The ICMA Information Package on Medical Abortion Home > The ICMA Information Package on Medical Abortion > Information for women’s organizations and NGOs
The International Consortium for Medical Abortion (ICMA) works to promote medical abortion (Box 1) within the framework of support for safe abortion worldwide, focusing on the needs of women in developing countries, including those countries where abortion is unsafe or not accessible. This chapter is part of a comprehensive information package developed by the Consortium. The information package consists of five chapters, each aimed at a specific audience: women and women’s groups, women’s health advocates, providers of sexual and reproductive health services and health managers, and policy makers. There is also a chapter with resources on medical abortion.
This chapter is aimed at organisations working with women and for women’s health and rights at community or national level or as advocates for policy and programme interventions. The chapter is based on the premise that expanding women’s access to safe, legal abortion is an important component of any agenda for the promotion of women’s reproductive health and rights. Drawing mainly on the rich history of campaigning and organising for abortion rights (and more broadly, reproductive rights) in many parts of the world, it describes ways in which women’s organisations and NGOs could expand public information and awareness, build community support and advocate for policy and programme changes to make medical abortion widely available globally.
Women will never attain equal status with men without control over their reproductive lives. Restricting women’s ability to safely terminate an unwanted, unhealthy or unsafe pregnancy is perhaps one of the most blatant manifestations of discrimination against women.
Abortion has existed since time immemorial, because women have always sought to control their fertility. The right to safe abortion services has been a central demand of the women’s movement across the globe for more than four decades. Women’s health advocates and NGOs have collaborated effectively to make abortion legal and accessible in many countries and settings. Today, 60% of women live in countries where abortion is legal and safe [1].Yet, there is still a long way to go before women everywhere and across all age and social groups do not have to jeopardise their lives and health in attempting to terminate an unwanted pregnancy.
The first section of this chapter describes what is known about the safety and availability of medical abortion and makes the case for why women’s organisations and NGOs have an important role to play in promoting access to medical abortion. The second section outlines the role women’s organisations and NGOs play. The next two sections give examples of action they can take at national and community level. The last section discusses how to prepare for the opposition and the challenges that abortion advocacy is likely to evoke.
Medical abortion is termination of pregnancy through the use of a drug or a combination of drugs. The most commonly used combination of drugs for medical abortion is
mifepristone, an anti-progestogen drug, taken first, and
misoprostol, a prostaglandin, taken 36-48 hours later
In some settings, misoprostol alone is used for medical abortion because mifepristone is not available or not affordable
Unplanned pregnancy is a common experience for many women. An estimated four out of ten pregnancies globally are unplanned, and about two out of ten end in induced abortion [2]. Of the 45 million abortions that take place globally every year, close to half, about 19 million, are unsafe (Table 1). An estimated 5 million women are hospitalized due to complications of unsafe abortion each year [3], and there are more than 68,000 deaths annually – about 13 per cent of pregnancy-related deaths – which are due to complications of unsafe abortion. In some African countries, almost 50% of pregnancy-related deaths are attributable to unsafe abortions, and 14 % of abortion-related deaths are in women 20 years or younger. A further 20% of all women who have an unsafe abortion suffer from reproductive tract infections as well [4].
An abortion by a trained professional under safe conditions is one of the safest procedures. In settings where access to abortion is legally restricted or because safe abortion services are unavailable, many women are forced to resort to methods that can give rise to life-threatening complications. These include inserting sharp objects, toxic substances or unclean instruments into the cervix – causing infections, drinking herbal preparations or taking high doses of drugs meant for treating other illnesses [2]. Risk of death following complications of unsafe abortion is several hundred times greater than when abortion is performed by trained professionals under safe conditions [4].
