will be able to: • • • •

Understand basic facts about abortion.

Know the differences between safe and unsafe abortion.

Understand the social and cultural forces that shape our attitudes about abortion and unwanted pregnancy.

Share how their thoughts regarding the cultural and legal situation of abortion in their countries.

EXPECTED TIME : 45 minutes MATERIALS: • • • •

Flipcharts Pens Balloons Post-its

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Markers

PROPOSED ACTIVITIES : The participants try to link the definitions in the room with the right words while working in a group. They have a balloon between them and they should not let the balloon fall down while moving around the room. Then, debrief about each definition and discuss the access to abortion situation in the NMO from a legal, safe and restrictive point of view.

-Debrief questions : What do you think the situation is like in our NMO? Have you faced / heard of a situation of restriction regarding abortion?

What information surprised you the most?

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PROPOSED ACTIVITIES: Definitions : Abortion is the termination of pregnancy before fetal viability.

Induced abortion is The intentional termination of a confirmed pregnancy.

Menstrual regulation is Intentional evacuation of the uterus without confirmation of pregnancy.

Safe abortion is performed by persons with the necessary training and skills, and in an environment meeting minimal medical standards.

Unsafe abortion is a procedure performed either by persons lacking the necessary training and skills, in an environment that fails to meetminimal medical standards, or bot.

Abortion is legal when it is allowed by the state, under the direction of national health institutions and guidelines.

Abortion is restricted when access to safe services is limited, such as with few legal indications, national guidelines that impose barriers not mandated by law, abortion stigma, cost of services, and a lack of facilities that offer the services.

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Session 3: a new perspective on abortion DESCRIPTION: After a run through the basic information we will dive more into the magnitude of unsafe abortion and how it affects women and societies. The participants will also begin to explore and broaden their own personal perspectives on abortion.

GOALS: By the end of this activity, participants will be able to: Articulate their thoughts regarding abortion.

Change some of their perspectives regarding abortion.

Expected time: 30 minutes

MATERIALS: • •

Presentation ‘Module 1’ Slides 8–19 Supporting document ‘A new perspective: Cards

PROPOSED ACTIVITIES: •

• • • • • •

Invite participants to actively participate in this activity. Inform them the purpose of this activity is to learn basic information about abortion, including definitions and the impact of unsafe abortion on women and societies. We will also begin to explore and broaden our own personal perspectives on abortion.

Write the following, unfinished sentence on flipchart: “Abortion is…”

Ask participants to complete the sentence without discussing it with anyone else. Instruct them to write down their answers in their notebooks.

While participants are writing, quietly tape the ‘A new perspective: Cards’ around the room.

Tell participants they are going to complete a gallery walk and see other perspectives of abortion. Allow 10 minutes for participants to walk around and read the cards.

Ask participants to return to the plenary. Invite them to revisit their answer to the statement “Abortion is…” and make any edits they want to it.

Facilitate a brief, large group discussion. You may wish to use the discussion questions below. Allow 10 minutes for the discussion.

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PROPOSED ACTIVITIES: a. How would you describe your new statement compared to your original one? b. If you edited your statement after the walk, what made you edit it? c. What did you learn about your own perceptions of abortion through this activity? d. What did you learn about abortion through this activity? •

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Summarize key points from the discussion. If you want, you can present the slides for this activity (slides 8-19) to reinforce learning messages. Allow 10 minutes for this presentation.

Solicit any final thoughts or comments from participants.

Thank them for their participation and segue to the next activity.

Note to facilitator: At the end of the workshop, ask participants to revisit their statement on abortion once more. Invite them to reflect on how their beliefs, attitudes, knowledge and skills related to abortion have changed as a result of the workshop, and ask them to write a new statement. Make sure there is space in your agenda for this.

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Session 4: reason why?

DESCRIPTION: In this activity, participants explore the full range of underlying reasons for young women’s unintended pregnancies, pregnancy termination or continuation, and governments’ regulation of pregnancy and abortion. Participants are encouraged to identify how their and others’ level of comfort with young women’s reasons affects reproductive health policies and services, and social stigma.

GOALS: By the end of this activity, participants will be able to: • • • • •

Identify diverse reasons for young women’s pregnancies, unintended pregnancies, and the continuation or termination of unintended pregnancies.

Name the reasons why young women may make decisions about their unintended pregnancies that they really don’t want to make.

Discuss the reasons why governments regulate pregnancy and abortion more than many other medical conditions and procedures, particularly for young women.

Differentiate their comfort levels with regard to the different reasons.

Discuss how individuals’ subjective level of comfort affects women’s access to safe abortion care.

