Safe Abortion Care: Our midwife talks about challenges and (overcoming) obstacles over the years

Unsafe abortion will continue to pose a significant health risk to millions of women and girls each year in 2022.

  • About 45% of all abortions worldwide are performed unsafely, in a non-medical setting
  • Today, unsafe abortion is responsible for at least 1 in 12 maternal deaths worldwide.
  • 97% of unsafe abortions occur in countries in Africa, Latin America, and South and West Asia

As part of our commitment to reducing maternal mortality in the places where we work, MSF provides safe abortion care in many of our projects. Providing such care can be challenging, and in recent years MSF has made efforts around the world to address obstacles and expand our safe abortion services. Successfully, the number of safe abortions provided by MSF increased from around 74 in 5 countries in 2015 to nearly 35,000 in 33 countries in 2021.

Asha*, a midwife from East Africa, worked for Doctors Without Borders from 2003 to 2021, helping drive the development of safe abortion care within the organization. She talks about the challenges, breakthroughs, and growth she has seen in her work providing life-saving services to women** for nearly two decades.

This is not a picture of Asha who would like to remain anonymous; This archive image is for illustrative purposes only. Louise is a nurse at our sexual and reproductive health project in Kigolube, Democratic Republic of the Congo. It was the first point of contact for women in the region regarding safe abortion care. In many of the countries where MSF works, abortion is taboo in society. © David Scalingi

2003: Education, the first hurdle

When I started working as a midwife at MSF in 2003, I supervised deliveries and newborn care, but I also saw a huge need for abortion care. I wanted to help, but I didn’t have the training or experience. It was a dilemma for me.

In the country where I come from, in East Africa, doctors have always taken this part of healthcare. But I felt the change. When I came home from my first assignment with Doctors Without Borders, I visited the health center where I worked and saw that midwives were now treating abortions. I felt like I was left behind.

In 2004, I heard that MSF had adopted a policy that we would begin providing safe abortion care where it was necessary to prevent maternal death and injury from complications of unsafe abortion. I was amazed. I thought, “This is what I should do.” But I still lack training.

Few patients sought abortion care at that time. Abortion is taboo in Central Africa, where I work, and it is in many of the places where MSF works. But I have learned that many women suffer in silence because I have treated them for complications of an unsafe abortion, such as septicemia or severe bleeding that can lead to severe anemia. Fortunately, the local doctors who worked with MSF on the projects I was placed in had a lot of knowledge and experience and were able to help me solve the complications of unsafe abortion.

2009: Internal Obstacles

Finally, in 2009, I was able to follow an MSF training on sexual and reproductive health care in the Netherlands. I learned how to perform a safe abortion using the pill – a method still preferred in MSF projects today – and how to perform manual vacuum aspiration, a procedure to remove pregnancy tissue. It helped me a lot, and I was able to safely provide abortion care myself.

In preparation to use my newly acquired skills, I departed with MSF for my next assignment in West Africa. But I soon found another obstacle in managing the abortions: my own team. They were not aware of MSF’s policy on abortion. They adopted a negative view of abortions and speculated about the consequences: “What about the family? What about the community? What if it jeopardizes the project?”

I remember a young couple who came to the clinic. The woman was pregnant. They already have three children under the age of five and said they couldn’t handle a fourth. They wanted an abortion. I put this on one of my colleagues who was not from the project country and I think it is too risky for MSF. “What if the patient dies?” He said.

When there is a lack of knowledge about abortion, the response is often: What if the patient dies? We hear stories of women dying after an abortion, but this is because the circumstances or conditions of the abortion were unsafe – for example, because an untrained person used a dangerous and invasive method. Unsafe abortion is one of the leading causes of maternal death, but we know there is another way.

Medical abortion, or safe abortion using the pill, terminates pregnancy successfully in more than 95% of cases, and the risk of serious life-threatening complications is less than 1%. My colleague’s view reflected the fear of the unknown – the lack of knowledge.

I spoke to another colleague, a local doctor with MSF, and we both spoke to the couple and decided to have a safe abortion.

Although I have the skills now, in the two years I have worked on this project, I have often not been able to help women because members of my team have not always understood that safe abortion is an important part of reproductive health care and that unsafe abortion, which you resort to Many women when they do not have access to safe abortion care, one of the leading causes of maternal death.

Fortunately, MSF is a good listener. When I reported to sexual and reproductive health counselors that some staff were interfering with abortion care, they were surprised to hear. In the years since, they have worked to better understand the various internal obstacles and work to resolve them so that we can continue to ensure safe abortion care in MSF projects.

2017: Research on values ​​and attitudes

Several years later, I participated in a workshop entitled “Exploring Values ​​and Attitudes Towards Abortion”, known within MSF as EVA (Editor: EVA Workshops are critical, honest and open-minded days within MSF about abortion. The goal is for all participants to examine or questioning or affirming values ​​and attitudes about abortion). It was very educational and changed many colleagues’ perceptions and attitudes.

Many of my colleagues were unaware of the devastating effects of unsafe abortion, as it kills at least 22,800 women and girls and infects millions of women every year. Very few of my colleagues linked the deaths we saw to the health care system of which we are a part. We simply waited for people with complications of an unsafe abortion to arrive at our clinics, and although we treated those who arrived quickly enough to save them, countless lives were lost.

The first patients to seek safe abortion care after my team attended the EVA workshop were referred to us through colleagues. send relatives, friends and neighbors who need help; I immediately saw the effect of the EVA workshop.

2019-2021: listen and tune

In 2019 I returned to work in a country in Central Africa. When she arrived, she found that MSF had stopped providing safe abortion care at the Ministry of Health hospital. This time it was due to lack of knowledge and negative attitude from some Ministry of Health employees who worked in the hospital, even though we were allowed to provide safe abortion care.

I managed to find a way to restart the services. I told my team that if they have any issues with someone who doesn’t understand the need for these services, they can turn to me. I only did this because I knew safe abortion care was the safest way to help these women.

One day, a woman who underwent a mastectomy came to the hospital. She had a baby and got pregnant again. Her husband had left. She told me that she could not have another child because she could not breastfeed and could afford to breastfeed. Her pregnancy was in her second trimester, but I was unable to help her in the hospital because the staff did not support safe abortion care.

So I decided to help this patient perform a safe self-abortion at home. A self-administered abortion essentially means taking the abortion pill outside of a medical setting, but with the support of online platforms, hotlines, or in this case, my help. The woman’s brother was willing to take care of her. I helped her. All went well and I realized: “I can do it.”

Most of the women who came to me for abortion care had a relative with them – a sister, a mother, a brother. If the patient agrees, she explains to family members how they can support the woman with a self-managed abortion. And if there are complications – they were rare – they know what to look for and how to contact me. This is how I expanded the scope of safe abortion care in this project.

It’s not always easy, but taking care of a safe abortion is really vital. During the nineteen years that I worked for Doctors Without Borders, I had to be very good at providing this care. It took a lot of confidence and sometimes courage. Listening to women is essential, and that’s how I figured out ways to help them, even when there were obstacles.

*Name changed

**While this article focuses on MSF’s experience treating women and girls in our medical projects, we recognize that all persons of childbearing age deserve access to safe abortion care – including those considered transgender, non-binary and intersex.

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