Table 1. Incidence of and deaths from unsafe abortions: estimates, 2000+ [1]
Number of unsafe abortions
Number of maternal deaths due to unsafe abortions
% of all maternal deaths
Case-fatality rate (%)
Unsafe abortion deaths to 100, 000 live births
World
19,000,000
67,900
13%
0.4%
50
Developed countries*
500,000
300
14%
0.1 %
3
Developing countries
18,400,000
67,500
13%
0.4%
60
Africa
4200,000
29,800
12%
0.7%
100
Asia*
10,500,000
34,000
13%
0.3%
40
Europe
500,000
300
20%
<0.1%
5
Latin America and the Caribbean
3700,000
3700
17%
0.1%
30
North America
o
o
o
o
o
Oceania*
30,000
<100
7%
0.1%
20
+ Figures may not exactly add up to totals because of rounding
* Japan, Australia and New Zealand have been excluded from the regional estimates but are included in the total for developed countries
o No estimates are shown for regions where the incidence is negligible
It is often young women, unmarried women, low-income women, women with little education and women who live in rural areas who are worst affected when access to abortion is restricted. Those who can afford to pay often manage to access safe abortion services even when they are illegal. Death and disability from complications of unsafe abortion represent an entirely preventable public health tragedy that affects women in the prime of their lives.
Safe, legal abortion is a woman’s right
Women’s right to terminate an unwanted pregnancy is implied and supported by several international treaties and instruments. For example, access to safe abortion services is essential for the protection of women’s right to health, and of their right to life. Women’s right to enjoy the benefits of scientific progress and its applications, enshrined in the Covenant on Economic and Social and Cultural Rights, also implies that women should not only have access to safe abortion, but also to the latest methods, including medical abortion, deemed safe and effective for inducing abortion [5].
Freedom from discrimination is enshrined in every international human rights document. Since only women need abortion services, restriction of access to abortion services is viewed as discrimination against women [5].
Recognition of women’s right to make decisions regarding their own bodies – including the right to physical integrity, the right to decide freely and responsibly on the number and spacing of their children – is found in many international documents. (See Chapter 4) Many governments have committed themselves to respecting, protecting and fulfilling these rights. In order to do so, governments have to make abortion services legal, safe and accessible for all women who seek an abortion. While contraceptive use is increasing across the globe, when faced with an unwanted pregnancy, abortion is a woman’s only means of exercising her right to decide on the number and spacing of her children [5].
1.3. Medical abortion is a safe and acceptable method of pregnancy termination
Prevention of unsafe abortions is a global responsibility. Non-governmental organizations working for the promotion of social justice and human rights, and those working for women’s health and rights ought to make promotion of safe, legal abortion services, including medical abortion, an integral part of their advocacy and action agenda.
Getting set for advocacy
Advocacy may be defined as “the act or process of supporting a cause or issue. ..We advocate for a cause or issue because we want to build support for it, influence others to support and try to influence or change legislations and policies that affect it” [6]. Box 2 describes various steps involved in devising advocacy strategies.
Advocacy to make medical abortion available through health services is something that women’s organisations and NGOs need to engage with in all countries. This is because even in countries where abortion is restricted to a narrow range of indications, those who are legally eligible for abortion should be able to use medical abortion.
There is a wealth of historical as well as current experiences in promoting access to safe abortion. Women’s groups and NGOs have provided clandestine safe abortion services, collaborated with health providers to introduce abortion services in health service settings, organised protests and demonstrations, carried out media advocacy, moved the court to challenge laws, submitted shadow reports to international human rights bodies, lobbied policy makers, and successfully mobilised support from a wide range of stake-holders to bring about changes in law [7], [8], [9], [10], [11], [12], [13], [14], [15], [16].
There is a lot that that can be learned from these experiences in terms of advocacy strategies and specific actions for winning access to medical abortion.
Preparing for opposition
Opposition to women’s access to safe abortion comes from many sources: religious groups, opponents of women’s equality and of abortion as western feminist concepts, health professionals who believe abortion is unethical and community leaders who worry that liberalising the abortion law will make them lose elections or lead to unrestrained sexual activity among young people. Since 2001, the Bush administration in Washington has added its considerable might to opposition to abortion, alongside that of the Vatican.
There is a well-organised and well-funded “anti-choice” movement in several countries, opposed to abortion law reform. Opposition to the licensing and availability of medical abortion may be especially fierce. Language such as “chemical abortion” has been used, with its negative connotations. It is important to anticipate and prepare to contend with such opposition.
To help develop a focused advocacy strategy for medical abortion, it is important to carry out an analysis of potential sources of support for and opposition to abortion, and medical abortion in particular. For example,
Is abortion discussed in the media? What are the positions taken?
Are prominent individuals in government and civil society openly supportive of or opposed to legal abortion services? Of medical abortion?
What are the positions of prominent lawyers and religious leaders, national and local nursing, midwifery, medical and obstetrician/gynaecologists associations on abortion, and medical abortion?
