PRB

In Nigeria, a country with one of the highest maternal death rates in the world at 67,000 maternal deaths per year, it is crucial that the crisis of unsafe abortion—a preventable cause of maternal death—be addressed.

PRB’s SAFE ENGAGE project recently contributed to a key policy dialogue about how to do just that. Through the SAFE ENGAGE co-creation process for developing an advocacy tool and dissemination strategy, stakeholders influenced the Lagos State commissioner of health to require medical directors and staff of public health facilities to provide safe abortion services to the full extent allowed by law—that is, to preserve a woman’s life and physical health.

Intervention Paves the Way for Improved Access Amidst Challenges

In his role as the chair of a high-level SAFE ENGAGE task force, the commissioner heard details of the 2011 Lagos State Criminal Code update that expanded the legal provisions of abortion but had not been widely recognized or implemented in practice. Until 2011, access to safe abortion in Lagos State was governed by a 95-year-old state law that only permitted abortion to save the life of the woman. In 2011, the Criminal Code was updated to also allow abortion to protect a woman’s physical health. Because of severe penalties under the old law, service providers were reluctant to do more than offer postabortion care. Ensuring providers had this updated information would give them confidence to extend legal abortion services.

Through the SAFE ENGAGE intervention, PRB works to advance policy dialogue and strengthen the capacity of advocates, government representatives, and the media to communicate information on abortion to national and subnational policymakers. PRB collaborates with local partners to develop an advocacy tool that can help showcase the latest evidence, frame the dialogue, influence resource investments, and guide policy action. Key to the process is establishing a task force that includes high-level advocates who understand data and services, and policymakers from government ministries. These individuals come together to deliberate and jointly create a multimedia presentation—a compelling portrayal of the evidence conveying the incidence, trends, causes, and consequences of unsafe abortion. PRB’s partners in Lagos State, the Society of Gynaecology and Obstetrics (SOGON), helped convene the task force and navigate the policymaking landscape.

Contribution Tracing Demonstrates PRB’s Role in Policy Dialogue

To evaluate the project’s role in policy change, evaluators used contribution tracing, a technique that links outcomes through a causal chain of events produced by an intervention. The technique assesses a contribution claim that an intervention—in this case the SAFE ENGAGE co-creation and dissemination process—led to an outcome of interest through a specific pathway. The contribution claim in Lagos State was:

The SAFE ENGAGE co-creation process influenced the commissioner of health of Lagos State to issue an official circular (memorandum) with a directive calling for secondary and tertiary public health facilities to provide access to safe abortion within the full extent of the current law, which includes providing access to legal abortion to preserve a woman’s life and physical health.

In Lagos State, the causal chain began with the commissioner chairing the SAFE ENGAGE task force. Credible evidence shows that he, or his representative, was present at meetings where the existing laws were clarified and information was shared that abortions permitted by law were not actually being performed in public clinics. He actively participated in dialogue and deliberation around the multimedia presentation content and embraced its key messages, including that “secondary and tertiary medical facilities in the State of Lagos should expand provision of abortion services in alignment with the provisions of the law.”

In addition, the SAFE ENGAGE team organized a dinner with the commissioner where two members of the task force suggested that he issue a directive as a means of educating public health facilities that they could provide legal abortion to the full extent of federal and Lagos State laws without fear of punishment. Finally, the commissioner announced the memo at a meeting of medical directors shortly before his retirement, where he also showed a version of the SAFE ENGAGE presentation. The official memorandum was distributed shortly thereafter.

Contribution Tracing Is a Valuable Tool in Complex Policy Environments

Evaluating policy change is not easy. Nevertheless, it is critical to understand which factors influence changes in policy when lives are at stake. It is vital for advocates, program planners, and service providers to learn from and adapt their strategies, and crucial for all stakeholders to understand which investments lead to the impact they are seeking.

In addition to analysis for Lagos State, the SAFE ENGAGE project conducted contribution tracing for its work in Côte d’Ivoire. In both cases, the goal was to evaluate the role of the intervention in the project’s efforts to improve access to safe abortion.

In Lagos State, our contribution tracing provides high levels of confidence in the project’s effect on policy dialogue and modest levels of confidence in its effect on policy change.  A key takeaway from the analysis is that unexpected windows of opportunity exist when a ministry official might be changing jobs or retiring, as she or he might have more latitude to support a policy change that is not popular or one that has been historically challenged.

Drawing from lessons in Lagos State, change in the law is not the only meaningful outcome. SAFE ENGAGE’s intervention, through sharing information and influencing perceptions, can help ensure that practitioners offer safe legal abortion as directed by law.

The technical report is available for more information.