prb-hero

Prioritizing Youth Family Planning in Data Collection and Public Health Emergency Responses in Kenya

Young people face greater challenges than adults do in accessing and using contraceptive services that they trust and that are affordable, accessible, and non-judgmental. Understanding youth family planning needs can help civil society organizations and government agencies provide family planning services that are specialized for young people. PRB partnered with Organization of African Youth Kenya (OAY Kenya) to create a suite of materials highlighting the need for the Ministry of Health (MOH) and county leaders to prioritize youth family planning needs in data collection and during public health emergencies such as the COVID-19 pandemic.

Family planning data in general is poorly integrated in the Kenya Health Information System, especially compared to HIV and immunization data, and these gaps are even more pronounced for youth family planning data. A rapid assessment found that not all health facilities have a system to collect disaggregated data on service utilization and that the Kenya Reproductive, Maternal, Newborn, Child and Adolescent Health plus Nutrition Investment Framework does not explicitly outline specific adolescent and youth indicators. PRB and OAY Kenya created a fact sheet targeting MOH and county leaders to explain why decisionmakers need disaggregated data to provide age-appropriate family planning services and information. The fact sheet encourages leaders to develop specific youth indicators and improve existing data collection and reporting systems.

Kenya moved quickly to respond to the virus that causes COVID-19 by developing national guidelines in April 2020 for continuing reproductive, maternal, and newborn health and family planning care and services during the pandemic. But the current policy guidance does not specifically address the needs of youth ages 15 to 24. As of November 2020, more than one in three young men and women ages 15 to 24 in Nairobi County who were using contraception at the time had trouble accessing it during the COVID-19 pandemic.1 Between January and March 2021, health facilities in Nairobi and Kisumu counties experienced an apparent reduction in contraceptive service use by youth ages 18 to 24.2 In response, PRB and OAY Kenya produced a policy brief outlining the impacts of COVID-19 on the Kenya health system’s ability to provide contraceptive services to young people. The policy brief calls on the MOH and county leaders to create specific guidance on how to continue providing age-appropriate, safe family planning information and services for young people ages 15 to 24 during a public health emergency.

 

References

1 Performance Monitoring for Action (PMA) Agile and International Centre For Reproductive Health-Kenya (ICRHK), Gender & COVID-19: Access to Health and Contraception (Baltimore, MD: Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 2020).

2 Organization of African Youth (OAY) Kenya, Assessment of RMNCAH+N and Meaningful Adolescent and Youth Engagement Global, National and County Policies and Their Effect on Access to AY Services and Information in Nairobi and Kisumu Counties (draft report), 2021.

PRB-Oldest-Pop-Background

Which U.S. States Have the Oldest Populations?

While Southern states are regarded as retirement magnets, eight of the 10 states with the highest percentages of older residents are not in the South. What’s driving these regional patterns?

More than 55 million Americans are age 65 or older, according to the Census Bureau’s 2020 population estimates. One-fourth of these older Americans live in one of three states: California, Florida, and Texas. Seven other states—Georgia, Illinois, Michigan, New York, North Carolina, Ohio, and Pennsylvania—account for roughly another quarter of the 65+ population.

These 10 states are also the most populous and include over half of the total U.S. population. Sparsely populated states such as Alaska, North Dakota, Wyoming, and Vermont also have very small older adult populations—less than 130,000 each in 2020.

But the states with the most adults age 65 or older do not necessarily have the oldest population age profiles. California is a relatively young state even though it has the largest number of older residents: Only 15% of the state’s total population was age 65 or older in 2020. In contrast, Maine’s relatively small number of older adults represent 22% of its total population, the highest share of older residents in any state.

States Ranked by Percent of Population Age 65 or Older, 2020

wdt_ID Rank State Total Resident Population (thousands) Population Ages 65+ (thousands) Population Ages 65+ (percent of state population)
1 1 Maine 1,350 294 21.8
2 2 Florida 21,733 4,638 21.3
3 3 West Virginia 1,785 374 20.9
4 4 Vermont 623 129 20.6
5 5 Delaware 987 198 20.0
6 6 Montana 1,081 213 19.7
7 7 Hawaii 1,407 275 19.6
8 8 New Hampshire 1,366 263 19.3
9 9 Pennsylvania 12,783 2,448 19.1
10 10 South Carolina 5,218 976 18.7

Note: Older adults (ages 65+) made up 13% of the District of Columbia’s population and 22% of Puerto Rico’s population in 2020.
Source: U.S. Census Bureau, Vintage 2020 Population Estimates.

 

While southern states are regarded as retirement magnets, partly due to their warmer weather and tax benefits for seniors, states in the Northeast and Midwest have among the largest shares of older adults. What’s driving these regional patterns?

Migration, both internal and international, has a large impact on the distribution of older adults. States that have attracted older retirees, such as Arizona, Florida, New Mexico, and South Carolina, have larger proportions of older residents. Many states in the Midwest and Northeast also have large shares of older adults, but for different reasons. As young adults in these states have moved south and west looking for educational and job opportunities, the older population has been left to age in place. In contrast, Texas has been a popular destination for state-to-state and international migrants, which has kept its population relatively young.  Austin-Round Rock-Georgetown was the second-fastest growing metropolitan area in the country between 2010 and 2020, trailing only The Villages in Florida.

The share of older adults will continue to increase as more members of the large baby boom cohort reach retirement age. By 2030, 26 states are projected to have age profiles similar to those of Florida and Maine today, with at least 20% of their residents age 65 or older. This demographic shift has implications for many federal and state programs that support older adults. As more Americans become eligible for federal entitlement programs like Medicare and Social Security, spending reductions and tax increases may be inevitable.


Excerpted from PRB’s Population Bulletin, “Elderly Americans,” by Christine L. Himes, and updated in 2021.

 

PRB-Jeff-UN-1216-Background

Data and Demagoguery: Human Rights and Development in the Disinformation Age

Jeffrey N. Jordan, President and CEO, PRB
17th Rafael M. Salas Lecture, United Nations–New York, NY

December 15, 2021

Dr. Kanem, Madam Chef de Cabinet, Ambassador Salas, Mr. Ernie Salas, Excellencies, Distinguished Guests, Colleagues and Friends:

It is an honor and privilege to be here with you today to deliver the 17th Rafael Salas Lecture.

I stand here very much aware of the wise and eminent voices that have spoken before me and I am humbled and gratified to be among them.

I never met Mr. Salas, who was, by all accounts, an extraordinary man. He was a lawyer, a scholar, an economist, a diplomat…and a poet.

He was quoted as saying the only “honorable” excuse for tardiness was an unscheduled visit to a bookshop. In that regard, he was definitely a man after my own heart.

He rose to the highest levels of the Philippine government under Ferdinand Marcos. But as the regime became increasingly repressive, he grew disenchanted.

In 1969, he came to New York to run the UN’s population program, which was then a small, obscure office.

Under his leadership, it grew to become one of the UN’s most influential agencies. And family planning became an accepted and vital strategy in international development.

As a trained economist, Mr. Salas possessed a keen understanding of how evidence and data could be used to improve people’s lives.

More than 30 years after his death, his legacy lives on in UNFPA’s commitment to putting data at the center of its work.

An Improving World

Data tell us many important things—about ourselves and about our world.

At my organization, PRB, much of our work centers around analyzing, interpreting, and communicating demographic data.

If economics is the dismal science, demography might be considered its gloomy younger sibling.

It was the demographer Thomas Malthus who predicted that population growth would outpace the food supply, dooming mankind to unending poverty and hardship.

From population bombs to migration crises, demographers have gained a reputation for providing a depressing view of where the world is headed.

It’s ironic, since demography has such a good story to tell.