EXPECTED TIME: 45 minutes MATERIALS: • •

Supporting document ‘List of reasons’ Flipchart, tape and markers

PROPOSED ACTIVITIES: Preparation before the session: Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. (Article 7.20, International Conference on Population and Development, Cairo, 1994)

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Write the questions below on flipchart. a. What are the reasons women (over the age of 20) get pregnant? b. What are the reasons adolescents (under the age of 20) get pregnant?

PROPOSED ACTIVITIES : • Write the questions below on flipchart. a. What are the reasons women (over the age of 20) get pregnant? b. What are the reasons adolescents (under the age of 20) get pregnant?

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Write the questions below on flipchart. c. What are the reasons women (over the age of 20) have abortions? d. What are the reasons adolescents (under the age of 20) have abortions?

Instructions: 1. Invite participants to participate actively in this activity. Inform them the purpose of this activity is to identify women’s sexual and reproductive health needs, and explore reasons women and adolescents get pregnant and have abortions. Participants will also discuss how social norms and beliefs about these reasons affect women’s reproductive health and well-being.

2. Ask if anyone can define reproductive health. Invite a few participants to share their thoughts. You may wish to write the responses on flipchart.

3. After a few responses, post the flipchart ‘Reproductive health’ that you prepared in advance. Ask a participant to read it, and explain that this definition is an internationally recognized definition of reproductive health, agreed to at the International Conference on Population and Development in Cairo in 1994.

4. Next, ask participants to mention different sexual and reproductive health needs women face. You may wish to write the responses on flipchart. Make sure all the examples listed in this module’s narrative are mentioned.

5. Divide participants into two groups. Give each group flipchart and markers.

6. Tell the groups they are going to identify reasons why women or adolescents get pregnant. Post the flipchart with questions A and B. Ask one group to answer question A and the other group to answer question B. Instruct the groups to write down their answers on flipchart. Allow five minutes for the groups to identify reasons.

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7. Ask the first group to post their flipchart and present the reasons they identified why women get pregnant. Ask the second group to present their reasons why adolescents get pregnant.

Allow five minutes for sharing.

8. Once the groups have presented, ask if anyone can think of any other reasons to add. Record any additional reasons on the appropriate flipcharts. Use the supporting document ‘List of reasons’ to add any remaining reasons which have not been mentioned.

9. Tell the groups that now they are going to identify reasons why women or adolescents have abortions. Remind everyone that people have different beliefs and experiences related to abortion. It is important to respect each other’s differences and be mindful that to some people it may be a very personal subject.

10. Post the flipchart with questions C and D. Ask one group to answer question C and the other group to answer question D. Repeat instructions 6-8 to identify, present and discuss reasons why women and adolescents have abortions.

11. Invite participants to study the reasons noted on the flipcharts and facilitate a brief discussion. You may wish to use the discussion questions below. Ask one question at a time, and allow time for participants to respond to it before you move on to the next question. Make sure you have at least 15 minutes for this discussion. a. What observations can you make about women’s reproductive health needs based on this activity? b. Are there differences between the reasons adult women get pregnant and have abortions, and the reasons adolescents get pregnant and have abortions? If there are differences, why do you think that is? c. What reasons that women or adolescents get pregnant may society view as more acceptable? d. What reasons that women or adolescents have abortions may society view as more acceptable? e. How do these norms and attitudes affect women’s and adolescents’ opportunities to achieve reproductive health and well-being?

Note to facilitators: The order of the suggested discussion questions matters! The first question is less personal and possibly perceived as less sensitive. It is designed to create comfort for all participants to participate in the discussion. The following questions may require more self-reflection to answer which can make them more effective at learning. End 12.Summarize key points from the discussion..

Closing: To close the activity, emphasize there are many reasons women and adolescents get pregnant and have abortions. Some of these reasons are outside their control. We seldom know everything about a woman’s circumstance, how she got preg IPAS women's reproductive health and access to safe abortion training

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nant or why she is terminating the pregnancy. And we should be careful not to judge her actions. All women have the right to live free from violence and coercion and the right to bodily autonomy and to decide whether, when and with whom to have a child.

Thank participants for participating in this activity.

LIST OF REASONS: PREGNANCY: These are some of the reasons why women and adolescents become pregnant. There may be others that you and the participants think of.

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Desire for children and family

To have children To start or grow a family

Proving womanhood

To become ‘a real woman’ To prove they can get pregnant

Perceived or actual benefits of motherhood

To feel companionship with other pregnant women or new mothers To attain a higher social status in the family or community To be treated special and get more love from partner To overcome loneliness or abandonment To become responsible for something important To get access to social welfare programs

Enjoying sexuality

To enjoy sex To have fun

Lack of information

To think ‘it will never happen to me’ Lack of information about how pregnancy occurs and how to prevent it

Issues with contraception

Contraception is not available or affordable in their community Social stigma about using contraception is too high Lack of comfort negotiating contraceptive use Incorrect or inconsistent use of contraceptives Contraceptive failure

Social pressure or violence

To fulfill a ‘duty’ as a wife Family or partner demands for a child Pressured to have sex Physically forced to have sex Relied on sex work to feed themselves and other family members

Session 5: four corners DESCRIPTION: The purpose of this activity is to help participants come to a deeper understanding about their own and others’ beliefs about abortion; empathize with the underlying values that inform a range of beliefs and consider how their beliefs affect societal stigma on abortion; and understand how personal beliefs can affect the provision of highquality services.