What are the positions of other NGOs, women’s organizations, community-based organizations, trades unions, students’ organizations, progressive religious organizations, journalists’ associations?
What are the sources of opposition to induced abortion and medical abortion in particular?
The following steps may also help to address the opposition [18], [19].
Educate yourself about the opposition
The starting point is to identify anti-abortion groups and spokespersons, their agendas and their arguments, which have changed considerably over the years. This may be done by reading anti-abortion literature, listening to their programmes on television and radio, visiting anti-abortion websites, reading newspaper and other reports of the activities of anti-abortion groups. Find out how strong they are, what kind of messages they convey and through what means, and which sections of the community support them, including any legislators, and why.
Do not use anti-abortion language yourself
Check your own language and terminology to avoid using anything that is potentially anti-abortion, when preparing advocacy materials and messages. For example, abortion is not a “necessary evil”. Abortion is a legitimate and necessary part of women being able to decide the number and spacing of children. Or, calling for a “reduction in abortions” instead of a “reduction in unwanted pregnancies” implies you are opposed to “so many abortions”, as if some abortions are not necessary to the women who have them. Another example is that some pro-choice women’s organisations and other NGOs opposing sex-selective abortion may use the term “female feticide”, which implies that these abortions are murder. Similarly, pregnant women are sometimes referred to as “mothers”, implying that all pregnancies will be carried to term.
Head off the rhetoric and actions of opposition groups
Be pro-active and seize every opportunity to frame the issues in a positive way for the public and press. Let the public know why your work contributes to women’s health and rights and is part of a larger social justice agenda. Frame your arguments in reasonable language. Avoid rhetoric and counter-accusations. Do your homework thoroughly and give out clear positions, backed up evidence. Always correct any misinformation spread by the opposition and respond to charges they make against medical abortion or those who support it. Educate the press and public to recognise misinformation and to identify and use sources that provide unbiased and accurate information.
Network with natural allies in your community
It is equally important to identify who your supporters in the community are. Work with all NGOs, supportive health professionals and legislators from all parties who support the cause and draw on their support when counteracting an opposition move, such as introducing restrictive legislation. More importantly, find lawyers, doctors and law enforcement officials who can help you in countering opposition attacks.
Build a new generation of pro-choice activists
A new generation of pro-choice activists and advocates needs to be built to ensure that advocacy efforts are ongoing. Opportunities have to be created through internships, training workshops and meetings and conferences for younger activists to be involved in advocacy for abortion rights and more broadly for sexual and reproductive rights, and to take on a leadership role. This is especially important in countries where abortion laws are relatively liberal and/or where the younger generation has not had to encounter the consequences of restrictive legislation or lack of availability of safe services.
What are the long-term and short-term goals? What are the content goals (e.g. policy change) and what are the process goals (e.g. building community among participants)?
AUDIENCES: Who can give it to you?
Who are the people and institutions you need to move? This includes those who have the actual formal authority to effect the changes being advocated for (i.e. legislators), and also those who have the capacity to influence those with formal authority (i.e. the media and key constituencies, such as health professionals, both allied and opposed). In both cases, an effective advocacy effort requires a clear sense of who these audiences are and what access or pressure points are available to move them.
MESSAGE: What do they need to hear?
Reaching these different audiences requires a set of messages that will be persuasive. Although these messages must always be rooted in the same basic truth, they also need to be tailored differently for different audiences, depending on what they are ready to hear. In most cases, advocacy messages will have two basic components: an appeal to what is right and an appeal to the audience\'s self-interest.
MESSENGERS: Who do they need to hear it from?
The same message has a very different impact depending on who communicates it. Who are the most credible messengers for different audiences? In some cases, these messengers are "experts" whose credibility is largely technical. In other cases, we need to engage "authentic voices", those who can speak from personal experience. What do we need to do to equip these messengers, both in terms of information and to increase their comfort level as advocates?
DELIVERY: How can we get them to hear it?
There is wide continuum of ways to deliver an advocacy message. These range from lobbying to marches and ‘speak-outs’. Which means is most effective varies from situation to situation. The key is to evaluate them and apply them appropriately, weaving them together in a winning mix.
Some of the largest overall tasks for women’s organisations and NGOs at state and national level include:
Campaigns to build broad support for progressive abortion laws.
