Information for women’s health advocates, abortion rights organizations and other NGOs that support women’s sexual and reproductive rights / Updated in 2013

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1. Presentation

The International Consortium for Medical Abortion (ICMA) works to promote medical abortion within the framework of support for women’s right to a safe, legal abortion worldwide, focusing on the needs of women in developing countries, including countries where abortion is unsafe or not accessible.

This chapter is part of a comprehensive information package with four chapters, each aimed at a specific audience: women seeking information about abortion (https://medicalabortionconsortium.com/articles/for-women/main-book/?bl=en); women’s health advocates, abortion rights organizations, and other NGOs that support women’s reproductive rights; health care providers (https://medicalabortionconsortium.com/articles/for-health-care-providers/health/?bl=en); and policy makers (https://medicalabortionconsortium.com/articles/for-policy-makers/default/?bl=en)

This chapter is for women’s health advocates, abortion rights organizations and other NGOs that support women’s reproductive rights and who wish to support access to medical abortion. That includes organizations working with women and for women’s health and rights at community, national and/or international level, or as advocates for decriminalization of abortion and for policy, health service and programme interventions whose aim is to expand and improve access to legal and safe abortion.

This section is based on two premises: 1) making abortion safe must be part of any strategy aimed at reducing maternal mortality and morbidity; and 2) making abortion safe and legal for women is a critical component in the work for women’s sexual and reproductive health and rights, and for women’s right to life as a human right.

Drawing on the rich history of organizing and campaigning for abortion rights (and more broadly, for sexual and reproductive rights) in many parts of the world, this chapter provides figures, arguments and strategies that can be used to raise public awareness of the abortion issue; communicate scientifically accurate, evidence-based information on abortion to a wide range of audiences; build political and community support for women’s need for safe, legal abortions by working with a wide variety of stakeholders; and advocate for legal, policy and programme changes to make medical as well as surgical abortion available and affordable for every woman who needs it

It also makes the case for why women’s organizations and NGOs have an important role to play in promoting access to medical abortion. Lastly, it gives examples of action that women´s organizations and NGOs can take at local, national and international levels and discusses how to get ready for the opposition and the challenges that abortion advocacy is likely to create.

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2. Data and arguments to advocate for access to legal and safe abortion as a public health problem and a human rights issue

Unsafe abortion is a major public health issue

The 1994 International Conference on Population and Development identified unsafe abortion as a major public health problem and called for universal access to reproductive health and supported reproductive rights. Universal access to reproductive health, which includes reducing the maternal mortality ratio by 75% by 2015 is one of the eight Millennium Development Goals (MDGs) endorsed by 189 countries between 2000 and 2005. [1] [2]

WHO estimates that some 358000 women die each year from complications related to pregnancy, childbirth and unsafe abortions. Most of them die because they have no access to skilled routine and emergency care.[3] Deaths from complications of unsafe abortion constitute 13% of all maternal deaths; however, depending on the country, this ranges from very few to over 30% of the total. An estimated 22 million of the 42 million abortions every year were unsafe in 2008 - almost all of these in developing countries. Approximately 47,000 women died from complications of unsafe abortion in 2008 [4] while an estimated 5 million women are hospitalized due to such complications each year.[5]

The rate of unsafe abortions per 1,000 women globally barely fell between 1995 and 2003 (15 vs. 14 abortions per 1,000 women aged 15–44, respectively). However, because the overall abortion rate declined during this period, the proportion of all abortions that were unsafe increased from 44% to 48%.[6] [7] In 2011 WHO said that “It is likely that the numbers of unsafe abortions will continue to increase unless women’s access to safe abortion and contraception – and support to empower women (including their freedom to decide whether and when to have a child) – are put in place and further strengthened”. [4]

However, in developed regions, nearly all abortions are safe (92%), whereas in developing countries, more than half are unsafe (55%). In Latin America and Africa, more than 95% of abortions are performed under unsafe circumstances, as are about 60% of abortions in Asia (excluding Eastern Asia).[7]

Although the mortality rate for an abortion done safely is less than 1 per 100000 procedures for all abortions, the mortality rate in regions where unsafe abortion is commonplace is very much higher: 350 deaths per 100000 procedures in low‐resource countries overall and, specifically in Africa, 680 per 100000 procedures. Global estimates of the disability burden of unsafe abortion show a loss of approximately 5 million years of productive life each year, representing an estimated 14% of all annual disability from pregnancy‐related conditions. [8]

A surgical abortion by a trained professional or using medical abortion pills under safe conditions is one of the safest available medical procedures. Yet in settings where access to safe abortion is legally restricted or 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, drinking herbal preparations or taking high doses of drugs meant for treating other illnesses. [9] The risk of death following complications of unsafe abortion is several hundred times greater than when abortion is performed by trained professionals under safe conditions. [10]

Box: What is medical abortion?

Medical abortion is the termination of pregnancy through the use of a drug or a combination of drugs, in the first trimester. It has revolutionized abortion procedures, because it is not dependent on surgical intervention. Medical abortion means that women can now have a choice between abortion methods, including those women who are prevented by the lack of health service facilities from having a safe abortion. Because it is a simple procedure, it has the potential to expand access to abortion provided by clinicians and mid-level providers who may or may not have training in surgical methods of abortion. It also enables women with anearly pregnancy to take the medication(s) and have their abortion at home if they prefer to do so, as long as they have access to appropriate back-up medical services.

For more detailed clinical information (safety and efficacy, dosages and regimens) of medical abortion, go to ( https://medicalabortionconsortium.com/articles/for-health-care-providers/health/?bl=en )

It is often young women, unmarried women, low-income women, women with little education and women who live in poor urban and 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..

The rate and severity of abortion complications are directly related to the safety, affordability and accessibility of abortion services and where abortions are unsafe, to the management of complications. Mortality and morbidity are consequences of lack of access to information on safe abortion and where to find one; lack of money to be able to pay for a safe abortion; use of hazardous substances or methods to cause an abortion; lack of access to skilled providers and good quality services, including due to stigma and socio-economic barriers; and lack of post-abortion care, including access to contraception to prevent repeat unsafe abortion. [8] [5] [11]

The costs of unsafe abortions are high. In addition to the loss of women’s lives, there are high rates of morbidity in women who experience complications, some of which are lifelong, such as infertility. The the treatment of complications is expensive, resulting in a critical burden on public health systems. In addition, unsafe abortion translates into indirect economic costs related to loss of productivity and increased health problems for those women who survive, as well as the non‐economic costs, particularly the impact on women’s existing children, their partner and the extended family. [12]

Experience in a growing number of countries has shown that unsafe abortion mortality has been reduced by making abortion legal and making safe abortion services available, both surgical and medical methods. [13] In most countries, however, laws and policies regulating access to abortion and abortion services were developed at a time when only surgical methods existed. In countries that approve medical abortion using mifepristone + misoprostol, or misoprostol alone, laws, policies and health services need reforming so as to ensure that this new technology is included. Medical abortion is safe and effective for both first and second trimester abortions, and also allows women to have a very early abortion, as soon as they miss their menstrual period.

Additionally, medical abortion can be provided at primary level by a range of mid‐level health professionals, which requires less health system infrastructure. Therefore, expanding access to medical abortion is a critical aspect of any intervention aimed at reducing the impact of unsafe abortion and consequently reducing abortion-related mortality and morbidity.