GOALS: By the end of this activity, participants will be able to: • • • •

Articulate their beliefs about abortion and defend and respectfully explain other, sometimes conflicting, points of view.

Explain different values underlying a range of beliefs on abortion.

Discuss how personal beliefs affect societal stigma or acceptance of abortion.

Explain how personal beliefs can affect the provision of abortion-related services.

EXPECTED TIME: 40 minutes MATERIALS: • • •

Four signs labeled Agree, Strongly Agree, Disagree and Strongly Disagree Pens Tape

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Four Corners worksheet

PROPOSED ACTIVITIES: Instructions: 1. Inform participants that this is an activity where we will be speaking from a personal point of view, as well as defending others’ views. Encourage them to be completely honest to get the most out of the activity.

2. You can tell the group: Often, our beliefs about abortion are so engrained that we are not fully aware of them until we are confronted with situations and compelling rationale that challenge them. This activity helps us to identify our own beliefs about abortion, as well as understand the issues from other points of view.

3. Hand each participant a Four Corners worksheet. Instruct IPAS women's reproductive health and access to safe abortion training

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them not to write their names on either of their worksheets.

Ask them to complete the worksheet and then turn the sheet over.

4. Ask participants to stand in a circle and crumple their worksheets into a ball and throw them into the middle of the circle. Randomly toss a “ball” back to each participant or ask them to pick one of the worksheets from the floor.

5. Explain that for the remainder of the activity, they will represent the responses on the worksheet they have in their hands. If they got their own worksheet, they should act as though someone else completed it.

6. Point out the four signs placed around the room. Tell them they will be discussing a select number of statements from the worksheet, one at a time.

Note to facilitator: This activity will be too long if you try to discuss all, or even most, of the statements. Three statements are normally enough to gain the desired effect from the activity. If participants want to see how the group responded to all of the statements, you can have them move to the four corners for each statement and see how the responses are distributed, but then only discuss a select number of them. Select the statements that will elicit the most important discussion for that audience and setting. You can select the statements in advance or after you have seen how participants responded and where the greatest differences in opinion are.

7. Read the first statement out loud. Ask participants to move to the sign that corresponds to the response circled on the worksheet they are holding. Remind participants that they are representing the responses on their worksheets, even if they conflict with their personal beliefs.

8. Invite participants to look around the room and note the opinions held by the group. There may be different-sized groups in the four corners, and sometimes all four corners may not be occupied. You can then ask some people to move to another group if the four are not evenly distributed.

9. Ask the group under each sign to discuss for two minutes the strongest rationale for why people might hold that opinion.

10. Start with the spokesperson under Strongly Agree and proceed in order to Strongly Disagree.

• •

Remind participants that the designated spokespeople may or may not personally agree with the opinions they are presenting.

Do not allow other groups to comment at this time.

11. Read the next statement, and ask participants to move to the sign that corresponds to the response circled on their worksheet. Invite participants to note the opinions held by the group.

Ask groups to select someone who has not yet spoken to be 20

their spokesperson. Reverse the order of the groups’ presentations.

12. Continue in the same manner for the remaining statement(s).

13. Have participants return to their seats. Discuss the activity by asking some of the following questions: • • • • • • • •

What was it like to represent beliefs about abortion that were different from your own?

What was it like to hear your beliefs represented by others?

What rationale for certain beliefs caused you to think differently?

What are your general impressions about the beliefs held by the people in this room (but not by any particular individual)?

What is your sense of the underlying, core values that inform these beliefs?

How do our beliefs about abortion affect societal stigma or acceptance of abortion?

What relevance do the beliefs discussed in this activity have for abortion care in our setting or country?

How might our beliefs about abortion affect our provision of abortion-related services?

Closing: Solicit and discuss any outstanding questions, comments or concerns with the participants.

Thank the group for their participation.

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Session 6: access denied: human rights and abortion DESCRIPTION: Participants will increase their understanding of human rights and sexual and reproductive rights and examine, through real-life case studies, how a lack of safe abortion care can be a violation of these rights. Participants will also discuss how conditions in a woman’s community affect whether her rights are fully achieved or not.

GOALS: By the end of this activity, participants will be able to: • •

Increase their knowledge on human rights and SRHR. Understand how a limited access to abortion is a human rights’ violation

•

Discuss the community conditions’ effect on women’s rights.