Advocacy with policy makers for approval and availability of medical abortion within the range of legally permissible options.
Advocacy with health professionals to start offering the choice of medical abortion to women seeking abortion, perhaps initially running an introductory trial using medical abortion to show that its use is safe in the national setting and that it is accepted by women.
3.1 Mass mobilisation to win popular support for abortion law reform
There have been many examples of mass mobilisation to win popular support for abortion law reform starting from the 1960s and 1970s up to the present day. Klugman and Budlender [20] offer eleven valuable case studies, for example. In settings where abortion is legally restricted, the strategy may be to integrate advocacy for medical abortion within existing campaigns for abortion law reform, positioning it as a method that is appropriate for medium- and low-resource health settings.
Media campaigns can be very effective in reaching a broad section of the population with reasons why abortion law reform is important or to create greater awareness about medical abortion. Media campaigns have been used by women’s organisations and NGOs in many countries to create a more favourable public opinion on liberalisation of abortion law and publicise the consequences of most abortions being illegal and unsafe. Campaigns have usually been run by broad coalitions of civil society actors, most often with the women’s movement at the helm. An analysis of these campaigns shows that a wide range of activities are best launched simultaneously to increase the visibility of the issues and make an impact on public opinion.
Media campaigns can take the form of:
articles in newspapers and popular magazines written by your organization or with supportive journalists
messages on radio and TV
posters on public transportation and billboards
postcards sent to a wide network of stakeholders
creating and publicising websites which carry information on abortion and specifically on medical abortion, including testimonies and experiences of women who have had an abortion
media events such as press conferences or public tribunals (Box 3) attended by large numbers of supporters and advocates for safe, legal abortion
“speak-outs” by women, e.g. those who have experienced unsafe abortion or those who have used medical abortion successfully.
In Italy, during the campaign for liberalisation of the abortion law in the early 1970s, the feminist monthly magazine Effe published articles about abortion and the discussion in Parliament on abortion in every issue. Effe then published a special issue on abortion in December 1975 to coincide with a major rally organised by CRAC, a coalition of women’s organizations and NGOs working for abortion law reform. Thanks to the efforts of feminist journalists, documentaries and women’s stories on abortion were also featured regularly in a weekly television programme on women’s issues called Si dice donna (So say women) [11].
In Brazil, the women’s movement adopted the strategy of requesting people favourable to abortion to send letters, faxes and e-mails to newspapers and magazines. In 2000, the movement produced a series of materials on abortion aimed at different target audiences: a pamphlet for the general public, a special edition of the electronic bulletin of the Brazilian National Network for Health and Reproductive Rights (RedeSaude) for network members, a special edition of the RedeSaude newspaper aimed at health professionals, researchers and women’s organizations, and a dossier for legislators. Electronic panels were placed at the busiest cross-roads of São Paulo, with the message “Abortion is not a sin. Abortion is a health right, the right to choose and the right to citizenship” [22].
Whatever the form of media campaign, there are two important points to bear in mind: first, that the message needs to be drafted after careful research and pilot testing, and modified before being used in a mass campaign; and second, that the campaign has to be publicized extensively, e.g. by e-mail, through press releases and through announcements in such places as newspaper or magazine calendar listings.
Creating an evidence base on the safety and acceptability of medical abortion
Targeted, truthful evidence is powerful and can play a major role in influencing public opinion in favour of medical abortion. Research has also played an important role in winning support for legalising abortion in many settings. In South Africa, for example, one research NGO promoted an initiative to gather national base-line data on abortion-related morbidity and mortality under the auspices of the Medical Research Council, deemed to be an unbiased investigator. The evidence from this study made a major public impact, including on policy makers, and contributed to the success of the campaign to legalise abortion [7].
Opinion polls have been a strategy adopted by women’s organisations and NGOs in many countries to gather evidence of public support for abortion. For example, in Nepal, the non-governmental organization CREHPA conducted a public opinion poll which demonstrated broad support for legalisation of abortion [13]. Public opinion polls were conducted in 2003 in Mexico, Colombia and Bolivia. These showed that a majority of Catholic respondents believed abortion should be permitted to save a woman\'s life, when doctors believe the fetus will not survive or when the pregnancy is the result of rape [23]. In Nicaragua, in 2002, a survey showed that 95% of the members of the Nicaraguan Society of Obstetrics and Gynecology believed that therapeutic abortion should be legal and 98% that the Society should be the principal expert group consulted on the medical and technical issues related to the regulation of abortion [24].