This is a crucial aspect of efforts to strengthen other reproductive health services, including maternity care, the provision of contraception and emergency contraception, infertility services, and prevention and treatment for sexually transmitted infections, which together will improve women’s health, and reduce avoidable deaths and obstetric and gynaecological morbidity.

Safe and legal abortion as a woman´s right within the human rights paradigm

Unplanned pregnancy and induced abortion have always existed as part of women’s experience because women have always sought to have some control over their reproductive lives.

The impact of an unwanted pregnancy can be enormous. Given the complexity of the factors influencing a woman´s decision whether to carry a pregnancy to term or have an abortion, the only person who can take this decision is the pregnant woman herself.

Women will never attain equal status with men without control over their sexual and reproductive lives. Women’s equality and status in society are directly linked to their enjoyment of reproductive rights. Without the ability to make basic decisions about their bodies and lives, women cannot enjoy their rights to participate in education, the workplace, or the political sphere. Restricting women’s ability to safely terminate an unwanted, mistimed and/or unhealthy pregnancy is perhaps one of the most blatant manifestations of discrimination against women.

Today, 60% of women live in countries where abortion is legal and safe. 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.

There is growing attention on the part of international and regional human rights bodies to maternal mortality and morbidity, and to safe abortion as a public health issue and a woman’s right. These bodies have called upon governments to ensure women’s access to pregnancy care and to abolish social practices that negatively impact women’s health and have also recommended that States parties implement measures to reduce the causes of maternal mortality and morbidity. Moreover, women’s right to abortion has also been grounded in a broader range of fundamental human rights, [14] most recently in 2011 by the Special Rapporteur for the Right to Health, Anand Grover, whose report to the UN said:

The right to sexual and reproductive health is a fundamental part of the right to health. States must therefore ensure that this aspect of the right to health is fully realized… Realization of the right to health requires the removal of barriers that interfere with individual decision-making on health-related issues and with access to health services, education and information, in particular on health conditions that only affect women and girls. In cases where a barrier is created by a criminal law or other legal restriction, it is the obligation of the State to remove it. The removal of such laws and legal restrictions is not subject to resource constraints and can thus not be seen as requiring only progressive realization. [15]

The report outlined 14 recommendations on the right to health, including encouraging States to: decriminalise abortion; decriminalise the use and supply of all forms of contraception and remove barriers for spousal and/or parent consent; and ensure access to evidenced-based information and education on sexual and reproductive health. [16]

The international and regional human rights systems have a growing legal and political importance. [17] [18] UN human rights bodies and consensus documents have directly and indirectly recognized the connection between high rates of unsafe abortion and maternal mortality. [129] And have clearly indicated that denying women the right to a therapeutic abortion can violates her right to life, and the rights to health, [130] privacy [131] and to be free from cruel, inhumane and degrading treatment.[132] They have also have noted that where abortion is legal, States must ensure that it is available, accessible (including affordable), acceptable and of good quality and that despite the legal status of abortion, States must ensure women receive confidential and adequate post-abortion care.[133] Many countries have given constitutional status to human rights treaties and/ or have made them part of their national laws. Additionally, national courts and congresses have recognized the legal value of the decisions made by the international human rights bodies. On the other hand, the human rights framework not only includes legal instruments which can be applied at local, regional and/or international tribunals; it also has other uses such as for political discourse, as an advocacy tool, as a means for holding governments accountable; and as a guideline for the development of health care standards, among others. [19]

Moreover, the first decade of this century saw groundbreaking decisions from national courts and legislatures around the world, as well as in the regional and international human rights bodies on the right to access abortion. Emerging norms in these decisions include a wide range of human rights that are violated when women are denied access to safe abortion – the right to life,equality, dignity, heath, autonomy, freedom from cruel and degrading treatment, and non-discrimination. This important new legal framework provides increasingly robust protection for women’s health and reproductive self-determination.

At present, women’s right to comprehensive reproductive health services, including safe abortion, is rooted in international human rights standards guaranteeing the right to life, right to health, right to non-discrimination, the right to enjoy the benefits of scientific progress, and right to reproductive self-determination. International legal support for a woman’s right to safe and legal abortion can be found in numerous international treaties and other instruments. [20]

Box: International human rights standards applied to access to safe abortion [20]

The right to life is protected in multiple human rights instruments. It is widely acknowledged that in those countries where abortion is legally restricted, women have no other choice than to seek abortion in a clandestine environment, under conditions that are medically unsafe and therefore life threatening. Forcing a woman to go through a life-threatening unsafe abortion violates her right to life. [21]

The right to health is understood as the enjoyment of the highest attainable standard of physical, mental and social well-being, in accordance with human rights treaties and instruments. , [22] Unsafe abortion can have devastating effects on women’s health, causing death as well as long-term disabilities (such as uterine perforation, chronic pelvic pain or pelvic inflammatory disease). While the right to health does not guarantee perfect health for all women, it has been interpreted to require governments to provide health care and to work towards creating conditions conducive to the enjoyment of good health. In the context of abortion, this right to health can be interpreted to require governments to take appropriate measures to ensure that women are not exposed to the risks of unsafe abortion. Such measures include removing legal restrictions on abortion and ensuring access to high-quality abortion services.

The right to non discrimination is a fundamental principle of human rights law. Freedom from discrimination in the enjoyment of protected human rights is ensured in every major human rights instrument. Denying women access to safe abortion is a form of gender discrimination. According to the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) , "discrimination against women" includes laws that have either the "effect" or the "purpose" of preventing a woman from exercising any of her human rights or fundamental freedoms on a basis of equality with men. Restrictions on abortion discriminate against women by criminalizing a health-care procedure that only women need, thus compromising their rights to health and autonomy in reproductive decision making. The impact of abortion restrictions are felt primarily by women, who bear the physical and emotional burden of carrying an unwanted pregnancy to term or risking their lives and health by undergoing unsafe abortions.

The right to enjoy the benefits of scientific progress entitles any woman to the full range of technologies for the safest abortion care and it is enshrined in the Covenant on Economic, Social and Cultural Rights. As the medical and scientific communities make advances in abortion technologies, governments must seek to help all women benefit from those advances.

The right to reproductive self determination is supported in international guarantees of the rights to physical integrity and privacy and protects the right to make decisions about one’s body—particularly those that affect reproductive capacity. The global community has repeatedly acknowledged the right to decide freely and responsibly the number and spacing of one’s children. This right entitles women access to all safe, effective means of controlling their family size, and therefore supports access to safe abortion.

All these rights are violated when the normative frameworks and public policies make abortion services inaccessible and/or unaffordable to the women who need them. Under international law, governments can be held accountable for highly restrictive abortion laws and for failure to ensure access to abortion when it is legal. Governments also bear responsibility for deaths and injury among women forced to resort to unsafe abortion. [23] [24]

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3. Why advocate for safe, legal abortion?

Advocating for safe, legal abortion is needed for two primary reasons: to expand the supply of high-quality, affordable abortion services, and to support the demand from women and societies for accessible, non-judgmental care. Both aspects are vital and complementary parts of any effort to make abortion a legitimate health service for women.

Given its low cost, safety and efficacy and acceptability to women, medical abortion certainly has an important role in the expansion of access to safe abortion.