When we hear about the suffering, pain, and injustice that exists today, we can take comfort in the data, which remind us that for most people globally, life is better now than at any other time in history.

As recently as 1990, the majority of the planet’s 5 billion people lived in countries of extreme poverty. Today, the proportion of people living in extreme poverty is at its lowest point ever. Demographic data tell us that fewer women are dying in childbirth and child survival rates are rising.

We don’t collect population data merely for the sake of it. The data that we distill from censuses and surveys has led to advances in science, medicine, and technology that are helping people everywhere lead longer, healthier lives.  Back in the 1850s, it was census data that enabled Dr. John Snow to make the link between contaminated drinking water and London’s deadly cholera outbreaks.

Population dynamics and its supporting evidence provide a lens to form common understanding of complex issues that defy easy solutions—whether they be environment and climate change, food and water security, uneven economic growth, migration, resilience, and human rights.

In Africa, an understanding of the demographic dividend is helping the African Union identify strategies to drive economic growth and empower youth, while addressing an array of challenges, including forced migration, violence and extremism.

But increasingly, we’re seeing data misrepresented to serve less noble purposes.

With help from social media, misinformation is being disseminated in ways designed to polarize society by creating a toxic climate of doubt and mistrust.

Informed skepticism is essential to good decision-making. But indiscriminately dismissing the authority of all knowledge-producing institutions has dangerous consequences—with profound implications for the lives of real people.

A Wake-Up Call

Less than a year ago, the world watched in disbelief as an angry mob broke into the U.S. Capitol because they falsely believed the U.S. presidential election had been “stolen.” There was no credible evidence to support this belief—just rumors and conspiracy theories fueled by the echo chamber of social media.

One of the biggest surprises turned out to be the rioters themselves. Most had no connection to extremist groups. They included doctors, lawyers, accountants, and real estate agents. Middle-aged and middle class. Just regular folks.

How does this happen? How do otherwise rational people seemingly cast aside logic and common sense to embrace lies and conspiracy theories that lead them to take part in an armed insurrection against their own government?

It doesn’t happen overnight. It starts with distortion of the truth, then one lie. And then another. And another.

Lies and liars are nothing new. What’s different is the technology. The internet and social media have not only changed how we interact with our fellow human beings but impacted peoples’ ability to form reliable beliefs.

January 6 was more than an attack on the U.S. Capitol building. In many ways, it was the culmination of a longstanding war on science, data, and truth.

It was also a wake-up call for many Americans, myself included, who had taken for granted the resilience and strength of democracy in the United States.

War on Science

A belief in science and a commitment to evidence-based decision-making are at the heart of the modern democratic state.

The men who devised the U.S. system of government were greatly influenced by the Enlightenment, whose philosophers championed scientific achievements and the pursuit of knowledge through reason and evidence.

Nearly 200 years later, when humans first rocketed into space, it felt as if people everywhere were united by a shared faith in science as a force for good in the world.

But by then, science was already under attack from tobacco companies who pioneered the strategy of using paid experts to cast doubts on the science linking smoking to lung cancer. Their methods would later be copied by the fossil fuel industry to attack climate science, delaying action on climate change for a generation.

But we have experienced what can be achieved when the world comes together around a shared understanding of science and data.

In the late 1970s, political leaders worked with the scientific community to ban the chemicals that were threatening the ozone layer. More recently, despite political headwinds and science denial, the scientific community has worked at incredible speed to deliver vaccines protecting people from the coronavirus.

Nowadays, battle lines are drawn around science the same way they are on social issues.

Long-established facts are questioned and debated by conspiracy theorists and those who believe themselves to be scientific experts because they know how to do a Google search or watch YouTube videos.

We human beings like to believe we’re rational creatures who make logical decisions based on reason and fact. But in reality, we base our beliefs on a variety of factors, including our social and cultural networks, and what we want to believe because it’s convenient.

We seek out information (not facts) that fit within our preconceptions of how the world works, and discard things that contradict those beliefs.

Social media allows us to surround ourselves with those who share our biases and then expose us to even more extreme views:

  • That the moon landing was staged.
  • Vaccinations cause autism.
  • Climate change is a hoax.
  • There’s a deep state sabotaging the government.

Before long, we’ve created our own personal echo chamber, where innuendos and rumors are validated by the number of “likes” and “retweets.” And algorithms block opinions that might contradict our own.

Over time, the sheer number of accusations and attacks chip away at public faith, gradually weakening the legitimacy of experts and institutions, and their role in the normal processes of legislation and governance.

Until, at long last, no one can be trusted, and everything is fake.

A Common Basis of Understanding

In the earliest days of the HIV and AIDS crisis, I worked in public health in the Global South. And I can still vividly recall those feelings of utter helplessness in the face of so much suffering and despair. We had little information and few tools with which to fight the disease, which had created such fear and stigma that there was little space left for public dialogue or shared learning.

Analysis of data about young military conscripts and pregnant women provided some of the first important clues about how the disease was being spread.

When that information was shared at multicountry conference hosted by the Benin government, a cabinet minister who was in attendance revealed publicly that he and his wife were raising their grandchildren due to the death of their own children from AIDS.

It was as if the floodgates had been opened.

Leaders and people at all levels of society were finally free to acknowledge their pain and loss. And that spurred others to begin working together to find solutions to the crisis that were based on evidence and data instead of rumor and superstition.

Many countries took action, but not all. Even in those pre-social media days, there were leaders who rejected the science, and many of their citizens tragically and unnecessarily lost their lives as a result.

Three decades later, our world continues to be driven by ever-more rapidly evolving technologies.

What will it mean, not just for governance, but for people’s lives, if our leaders don’t use solid evidence in their decision-making?

If data are ignored or misrepresented to support social or political agendas, how do we have any hope of tackling the challenges we face as a global community? Issues like climate change and climate justice. People fleeing war and crisis. The global pandemic and decline in vaccinations that is leading to more deaths from diseases like measles.

Scientists aren’t perfect and science has been rightly criticized for falling victim to the many of same biases we see in society. From census-taking to clinical trials, data collection has historically focused on people like me—white, male, educated, of a certain age, from a wealthy Western nation—excluding women and nonwhites.

If we are to benefit from the full power of data, we must take care to ensure there is equity and diversity in our collection and analysis of information.

Because without accurate information, we cannot hope to form a common basis of understanding. Without a shared set of facts and agreed upon standards for verification, rational decision-making becomes impossible.

This makes it even more critical that every person regardless of race, sex, age, orientation, economic status, or legal status, is counted, laying the groundwork for both voice and agency across all levels of society.

Call for Action

Rafael Salas had seen information manipulated by those in power to silence dissent and impose martial law in his native country.

But whether he was improving rice production in the Philippines or arguing that access to family planning is a human right at the 1968 International Conference on Human Rights, he never lost faith in the power of evidence to improve policies, programs and most importantly, countless lives.

Today, linkages between data and human rights and development are at the heart of the UN’s Sustainable Development Goals, as well as embodied in UN Secretary General Guterres’ Data Strategy and Dr. Natalia Kamen’s declarations at the 2019 Nairobi Summit on ICPD+25.

If we are to defeat the threats posed by demagoguery and disinformation, we must act quickly and decisively, because we have no time to waste.

The next two years mark a critical and potentially chaotic period for the world, as many of the largest democracies conduct censuses, and elections are held in countries like Brazil, India, Indonesia, Ukraine, as well as in the United States.

All nations and the international community must be on high alert. The world has a shared responsibility to put a stop to those seeking to interfere with democratic processes or create instability through the spread of disinformation.

What does that mean in practical terms?

