Safe Abortion Care: Should we (and can we) provide it?

Questions around whether, where, who can and who should provide safe abortion care, exist among organizations that provide medical care during crises across the world. It should be clear that questioning and challenges are not unique to countries with restrictive legal frameworks, but also exist in countries with laws that permit abortion. For instance, a recent study shows that despite abortion being decriminalized in Colombia, with no restrictions up to 24 weeks of pregnancy, abortion stigma persists and continues creating barriers to safe abortion care (Lopez, et al., 2022).

Arguments for or against the provision of abortion are constructed based on medical facts, personal beliefs, and professional duties, among others. But what role do the principles that drive medical humanitarian organizations have in this regard? Do we sufficiently analyze the principles that drive the organizations we are a part of and importantly, do we reflect upon whether and how we choose to translate those principles into practice?

Do we sufficiently analyze the principles that drive the organizations we are a part of and importantly, do we reflect upon whether and how we choose to translate those principles into practice?

Before analyzing the relevance of humanitarian principles in the discussion of safe abortion care, it is useful to consider certain facts. First, abortion is a common procedure, with 6 out of 10 unintended pregnancies and 3 out of 10 of all pregnancies ending in induced abortion; yet approximately 45% of all abortions are unsafe (Bearak et al., 2020). Second, unsafe abortions contribute to between 4.7% and 13.2% of all maternal deaths, which equates to between 13,865 and 38,940 lives lost annually (Say et al., 2014). Third, this is a public health and human rights issue increasingly concentrated in developing countries (where 97% of unsafe abortions take place) and among groups in vulnerable and marginalized situations (WHO, 2022; Ganatra et al., 2010). At the International Federation of Red Cross and Red Crescent Societies (IFRC) we recognize that these are the very places where our emergency response teams work and the population groups we aim to assist.

The IFRC started discussions around the provision of safe abortion care soon after the signature of the Red Channel Agreement in 2020, and within discussions around standards to ensure protection and gender inclusion in emergency health response operations. The Red Channel Agreement establishes that IFRC and the World Health Organization (WHO) will collaborate to better meet healthcare needs of populations in times of crises. It acknowledges the IFRC’s field hospitals or clinics, also called “Emergency Response Units”, align with the WHO’s core standards, which are part of the WHO’s Emergency Medical Teams (EMT) initiative.

Unsafe abortion is a public health and human rights issue increasingly concentrated in developing countries (where 97% of unsafe abortions take place) and among groups in vulnerable and marginalized situations.

The EMT initiative established as a premise that in clinical care and health response “good intentions are not enough” (WHO, 2018). The initiative was formed after the 2010 devastating Haiti earthquake, which highlighted that in many disasters, international medical relief teams have been deployed not always based on the needs of the situation, and with significant variation in capacities, competencies and professional ethics of such teams. Therefore, the EMT initiative sets minimum standards to promote high quality and efficient deployment, including standards for reproductive, maternal, newborn and child health care.

Such standards recognize that pregnant individuals, women in labor, neonates and children form approximately 75% of those affected by humanitarian crises globally (WHO, 2021b). The standards require that hospitals with or without surgical capacity and clinics, are capable of providing adequate reproductive, maternal, newborn and child health care, “no matter what the primary mandate or focus of their deployment”. The standards specifically establish that safe abortion care should be provided to the full extent of the law of the countries of operation. Red Cross and Red Crescent national societies have an auxiliary role, which means that they support public authorities through humanitarian services, while acting in accordance with the fundamental principles. In practice, however, the translation of such principles is not without challenges.

How do we translate principles?

There exists very limited to no published data that documents the incidence of or experiences with abortion among individuals living in humanitarian settings. However, studies that are available point at a nearly 2-fold increase in post-abortion care utilization between 2012–2013 and 2015–2017 in humanitarian crises including the Democratic Republic of Congo, Somalia, and Yemen, highlighting the critical role that comprehensive safe abortion services could play (Jayaweera, 2021).