Moreover, since abortion is legal for some indications in practically all countries of the world, making safe abortion available is relevant everywhere, including in legally restricted settings where women are increasingly using this method, despite a wide range of barriers, through self-medication or on the advice of a health professional (including mid-level providers) because it is safer than any other traditionally used method. Indeed, based on widespread anecdotal information from health professionals and the few places where data have been recorded, the widespread use of misoprostol has led to a large decrease in the numbers and seriousness of abortion complications and deaths. [25] [26] [27]

Why advocate for access to medical abortion?

There are many reasons which support the need for advocating for medical abortion as follows:

Medical abortion has proven to be effective for the reduction of unsafe abortion complications and related mortality

Given the urgent need to contribute to the reduction of maternal mortality and morbidity, the global trends in liberalizing abortion laws, and policy evaluation results showing that medical abortion has lower costs, this technology is called to play an important role in the expansion of access to safe abortion. Moreover, since abortion is legal for some indications in practically all countries of the world, making safe abortion available is relevant everywhere, including in legally restrictive settings where women are increasingly using this method despite a wide range of barriers. [25] [28]

In countries where abortion is legally restricted, the use of medical abortion by women through self-administration or on the advice of a health professional (including a mid level provider) is safer than other traditionally used methods, particularly unsafe invasive methods or other hazardous substances. Indeed, in the few places where data have been recorded, the widespread use of misoprostol has led to a large decrease in the numbers and seriousness of complications. [29]

Medical abortion has been noticeably acknowledged by international scientific organizations

2001: the International Federation of Gynecology and Obstetrics (FIGO) issued the “Consensus Statement on Uterine Evacuation” that recommended to “Evacuate the uterus with vacuum aspiration or medications, not sharp curettage (also known as dilatation and curettage or D&C). Vacuum aspiration and medications for uterine evacuation should be introduced instead of sharp curettage to improve the safety and quality of abortion services for women”. [30] It was also recognized that the safety and tolerability of medical regimens for uterine evacuation were well documented [31] [32] that misoprostol is as effective as vacuum aspiration in the management of incomplete abortion [33], and that the complete abortion rates are generally lower in women who use medication compared to aspiration for the treatment of missed and induced abortion. [34]

2003: WHO included medical abortion in its technical and policy guidance on safe abortion, based on almost two decades of international research on its safety and efficacy. [35]

2005: WHO added medical abortion drugs (mifepristone and misoprostol) to its Model List of Essential Medicines. [36] This list includes the most efficacious, safe and cost-effective medicines for priority health conditions and are selected on the basis of current and future public health relevance, and their potential for safe and cost-effective treatment. [37]

2011: WHO included both drugs in the List of Essential Medicines for Mothers and Children and made recommendations to governments to make these drugs available for the improvement of maternal and child health. [38]

Medical abortion is acceptable for women

Unintended pregnancies are a fact of life. Even in societies where contraceptive use is very high, women (and their partners) may end up with an unintended or an unwanted pregnancy for many reasons, ranging from sexual abuse or coercion to contraceptive failure or failure to use contraception. Among over 700 million women using a contraceptive method, 33 million (or 5%) are likely to experience an accidental pregnancy. [4] Some pregnancies that are wanted may become unwanted due to the diagnosis of serious foetal impairment or the woman’s life or health may become at risk during or due to the pregnancy. Lastly, pregnancy tests can now identify a pregnancy even before a woman misses her period. Where medical abortion is accessible, this means that the pregnancy can be terminated very early and effectively.

Box: Evidence shows that many women prefer medical abortion for a range of reasons: [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51]

it is more natural
it does not involve surgery or anaesthesia
it is less painful and easier
it can be used as soon as a woman learns that she is pregnant
they feel more in control of the process because it happens in their bodies
they perceive it to be consistent with the body´s natural processes
those who have used medical abortion have said they would use it again or recommend it to a friend.

As has been shown with contraception, the choice of abortion method is an important feature of quality of care. Medical abortion provides women with the option of an early abortion that is safer, more easily accessible and less medicalized, while surgical abortion with manual or electric vacuum aspiration offers a procedure that takes only a short time and is carried out by a provider. Offering a choice between medical and surgical abortion allows women to choose the method that is more suited to them and upholds women’s right to benefit from technological and scientific advances.

Besides, medical abortion can easily be used by women themselves. Abortion with pills is far safer than the unsafe surgical or traditional abortion methods that women will use when desperately trying to end an unwanted pregnancy, and it has the same health impact as a spontaneous miscarriage. Follow-up treatment for miscarriage and even post-abortion care is available and legal everywhere although good standards of quality of care are not always guaranteed and post abortion contraception is not always available.

Given these conditions, in the last years, the expansion of access to medical abortion all over the world has increased considerably. Different strategies such as informational and referral hotlines, internet purchase, email counselling, pre and post abortion counselling, as well as the use of other communicational strategies for providing information and counselling to women in need of an abortion have been increasingly used mainly by civil society organizations, health services, and women´s groups to improve access to safe abortion, particularly in legal restrictive settings. [52] [53] This phenomenon has proven to be an additional indicator of how women are accepting medical abortion drugs as a good option for an abortion.

Medical abortion is more effective and less costly than other abortion methods

It is highly safe and effective for delivering both abortion and post‐abortion care services and they are also effective for both first and second trimester abortions as well as extremely early abortions. [31] [54] [55] [56] [57]
It is safer than other abortion procedures. The risk of developing a complication following any safe abortion procedure, including medical abortion, is very low: less than 1% of women have developed an infection after medical abortion in the first nine weeks of pregnancy, and no more than one in 1,000 women experiences heavy bleeding requiring a blood transfusion. [58] Medical abortion related mortality rate is indistinguishable from spontaneous abortion. [59]
It is cost‐effective, in large part because services can be provided by a range of midlevel health professionals (task-shifting) and because they require less infrastructure to be delivered. Given that mid-level providers often work in rural or remote areas where physicians are scarce or where there are few surgical facilities or equipment thus, the expansion of the medical abortion provider pool has the potential to greatly improve the reproductive health of women worldwide. [60] In France, Great Britain, Switzerland, Germany, Sweden, Viet Nam, South Africa and a growing number of states of the United States, nurses and midwives are permitted to provide medical abortion under the supervision of a physician. [61] [62] [63] [64]
It offers a choice for both the women and the providers, and can put the means of abortion into women’s hands, preserving their privacy and confidentiality.
It reduces health service costs since it requires a modest initial investment in facilities and equipment, and the training of appropriate providers. Medical abortion within 9 weeks of pregnancy can be provided in primary care settings, including low-resource settings. [65] There are few complications and most do not require emergency referral. [43] [66]
It is also useful for second-trimester abortion. [67] These abortions generally account for approximately 10% of all termination procedures in countries where abortion is legal, [68] [69] although in some, such as India and South Africa, they have been reported to be as high as 25%-30%. [70] [71] [72]

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4. What to advocate for?

Women´s health and rights advocates can use both public health and human rights principles and information to promote safe, legal abortion and to hold governments accountable for ensuring it, as follows:

Legal and policy restrictions on abortion should be removed and the law reformed so as to guarantee women’s right to a safe abortion

Liberalization of abortion laws can be incremental or all at one time. However, it takes many people and a huge amount of time and effort to reform the law and it is probably preferable, where possible, to propose substantive reform once, rather than in stages. On the other hand, in some countries it is only possible to make changes in stages, as it takes time to bring sufficient support on board to ensure success.