We know data are critical to making smart decisions, yet demographic data are incomplete in parts of the world where some of the most dramatic changes are taking place. Countries must prioritize the collection of data and provide the necessary tools and resources to conduct accurate censuses and demographic and health surveys and strengthen civil registration and vital statistics.

Governments, aid agencies, and private philanthropy must continue to fund research and support scholarship on population dynamics. All actors must come to the table with solid evidence as the basis for finding solutions.

Public trust in science has been dropping in recent years, and those of us working in science-related fields like public health and demography must shoulder some of the blame. We believed that if we made the evidence available, people would make good decisions. Often, they do. But as the current pandemic has vividly demonstrated, simply presenting the facts, and hoping for the best isn’t enough.

All of us in civil society must raise our voices and take a more active role in advocating for good data and providing support for evidence-based solutions.

Institutions of knowledge have an obligation to be more thoughtful about how information is shared, using clear language to explain findings and providing context to enable a better understanding of scientific methods and conclusions. We must avoid providing fuel to those who seek to undermine truth by twisting and misinterpreting science.

Elected officials everywhere have a moral and ethical obligation to step up and speak the truth about fringe beliefs and conspiracy theories. And we must hold them accountable when they fail to do so.

The media have also contributed to the public’s confusion by creating false equivalence:  presenting results from opposing sides of a debate as if all views carry equal weight, even those that have been debunked or discounted by mainstream science. Dissenting voices should be heard, of course, but given their appropriate weight in the context of accepted principles of knowledge.

Last, but not least, we must call upon the public—ourselves included—to exercise common sense in our thinking about the world and her leaders.

As the 20th century American poet and playwright Archibald MacLeish once said, “It is not enough, in this war of hoaxes and delusions and perpetuated lies, to be merely honest. It is necessary also to be wise.” And I would add, “Be Bold.”

To all who care about humanity, are inspired by democracy, and share my optimism for a brighter future—this is the moment.

We cannot wait.

We must not fail.

Through our words and our actions, we must demonstrate unyielding support for truth, for facts, and for wisdom, wherever they may be found.

Thank you.

new_1020f-digital-health-compendium

Digital Health

Explore PRB and PACE’s work at the intersection of digital health technologies and family planning programming.

Digital health is an umbrella term that encompasses an array of information and communications technologies used in health care, including mobile health (mHealth), telehealth/telemedicine, eHealth, health information technology (IT), health management information systems, use of blockchain technology, and artificial intelligence. These digital health technologies can support individuals, health providers, and health systems managers to make informed decisions and engage individuals to improve demand, access, coverage, quality, and affordability of health care for everyone.

As low- and middle-income countries transition from paper to digital systems, family planning programs can benefit from unprecedented opportunities to improve services. Investments in digital health tools have expanded exponentially, but information on what works—and what does not— remains limited and scattered. As investments have increased, digital applications and data fragmentation have proliferated, but stakeholders are moving toward more coordinated efforts to scale digital health solutions, support countries’ digital health infrastructure, and share evidence-based learnings.

Digital Health Compendium

The interactive Digital Health Compendium, launched by PACE in 2020, features case studies across a range of digital health technologies used to enhance the impact and efficiency of family planning programs. In 2021, PACE transitioned leadership of the Compendium to The Medical Concierge Group (TMCG), a digital health and telemedicine company based in Uganda.

This Digital Health Compendium enables users to explore case studies across a range of digital health technologies used to enhance family planning programs mainly in sub-Saharan Africa, but also in other regions of the world. Digital health applications in family planning programs can be broadly classified as those affecting demand generation, service delivery, supply chain management, and the policy and enabling environment. In many low- and middle-income countries, digital health innovations were adopted earlier in other health sectors, including HIV/AIDS, maternal and child health, and noncommunicable disease prevention and response. As a result, much of the impact evidence is restricted to those sectors. To advance greater adoption of digital technology in family planning programs, more data and information on the challenges, opportunities, scalability, and results are needed. This compendium aims to consolidate emerging information and data on applications of digital technology in family planning programs to inform adoption and scale-up of successful approaches.

Webinar: Designing or Implementing a Family Planning Program? How To Introduce Digital Solutions Sustainably and at Scale

PRB alongside The Medical Concierge Group, Knowledge Success, and Maternal & Infant Health Consulting hosted a webinar during Transform Digital Health Week 2021 titled “Designing or Implementing a Family Planning Program? How To Introduce Digital Solutions Sustainably and at Scale.” Four projects featured in the Digital Health Compendium highlighted trusted and innovative lessons on scaling and sustaining family planning and reproductive health initiatives through leveraging digital health solutions. The panel of national and international experts discussed broader implementation topics including involvement of government counterparts, partnerships, and revenue models. Technology-specific lessons included adaptability, integration, flexibility, and uptake. Recordings available below.
 
 

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In English

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En français

I already have a strong bond with my growing baby

Black Women Over Three Times More Likely to Die in Pregnancy, Postpartum Than White Women, New Research Finds

Stark racial disparities in U.S. maternal deaths underscore the need to address equity.

In the United States, Black-white disparities in maternal mortality—deaths related to pregnancy or childbirth—may be larger than previously reported, new research shows. Closing the gap involves addressing structural racism—that is, those aspects of social, political, economic, and health care systems that reinforce inequity, researchers say.

Because pregnancy is riskier to women’s health than abortion, state initiatives to restrict abortion could lead to more deaths, particularly among Black women, new estimates suggest.

Black Women Five Times More Likely to Die from Pregnancy-Related Cardiomyopathy, Blood Pressure Disorders Than White Women

By thoroughly reexamining death certificates from 2016 and 2017, researchers found that the maternal mortality rate among non-Hispanic Black women was 3.5 times that of non-Hispanic white women.1 This is a dramatic increase from previous analyses, based on standard medical codes, that found that Black women faced a maternal death rate 2.5 times that of white women, according to Marian MacDorman of the Maryland Population Research Center (MPRC) at the University of Maryland, who led the study.

The new analysis also revealed that these disparities were concentrated among a few causes of death. Postpartum cardiomyopathy (a form of heart failure) and the blood pressure disorders preeclampsia and eclampsia were leading causes of maternal death for Black women, with mortality rates five times those of white women. Pregnant and postpartum Black women were also more than two times more likely than white women to die of hemorrhage (severe bleeding) or embolism (blood vessel blockage).

In the researchers’ analysis, embolism and preeclampsia/eclampsia tied for the leading cause of maternal death across all racial and ethnic groups during pregnancy or within six weeks after pregnancy (see figure). These were followed by postpartum cardiomyopathy, hemorrhage, and complications from obstetric surgeries such as cesarean sections.

Among White and Hispanic women, causes of maternal death ranked somewhat similarly. However, for Black women, preeclampsia/eclampsia was the leading cause of maternal death, followed by postpartum cardiomyopathy, embolism, and hemorrhage. Ectopic pregnancy, the fifth leading cause of maternal death for Black women, was not a leading cause for white or Hispanic women.

Preeclampsia/Eclampsia Is the Leading Cause of Maternal Death Among Black Women

U.S. maternal deaths per 100,000 live births for five leading causes of maternal death by race/ethnicity, 2016-2017


Notes: Maternal deaths include those during pregnancy and up to 42 days postpartum. For Hispanic women, the values for preeclampsia/eclampsia, obstetric hemorrhage, postpartum cardiomyopathy, and other complications of surgery and procedures are not statistically reliable, based on 10-19 deaths in the numerator. 
Source: Table 2, Marian F. MacDorman et al., “Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017,” American Journal of Public Health 111, no. 9 (2021): 1673-81.

The study also found that late maternal deaths—those occurring between six weeks and one year postpartum—were 3.5 times more likely among Black women than white women. Postpartum cardiomyopathy was the leading cause of late maternal death among all races, with Black women having a six-times-higher risk than white women.