The sampling methodology used for choosing participants who are representative, the wording and order of the questions and the analysis of data from opinion polls are all extremely important, as they can be manipulated to elicit skewed answers toward a more anti-choice or prochoice stance. Moreover, the use of non-specific questions may yield vague answers that can be interpreted in any number of ways. How to avoid these problems is shown in relation to an opinion poll conducted in Mexico in 2000 asking 3,000 people about their knowledge and views on abortion [25].
Working with community-based organisations to mobilise support
It is important for women’s organisations and NGOs to work with and build the capacity of community-based organisations (CBOs) that are concerned with women’s rights and health (Box 4). Examples include women’s self-help groups and community health committees.
Interested individuals with leadership traits may be recruited from CBOs that are committed to promoting access to safe abortion, including medical abortion. The CBOs and interested individuals must be in a position to implement health education and advocacy interventions at the community level, as part of their ongoing activities. Training workshops to build the capacity of this leadership cadre in developing health education materials and community advocacy strategies may be undertaken, and followed up with technical support as required.
Chapter 1 of this information package provides information aimed at potential users of medical abortion from developing country settings, presented in question-and-answer format. This material may be adapted, with the help of CBO volunteers, to meet the needs of the specific context in which it will be used.
3.2.Advocacy with health professionals
In many developing countries, obstetrician–gynaecologists and other health professionals, including abortion providers, are compassionate people who support women’s needs and have played a lead role in reforming the abortion law and offering abortion services. In India, for example, they have also taken leadership in introducing medical abortion among the range of methods used [27].
It is important to reach health professionals with the message that medical abortion can be included as one of the method options available to women who are eligible for abortion, and that women should be allowed to choose the method that best meets their needs and circumstances.
One way in which health professionals have been included in the process of introducing medical abortion is through introductory trials. Clinical trials sponsored by the Special Programme of Research, Development and Research Training on Human Reproduction at the World Health Organization, Geneva, have successfully introduced medical abortion in Sweden, UK, Cuba, India, Mongolia, Romania, Turkey, Tunisia and Vietnam. The Population Council, and more recently Gynuity Health Projects, a US-based NGO have played a pioneering role in setting up introductory and clinical trials of medical abortion regimens to introduce the technology in new settings, including where there is limited access to legal abortion services [28].
Women’s organisations and NGOs that provide reproductive health services could also conduct introductory trials of medical abortion. Those who work collaboratively with health professionals in the public health system may be in a position to create interest among them to set up introductory trials as well .
Chapter 3 of this information package is directed at informing health professionals about the clinical aspects of medical abortion as well as with the service delivery aspects related to integrating medical abortion into an existing service delivery setting, and the role of health providers as advocates.
Some ways to involve and engage health professionals:
Get an eminent medical professional to speak on medical abortion at a Continuing Medical Education session (usually run by professional associations), and in a national conference.
Sponsor health professionals to attend and present papers in national scientific meetings.
Prepare an information package with key articles on medical abortion that have been published in well-known professional journals.
Arranging for exposure visits of policy makers and health professionals to countries or settings in which medical abortion is provided.
Organising a day of recognition and appreciation for abortion providers, especially those who are fighting for safe, legal abortion.
Run “values clarification” workshops for health professionals to address their attitudes towards (medical) abortion (Box 5).
Work with health professionals to make abortion services available in the public health system, including medical abortion, and to help develop national guidelines.
Work with obstetrics–gynaecology departments in teaching hospitals to include training on medical abortion in the core curriculum.
Convince a hospital or a doctor to provide legal abortions, including medical abortion, in a legally restricted setting.
3.3.Working with policy makers
Advocacy efforts are needed to win support from policy makers for abortion law reform in legally restricted settings, for abortions that are legal under existing law should be made available, and for making mifepristone and misoprostol available for medical abortion (Box 6). It is important to know:
Which bodies and committees make the decisions about these issues?
Which policy makers are supportive?
What would be appropriate ways of making more policy makers pay attention to and prioritize these issues?
A briefing paper by the Centre for Reproductive Rights provides guidelines for crafting an abortion law that respects women’s rights [31]. Medical abortion may be included among legally authorised abortion methods when drafting such a law.