Law reform requires detailed knowledge of all relevant existing laws and the help of pro-choice legal experts in drafting either a new law or proposing total decriminalization by removal of all laws restricting abortion. Where laws list grounds upon which abortion is allowed (or exceptions which are not criminal), these almost always include: risk to the woman’s life and health; risk to the woman’s mental health; pregnancy as a result of rape and incest; fetal abnormality; risk to the woman’s existing children; contraceptive failure; and most importantly in terms of numbers of women affected, socioeconomic reasons such as unable to look after the child, poverty, young age, single marital status, recently born child, and so on. Positive laws permitting abortion at the woman’s request with no other restrictions are the best laws to try for if decriminalization (removal of abortion from the Penal or Criminal Code) is not possible. More far-reaching liberalization can include the reinforcement of the right to an abortion in the Constitution.

Procedural barriers, including spousal or parental consent, mandatory counseling or a waiting period between the request for abortion and the abortion itself should also be removed.

A number of countries have reformed their laws to allow abortion at the woman’s request but only up to a certain number of weeks of pregnancy, almost always the first 10-12 weeks of pregnancy, with greater restrictions on the second trimester. Sweden exceptionally allows abortion on request up to 18 weeks. While it is much more difficult to argue for allowing second trimester abortions, it is also essential to ensure they are addressed as it is often the youngest and most vulnerable women, and those for whom access to abortion is least possible, who tend to have second trimester abortions, and the risk of mortality and morbidity if these abortions are unsafe is higher.

ICMA organized an international meeting on second trimester abortions (the papers were published in 2008), and commissioned a review of laws globally on second trimester abortion that was published in 2010, which can serve as definitive texts on taking up this aspect of abortion law. [73]

Accessibility of abortion should be ensured

There are many potential barriers to obtaining an abortion and governments have an obligation to overcome them. Strategies include ensuring that medical education and training includes how to provide safe abortion care and health departments issue guidance to abortion providers; developing information for women; ensuring that lack of financial means does not impede access; and passing legislation and implementing policies that clearly outline the circumstances under which providers may conscientiously object while also ensuring that women can still access services without delay from willing providers. [65] [74]

WHO recommended abortion methods, including medical abortion, should be available

Access to a choice of surgical and medical abortions is preferable, but in countries with limited resources, it may not be possible. Because medical abortion requires less infrastructure and can be provided at primary or even community level, it may be the method of choice where surgical abortion cannot be provided. To ensure that all women have access to medical abortion in a safe setting, staffed with trained providers, medical abortion protocols should be officially approved, mifepristone and misoprostol should be registered for use as for abortion indication, and a broad cadre of mid-level providers should be allowed to provide medical abortion in settings that are close to where women live.

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5. Women’s organisations and NGOs have an important role to play in advocating for medical abortion in the context of safe and legal abortion

The right to safe, legal abortion services has been a central demand of the women’s health movement across the globe for more than five decades. [75] [76] [77]

Prevention of unsafe abortions is everyone’s responsibility. NGOs and women´s groups working for the promotion of human rights and social justice, and those working for women’s health and rights have made promotion of safe and legal abortion services, including medical abortion, an integral part of their advocacy agenda.

Advocacy may be defined as “the act or process of supporting a cause or issue (…) because we want to build support for it, influence others to support it, and try to influence or change legislation and policies that affect it”. [78]

Advocates can play various roles: to educate, to represent and to persuade

As an educator, the advocate is an expert on the topic (which does not mean that he/she has to be a professional) and this expertise may come from years of experience working in the reproductive rights movement, or from personal experience. A good advocate is confident about the information she/he is presenting and works to convince the others ( the public, the medical profession, policymakers, parliamentarians, and other stakeholders) that the issue at hand is worth paying attention to.

As a representative, the advocate presents the experience of the people whose lives are affected by the issue. One of the advocate´s goals is to bring alive the experiences of the people who are affected for diverse audiences, including policymakers. If the advocate wants to be heard, she/he has to convince them that she/he can and does speak for many others, and brings together representatives of others (women and women’s groups and work-related organizations such as trade unions, health professionals, legal experts) to raise their voices together.

As a persuader, the advocate should work to gain the support and backing of people and policymakers who will commit to his/her cause throughout the legislative, administrative or governmental process. This might mean getting a government official to vote for or co-sponsor reproductive rights legislation or declarations, getting a relevant ministry or executive branch official to support reproductive rights issues, or even just getting a member of a key official’s staff to care enough. [79]

Advocacy can take diverse forms and include very different kinds of activities

Despite the specific shape that advocacy work finally takes, it always needs good quality information (statistics, case studies, law and policy information, and other kinds of data, including real life stories) and a planned and comprehensive strategy. Good data has proven to be an effective tool for gaining attention as well as for moving key decision makers and other stakeholders to take action. A well-designed advocacy strategy has proven to be a critical condition for successful results.

Advocacy for making medical abortion available through health services is something that women’s organizations 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 have medical abortion as a choice.

There is a wealth of historical as well as current experiences in promoting access to safe and legal abortion worldwide. These experiences have included the use of:[80] [81] [82] [83]

provision of clandestine safe abortion services
collaboration with health providers to introduce abortion services in health service settings and clandestinely
organizing, supporting and attending days of action, street stalls, public meetings, conferences, petitions, protests and demonstrations
working with media
taking court cases to both national courts and constitutional courts to challenge laws and public policies
defending women and health professionals charged with illegal abortion in trials
submission of shadow reports to international human rights bodies
lobbying parliamentarians and policy decision-makers
running hotlines and using other communication strategies such as websites and social media to make abortion information and counselling available to women
mobilization of support from a wide range of stakeholders to bring about changes in law and policies

How to plan and implement advocacy strategies

There is a lot that can be learned from those experiences in terms of how to plan and implement advocacy strategies and specific actions for getting or expanding access to medical abortion in the context of safe abortion. Besides, there have been many articles and publications describing these experiences and manuals which help in strategizing to carry out advocacy activities. [79] [84] [85] [86] [87] [88]

Box: Some key steps in developing an effective advocacy strategy [85] [89] [90]

Objectives: What do you want? What are the long-term and short-term goals? What are the content goals (e.g. policy or legal change) and what are the process goals (e.g. building alliances with other stakeholders or sense of community among participants)?

Audiences: Who can give these to you? Who are the people and institutions you need to address? This includes those who have the actual formal authority to effect the changes being advocated for (i.e. legislators or policy makers), 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. Mapping the scenario, identifying all the stakeholders engaged in different ways in the dynamics of the current situation and in the future change process is critical for an advocacy strategy.

Message: What do you want to say and what do they need to hear? Reaching different audiences requires a different set of messages that will be convincing. Although these messages must be rooted in the same basic principles (those which are the fundamentals of your political thought), they need to be tailored differently for different audiences, depending on what they are ready to hear and what is the best way to frame the message for them according to their interests and particular perspectives on the issues. 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 trustworthy messengers for different audiences? In some cases, "experts" might be the most appropriate messengers because their credibility is largely technical and they have social standing. In other cases, there is a need to engage "vivid 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? Use the most effective means, depending on the situation. The key is to choose and apply them appropriately, weaving them together in a winning mix.