EXPECTED TIME: 45 MINUTES MATERIALS: • • • • •

Presentation ‘Module 2’, Slides 5-15 Supporting document ‘Case studies’ Supporting document ‘Case resolutions’ Table ‘Human rights and abortion’ Flipchart, tape and markers

PROPOSED ACTIVITIES : Preparation before the session: • •

•

Review the presentation slides.

Review the court resolutions of the different cases to familiarize yourself with the different ways international and regional courts have resolved cases in which women were denied safe abortions.

Write the following discussion questions on flipchart. These questions will guide participants through the discussion of the cases. a. What human rights do you think were violated, or were not guaranteed, in your case? How? b. What conditions need to be in place in a community for all women’s human rights to be fully realized? c. What do you think is the role of health sciences students in protecting and guaranteeing human rights,

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including safe abortion? What is the role of practicing health professionals?

Instructions: 1. Invite everyone to actively participate in this activity. Inform them the purpose of this activity is for participants to increase their understanding of human rights and sexual and reproductive rights and examine, through real-life case studies, how denied access to safe abortion care can violate these rights.

Participants will also discuss how conditions in a woman’s community can affect whether her rights are fully realized.

2. Show participants all the slides for this activity (slides 5-15).

Allow 10 minutes for this presentation. Encourage participants to ask clarifying questions as needed.

3. After the presentation, post the flipchart with the discussion questions.

a. What human rights do you think were violated, or were not guaranteed, in your case? How? b. What conditions need to be in place in a community for all women’s human rights to be fully realized? c. What do you think is the role of health sciences students in protecting and guaranteeing human rights, including safe abortion? What is the role of future health professionals?

4. Divide participants into four small groups. Provide each participant a copy of Table ‘Human rights and abortion.’ Give each group one of the case studies. There are only two cases, so therefore two groups will have the same case. Ask the groups to read their case and answer the discussion questions you posted on flipchart. Ask the groups to write their answers on a flipchart. Allow 20 minutes for this small group discussion.

5. Ask participants to come back together in plenary. Invite one representative from each group to briefly summarize their case and share highlights of their discussions.

6. Summarize key points from the participant-led discussions.

7. Tell participants how each case was resolved in the regional courts of human rights that tried them, using the supporting document ‘Case resolutions.

8. Ask participants to share their reactions and thoughts about the resolutions of the cases.

9. If time permits, you can invite the groups to elaborate on how they as future health professionals could have advocated for the women in their cases.

10. To close this activity, tell participants: All people have the right to enjoy mutually satisfying and safe relationships, free from discrimination or violence. Women have the right to manage their fertility without adverse or IPAS women's reproductive health and access to safe abortion training

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dangerous consequences, which includes access to safe contraceptive and abortion services. As members of a global community, we have a responsibility to work every day to protect and guarantee human rights and sexual and reproductive rights for all people. We have to strive to create the social, political and economic conditions that enable and empower all people to exercise their rights. When states violate, deny or fail to guarantee an individual’s rights, we have to hold them accountable. We can support justice through national, regional or international courts, and through our advocacy work.

11. Solicit any final thoughts from participants.

Thank the group for participating in this activity.

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CASE STUDIES

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CASE STUDIES: Case A: Lidia In 1999, Lidia was 13 years old when an unknown man came into her house and raped her in front of her sister and her sister’s children aged two and five years old. A few weeks later, she and her mom found out she was pregnant. The doctor at the hospital informed them that Lidia had the right to abortion because the pregnancy was less than 12 weeks gestation and the outcome of a crime, but she needed legal authorization. Lidia decided she wanted to terminate her pregnancy and her mom supported her decision. They went to get legal authorization from the public prosecutor and it was granted. The public prosecutor sent the legal authorization to terminate Lidia’s pregnancy to the local health authorities. A series of bureaucratic barriers, harassment and abuse by the local health authorities, providers’ misunderstandings of the law and psychological pressures and violence from conservative and religious individuals working at public institutions prevented Lidia from ever having an abortion.

Lidia gave birth to her son. It took over six years for the government of her country to recognize, through a resolution by the Inter-American Human Rights Court, that her human rights had been violated.

Case B: Margaret Margaret got pregnant for the third time in 2000 when she was 29 years old. At that point, she had severe myopia (nearsightedness) and was evaluated as having a visual disability of medium severity. She was taking care of her two children by herself. Yet she did not qualify for disability payments by the state. Three ophthalmologists recommended termination of the pregnancy given the risk of retinal detachment, but all three refused to issue an abortion certificate to Margaret even though she decided to terminate the pregnancy on their recommendations. A general practitioner also recommended abortion because Margaret had had two Cesarean sections and her risk of uterine rupture was elevated. When Margaret visited her obstetrician and gynecologist, he refused to perform the abortion, saying that a Cesarean section would prevent retinal detachment. He ordered bed rest for Margaret to avoid more damage to her eyes. Bed rest was almost impossible for Margaret since she was the primary caregiver of her two children. Margaret never had her abortion.