One way to get attention to the issues is to send policymakers and legislators a petition or letter signed by a large number of voters and prominent members of the community. The petition/letter could call for support for (or opposition to) a bill that is pending or explain how and why a specific law needs to be modified. Another standard campaign strategy has been to get thousands of people to send postcards to legislators calling for specific action.
With policy makers who are your “friends within the system” it is important to maintain contact and keep visibility of the issues high on an ongoing basis. You could, for example, send them research reports and other materials on medical abortion, make them special invitees at meetings and workshops, and so on.
Another strategy is to carry out extensive research regarding services and/or among national and local stakeholders, and present the findings to a relevant policy-making body, such as a task force on reproductive health or a standing parliamentary committee, e.g. on women’s status.
More often than not, abortion rights advocates have had to work to ensure that there is no back-sliding on gains that have been made after much struggle. This has also been true for medical abortion, as evident from developments in France in 1988 soon after the drug was approved (Box 7). Anti-abortion groups see medical abortion as a major threat because the “little white pill”, as it is called, has the potential to take abortions out of easily identifiable clinics, making it more difficult to picket or attack providers and users.
3.4. Using the courts
Another strategy is to use the judicial system to focus attention on the need for expanding access to safe abortion services. A legal challenge to the denial of access to safe abortion services as a violation of women’s rights has been used in many countries to initiate a process of law reform. For example, in the United States, court actions to do away with laws against abortion began in over 20 states between 1968 and 1970; these preceded the US Supreme Court decision in 1973, which itself was the result of a case that came up from the lower courts. The most recent example of successful legal action through the court system took place in the Constitutional Court of Colombia (Box 8).
Concluding remarks
Anyone who engages in abortion advocacy has to be ready for the long haul and prepared for fierce opposition. The history of struggle for abortion rights over the past 100 years has always been one of “two steps forward, one step back” – and of having to run just to stay in place.
Making medical abortion available to all women seeking abortion is part of the broader public health and rights struggle for making safe abortion accessible to all women. Advocacy for promoting access to medical abortion calls for continued review of goals, strategies and tactics and renewal of financial and human resources.
Success in achieving law reform must be followed by equally difficult efforts to make services available to women. Advocacy and active collaboration with the health services is needed to ensure that sufficient resources are allocated, health providers are trained and infrastructure and guidelines are in place for delivering medical abortion services. Continued engagement of advocates is necessary also for disseminating information to women, including about service delivery points, including for medical abortion, and ongoing monitoring of access to and quality of services.
The long-term goal is for abortion to become a legitimate component of women’s health care and new technology such as medical abortion is not denied to women at the cost of their health and lives.
On 25 July 2001 the Polish Federation for Women and Family Planning organised a Tribunal on Abortion Rights in Warsaw, to publicise the negative consequences of the criminalisation of abortion in Poland.
After decades of legal access to abortion under communism, Polish women suffered a major set-back with the legislation passed in 1993. The 1993 “Anti-Abortion Act” allowed abortion only in cases of rape, or if the pregnancy threatened a woman’s life or if the fetus was damaged.
Testimonials of seven Polish women were presented before a panel of Polish and foreign experts. National and foreign journalists were in attendance, as well as observers from all walks of life – writers, students, mothers, activists, feminists, husbands. The testimonials provided compelling evidence that restrictive abortion laws make abortion unsafe by pushing it underground, were endangering women\'s health, creating a climate where even those services that were allowed by law were becoming unavailable and contravened standards set by international human rights law. The Tribunal brought the issue of abortion into the media prior to an election campaign and galvanised Polish and other Eastern European women\'s groups into becoming more active in defence of abortion rights.
The Programme for Alternative Technologies in Health (PATH) is currently working with NAMUNA, a local women’s NGO and one of the branches of the Family Planning Association of Nepal to implement a Behaviour Change Communication (BCC) intervention. The intervention aims to win community support for safe abortion, following the legalisation of abortion in the country through facilitated dialogue in groups and use of participatory drama. In the facilitated dialogue groups, trained community volunteers bring together women of reproductive age, and sometimes men and older women who are the decision-makers at household level, on matters related to reproduction. A variety of techniques are used to initiate discussion, such as stories, role plays and experience-sharing. This is followed by informal, facilitated discussion whose aim is to create a safe space to reflect on community values and beliefs. In participatory drama, incomplete stories are enacted. The actors freeze at dilemma points and the audience is challenged to come up with suggestions on how to proceed. Afterwards there is facilitated discussion and reflection on the issues presented. The dramas are enacted twice every month and the community returns to watch the next episode.