The prominence of cardiovascular conditions—eclampsia, preeclampsia, embolism, and cardiomyopathy—among the leading causes of maternal death, particularly for Black women, “highlights the importance of increased vigilance to improve early diagnosis and treatment of these complications,” MacDorman says.

The elevated risk of maternal mortality for Black women, from multiple causes, reflects the impact of structural racism on health and health care in the United States, argues study coauthor Marie Thoma of the University of Maryland School of Public Health and the MPRC.

“Further research into the experiences of people of color can inform efforts to improve health care systems and, thus, improve the birthing experience for all,” Thoma says. “We need new models of care before, during, and after birth to address these inequities.”

Promoting Equity in Women’s Health Requires Fundamental Changes in Approach

Addressing the stark racial disparities that MacDorman’s team highlighted requires fundamentally reorienting the current approach to health care, argues Rachel Hardeman of the Minnesota Population Center at the University of Minnesota. Research and action must be grounded in the understanding that racism is at the root of health inequities, she says.

“We must first ask, ‘How do systems, policies, and social structures combine to create the conditions for poor health?’ rather than asking, “’What’s wrong with people of color that makes them die younger and at higher rates and suffer more illnesses?’’” says Hardeman, who is also director of the new Center for Antiracism Research for Health Equity at the University of Minnesota.

As part of a four-person team, Hardeman documented that Black newborns’ in-hospital death rate was one-third lower when Black newborns were cared for by Black physicians rather than white physicians.2

Hardeman is now studying a model prenatal care program designed to reduce birth complications and maternal death that “treats a mother’s culture, racial identity, and background as assets during pregnancy, rather than pathology or a problem.”3 The Roots Community Birth Center is an African American-owned, midwife-led, freestanding birth center located in a Minneapolis neighborhood with one of the highest infant mortality rates in the city. The care plan includes regular prenatal classes on gestational diabetes, nutrition, and other topics, and longer and more frequent-than-typical prenatal and postnatal visits, including three home visits in the first week after birth.

Since opening in 2015, the birth center has cared for 284 families with no premature or low-birthweight babies and a high proportion of mothers successfully breastfeeding. Preliminary findings suggest this model shows promise for providing midwifery care in a culturally centered environment, according to Hardeman.

However, the birth center faces financial challenges due to current maternity care payment models and inadequate Medicaid reimbursement, Hardeman says. To support innovative centers such as Roots, Hardeman suggests policymakers increase Medicaid reimbursement rates. In the long run, the added expense will lead to increasing numbers of healthy babies and mothers who avoid expensive and dangerous complications, and—ultimately—reduce racial disparities, she says.

Banning Abortion Could Raise Pregnancy-Related Death Rates

Legislation designed to limit abortion could exacerbate racial disparities in women’s health and survival. New research by Amanda Stevenson of the CU Population Center at the University of Colorado Boulder shows that banning abortion nationwide would lead to a 21% increase in the number of pregnancy-related deaths for all women and a 33% increase among Black women, compared with rates for 2017.4

Published in the journal Demography, the study estimates only the portion of increased deaths from such a ban due to complications of being pregnant and delivering a baby. Any increases due to unsafe abortions or attempted abortions would be in addition to these estimates.

“The takeaway here is that if you deny people abortion, pregnancy-related deaths will increase because staying pregnant is more dangerous than having a safe, legal abortion,” Stevenson says.

Stevenson points out that media outlets and some supporters of abortion rights often raise the specter of dangerous “back alley” or self-induced abortions. But deaths from such incidents, which numbered in the hundreds annually prior to the 1973 Roe v. Wade decision, would be far less common today due to the advent of safe, self-managed abortions using medications, including misoprostol, available via prescription or online, Stevenson reports.

“We expect a lot of people will turn to these safer forms of self-managed abortions, but a lot of people will also just stay pregnant,” Stevenson says. “What happens then?”

Carrying a pregnancy to term is many times riskier than having an abortion—14 times riskier, according to one estimate.5

To predict the maternal mortality consequences of stricter abortion laws, Stevenson used published statistics on the number of abortions and births that occurred annually in recent years, calculated how many more pregnancies would be continued in the absence of legal abortion, then applied pregnancy-related mortality statistics to that number.

The study estimated that in the years following a national abortion ban, an additional 140 women would die annually from pregnancy-related causes, representing a 21% increase from 2017. Among non-Hispanic Black women, pregnancy-related deaths would increase by one-third.

Among white women, the lifetime risk of pregnancy-related death following a national ban would increase from 1 in 4,500 to 1 in 3,900, Stevenson found. By contrast, among Black women the lifetime risk of pregnancy-related death would increase from 1 in 1,300 to 1 in 1,000.

Research also shows that those most likely to seek abortion care, including Black and Hispanic women, women with lower income, and those with chronic or acute health conditions, are also more likely to encounter serious complications during pregnancy, Stevenson explains.

Black women are more likely to seek an abortion for a variety of reasons, including unequal access to housing, education, jobs, and health care, Stevenson says. Meanwhile, the mortality risk of carrying a pregnancy to term is more than three times higher for non-Hispanic Black women compared with non-Hispanic white women.6

“Increasing Black women’s exposure to the risk of pregnancy-related mortality by denying them access to abortion would exacerbate an existing public health crisis,” Stevenson says.

_____________________________________________________

This article was produced under a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The work of researchers from the following NICHD-funded Population Dynamics Research Centers was highlighted: University of Maryland (5P2CHD041041-18), University of Minnesota (5P2CHD041023-19), and University of Colorado Boulder (5P2CHD066613-10). Lisa Marshall of the University of Colorado Boulder and Charlie Plain of the University of Minnesota contributed to this report.

References

1 Marian F. MacDorman et al., “Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016-17,” American Journal of Public Health 111, no. 9 (2021): 1673-81.

2 Brad N. Greenwood et al., “Physician–Patient Racial Concordance and Disparities in Birthing Mortality for Newborns,” Proceedings of the National Academy of Sciences 117, no. 35 (2020): 21194-200.

3 Rachel Hardeman et al., “Roots Community Birth Center: A Culturally-Centered Care Model for Improving Value and Equity in Childbirth,” Healthcare 8, no. 1 (2020).

4 Amanda Jean Stevenson, “The Pregnancy-Related Mortality Impact of a Total Abortion Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant,” Demography (2021).

5 Elizabeth G. Raymond and David A. Grimes, “The Comparative Safety of Legal Induced Abortion and Childbirth in the United States,  Obstetrics and Gynecology 119, no. 2 Pt 1 (2012): 215-9.

6 U.S. Centers for Disease Control and Prevention, Pregnancy Mortality Surveillance System, accessed on Nov. 30, 2021.

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Guide de référence : l’interruption sécurisée de grossesse selon la loi au Burkina Faso

Le PRB et l’Association Burkinabè pour le Bien Être Familial ont créé un guide de référence visant à permettre aux principales parties prenantes (prestataires de santé, agents de l’action sociale, magistrats, patientes) de connaître le processus pour l’accès à l’interruption sécurisée de grossesse dans le cadre de la loi au Burkina Faso.

