Dr Munyaradzi Murwira
Due to the restrictive abortion laws in Zimbabwe, both medical and non-medical individuals clandestinely perform most of the abortions. Legal and administrative barriers coupled with stigma among both women and health service providers, and fear of social repercussions as well as risking imprisonment are barriers to access legal abortion in Zimbabwe. The legal termination of pregnancy is performed only in public health facilities at district, provincial and central hospitals, after authorisation from the magistrate. Rather than reduce abortion incidence, the restrictive abortion laws result in women pursuing backyard and unsafe abortions. Many women and girls resort to self-induced abortions leading to trauma (psychological and physical), severe complications and sometimes death.
Zimbabwe through the Ministry of Health & Child Care (MOHCC) recently launched the comprehensive abortion care (CAC) guidelines. These guidelines were adapted from the latest World Health Organisation (WHO) guidelines, which aim at the provision of comprehensive abortion care based on current evidence and best practices globally. Through the new guidelines the Ministry of Health and Child Care is committed to enhance skills and techniques in abortion care that are feasible in low resource settings. The objective of the guidelines is to guarantee access to comprehensive abortion care to all women requiring services thereby reducing the risk of complications and death. These services should also be accessible at all levels of health care in Zimbabwe including the primary care level and the private sector. The new guidelines present an opportunity to embrace and engage the private health sector in the provision of affordable post abortion care (PAC) services in Zimbabwe. The wider dissemination of the guidelines and adequate orientation of service providers (both public & private) will ensure provision of quality comprehensive abortion care. Current evidence emphasizes the key role of medical options in provision of care and including post abortion care (PAC). This presents a strong case for greater private sector engagement in implementation of the new guidelines for improved access to comprehensive abortion care services in Zimbabwe.
It will be critical to have a well-coordinated and structured dissemination of the new guidelines in both the public and private sector. This should include orientation of providers and on the job training to ensure effective implementation of the new guidelines. It is key that the private sector leverages on this opportunity to build capacity of their providers to offer comprehensive abortion care. The MoHCC and key stakeholders should provide leadership and technical guidance in the dissemination of the guidelines to both public and private sectors. The Guttmacher Commission Report of 2018 indicates that the training of middle level providers in medical abortion is as effective as services provided by physicians. A 2012 Study on Perception of medical abortion among providers in Zimbabwe showed that technical barriers due to lack of training, lack of adequate information, and poor standardisation of treatment protocols for medical abortion affect service provision. Therefore, capacitating private sector providers will enable them to provide CAC services confidently. There is need for a robust referral system from private sector to public health system for complicated cases.
A market survey on abortion services conducted in 2020 by Concept foundation found that some private medical practitioners are taking advantage of women desperate to get rid of unwanted pregnancies by charging fees ranging from US$100 up to US$3,000 for a “safe” illegal abortion. These exorbitant charges force many women who cannot afford such fees to seek alternative ways to abort the pregnancies including use of traditional herbs and harmful objects. Most of these women subsequently present to public health facilities seeking treatment for complications of unsafe abortions. There are no legal or regulatory provisions for pricing of services and medicines in the private sector thus service charges are not uniform. In government facilities, provision of legal abortion and post abortion care services is free as enshrined in maternal health service provision. However, at times when clients present themselves at public health facilities seeking services, they may be required to pay a nominal consultation fee (for general consultation) before they are directed to “free maternal health services”.
In Zimbabwe, the most common procedure used for post abortion care is the surgical and invasive methods (61%) followed by medical options (18%). Public hospitals mainly use the surgical methods due to the low costs associated with the method. Although the drug market is extensive in Zimbabwe, there is limited availability of medical options for abortion care. There are limited brands of the necessary drugs currently registered in Zimbabwe. Medical options present an opportunity for the privates sector to contribute significantly in the provision of CAC through cheaper non-invasive options thereby improving access to services in Zimbabwe.
In conclusion, the private sector is a key pillar of improving access to healthcare including comprehensive abortion care services. It is essential that government engage private sector as important partners to ensure affordability and access to these essential services. Inclusion of private sector health players in the implementation of the new CAC guidelines will be a key aspect towards universal access to sexual reproductive health services. The strategic engagement of relevant health professional associations, private institutions and pharmaceutical stakeholders in dissemination of the new guidelines should be a priority. Private sector engagement in the provision of comprehensive abortion care will significantly reduce unsafe abortions and resultant deaths of many women in Zimbabwe.
Dr M Murwira is a Public Health Expert with special interest in Sexual Reproductive Health, Population & Development.