Abortion is a safe health-care intervention, when carried out with a method appropriate to the gestational age of pregnancy and – in the case of a facility-based procedure – by a person with the necessary skills. Evidence demonstrates that medicines for abortion can be safely and effectively self-administered outside of a facility (e.g. at home) (WHO, 2022). Yet, the provision of safe abortion care remains rarely included in packages of sexual and reproductive health in emergencies.

Obstacles to the provision of safe abortion care have been documented in the past. For instance, McGuinn and Casey (2016) identified four challenges or reasons often given for which abortion services are rarely provided in humanitarian settings including: ‘there’s no need’; ‘abortion is too complicated to provide in crises’; ‘donors don’t fund abortion services’; and ‘abortion is illegal’. Another challenge comes with arguments which deem the topic of abortion as “too sensitive”. This can result either from an assessment that the provision may be too problematic to the reputation of the organization; or from a perception that such services are better suited to other perhaps more liberal organizations, but not the organization we work at.

While all these arguments could be further analyzed in detail, the focus of this article is not on why we do not or should not provide the service, but instead on how we can overcome challenges to its provision and what role the RCRC principles play for that matter. As such, at the IFRC discussions about the provision of safe abortion care have from the start been and continue to be focused not on personal beliefs of individuals in any given society, but instead on medical needs of pregnant individuals in emergencies, and on two of the fundamental principles of the RCRC Movement: humanity and impartiality.

As such, at the IFRC discussions about the provision of safe abortion care have from the start been and continue to be focused not on personal beliefs of individuals in any given society, but instead on medical needs of pregnant individuals in emergencies, and on two of the fundamental principles of the RCRC Movement: humanity and impartiality.

Humanity

Humanity is the overarching principle that motivates the RCRC Movement’s work, as the articulation of common human values including compassion, empathy, and mutual aid (RCRC, 2020). Its purpose is to protect life and health and to ensure respect for the human being. So do we translate the principle of humanity into compassionate health care for a woman that has decided to end her pregnancy? Can the principle compel health care workers to actively take actions to ensure safe abortion services are available? For instance, those performed by unskilled providers under unhygienic conditions; procedures that are self-induced by a pregnant individual inserting a foreign object into the uterus or consuming toxic products; or procedures instigated by physical trauma to the abdomen or from jumping from a certain height. Mortality from unsafe abortion is often caused by suffering from severe infections, bleeding caused by the procedure or organ damage, resulting from an unsafe method (Barot, 2011).

In the RCRC (2020), we sustain that a central tenet of the principle of humanity is “to ensure respect for the human being”, which means assisting in a way that does nothing to disempower people and honors their inherent dignity. Therefore, it entails providing compassionate and respectful care to individuals seeking sexual and reproductive health care services at RCRC health facilities in emergencies. But do we invoke the principle to encourage health care providers to seriously consider that there are many pathways through reproductive life (for instance, having children at a specific moment in time, fewer children, or no children at all), and that what is right for one woman is not necessarily right for another?

In the RCRC (2020), we sustain that a central tenet of the principle of humanity is “to ensure respect for the human being”, which means assisting in a way that does nothing to disempower people and honors their inherent dignity. Therefore, it entails providing compassionate and respectful care to individuals seeking sexual and reproductive health care services at RCRC health facilities in emergencies.

The United Nations Population Fund (2023) describes a “continuum” between definitely wanting a pregnancy now and definitely not wanting a pregnancy now, which contains grey areas of ambivalence, accidents and contraceptive failures, and a range of constraints. In the absence of crises when services are undisrupted and where rights are not being violated, reproductive decision-making can be complicated by many external factors and influences, whether political, religious, cultural, social or relational (UNFPA 2023; Johnson-Hanks and others, 2011). At times of crises when sexual and reproductive health services are disrupted and human rights may be violated, choice can be further limited or even removed altogether due to reproductive coercion, patriarchal dominance, or sexual violence.

Evidence from settings where self-induced abortion is common indicates that fear of mistreatment and stigma from health care workers, as well as concerns around privacy, are the main reasons why people choose to self-manage despite the availability of abortion services within the formal healthcare system (Jayaweera, 2021). During conflict, natural disasters or displacement, these concerns are likely increased as known caregivers are replaced and community support networks are disrupted.