She gave birth by Cesarean section. Six weeks after the delivery, she was taken to the emergency unit of an ophthalmologic clinic, but surgery was not possible since the damage done to her eyes could not have been corrected by it. Almost a year after her third child was born, the state declared her significantly disabled due to her myopia. Her government recognized violations of her human rights through a ruling by the European Court of Human Rights.

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CASE RESOLUTIONS: LIDIA and the Inter-American Human Rights Court resolution: In 2007, the Inter-American Human Rights Court resolved that several rights were violated by the state, including: the right to non-discrimination and protection of the law; the right to bodily integrity; the right to freedom; the right to judicial guarantees and judicial protection; the right to protection of personal dignity; the right to freedom of conscience and religion; and the right of minors to be protected by family, society and the state.

Among the treaties referenced in the resolution are the Universal Declaration of Human Rights; The Convention on the Rights of the Child; The American Covenant on Economic, Social and Cultural Rights; and The Inter-American Convention for the Prevention and Elimination of Violence against Women. The Court also facilitated a “friendly settlement” of the case between the state and Lidia, in which several personal benefits were granted to her and her son, as well as changes in national guidelines for the provision of safe abortion in cases of rape.

MARGARET and the European Court of Human Rights resolution: In 2007, the European Court of Human Rights ruled that in Margaret’s case the state violated human rights #3 (the right to not be subjected to inhuman or degrading treatment) and #8 (the right to private life and non-interference by a public authority with the exercise of the right to privacy) of the European Convention on Human Rights. Margaret was compensated with 25,000 euros in respect of non-pecuniary damage and 14,000 euros in respect of legal costs and expenses.

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Session 7: why did she die?

DESCRIPTION: This activity features a case study that highlights the sociocultural context around a young woman’s unwanted pregnancy and abortion decision. Participants are confronted with the tragic consequences that can result when access to safe, legal abortion services is restricted, and are asked to articulate their personal or professional responsibility to prevent deaths such as this one. The activity also deepens participants’ understanding of the values clarification process.

GOALS: By the end of this activity, participants will be able to: • • •

Discuss the sociocultural context surrounding unwanted pregnancy and abortion among young women.

Explain the tragic outcomes that can result from restricting access to safe, legal abortion services for young women.

Articulate their personal or professional responsibility to prevent deaths, such as those described.

EXPECTED TIME: 45 minutes MATERIALS: • • • •

Copies of the story Why Did She Die? Values Clarification for Abortion Attitude Transformation theoretical framework (from this toolkit) Flipchart and markers (optional) Ball of string (optional)

PROPOSED ACTIVITIES: Preparation before the session: •

•

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Choose one story, and adapt it for local relevance, if necessary. If you are working with a large group you can use both stories: one for half of the group and the other for the other half of the group. Remember to adapt both stories for local relevance if you do this.

Prepare global, national and local statistics on abortion-related morbidity and mortality among young women and how they relate to restrictions on access to abortion. General overviews can be found on www.ipas.org. Youth-specific information can be found in Ipas’s Abortion care for young women: a training toolkit, including in the resource materials of the toolkit. The Youth Program also has statistics related to young women and abortion, and can be contacted at youth@ipas.org.

•

Make copies of the story(ies) and the Values clarification for abortion attitude transformation (VCAT) theoretical framework, one per participant.

Instructions: 1. Distribute a copy of either version of the story Why Did She Die? to all participants.

2. Ask participants to read the story silently, or ask one participant to read it out loud for everyone.

3. Facilitate a discussion about why Mia or Agnes dies. You can opt to record responses on the flipchart. Suggestions for questions include: • • • • •

What happens in this story?

Why did she die?

What choices did Mia/Agnes have in the story?

How does this story make you feel?

Who do you think is responsible for her death? Why?

(If participants respond that the young woman is responsible for her death, challenge them to think more deeply about who is responsible and has the capacity to fulfill the young woman’s human rights, including her rights to information, education, health care and life. How could her community and the health system have prevented her death? Probe further on whether young people can be blamed for their lack of information and whose responsibility it is that they have access to information and health care.)

• In addition to the young woman, who else was directly affected by her death?

• What real stories or situations does this story make you think of (without revealing any identifying information)?

• What does this story tell us about our responsibility to safeguard young women’s health and lives?

• What could have been done to prevent her death? Who could have helped prevent her death?

• What could have made this situation better for her?

• What information or resources may have helped her avoid this situation?

• What will you do, personally or professionally, to prevent deaths such as this one from occurring?