En 2020, le PRB et l’Association Burkinabè pour le Bien Être Familial (ABBEF) ont créé, avec le soutien du groupe de travail du projet SAFE ENGAGE Burkina Faso, un outil de plaidoyer multimédia appelé « Préserver la santé et bâtir l’avenir du Burkina Faso : rendre accessible l’avortement sécurisé. » À la suite de l’élaboration de cet outil de plaidoyer important, l’ABBEF a jugé nécessaire de concevoir et de diffuser un manuel de référence destiné aux praticiens (magistrats, forces de l’ordre, agents de santé et de l’action sociale) et aux bénéficiaires qui énumère clairement les étapes à suivre afin d’obtenir une interruption sécurisée de grossesse (ISG) pour les cas particuliers autorisés par la loi. De plus, ce manuel souligne les conséquences de l’inaction concernant l’enjeu de l’avortement non sécurisé au Burkina Faso. Le guide de référence s’inscrit dans le cadre des efforts de plaidoyer pour améliorer l’environnement juridique et social en faveur de l’accès à l’ISG afin de lutter contre la mortalité et la morbidité liées à l’avortement non sécurisé.

Au Burkina Faso, le Code pénal et la loi portant sur la Santé de la Reproduction de 2005 constituent les deux principales sources de loi en matière d’accès aux services d’ISG. Mais en dépit de ces textes, de nombreuses filles et femmes éprouvent des difficultés à accéder aux services d’ISG même lorsqu’elles sont éligibles au regard de la loi. Cette situation s’explique entre autres par :

  • La méconnaissance de la loi et des politiques, normes et protocoles par les prestataires de santé et autres parties prenantes (agents de l’action sociale, magistrats, etc.) ;
  • Les réticences de certains prestataires à offrir les services ;
  • La méconnaissance des dispositions et des procédures par les victimes.

En vue de permettre aux principales parties prenantes de maitriser le processus pour l’accès à l’ISG dans le cadre de la loi, le PRB et l’ABBEF ont élaboré un guide décrivant la procédure pour avoir accès aux services d’ISG au profit des praticiens (magistrats, forces de sécurité, agents de santé, agents de l’action sociale) et des patientes. Ce guide permettra à ces personnes de connaitre le processus, les étapes, les actes administratifs à établir et les délais requis pour l’accès à l’ISG dans le cadre de la loi. Et d’autre part, cet outil servira de guide pour les prestataires de santé en énumérant les étapes et les protocoles à suivre concernant l’offre de services d’ISG décrits dans les politiques, normes et protocoles du ministère de la Santé, que l’intervention soit médicamenteuse et/ou chirurgicale.

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The Democratic Republic of the Congo Leads the Way on Abortion Access: A Pathway for Reproductive Rights Advocates in Francophone Africa

Policy Change for Safe Abortion in Sub-Saharan Africa

Women in sub-Saharan Africa face the greatest risk globally for an unintended pregnancy to result in an unsafe abortion. In 2019, 92% of women of reproductive age in Africa lived in one of 43 countries where access to abortion was restricted or penalized.1 The legal status of abortion in a country is directly connected to its maternal mortality and morbidity rates.2 Evidence has shown that restricting access to abortion does not reduce the number of abortions; it only makes abortion less safe and more likely to lead to preventable complications, including maternal death.3 Conversely, expanding access to safe, legal abortion—a common medical procedure that carries very little risk when performed by a trained provider in an appropriate environment—is associated with improved maternal health outcomes.4 For example, soon after Chad, Ethiopia, and Nigeria amended their abortion laws to permit safe abortion under more circumstances, they experienced notable declines in their maternal mortality rates.5

Policy change to expand access to legal abortion in sub-Saharan Africa is possible through various avenues. Some countries have modified existing national laws or passed new laws to introduce access to safe abortion, including reforming colonial-era penal codes. As of October 2021, ten sub-Saharan African countries had passed reproductive health laws specifying grounds for abortion care, including expansions to abortion rights in the Gambia passed in 2010 under the Women’s Act.6 Other countries, such as Kenya and Somalia, have chosen to institute constitutional reform. Yet other countries, such as Ghana, have widened guidance for interpretation of existing laws.7 However, one of the most important and powerful avenues to expanding legal access to abortion in Africa has been through adherence to the 2003 African Union treaty, the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, known as the Maputo Protocol.8 Legal change through the Maputo Protocol not only enshrines the international treaty within a country’s constitution but also introduces an extensive array of legal changes aimed at empowering women.

The Maputo Protocol, through its Article 14, is the sole judicial instrument regarding the right of women and girls in Africa to access safe abortion. Article 14 guarantees “the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus.”9 While most sub-Saharan African countries have ratified the Maputo Protocol, only seven countries* have pursued legal reform to harmonize their laws to incorporate the Protocol’s criteria for access to safe abortion.10

The Democratic Republic of the Congo’s Landmark Policy Change

In 2018, the Democratic Republic of the Congo (DRC) published the Maputo Protocol in its official gazette, rendering the text superior to national laws.11 This action, alongside other steps such as publishing a circular guaranteeing access to abortion care under the Protocol’s indications and the Ministry of Public Health’s 2020 endorsement of standards and guidelines for implementing the Protocol’s directives, marks the DRC as the first country in Francophone Africa to have implemented sweeping changes to broaden access to abortion care. Given that the DRC’s population is the largest in central Africa at 92.5 million people and the third-largest in sub-Saharan Africa, these legal changes have important implications for a large percentage of the subregion.12

Under the SAFE ENGAGE project—a four-year initiative supporting safe abortion access in Africa by providing decisionmakers with the latest data on abortion, strengthening capacity of civil society advocates, and improving evidence-based media reporting on abortion-related topics— PRB and the African Population and Health Research Center (APHRC) have jointly developed a suite of resources to document the DRC’s process of domesticating the Maputo Protocol. These resources include a case study, completed worksheets for advocates and researchers from the SAFE ENGAGE Policy Communication Guide, and this commentary. Together, these resources document the DRC’s policy change process to identify the key elements contributing to this success, and analyze the lessons learned and applicable best practices for other contexts across the African continent.

With policy advocacy efforts expended over more than 10 years, and in the face of considerable challenges and opposition from religious leaders and other cultural gatekeepers, local actors in the DRC succeeded in advancing a significant policy change to improve women’s and girls’ rights and access to health care. The course of this policy advocacy can serve as an example for other actors across the region facing similar challenges and wishing to achieve the same goal. In addition, the DRC’s policy process is a recent case—not yet documented in detail—for use in learning around policy change. It is a valuable example given the scarcity of documented case studies of policy change processes from Central Africa or Francophone Africa on sexual and reproductive health and rights.

Francophone Africa: Challenges and Opportunities for Abortion Access

Countries in Francophone West and Central Africa generally have more restrictive abortion laws than other countries on the continent.13 In Francophone Africa, most countries have highly restrictive or moderately restrictive laws. The DRC and Chad allow abortion in the case of rape, incest, fetal malformation, and to save a woman’s life and preserve her health, with explicit mention of mental health.14 In October 2021, Benin became the most recent country in Francophone Africa to expand access to abortion care, amending its 2003 reproductive health law to authorize abortion in cases when the continuation of the pregnancy would cause material, educational, professional, or moral distress to the woman, adding to existing authorizations for rape, incest, and preserving the health of the woman or fetus.15 To date, no Francophone African countries allow abortion without restriction. However, all countries of the region, excepting Niger, Chad, and the Central African Republic, have ratified the Maputo Protocol.16 In this context, the DRC’s steps to integrate the Maputo Protocol into their legal framework, and the expansive interpretation of the law outlined in the 2020 Standards and Guidelines for Women-Centered Abortion Care in the DRC, represent a powerful example for Francophone Africa in utilizing policy change for women’s health and well-being.17

Advocates pushing for legal access to abortion in Francophone West and Central Africa face additional hurdles to those faced by other countries on the continent. There is a greater lack of data on the incidence of abortion and its consequences across the Francophone region, which contributes to a general lack of evidence use in policymaking. The region has received less foreign donor investment than other regions to support civil society, promote evidence-based policy, and advance international norms on gender equity, reproductive health, and human rights.18 Partially due to these factors, Francophone West and Central Africa has some of the world’s highest maternal mortality rates and lowest contraceptive prevalence rates, in addition to the world’s highest fertility rates.19