In South Africa, even after the Choice on Termination of Pregnancy Act was passed in 1996, winning the support of health providers and community opinion makers remained a major challenge. Ipas South Africa worked with the Department of Health in the Limpopo province to organise a series of “values clarification” workshops for health providers and other stakeholders during 2002–03.
The workshops were designed to encourage attitudes and behaviours that support women’s reproductive rights and lead more health workers to agree to implementation of the new law at the health facility level. A follow-up evaluation showed that three-fourths of the health providers who attended the workshop reported behaviour changes in their workplace which they attributed to the workshops. They took a more tolerant, positive stand on abortion, abortion seekers and providers. Health providers’ ability to respond professionally and appropriately to women seeking abortion and their situations increased. There was also better communication and open discussion about abortion among staff members and between staff members and women.
Catholics for a Free Choice (CDD-Brazil) undertook a similar initiative in Brazil but on a smaller scale. CDD organised workshops where hospital staff, social workers, nurses, psychologists and physicians could reflect on their personal attitudes about abortion, and discuss these in the light of legal, professional and ethical responsibilities. While there was initial resistance, this initiative gradually won support from health providers
In Queensland, Australia, a coalition of women’s organisations and NGOs successfully lobbied for the removal of legal barriers to availability of mifepristone.
The Therapeutic Goods Administration (TGA) has to give approval for the importation and distribution of therapeutic drugs into Australia. In 1996, an amendment to the Therapeutic Goods Act was passed that required approval to import mifepristone to be obtained from the Federal Minister for Health as well as the TGA. There were no guidelines for Ministerial approval or rejection. This discouraged pharmaceutical companies from undertaking the expensive application process, given that the Minister might overturn the TGA’s approval.
A sustained campaign to change the requirement of ministerial sanction was undertaken by Reproductive Choice Australia (RCA), a national coalition of over 20 women’s organizations and NGOs working for sexual and reproductive health and rights, formed in 2005.
RCA won the support of four women senators, who agreed to sponsor a Private Member’s Bill in the Senatethat would overturn the ministerial sanction requirement for importation of mifepristone. Coalition members worked together to garner public support for the Private Member’s Bill and informed MPs, the media and the public about mifepristone. RCA and the Australian Reproductive Health Alliance jointly produced a briefing document RU486/Mifepristone: A factual guide to the issues in the Australian debate.
In both Houses of Parliament, women senators and MPs overwhelmingly supported the Bill. On 16 February 2006, the Private Members Bill passed through the Federal Parliament’s House of Representatives. This means that the Federal Health Minister no longer has the power to veto any application to allow mifepristone to be used in Australia, and the decision of the TGA would be final. At the time of this writing, one woman doctor had won the right to import the drugs to provide medical abortions.
As mifepristone moved close to approval in France in 1988, the manufacturer, Roussel Uclaf came under tremendous anti-abortion pressure to withdraw the drug. The chairman of the company received threatening letters – up to 25 a day – and protests were held outside the company’s headquarters. Despite these threats, the French regulatory agency approved the marketing of mifepristone in September 1988.
On 26 October 1988, Roussel announced that it was suspending distribution of the drug. . Supporters of medical abortion across the globe responded with petitions and statements. On the same day as Roussel made the announcement, an international conference on gynaecology and obstetrics was taking place in Rio de Janeiro. Three thousand participants from this conference signed a petition calling the move “dangerous”. Dr Etienne-Emile Baulieu, a scientist closely associated with the development of mifepristone, condemned the action of the company. The World Health Organization expressed regret about the withdrawal of the drug because it would deprive developing countries of the possibility of running clinical trials on mifepristone. Pro-choice organizations and family planning associations also sent letters demanding that the drug should not be withdrawn. The swell of public opinion in favour of the drug led to decisive political action by the French government.
On 28 October, the French Minister of Health Claude Evin ordered the company to put the drug back on the market, where it has stayed ever since, though distributed by a different company. The Minister described mifepristone as the “moral property of women”, a term which captured public imagination and has been extensively used since by those advocating for availability of medical abortion.
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