4. After the discussion, present, or ask participants to summarize (if you have already covered it previously), some basic information on global, national and local statistics on abortionrelated morbidity and mortality and how it relates to restrictions on access to abortion for young women.

5. Ask participants to return to their seats. If time permits, and you have already discussed the VCAT theoretical framework and would like to review it using a VCAT activity as an example, facilitate the following discussion on it. Otherwise, solicit and discuss any outstanding questions, comments or concerns and thank the group for its participation.

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6. Provide participants with a copy of the Values clarification for abortion attitude transformation theoretical framework. Ask participants to divide into pairs.

7. Facilitate an additional dialogue to extend the discussion of this story and deepen participants’ understanding of the values clarification and behavior change process.

Using this story as the context for discussion, ask pairs to talk through each box in the framework to help them better understand the value clarification process. The aim is for them to clarify their values and understand how those values inform their attitudes and behaviors in relation to situations like the one described in the story. Give the pairs time after each question to discuss. Some questions could include: • • • • • • • • • • • •

What new information did you learn about unwanted pregnancy, abortion and maternal mortality from this story?

How did this story deepen your understanding of the context surrounding a young woman’s unwanted pregnancy, abortion and maternal mortality?

How has this story increased your empathy for young women in Mia’s or Agnes’s situation, or other equally desperate situations?

What are your current values on abortion in relation to this and similar stories?

What are other possible values on abortion in relation to this story? What would be the consequences of acting on these other values?

How open do you feel to experiencing different values on abortion in relation to this and similar stories? What would you need to become or remain open to change?

Having weighed all of the possibilities, what values do you choose for yourself at this time in relation to this story?

What would help you affirm these values?

What actions have you taken in the past that are not consistent with your values?

What actions could you take from now on that would be consistent with your values?

How has this story contributed to a change in your attitude about abortion and young women who seek one?

What can you commit to doing in relation to abortion situations like this one?

8. Recall the global, national and local statistics on abortion-related morbidity and mortality that you presented earlier in the activity. Discuss how restricting access to safe abortion services does not decrease the number of abortions, but actually increases the number of women, particularly adolescents and young women, who are injured or die from them. Ask participants to articulate their personal and/or professional responsibility to prevent deaths such as this one.

9. Solicit and discuss any outstanding questions, comments or concerns with the participants.

Thank the group for its participation.

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Note to facilitators: It may be necessary to change the names and certain elements of the story to be more culturally or geographically appropriate for the audience or setting. You may want to adapt a real-life story from the media or clinical experience, making sure to change any potentially identifying information to protect people’s privacy. Since the point of this activity is to consider the socio-cultural contexts around a young woman’s unwanted pregnancy and abortion decision, the story should be about a young woman (10 – 24 years). It may be helpful to provide participants with national statistics on abortion-related morbidity and mortality to illustrate how common tragic events, such as this one, are.

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WHY DID SHE DIE? STORIES

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INSTRUCTIONS: Please read the following story, and then be prepared to answer some discussion questions about it.

Version 1 (Young woman): My name is Mia. I was the eldest daughter in my family. I was intelligent and hardworking. Even though I worked hard at home helping my mother, school was my top priority. I always came first in my class, and I was the pride and joy of my family and community.

I won a scholarship to go to university. It was my first time in a big city, and I found it difficult to make new friends. But slowly that changed, and I settled into my new environment.

I continued to study diligently and made sure I was always at the top of my class. My professors were very proud of me and took special interest in me. They encouraged me to pursue my professional dreams.

After graduation, I joined a professional firm and sent money home to pay school fees for my younger brothers and sisters.

I became the breadwinner for my extended family. I met and fell in love with a colleague at work, Richard. At first Richard was gentle and loving, but gradually that began to change. He became distant and unkind to me.

I soon discovered that Richard had another girlfriend. When I discovered this, I told Richard that our relationship was over.

Richard became very angry and forced me to have sex. He knew that I wasn’t using contraception. As he pushed me out the door, he declared, “I know that when you become pregnant, you will return to me.”

Three months later, after feeling sick for quite a while, I went to a clinic. When I got the results, I was shocked to discover that I was, in fact, pregnant. I had always had an irregular menstrual cycle and had never been taught the symptoms of pregnancy. I determined that there was no way I would go back to Richard. When I inquired at the clinic about ending the pregnancy, the staff looked at me with disgust and refused to answer my questions. I went to another clinic to ask about terminating the pregnancy, but they also turned me away. I felt afraid and was too ashamed to tell anyone in my family about the rape and pregnancy. I felt that no one would believe or help me, and I became desperate. I tried drinking a toxic potion of household chemicals that I had heard from my friends would terminate a pregnancy. I tried inserting sticks into my cervix. I became terribly sick and developed a painful infection but was still pregnant.

Eventually, after trying all of these things, I took my own life.