Some other key elements of an advocacy strategy to take into account are:

Choosing the forum

To influence laws and public policies, your effectiveness may depend upon the forum chosen to take action. The message needs to be heard by those who can have some influence in changing the status quo, both inside and outside government, and including Ministries of Health, Education and Finance as well as the legislative and executive branches, which draft and change the law and create bodies, regulations, rules and policies to implement it. Advocacy might also aim to influence the design, implementation, and/or evaluation of a public policy. These are different stages in public policy development that can be assessed as windows of opportunity to generate change.

Developing the message and selecting the key tools to use

The advocacy strategy should plan what is going to be said, the language that is going to be used, and the key concepts and relevant data that are going to be used to make your arguments consistent and persuasive. Be especially careful to avoid using erroneous information. There is lot of accurate evidence and very well-developed arguments out there to be used. It is a matter of searching for them, assessing their appropriateness for the local political situation and deciding what the key messages will be.

Box: It is important to use be consistent and to stay on the same message in all the different tools:

blogs
Facebook posts
tweets
presentations
leaflets
reports
public opinion polls
publications
letters to the editor, guest editorials and opinion pieces in the press and women’s and other magazines
discussions with policymakers
interviews with the media
fact sheets
briefing/position papers
lobbying letters (including open letters, petitions and sign-on letters)

Conducting legal and policy analyses

The assessment of current law and policies, both in terms of their scope and language discourse, their implementation procedures, and their outcomes and impact can help to understand how they regulate and restrict access to abortion services, including to medical abortion. This kind of analysis is very fruitful to identify facilitators and barriers. It may also point the way to how laws or policies should be reformed to improve women’s access to abortion.

For example, in relation to medical abortion, priority changes might be identified, such as:

registering and/or expanding indications for mifepristone and/or misoprostol for use as a medical abortion drug
broadening the cadre of providers allowed to offer medical abortion
broadening the range of clinics/settings in the health system where abortion services can be provided
training providers to offer medical abortion with up-to-date regimens and improving their communication skills to offer women a choice of methods and create a women-centred counselling environment
ensuring adequate funding for abortion services through public budget commitments
removing procedural barriers (such as mandatory counselling, spousal and/or parental consent)

Based on the analysis, additional advocacy priorities, e.g. for reforming current laws, might be identified, such as:

convincing the government to accept assistance in drafting new legislation on abortion
commenting on the draft legislation being proposed
commenting on how current laws are affecting access and quality of care
contributing to negotiations throughout the stages of the passage of a bill you support or defeat of a restrictive bill you are opposed to

You may also find it important to carry out an analysis of potential sources of support for and opposition to your proposals. Strategic questions should be answered, such as:

How is abortion discussed in the media? Who usually participates and what are the main positions taken?
Are there well-known individuals in government and civil society openly supportive of or opposed to legal abortion? And specifically medical abortion?
What are the positions of prominent lawyers, health professionals and their professional associations (nurses, midwives, general practitioners, obstetrician-gynaecologists) , religious leaders and others on abortion and medical abortion?
What are the positions of other NGOs, women’s organizations, community-based organizations, trades unions, students’ organizations, and journalists’ associations?
What are the sources of opposition to induced abortion and medical abortion in particular?

Building coalitions

Having identified who the supporters are nationally and locally, it is important to broaden the base of political support. Working with women´s NGOs and organizations, health professionals and lawyers – individually and with their associations, journalists and members of political parties who support the cause and/or may be persuaded about its relevance is a critical part of the political work needed.

Preparing for opposition [91]

Opposition to women’s access to safe abortion comes from many sources: conservative religious authorities and groups, opponents of women’s equality and of abortion, health professionals who object to abortion ethically, and political and community leaders who are afraid that supporting safe, legal abortion will make them lose elections.

Since abortion began to be legalised, there has been a well-organised and well-funded anti-abortion movement in many countries, which is opposed to abortion law reform and to any public policy that includes abortion access. Opposition to the licensing and availability of medical abortion drugs may be especially fierce.

There are many things to do to be well-prepared to address the opposition: [85]

Educate yourself about the opposition: identify anti-abortion groups and spokespersons, their agendas and their arguments 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. It is important to 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, public officials, judges, newspapers and journalists.

Avoid using anti-abortion language and terminology yourself 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 their children. Don’t call for a “reduction in abortions” but instead for a “reduction in unwanted pregnancies”. Never imply there are “too many abortions”, as if some abortions are not needed by the women who have them. Also be aware about not using the concept of “female feticide” when discussing sex-selective abortion as it implies these abortions are murder. Similarly, avoid using the term “mothers” to refer to pregnant women, not all of whom are mothers or want to be mothers.

Respond to opposition groups not directly, but by being pro-active and seizing 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 and take clear positions, backed up by evidence. Always correct any misinformation spread by the opposition by providing correct information and respond to false 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.

Building a new generation of pro-choice activists

A new generation of pro-choice activists and advocates continually 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 leadership roles. This is important even in countries where abortion laws are already relatively liberal and especially where the younger generation has not had to encounter the consequences of restrictive legislation or lack of availability of safe services.

History shows that to make abortion a woman’s right to decide, the following are key conditions to be built: [92]

a strong and diverse women’s health advocacy movement
the support of at least one political party, preferably more, and a government that takes responsibility for public health, including women’s health, in spite of the controversy it may cause
the involvement of health professionals whose commitment to health care includes providing abortion in a supportive way, using the safest available methods and without barriers
the development and dissemination of information about abortion laws and public policies to educate the public, find supporters and reach policymakers, health care professionals and the media
readable publications and leaflets, describing women’s experiences
use of sympathetic media and new communications technology to reach broad audiences
to lobby and work together with parliamentarians to table and debate bills, and promote a model law
to challenge restrictive laws in court and/or oppose criminal action against women and abortion providers
to develop social mobilization events (demonstrations, press conferences, public meetings) to put abortion on the agenda
to create a critical mass of support in the country, and especially among women

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6. Advocacy strategies for promoting access to medical abortion worldwide

Some of the activities that woman’s organisations and NGOs have been developing to make legal and safe medical abortion available include:

advocacy with policy makers for approval and availability of medical abortion drugs for the provision of legally permitted abortions

dvocacy with policy makers – particularly drug regulatory bodies – to approve mifepristone and misoprostol for a range of obstetric indications and for use in post-abortion care and provision of abortion as permitted by law

advocacy with health professionals to sensitize them to women’s need for safe abortions, and encourage them to speak out about their experiences of dealing with unsafe abortions, and encourage them to offer the choice of medical abortion to women seeking an abortion

advocacy with human rights and other social movement organizations to include access to legal and safe abortion as a priority in their own political agendas

Social mobilisation campaigns

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 offer eleven valuable case studies. [80] 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 widely acceptable to women and 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 organizations and NGOs in many countries to create a more favourable public opinion on liberalization of abortion law and publicise the consequences of abortions being illegal and unsafe. Campaigns have usually been run by broad coalitions of civil society actors, with the women’s movement at the helm or in leadership roles. An analysis of these campaigns shows that a wide range of activities are best launched together over a period of time to increase the visibility of the issues and make an impact on public opinion.

Media campaigns can take the form of:

social media messages and blogs
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
a mass postcard campaign sent to legislators by advocates, organizations and their members and the public
websites with information on abortion and specifically on medical abortion, including testimonies and experiences of women who have had an abortion
press conferences or public tribunals attended by large numbers of supporters
“speak-outs” by women, e.g. those who have experienced unsafe abortion or those who have used medical abortion successfully

Pilot test the messages first with friends and colleagues, and modify before being used in a mass campaign. Publicise the campaign extensively, e.g. via social media, invitations, e-mail, press releases and announcements in such places as newspaper or magazine calendar listings.