In addition to fear of mistreatment and stigma, other forms of discrimination to abortion providers and abortion seekers in health care settings include: verbal or physical abuse, public shaming, excessive fees charged by health-care providers, the provision of inaccurate medical information, and experiencing low-quality treatment from health-care professionals (IPAS, 2018b). All of these, in direct opposition to the principle of humanity, therefore highlighting its relevance in discussions about abortion.

Impartiality

Impartiality requires staff to put aside personal biases; it means to reject the influence of personal factors, whether conscious or unconscious, to make decisions on the basis of facts alone, and to act without prejudice (RCRC, 2020). As such, the principle translates into the provision of safe abortion care based on medical need, without prejudices about the individual seeking an abortion or her circumstances. Do we sufficiently invoke the principle of impartiality to help health workers to consciously separate personal beliefs about abortion, from the professional responsibility to reduce maternal morbidity and mortality linked to unsafe abortion?

Impartiality is not a given. It is instead a principle we all have to continuously work on. This is why as an organization that provides medical care, we have a responsibility to provide tools to develop skills for the provision of information and/or the service, and importantly to create safe spaces for respectful discussion and open exchange about abortion. At the IFRC we support National Societies to organize workshops for those who will be deployed with Emergency Response Units to assess where their personal beliefs are in alignment or in conflict with their professional responsibilities to provide or support the provision of safe abortion care. That is, to help individuals develop skills required to put the fundamental principles into action in their day-to-day work, such as an ability to put aside biases and to think critically in challenging situations.

Impartiality is not a given. It is instead a principle we all have to continuously work on. This is why as an organization that provides medical care, we have a responsibility to provide tools to develop skills for the provision of information and/or the service, and importantly to create safe spaces for respectful discussion and open exchange about abortion.

To achieve that, we have greatly benefited from the valuable work of the organization IPAS (2018a), which has produced materials to help humanitarian staff to facilitate “values clarification and attitude transformation workshops” to support the integration of safe abortion care into humanitarian settings. In order to reduce abortion stigma, these are spaces to build a shared awareness of the variety of experiences and level of understanding people have had with abortion in their communities, as this can contribute to a richer understanding of the social forces that shape our attitudes about abortion and unwanted pregnancies (IPAS, 2018b), and indeed about the way we chose to translate the humanitarian values that drive the organizations we have chosen to be a part of. These exchange spaces help us translate into practice the “do no harm” imperative, which indicates the need to avoid exposing people to further harm as a result of humanitarian actions (Sphere Project, 2018).

While answers to questions about the provision of safe abortion care are not straightforward and generate difficult internal debates, they represent essential discussions and require important decisions to make, no matter how challenging. Saying we uphold certain values or working in an organization that is driven by such values is not enough. It is important to be prepared to translate those values into real life situations and to help us address the challenges that exist for the provision and protection of sexual and reproductive health and rights. Contextualizing the values of impartiality and humanity in emergency settings must ultimately help us recognize that supporting women to have the number of children they want to have, at the time they want to have them, or whether to have them at all, is key to healthy women, healthy communities, and indeed, to respectful health care.

While answers to questions about the provision of safe abortion care are not straightforward and generate difficult internal debates, they represent essential discussions and require important decisions to make, no matter how challenging. Saying we uphold certain values or working in an organization that is driven by such values is not enough.

References

• Barot, S. 2011. Unsafe Abortion: The Missing Link in Global Efforts to Improve Maternal Health. Guttmacher Policy Review, Vol 14 (2). Available at: https://www.guttmacher.org/sites/default/files/pdfs/pubs/gpr/14/2/gpr140224.pdf
• Bearak, J. et al. 2020. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. The Lancet, Vol. 8 (9), pp. 1152-1161. https://www.thelancet.com/action/showPdf?pii=S2214...
• Ganatra, B., Gerdts, C., Rossier, C., Johnson, B. R., Tunçalp, Ö., Assifi, A., et al. 2010. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet, ;390(10110):2372-81.
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