Version 2 (Adolescent woman): My name is Agnes. I was an adolescent girl who looked older than my age. In my health class at school, my friends and I were introduced to an abstinence program that taught us IPAS women's reproductive health and access to safe abortion training

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about the reproductive organs and how sexual intercourse happens, but not about contraception, pregnancy, or how to prevent pregnancy. With my friends, I often went to my small town’s Internet café on our way home after school. There I met a boy a few years older, Luis, who told me I was pretty, and asked if he could visit me at my home.

I was very flattered, and agreed. Luis began to stop by my home after school. He was very polite to my parents, and gradually they began to trust him with me. After a few weeks, they felt comfortable to allow me to go for unaccompanied walks with Luis. Luis and I grew close, and I felt confident that he really cared for me.

After a few months of courtship, which included kissing and hugging, Luis asked me to become more intimate. He told me that he planned to marry me as soon as he finished school, which was only a year away. He told me that he loved me very much and didn’t want to wait any longer to be as close as possible to me. I also didn’t want to wait, and so we had sex in the privacy of a field where we often walked. Since neither Luis nor I had learned about contraception, and since we didn’t know who we could comfortably ask for information, we had unprotected sex.

A few weeks later, I began to feel sick each morning. My school uniform felt tight. My breasts felt tender. I remembered that the last time my mother was pregnant, she had complained of nausea. Suddenly I realized that I might also be pregnant. I was very frightened. My school had a policy to expel female students who got pregnant. And I knew my parents would be angry and ashamed of me, and disappointed in Luis.

I told Luis that I might be pregnant. He was very concerned for me. Both of us felt afraid to ask our parents for help or guidance, so Luis asked his older married brother for advice. His brother told him about a small, private clinic that performed abortions, and also about an older woman just outside of town who was known to quietly put an end to unwanted pregnancies.

We went first to the clinic. The doctor there told us that I was too young to have an abortion without parental consent, and sent us away. A few days later, Luis took me after school to the old woman. She inserted several sticks into my uterus. It was very painful. I hobbled home with Luis’s help and went to bed.

Overnight I developed a high fever and began to hemorrhage. I was too afraid to awaken my mother for help. By morning, I was dead from blood loss. Why did Agnes die?

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Session 8: the quest for safe abortion DESCRIPTION: It is essential to start the training with sufficient time to get to understand the aim of the training, align expectations and to get to know each other in order to build a comfortable environment.

GOALS:

By the end of this activity, participants will be able to: • • •

Know and understand their country’s law on abortion.

Understand the ways the law may perpetuate stigma and limit access to safe abortion services.

Identify how to advocate for improved abortion laws in the country or how to re-interpret current laws to expand access to abortion care.

EXPECTED TIME: 60

minutes

MATERIALS: • • • •

Tape Flipcharts Post-its Copies of the summary and the national law

PROPOSED ACTIVITIES : Instructions: 1. Introduce the activity (2 minutes): For people who are pregnant or may become pregnant to exercise their human rights, they need access to abortion. But for some, abortion remains a controversial issue. In many countries, restrictive laws and social stigma around abortion are common. Restrictive abortion laws do not stop people from having abortions, but they may result in unsafe abortions. This activity will help us understand what the law says about abortion in our country, so we can consider our role in helping reinterpret or change it.

2. Buzz and brainstorm (10 minutes): Find a partner and discuss: What do we know about the abortion law in this country? After a few minutes: Share what you know with the full circle.

3. Small groups (15 minutes): Divide participants into five small groups and hand out copies of the law. Choose someone in your group to read our country’s abortion law out loud. Assign each group one of the following questions (if you have a small group assign 2 or 3 questions per group):

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a. What does the law say about abortion in this country? b. How might this law prevent access to abortion services? c. What other barriers this law may create in the health services? d. Is there anything missing from the law that you would like to see included? e. What other barriers (social, cultural barriers) to access to safe abortion exist in your country? How are the different barriers interdependent? f. What can future health professionals do to address barriers to safe abortion?

4. Report back (7 minutes): Ask each group to present key points from their discussion. Encourage discussion after each presentation.

5. Process using 2-4-All (10 minutes): Find a partner and share ideas on this question: What can we do to advocate for more supportive laws around abortion? After a few minutes: Now join up to make groups of four and identify your top three ideas for action.

After a few more minutes: Come back to the full circle and present your ideas. After each group’s presentation, we’ll discuss what we think about the ideas.

6. Summarize (3 minutes): Women and adolescents face many barriers to safe abortion, such as gender discrimination; unequal access to and control of financial resources, which makes safe abortion services unattainable because of their cost; abortion stigma; fear of a judgmental provider; and a lack of privacy at the facility. Because of these barriers, many women and adolescents who seek to terminate pregnancies have no choice but to resort to unsafe abortion, even when their circumstances fit the legal indications for safe abortion. The barriers explain why adolescents tend to access abortion care later in pregnancy than adults, and why they are more likely to delay seeking help for complications than adults. It is urgent to remove as many of these barriers as possible to ensure that women and adolescents get the care they need and to which they are entitled.