Box: Italy and Effe magazine campaign in the early 70s [93]

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).

Box: Campaigns to break the silence of the abortion experience

Women on Web website campaign “Show your face” [94]

This international organization has been working in this campaign to break the taboo and give mental support to women who seek for an abortion, are undergoing an abortion and/or have had an abortion around the world. Women are invited to write about their experiences and to keep anonymity if they want. In their website women´s abortion stories are shown in a friendly way, highlighting the wide range of reasons and contexts in which women decide that an abortion is what they need and/or want to do. Their website also provides up-to-date information and on line consultation on how to induce an abortion using drugs, and gives counselling for women going through this process.

Campaign in Chile: “Yo aborté” (“I had an abortion”) [95]

The organization of young women Conciencia Feminista (Feminist Consciousness) has a blog through which abortion experiences are shared. Abortion is totally prohibited in Chile and women have little access to information and support. The purpose of this initiative is to share a space where women can comment on their doubts, get information, share their feelings and any other need related to the abortion decision making process and on the abortion experience. As it is said in their blog “Invitation is opened to share the abortion experience, no matter what the feelings might be … pain, relief, hope or distress”.

Box: 2010 Campaigns in Australia [96]

WAAC (Women's Abortion Action Campaign), PCAC (Queensland), Radical Women (Victoria), Campaign for Women's Reproductive Rights (CWRR Victoria) and many other organisations and individuals from around Australia took part annually in the National Day of Action. “Supporters of a woman’s right to choose abortion will hold actions around Australia on October 9 to support the young couple in Cairns who have been charged under the Queensland Criminal Code provisions which relate to abortion. The charges relate to the use of RU486, an abortion drug, which they obtained from relatives overseas. RU486 is considered a safe, legal treatment in Australia. However its distribution remains tightly controlled. The laws under which they have been charged date from 1899, are archaic and out of touch with community opinion on the issue of abortion in Australia. The campaign stands up for the updating of the law by repealing all provisions relating to abortion and have it treated in the same way all other medical procedures are treated.

The organizations supporting the campaign and many other pro-choice groups from around Australia joined the National Rally and March every year, on a certain date, to focus on a specific topic and on the broad demand of better access to safe abortion in Australia and to demonstrate support for abortion rights.

Box: Ireland and the Abortion Rights Campaign [97]

The Safe and Legal (in Ireland) Abortion Rights Campaign represents the first major initiative aimed at moving forward on abortion in this country. Anti-choice groups seeking further regressive and unworkable responses to abortion have always led previous campaigns on abortion. The campaign can be found on You Tube, blogspot, facebook and twitter.

Since the first Constitutional referendum on abortion in 1983, Ireland has changed: more women living in Ireland cannot ? access abortion services and more women feel angry and frustrated that they have to travel to Britain and other countries to secure these services. As the Campaign says “The only thing that has not changed is the lack of courage and leadership demonstrated by successive Governments in dealing with abortion in a realistic and rational way”.

The Campaign is all about ending the hypocrisy of exiling women in crisis pregnancy that choose to have an abortion. It includes various strands, including a litigation strand, a public awareness strand and a national and international advocacy strand. A key component of the campaign is the challenge by three Irish women, ABC v Ireland, in the European Court of Human Rights. The three women, ABC, are basing their complaint around four Articles of the European Convention on Human Rights.

Their website invites people to join by sending an email, clicking the Take Action section and following through on some e-advocacy via their new media on You Tube, facebook, blogspot and twitter, or by sending a donation.

They also give tips to engage people in advocacy strategies such as:

Letters to the Editors of national newspapers on our issue of abortion. Pro-Choice letters are always valuable to raise our issue and give support to the pro-choice movement in Ireland. (Emails of important national newspapers are provided).
Write to the Taoiseach (leader of the country) urging that abortion be legislated for
Write a letter to the Minister for Health and Children
Write a letter to the following party leaders of the Labour Party, Fine Gael, Green Party and Sinn Fein.
Get involved with the Pro-Choice movement sending an email to get involved or express your support.

Using opinion polls and surveys to gauge and influence public opinion

Public opinion polls provide an important gauge of public views and can be influential in favour of abortion law reform and provision of services, and have been a strategy adopted by women’s organisations and NGOs in many countries. [98] However, skilled people should devise the questions and the methodology. The sampling methodology needs to include respondents who are representative, and the wording and order of the questions and the analysis of data from opinion polls are also extremely important aspects to be taken into account. Moreover, vague and hard-to-interpret questions may yield vague answers that can be interpreted in any number of ways. [99]

Box: The use of public opinion polls

Nepal: Advocacy for abortion law reform over several decades culminated in the passage of a new law on abortion in 2002. The parliamentary process took almost four years from the tabling of the bill. During the mid-1990s, the Center for Research on Environment, Health and Population Activities (CREHPA), a non-governmental organisation (NGO) specialising in research and advocacy, became involved in the abortion issue, carrying out a number of studies on the effects of the illegal status of abortion on women's rights and welfare, particularly poor women. In 1996, as part of its advocacy strategy, CREHPA conducted a public opinion poll which demonstrated broad support for legalisation of abortion. [100]

Mexico, Colombia and Bolivia: Public opinion polls were conducted in 2003. These surveys showed that a majority of Catholic respondents believed abortion should be permitted to save a woman's life, when doctors believe the foetus will not survive or when the pregnancy is the result of rape. [101]

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. [102]

Argentina: In 2005, a website (www.despenalizacion.org.ar) was launched as a resource center to support the right to safe and legal abortion. Analysis of public opinion polls showed that 60% of the general population supported abortion decriminalization. A fact sheet synthesizing the results of the opinion polls was developed to be used for sensitizing legislators, policy makers as well as for its use for social debate. [103] In 2011, a national public opinion poll was conducted which showed that most Argentineans are in favour of liberalising the abortion law. Over 80% of those polled support a woman's right to access abortion care when her health is at risk or when the pregnancy is a result of rape. Almost 70% support abortion being available when the fetus has severe abnormalities. The survey also showed that while abortion is officially almost completely unobtainable in Argentina, a third of the population surveyed know someone who has had an abortion. About three quarters of the population is Catholic, but 70% of the respondents rejected the idea that Catholics have a moral obligation to vote against candidates who support legal abortion. [104]

World Public Opinion Poll: In 2008, the results of an opinion poll were released. 18,465 people in 18 countries in five continents were surveyed. Three-quarters of the respondents rejected the use of criminal penalties such as fines and imprisonment, to discourage abortions, as did the majority in 17 out of 18 countries, for those who provide as well as those who have abortions. Only respondents in Indonesia had a majority (60%) that favoured criminal enforcement. None of the other Muslim countries surveyed (Iran, Egypt, Occupied Palestinian Territories, Azerbaijan, Turkey) had such majorities. Only 18% of all respondents thought that governments should use punitive means to discourage abortion. 52% of respondents thought that the individual woman, not the state, should control abortion decisions, with overwhelming support for this in North America and Europe. There were no significant differences between the answers given by men and women. [105]

Ireland: Abortion is currently legal if there is a substantial risk to the life of the pregnant woman, but illegal when the woman's health is at risk, where the pregnancy is a result of rape or incest, where the fetus will not survive outside the womb or where the women decides the continuation of pregnancy is not in her best interests. In 2010, a YouGov national opinion poll, indicated high levels of support for increased access to abortion in Ireland, representing a shift in public attitudes. Abortion was supported by 79% of the respondents if the pregnancy endangers a woman's health; 78% if the pregnancy is the result of sexual abuse, rape or incest; 87% if the pregnancy seriously endangers a woman's life; 62% if there is evidence of profound fetal abnormality; and 41% if the woman believes it is in her and/or her family's best interests. Only 3% felt that abortion in Ireland is not acceptable under any circumstances. [106]

Working with community-based organizations to mobilise support

It is important for women’s organisations and NGOs to work with and build the capacity of community-based organizations (CBOs) that are concerned with women’s rights and health. These CBOs may include women’s self-help groups and community health committees.