However, there are early, positive signs of growing mobilization and investment to advance access to women’s sexual and reproductive health and rights in Francophone Africa, both at the regional and national levels. At the regional level, key actors are working to strengthen networks and put in place a robust and sustainable framework to advance an enabling environment for safe abortion care, inspired by the successes of the Ouagadougou Partnership model for family planning. Major international partners have been increasingly active for the last five years following a strategic analysis of safe abortion in Francophone West Africa.20 In December 2019, a regional Safe Abortion Dialogue was held in Cotonou, Benin, bringing together major donors, international organizations, and regional and national networks to set a regional agenda for expanding abortion care in Francophone Africa. In 2021, the momentum generated from the Safe Abortion Dialogue and the work of involved partners led to the launch of the Centre ODAS (Organisation pour le Dialogue pour l’Avortement Sécurisé), based out of Ipas’s regional Francophone Africa headquarters in Abidjan, Côte d’Ivoire, to catalyze a growing movement across Francophone Africa, expanding the West African countries of the Ouagadougou Partnership to include the DRC, Cameroon, and Madagascar.21 Major funders, both governmental and philanthropic, are making larger commitments to support sexual and reproductive health and recognize the unique needs of the Francophone Africa region.

At the national level, several countries are undertaking reviews of their legal frameworks and guidance around abortion care. Some countries with some restricted access to safe abortion, such as Côte d’Ivoire and Burkina Faso, have active civil society coalitions working to expand awareness and implementation of the Maputo Protocol provisions. As cited above, Benin’s Parliament voted in favor of a new law with expansive provisions for legal abortion in October 2021.22 This new law is a promising precedent that exceeds even the indications of the Maputo Protocol for expanding access to women’s sexual and reproductive health and rights on the continent.

The DRC’s Policy Change Process: Lessons Learned

Policy change for access to safe abortion in the DRC did not happen overnight. Policy actors faced setbacks over more than 10 years of advocacy to legalize access to abortion and set in place guidance to ensure women can safely access services. Emerging from decades of conflict and desirous of re-engaging with the international community, the DRC has been making commitments to indicate its embrace of international norms and meet its development goals. Many of the challenges faced in the DRC may be common across other contexts in the region, and there are key lessons that can be drawn from the way they were addressed in the DRC.

1. Stronger Together: Cohesion of the Policy Community

A major element of success for the DRC’s policy change process came in the consolidation of the policy community under several prominent national and regional coalitions, especially the Kinshasa-based Coalition de lutte contre les grossesses non désirées (CGND) and Coalition Article 14 in Eastern DRC. Founded in 2016 with the support of an array of international organizations, the CGND brought together the major civil society actors who had been working separately using different approaches to advance access to safe abortion or address related topics in sexual and reproductive health and rights. In organizing the civil society movement and strengthening their shared agenda, along with the investment of financial and technical support from organizations working regionally or internationally, the creation of the CGND and Coalition Article 14 was a major milestone for policy change in the DRC. These coalitions worked to identify a cohesive policy objective, and then develop a workplan and targeted messaging to respond to opposition and to reach targeted policy audiences.

2. Clarifying the Issue: Credible Indicators and Legal Analyses

The CGND and their international partners enhanced and strengthened their messaging to policy decisionmakers as studies and analyses, concerning both the context of abortion care and the legal landscape in the DRC, brought to light the issue of safe abortion care. While the DRC’s elevated maternal mortality rate was underlined in the 2009 and 2014 Demographic and Health Surveys, the contribution of unsafe abortion to maternal mortality and its prevalence in the DRC were less clear. Thanks to a number of studies, including 2017 studies by the Guttmacher Institute and the University of Kinshasa and by the Ministry of Public Health supported by Ipas, advocates and government stakeholders not only gained a picture of the extent of abortion in the DRC (including within the public health system itself, where it was shown to be practiced in nearly a quarter of health facilities) but also of the contribution of unsafe, unregulated abortion care to maternal deaths.23

In addition to academic studies, legal analyses commissioned by Pathfinder International and Ipas helped abortion advocates to understand the mechanisms available to advance legal change for safe abortion in the DRC. Several analyses by legal scholars identified publication of the Maputo Protocol in the official gazette as the surest means of bringing the Maputo Protocol into force of law, necessitating only the support of the handful of officials associated with publishing in the official gazette, instead of the 251 parliamentarians required for national legal change. This shift in strategy away from harmonization of national laws (including the penal code, the reproductive health law, and the code of medical ethics) was a turning point in the DRC’s policy change process. Other countries with monist constitutions, in which international treaties take precedence over national law, may consider following this route instead of the often more onerous path of individually reforming each existing law.

3. Ensuring Sustainability: Government Ownership and Visibility

In the DRC, the CGND, Coalition Article 14, and international partners were intentional in identifying and building champions among the very decisionmakers whose support was needed to realize access to safe abortion in the DRC, specifically, within the Constitutional Court, the Ministry of Public Health, and the Ministry of Gender, the Family, and Children. Using the values clarification and attitude transformation (VCAT) methodology for exploring attitudes around abortion, coalition members cultivated strong support from key stakeholders who were able to ensure momentum to advance the Maputo Protocol’s publication in the official gazette, and sustain this momentum through the publication of the standards and guidelines for safe abortion care. This engagement built a multisectoral coalition in government and sustained political will, invigorated through high-level focusing events such as annual celebrations of International Safe Abortion Day on September 28. By building champions across several arms of government, safe abortion advocates also ensured that the movement for safe abortion access would be self-sustaining and self-policing, with the Constitutional Court issuing guidance to the Ministry of Public Health to fulfill its constitutional duties in developing standards and guidelines for safe abortion care.

4. Legal Change Is Not the End: Making Abortion Access a Reality

One of the most important lessons in the DRC example is that legal change, in and of itself, does not improve access to abortion for women and girls. Many other barriers must be eliminated through women-centered approaches across the health care system, legal system, and within communities to ensure quality, acceptable, equitable care. Capitalizing on the momentum and political will generated by the policy change process is key to establishing the necessary guidance and frameworks for ensuring sustainable abortion care and integrating it into the existing health infrastructure. In the DRC, advocates labored for 10 years after ratification of the Maputo Protocol, but were able to capitalize on the heightened visibility of the topic to publish standards and guidelines to comprehensive abortion care within two years of the Protocol’s publication in the official gazette.

The Standards and Guidelines for Women-Centered Comprehensive Abortion Care in the DRC, validated by the Ministry of Public Health’s ethics committee in December 2020, represent a milestone in expanding access to care among countries in Africa with legal access to abortion. The DRC’s standards and guidelines codify a progressive and expansive interpretation of the Maputo Protocol, circumventing many of the procedural barriers to care that exist in other countries’ guidelines, even in places where abortion is widely legal, such as Zambia. Women seeking abortion care in the DRC do not need to provide proof of rape or incest, nor do they need to provide marital consent. Minors seeking abortion care are automatically eligible to receive care under the legal age of consent, and, while they must be accompanied by an adult, this can be any trusted adult of their choosing. The guidelines for women seeking abortion care under health grounds, including mental health, follow the World Health Organization’s definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” and determinations are based on the abortion care provider’s determination of the potential negative effects of the unintended pregnancy on the woman’s current or future well-being.24 The standards and guidelines adopted in the DRC provide an important template for other countries in Francophone West and Central Africa in interpreting the Maputo Protocol in its widest sense and establishing clear norms for the practice of abortion care.