Or you may have this exercise in an ideas cafĂŠ by dividing the participants in three groups and they brainstorm about one type of barrier and then strategy per group and rotate each time. Each group tackles one type of barriers and then one type of strategy.

It is all followed then by a presentation and a debrief.

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FOR FACILITATORS USE ONLY: Legal and policy barriers

Social and cultural barriers

Health systems barriers

Restrictive abortion laws and/or national guidelines that: • Limit indications for safe, legal abortion • Limit what type of providers can perform abortion • Require signatures of multiple providers • Mandate waiting periods • Mandate third-party involvement (such as parents or spouse) • Immigration status

• Gender discrimination • Poverty and unequal access to financial resources for women • Religious institutions and beliefs • Abortion stigma • Inadequate access to information and education • Lack of social support systems

Lack of health-care facilities providing safe abortion services • Shortages of providers capable of and committed to providing safe abortion care • Low quality of care, including lack of privacy and judgmental provider and staff attitudes • Cost of services

Legal and policy strategies

Community related strategies

Health systems related strategies

• Seek to influence the legal and policy frameworks by making consensus documents and lobbying policymakers, testifying in legislative hearings and conducting media outreach

• Raise community awareness of unsafe abortion and/or existing abortion law • Sensitize community and religious leaders, and support champions for safe abortion • Train peer educators and do peer education on abortion • Run social networks that provide safe abortion accompaniment

• Advocate for the inclusion of safe abortion in health sciences curricula and ensure clinical training opportunities to build capacity and commitment of future providers

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Session 9: comprehensive abortion care DESCRIPTION: Participants will learn about comprehensive abortion care, including safe and effective abortion methods. Participants will also learn about warning sign of abortion related complications.

GOALS: By the end of this activity, participants will be able to: • • •

Know and understand their country’s law on abortion.

Understand the ways the law may perpetuate stigma and limit access to safe abortion services.

Identify how to advocate for improved abortion laws in the country or how to re-interpret current laws to expand access to abortion care.

EXPECTED TIME: 45

minutes

MATERIALS: • •

Presentation ‘Module 4,’ Slides 5–30 Projector

•

Computer/laptop

PROPOSED ACTIVITIES: Preparation before the workshop: Review the presentation slides (5-30).

Watch the videos below before the workshop: How does surgical abortion work?

How does medical abortion aka the abortion pill work?

Instructions: 1. Welcome participants to this activity. Inform them the purpose of this activity is for participants to become familiar with comprehensive abortion care and recommended methods for abortion.

We will also discuss warning signs of abortion-related complications.

2. Tell participants that this activity gives them an introduction to clinical aspects of safe abortion, but it does not prepare them for abortion service delivery.

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3. Explain that you will share resources for participants who are interested in learning more about abortion service delivery later in this activity.

4. Present all the slides for this activity (slides 5–30). At the end of the presentation you can present the videos. Allow 30 minutes for this presentation.

5. Solicit and answer any clarifying questions participants have. If participants have clinical questions about comprehensive abortion care that you cannot or do not feel comfortable to answer, tell them this. Refer them to the resources listed in this module for more information.

Thank the group for participating in this activity.

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Session 10: wrap up and closing session DESCRIPTION: Participants will learn about comprehensive abortion care, including safe and effective abortion methods. Participants will also learn about warning sign of abortion related complications.

GOALS: By the end of this activity, participants will be able to: •

Provide a summary of the ideas and outcomes of the day.

EXPECTED TIME: 20 minutes PROPOSED ACTIVITIES: Instructions: 1. Thank the group for their participation during the activities of the day and their openness to discuss topics that can be considered controversial.

2. Give participants a minute or so to write down the most significant learning they gained during this workshop.

3. After a couple of minutes invite participants to share some messages or takeaways they have from the workshop. Allow at least 2 or 3 participants to share their thoughts. You can also mention some of the main messages from the different activities of the day. Take note of all the learnings/messages in a flipchart.

4. Ask the group what changes they’re planning to make in their work as a result of the training. List these on the flipchart.

5. Invite participants to share those messages in their social media channels or share them with at least a friend on Whatsapp or any other way.

6. If available, give each participant three post-its of different colors and in a flipchart, write the following sentences and ask them to respond before they leave the room. Explain to the group that they don’t need to write their names: • Something I like today.

• One thing I didn’t like.

• A recommendations for future workshops.

7. Adjourn Session and thanks the group and the workshop organizers.

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EVALUATION TOOLS Contact da.scora@ifmsa.org to access the pre and post evaluation forms to measure your impact.

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