Interested individuals with leadership traits may be recruited from CBOs who 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.

The section of this information package which contains information for women needing to know about abortion, may be adapted, with the help of CBO volunteers and local women, to address women’s expressed needs in the local area. (https://medicalabortionconsortium.com/articles/for-women/main-book/?bl=en)

Examples of this work in relation to abortion are given below but there are many other examples in community-based work on sexual and reproductive health and HIV as well in the literature.

Box: Community-based involvement improves abortion care in rural South Africa [107]

In 1994 the Choice on Termination of Pregnancy Act in South African gave women the legal right to terminate their pregnancies on wide grounds. However, ten years later, quality abortion care was still mainly available in urban settings and used by those who could afford to pay privately. The fragmented and overburdened health care system, combined with patriarchal and conservative values, a lack of medical sophistication among women and the physical distance between home and the nearest approved centre, meant that the reality for rural women had barely changed. In Limpopo region a series of workshops helped to mobilise the community to improve this situation. A range of religious and traditional leaders, hospital managers, health care workers, municipal councillors, mayors, teachers and staff from community-based organizations were brought together to examine access issues. Using group work, fictional case studies, self-assessment and information-sharing sessions focused on both practicalities and attitudes, the workshops highlighted the contrast between the ideals of the law and the everyday reality of unsafe abortions for local women. The workshops identified key needs, including the recognition of women’s reproductive rights, increased tolerance of divergent views on abortion, a focus on quality of care for women seeking abortions, and the necessity to train more abortion providers. As a result of these workshops, 60 of the 92 midwives who attended volunteered to be trained, key members of the community became involved in the dissemination of relevant information on abortion and family planning, and more clinics have started offering abortion services.

Box: The Nepal experience [108]

The Programme for Alternative Technologies in Health (PATH) worked (2004-2006) 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 intervention. The intervention aimed to win community support for safe abortion, following the legalisation of abortion in the country, through facilitated dialogue in groups and the use of participatory drama. In the facilitated dialogue groups, trained community volunteers brought together women of reproductive age, and sometimes men and older women who were the decision-makers at household level, on matters related to reproduction. A variety of techniques were used to initiate discussion, such as stories, role plays and experience-sharing. This was followed by informal, facilitated discussion whose aim was to create a safe space to reflect on community values and beliefs. In participatory drama, incomplete stories were enacted. The actors froze at dilemma points and the audience was challenged to come up with suggestions on how to proceed. Afterwards there was facilitated discussion and reflection on the issues presented. The dramas were enacted twice every month and the community returned to watch the next episode.

Advocacy with health professionals

In many developing countries, in spite of restrictive abortion laws, obstetrician–gynaecologists and other health professionals, including abortion providers, are compassionate people who support women’s needs and have played a leading role in reforming the abortion law and offering abortion services.

It is important to reach health professionals with the message that medical abortion is a bona fide abortion method options, 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 in Human Reproduction at the World Health Organization, Geneva, have successfully introduced medical abortion in Sweden, UK, Cuba, India, Mongolia, Romania, Turkey, Tunisia and Vietnam. Besides this, Gynuity Health Projects has 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, and has a vast experience in introductory studies and in training of health professionals.

Women’s organisations and NGOs that provide reproductive health services could also participate in 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.

Another way is to carry out an assessment of abortion services in the country, using WHO’s strategic approach and involving policymakers, health professionals and advocates. [109] [110]

A specific section on this information package has been developed to target 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. (https://medicalabortionconsortium.com/articles/for-health-care-providers/health/?bl=en)

However, research also shows that although health professionals in legally restricted settings may be sympathetic to women’s need for safe, legal abortion, they may decide not to risk helping women who approach them unless they know them, e.g. for fear of being reported. Some studies show the importance of addressing this issue with obstetrician-gynaecologists. [111] [112] [113] [114] [115]

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 national conferences
Sponsor health professionals to attend and present papers on safe abortion and medical abortion in national scientific meetings
Prepare an information package with key articles on medical abortion that have been published in well-known professional journals
Arrange for exposure visits of policy makers and health professionals to countries or settings in which medical abortion is provided
Organise 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
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

Box: South Africa experience in working with health providers and stakeholders [117]

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. There was an increased ability of health providers to respond professionally and appropriately to women seeking abortion. There was also better communication and open discussion about abortion among staff members and between staff members and women.

Box: Working with values clarification workshops [118]

Nepal, South Africa, Viet Nam: Workshops aimed at clarifying values are useful for addressing barriers to access stemming from misinformation, stigmatisation of women and providers, and negative attitudes and obstructionist behaviours. They engage health care providers and administrators, policymakers, community members and others in a process of self-examination with the goal of transforming abortion-related attitudes and behaviours in a direction supportive of women seeking safe ? abortion. This is especially important for women seeking second trimester abortion, which tends to be even more stigmatised than first trimester abortion. Some recommendations that emerge are that values clarification should be included in abortion training, service delivery and advocacy programmes.

Working with policy makers and parliamentarians

Advocacy efforts are needed to win support from policy makers and parliamentarians for abortion law reform in legally restricted settings, for provision of abortions that are legal under existing law, and for making mifepristone and misoprostol available for medical abortion.

In working with these audiences it is important to know:

Which bodies and committees make the decisions about these issues?
Which policy makers and parliamentarians are supportive?
What would be appropriate ways of making more policy makers and parliamentarians take up and prioritize these issues?

The Centre for Reproductive Rights has developed guidelines for crafting an abortion law that respects women’s rights. Medical abortion should be included among approved abortion methods when drafting such a law. [119]

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. Sending research reports and other materials on medical abortion, inviting policy makers as special invitees at meetings and workshops, and creating specific policy briefs that policy makers can use in debates and conversations are also key tools for keeping policy makers informed, involved and committed to safe and legal abortion.

Another strategy is to carry out extensive research regarding services among national and local stakeholders, and present the findings to relevant policy-making bodies, such as a task force on reproductive health or a parliamentary standing committee, e.g. on women’s status or maternal mortality.

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 and progress. This has also been true for medical abortion, as evident from developments in France in 1988 soon after the drug was approved. Anti-abortion groups see medical abortion as a major threat because the “little white pill”, as it is sometimes called, has the potential to take abortion out of easily identifiable clinics, making it more difficult to picket or attack providers and users.