Conclusion

Advocates and researchers across Francophone West and Central Africa can benefit from the precedent set by the DRC in widely expanding access to abortion care for its population. Documentation and analysis of this process allow us to examine the elements that created a window of opportunity for political momentum around abortion access in DRC. The case study, worksheets, and commentary, in addition to the various policy communication and evidence translation tools developed under the SAFE ENGAGE project, can serve as resources for policy advocates in Francophone Africa and beyond who wish to achieve similar advances in their legal framework. Importantly, the DRC case elucidates how a motivated, coordinated, and informed coalition of local actors was able to effect sweeping policy change in one of the continent’s largest countries, opening the door for similar advances across the Francophone region and the African continent.

*Chad, the Democratic Republic of the Congo, Eswatini, Eritrea, Mauritius, Mozambique, and Rwanda. Two countries, São Tome and Principe and Benin (as of October 2021), have gone beyond the Maputo Protocol’s indications.

Photo: lpas DRC

 

En Français
 
 

References

1 Akinrinola Bankole et al., From Unsafe to Safe Abortion in Sub-Saharan Africa: Slow But Steady Progress, Guttmacher Institute (2020), https://www.guttmacher.org/report/from-unsafe-to-safe-abortion-in-subsaharan-africa.

2 Population Reference Bureau (PRB), Laws Change Lives, 2021, https://www.prb.org/resources/laws-change-lives-what-is-the-connection-between-abortion-laws-and-maternal-health/.

3 PRB, Abortion Facts and Figures, 2021, https://www.prb.org/wp-content/uploads/2021/03/2021-safe-engage-abortion-facts-and-figures-media-guide.pdf.

4 World Health Organization (WHO), Medical Management of Abortion, 2018, https://www.who.int/reproductivehealth/publications/medical-management-abortion/en.

5 PRB, Laws Change Lives.

6 Bankole et al., From Unsafe to Safe Abortion in Sub-Saharan Africa; République du Bénin, Loi no. 2021 (2021).

7 Bankole et al., From Unsafe to Safe Abortion in Sub-Saharan Africa.

8 African Commission on Human and People’s Rights (ACHPR), Protocol to the African Charter for Human and People’s Rights on the Rights of Women in Africa, Maputo, Mozambique, 2003, https://au.int/en/treaties/protocol-african-charter-human-and-peoples-rights-rights-women-africa.

9 ACHPR, Protocol to the African Charter for Human and People’s Rights on the Rights of Women in Africa.

10 Bankole et al., From Unsafe to Safe Abortion in Sub-Saharan Africa.

11 Official Gazette of the DRC, Cabinet of the President of the Republic, Special Issue, March 14, 2018, https://www.ilo.org/dyn/natlex/docs/SERIAL/84846/94671/F861828376/ratification%20protocole%20droits%20de%20la%20femme.pdf.

12 PRB, “2021 World Population Data Sheet: Middle Africa,” 2021, https://interactives.prb.org/2021-wpds/africa/#middle-africa.

13 Bankole et al., 2020; Center for Reproductive Rights, The World’s Abortion Laws, accessed October 18, 2021, at https://maps.reproductiverights.org/worldabortionlaws.

14 Bankole et al., From Unsafe to Safe Abortion in Sub-Saharan Africa.

15 République du Bénin, Assemblée Nationale, Loi no. 2021 modifiant et complétant la loi no. 2003-04 du 03 mars 2003 relative à la santé sexuelle et à la reproduction (2021).

16 African Union, High Level Consultation on the Ratification of the Maputo Protocol, January 29, 2018,  https://au.int/en/newsevents/20180129/high-level-consultation-ratification-maputo-protocol.

17 Democratic Republic of the Congo, Ministry of Public Health, Secretary General, Normes et Directives des Soins Complets d’Avortement Centrés sur la Femme en RDC (2020).

18 Ipas, Conclusions de l’analyse situationnelle : Besoins et opportunités pour une prise en charge des soins complets d’avortement en Afrique de l’Ouest francophone, 2016, https://www.ipas.org/resource/conclusions-de-lanalyse-situationnelle-besoins-et-opportunites-pour-une-prise-en-charge-des-soins-complets-davortement-en-afrique-de-louest-francophone/.

19 PRB, “2021 World Population Data Sheet.”

20 Ipas, Conclusions de l’analyse situationnelle.

21 Ipas, “New Regional Network Launches for Safe Abortion in Francophone Africa,” Sept. 22, 2021, https://www.ipas.org/news/new-regional-network-launches-for-safe-abortion-in-francophone-africa/

22 République du Bénin, Loi no. 2021.

23 Sophia Chae et al., “The Incidence of Induced Abortion in Kinshasa, Democratic Republic of Congo, 2016,” PloS ONE 12, no. 12 (2017) https://www.guttmacher.org/article/2017/10/incidence-induced-abortion-kinshasa-democratic-republic-congo-2016; Timothée Lunganga et al. « État des lieux de la contraception et de l’avortement en République Démocratique du Congo », Ministry of Public Health, 2017, unpublished.

24 WHO, Constitution of the World Health Organization (1946), https://www.who.int/about/governance/constitution; Democratic Republic of the Congo, Ministry of Public Health, Secretary General, Normes et Directives des Soins Complets d’Avortement Centrés sur la Femme en RDC.

 

 

 

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Leçons apprises des mesures prises en Côte d’Ivoire pour améliorer l’accès à l’avortement

Les défenseurs maîtrisent parfaitement l’adage selon lequel « le plus important est de choisir le bon moment ». Souvent, ils cherchent la fenêtre d’opportunité idéale, c’est-à-dire le moment où plusieurs facteurs politiques et sociaux convergent et permettent de réaliser des avancées en vue d’atteindre un objectif spécifique en matière de politique.

Au cours des trois dernières années en Côte d’Ivoire, le projet SAFE ENGAGE de PRB a espéré que la convergence d’une nouvelle constitution ivoirienne et des progrès réalisés dans le cadre d’un projet de loi sur la santé reproductive constituerait l’occasion idéale de collaborer avec des partenaires de la société civile et du gouvernement pour renforcer l’accès à l’avortement sécurisé. Même s’il n’est pas possible de démontrer concrètement le lien entre les activités du projet et le changement politique, ce projet a favorisé un dialogue important susceptible d’initier un changement à l’avenir.

Mesures de plaidoyer concentrées sur la fenêtre d’opportunité législative

Dans le cadre du projet SAFE ENGAGE, les premières mesures de plaidoyer s’efforçaient de faire voter un projet de loi relatif à la santé reproductive. C’était l’occasion idéale de rassembler les défenseurs locaux afin d’étudier les données disponibles sur le rôle de la contraception, l’avortement sécurisé et les soins après avortement dans la prévention des décès maternels. L’adoption d’une telle loi permettrait d’inscrire les questions de santé reproductive au programme politique national.

La plupart des femmes ivoiriennes n’ont pas accès à des soins d’avortement légaux et sécurisés : plus de six avortements sur dix pratiqués en Côte d’Ivoire en 2018 n’étaient pas sécurisés. L’avortement non sécurisé est l’un des principaux facteurs de décès et d’incapacité maternels dans le monde. Selon les estimations, il est la cause de plus d’un décès lié à la grossesse sur six en Afrique de l’Ouest. En élargissant l’accès à l’avortement sécurisé, la Côte d’Ivoire serait en mesure de réduire le nombre de décès et des incapacités maternels, mais aussi d’investir de manière plus importante dans l’avenir des femmes et des jeunes filles.

En collaborant avec des partenaires locaux, le projet SAFE ENGAGE a codéveloppé et diffusé un ensemble de vidéos dans le but de sensibiliser le grand public aux causes et aux conséquences des avortements non sécurisés en Côte d’Ivoire,  et renforcer le soutien en faveur d’un meilleur accès à des services complets de santé reproductive, comprenant l’avortement sécurisé. Le projet a créé un groupe de travail mené par un partenaire local appelé l’Association Ivoirienne pour le Bien-Être Familial (AIBEF), qui regroupe plus de vingt organisations et représentants du ministère de la Santé et de l’Hygiène publique, dont le Programme National de la Santé de la Mère et de l’Enfant (PNSME). Tout au long du processus de co-création du projet SAFE ENGAGE, des experts ont partagé des informations sur les cadres juridiques et la pertinence du Protocole de Maputo dans ce contexte. En outre, les défenseurs ont développé leur capacité à utiliser les données relatives à l’avortement, et des communications ont été diffusées à l’échelle nationale et locale.

En parallèle, le projet SAFE ENGAGE a organisé une formation destinée aux médias indépendants en Côte d’Ivoire afin de conférer aux journalistes les connaissances nécessaires et de leur donner accès au réseau adéquat pour produire des témoignages éclairés sur l’avortement sous une forme adaptée à leurs moyens d’expression et à leurs communautés. Les activités médiatiques ont été menées simultanément de manière intentionnelle au lieu d’être intégrées à la mission du groupe de travail, car elles n’étaient pas destinées à promouvoir cette dernière ni à mettre en avant la vidéo du projet SAFE ENGAGE.

Par ailleurs, la Côte d’Ivoire a adopté une loi importante, la loi no 2019-574 portant sur le Code pénal, en vertu de laquelle l’avortement en cas de viol n’est plus pénalisé si certains critères sont remplis. Conformément à l’ancienne loi, l’avortement était légal uniquement pour sauver la vie de la mère. Cette réforme du Code pénal a permis d’élargir l’accès à l’avortement et d’inscrire davantage le pays dans la lignée du Protocole de Maputo.

Changement juridique impulsé par plusieurs facteurs d’influence

La co-création et la diffusion d’une vidéo dans le cadre du projet SAFE ENGAGE ont-elles contribué à la révision du Code pénal concernant l’avortement ? Pour répondre à cette question, le projet a mené une analyse de traçage des contributions afin de déterminer si une chaîne d’événements pouvait avoir un lien de cause à effet en partant des éléments de l’intervention pour arriver à la modification du Code pénal en 2019.

Face aux réactions provoquées par la vidéo, l’équipe en charge du projet a estimé que l’intervention pouvait avoir joué un rôle dans l’adoption de la nouvelle loi. Néanmoins, l’analyse de traçage des contributions n’a pas pu confirmer avec certitude que l’intervention du projet SAFE ENGAGE en Côte d’Ivoire était à la source de ce changement politique. De fait, les évaluateurs ont défini que, pour pouvoir exercer une quelconque influence sur la loi, l’intervention aurait dû être lancée plusieurs mois avant la réforme du Code pénal ou aurait dû cibler des personnes spécifiques au sein du ministère de la Justice.

Les évaluateurs ont donc établi que l’influence des Nations Unies constituait une explication plus plausible à la révision du Code pénal. En 2015, le gouvernement de Côte d’Ivoire a annoncé qu’il modifierait le Code pénal pour se conformer au droit international humanitaire. En parallèle, le Comité des Nations Unies pour l’élimination de la discrimination à l’égard des femmes a exhorté le gouvernement à agir afin de traiter les questions de la violence basée sur le genre, du viol et de l’accès à l’avortement sécurisé. Il a plus précisément demandé la légalisation de l’avortement a minima dans les cas de viol, d’inceste et de malformation fœtale, et a appelé à une dépénalisation plus vaste de l’avortement.

Contribution des activités de localisation au dialogue sur les politiques et au changement de perspective

Même si les évaluateurs n’ont pas trouvé de preuve de l’influence de l’intervention sur le Code pénal, leur analyse a révélé d’autres résultats positifs. L’adhésion de la population locale aux messages et aux recommandations concernant l’avortement (spécificité de l’intervention du projet SAFE ENGAGE) a résonné en Côte d’Ivoire. Outre la vidéo principale, les membres du groupe de travail ont décidé de créer plusieurs vidéos secondaires afin de s’assurer de la conformité des messages au projet de loi sur la santé reproductive. Par ailleurs, ils ont organisé des réunions supplémentaires après le lancement des vidéos en vue de garantir une stratégie de diffusion plus complète en tenant compte des enseignements tirés de la première campagne de communication. Ainsi, ces organisations ont réalisé plus de 40 activités de diffusion, contribuant au dialogue sur les politiques à l’échelle locale et nationale.

À l’issue des événements du projet SAFE ENGAGE au sein des communautés locales, certains représentants officiels se sont engagés à sensibiliser le grand public sur les questions de santé reproductive. Au moins trois communautés ont signé des déclarations en faveur d’un accès gratuit aux contraceptifs pour toutes et tous. Certains chefs religieux se sont même déclarés en faveur de certaines des recommandations formulées.

Ensemble, ces résultats sont la preuve de l’engagement des parties prenantes en faveur d’une vision commune et d’une cohésion qui améliore l’efficacité du dialogue sur les politiques et du plaidoyer. Outre l’analyse concernant la Côte d’Ivoire, le projet SAFE ENGAGE a effectué un traçage des contributions pour son travail dans l’État de Lagos. Dans les deux cas, l’objectif était d’évaluer le rôle de l’intervention dans le cadre des activités du projet afin d’améliorer l’accès à l’avortement sécurisé.

Pour en savoir plus, lisez le rapport technique.

 

 

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Journalists and civil society organizations (CSOs) often struggle to work together effectively, despite their many mutual interests. This rift is especially apparent when it comes to topics such as abortion, which can be complicated by stigma, secrecy, and strong personal beliefs. Both sides stand to benefit from bridging this divide: Civil society has expertise and connections that can help journalists define priorities in news coverage and identify evidence and expert sources for stories, and journalists can offer civil society professionals a connection to the public to deliver accurate information about hidden realities.

This training was designed to bring civil society professionals working on sexual and reproductive health and rights together with journalists to learn from each other and consider how they might build (or rebuild) productive partnerships and communicate more clearly on abortion and related issues. Content is divided into four parts designed to be delivered over the course of one day, but organizers may wish to extend the time another half or full day to allow for more discussion or presentation of additional training content.

Resources include:

En Français

 

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Ressources sur l'avortement sécurisé pour les médias et les organisations de la société civile

Les journalistes et les organisations de la société civile (OSC) ont souvent du mal à travailler ensemble efficacement, malgré leurs nombreux intérêts mutuels. Cette rupture est particulièrement apparente lorsqu’il s’agit de sujets tells que l’avortement, qui peuvent être compliqués par la stigmatisation, le secret et de fortes croyances personnelles.

Les deux parties ont tout à gagner à combler ce fossé : la société civile possède une expertise et des relations qui peuvent aider les journalistes à définir les priorités dans la couverture de l’actualité et à identifier des preuves et des sources d’experts pour les histoires, et les journalistes peuvent offrir aux professionnels de la société civile une connexion avec le public pour fournir des informations précises sur les réalités cachées.

Cette formation a été conçue pour réunir des professionnels de la société civile travaillant dans le domaine de la santé et des droits sexuels et reproductifs et des journalistes afin qu’ils apprennent les uns des autres et réfléchissent ensemble à des partenariats productifs et aux manières de communiquer plus clairement sur l’avortement et les questions connexes.

Le contenu est divisé en quatre parties conçues pour être dispensées au cours d’une journée, mais les organisateurs peuvent souhaiter la prolonger d’une demi-journée ou d’une journée entière pour permettre plus de discussions ou la présentation de contenus de formation supplémentaires.

Les ressources comprennent :

In English