Box: Advocacy to keep mifepristone on the market in France, 1988 [120] [121]

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 mifepristone in September 1988. On 26 October 1988, however, 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 opportunity to do clinical trials on mifepristone. Pro-choice organizations and family planning associations also sent letters demanding that the drug 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.

Box: Mexico City law reform process [122]

Beginning in the 1970s, Mexican women’s groups and human rights activists worked to change local abortion laws, while conservative forces in the Catholic Church, the Parliament, and elsewhere fought to keep the practice outlawed. On 24 April 2007, the Legislative Assembly of Mexico City passed a landmark law decriminalizing abortion, regardless of grounds, within the first 12 weeks of pregnancy. Previously, abortion had been legal only in cases of rape and fetal anomaly, or to preserve the health and life of the woman. The new law mandated that public hospitals must provide legal abortion services, free of charge, to any Mexico City resident who requested it. Women from outside Mexico City receive services for a sliding scale fee.

High on the list of Mexican activists were members of the National Pro-Choice Alliance which acted as a key player in the reform movement, helping both to ignite and guide a series of legislative transformations. Alliance members impressed upon the delegation that the momentous 2007 vote, which changed the face of abortion in Mexico City overnight, was the result of a long, deliberate process of raising awareness and chipping away at the previous law. The Alliance built relationships with hospitals, private and government health officials, and civil society. As they became more active and influential the abortion debate was forced into the political arena. Over time, the Alliance also became the pro-choice contact for the media. They saw to it that media coverage of the abortion issue grew exponentially and included a spectrum of perspectives, such as public health, human rights, theology, social justice, and medical arguments in support of abortion.

The final bill was approved by a two-thirds majority and was part of a comprehensive initiative to promote women’s rights, prevent unintended pregnancies, and reduce maternal mortality. In addition to legalizing abortion, the bill also reduced sentences for women undergoing abortion after 12 weeks, guaranteed access to medically accurate sexuality education and contraceptive methods (including emergency contraception), and initiated public health campaigns on reproductive and sexual health and rights and the prevention of unintended pregnancies.

In the two years following passage of the law, more than 18,000 safe, legal abortions were performed in public facilities, compared to the four preceding years when there were only 66 legal abortions. The change in the law, and with it a change in the conditions under which abortion is typically performed, has meant a significant decline in abortion-related deaths. At present, mifepristone + misoprostol as well as manual vacuum aspiration are used to provide safe and legal abortions.

Box: Advocacy with policy makers to remove legal barriers to the availability of mifepristone: Queensland, Australia [123] [124]

In Queensland, Australia, a coalition of women’s organisations and NGOs successfully lobbied for the removal of legal barriers to the 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 Senate that 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.

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.

Box: Abortion law reform by the Constitutional Court of Colombia [125] [126] [127] [128]

A landmark decision on 11 May 2006 by Colombia’s highest court has ruled that abortion must be permitted when a pregnancy threatens a woman’s life or health, in cases of rape and incest and in cases where the foetus has malformations incompatible with life outside the womb. Until that day, abortion in Colombia was against the law in all circumstances.

The decision came as a result of a constitutional challenge filed by a Colombian lawyer, against Article 122 of the Colombian penal code, which criminalized abortion under all circumstances. This lawyer´s challenge to Colombia’s abortion law used international human rights law, arguing that Colombia was violating its obligations under international treaties ensuring women’s rights to life and health.

The petition set forth that the criminalization of abortion violated the following rights:

The right to equality and to non-discrimination (Political Constitution, Art. 13), by criminalizing a medical practice that only women need and which, in certain cases, is necessary to save their lives. This discrimination affects only women, and disproportionately impacts young, poor and rural women.

The right to life, health and integrity (Political Constitution, Art. 11, 12, 43 and 49), by failing to recognize the effects the total criminalization of abortion has on the life, health and integrity of women.

The right to dignity, reproductive autonomy and the free development of personhood (Political Constitution, Preamble and Art. 1, 16 and 42), by obligating women to carry unwanted pregnancies to term – in the case of rape from the beginning of the pregnancy, or in other cases, when serious fetal impairments, incompatible with life outside the womb, are found to exist – including when it goes against the woman’s best interest for her physical, psychological or emotional well-being. These rights are also violated in that women are treated as “reproductive machines”, ignoring the right to determine their own lives.

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7. Just to bear in mind when joining the advocacy world

All those who engage in abortion advocacy have to be ready for the long haul and be prepared for fierce opposition. The history of struggle for abortion rights over the past decades has always been one of “two steps forward, one step back” – and of having to run just to stay in one place.

Making medical abortion available to all women seeking abortion is part of the broader public health and human rights struggle for making safe abortion accessible to all women. Advocacy for promoting access to medical abortion calls for continual 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 high quality abortion services, including medical abortion. Continued engagement of advocates is necessary also for disseminating information to women about services and the 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 for new technology such as medical abortion not to be denied to women, especially not at the cost of their health and lives.

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[117] - Vincent, L. (January 01, 2011). South Africa's Abortion Values Clarification Workshops -- An Opportunity to Deepen Democratic Communication Missed. Journal of Asian and African Studies, 46, 3, 264-277.

[118] - Turner, K. L., Hyman, A. G., & Gabriel, M. C. (January 01, 2008). Clarifying Values and Transforming Attitudes to Improve Access to Second Trimester Abortion. Reproductive Health Matters, 16, 31, 108

[119] - Center for Reproductive Rights. (2006). Gaining Ground. A Tool for Advancing Reproductive Rights Law Reform. New York: Center for Reproductive Rights.

[120] - “Physically, it is just a little white pill”. (2012). leda.law.Harvard.edu/leda/data/278/Wilson,_Lisa.html, Accessed February 26, 2012.

[121] - RU-486: a continuing saga. (January 01, 1988). Abortion Research Notes / International Reference Center for Abortion Research, 17, 3-4.

[122] - Pathfinder International. (2010). Abortion Advocacy in Brazil and Peru. http://www.pathfind.org/site/PageServer?pagename=Programs_Peru_Pubs. Accessed on February 26, 2012.

[123] - From the website of Children by Choice, Australia. (2012) www.childrenbychoice.org.au/nwww/ru486.htm. Accessed on February 26 2012.

[124] - http://www.arha.org.au/Resources_and_Links/RU486/ARHA-RCA_RU486REPORT.pdf

[125] - Amado, E. D., Calderón, G. M. C., Cristancho, K. R., Salas, E. P., & Hauzeur, E. B. (November 01, 2010). Obstacles and challenges following the partial decriminalisation of abortion in Colombia. Reproductive Health Matters, 18, 36, 118-126.

[126] - Centre for Reproductive Rights. Landmark decision by Colombia's highest court liberalizes one of the world's most restrictive abortion law Accessed on 23 February, 2011 from http://www.reproductiverights.org/pr_06_0511colombia.html

[127] - Cook, R. (May 01, 2007). Excerpts of the Constitutional Court's Ruling that Liberalized Abortion in Colombia, Women's Link Worldwide (2007) Foreword by. Reproductive Health Matters, 15, 29, 160-162.

[128] - Challenging abortion law in Colombia. ( 2005). www.womenslinkworldwide.org/pdf_programs/prog_rr_col_articles_25.pdf . Accessed on February 26 2012.

[129] - See eg: UN Human Rights Council, resolutions on preventable maternal mortality and morbidity and human rights, resolution 11/8, 2009; , CEDAW/C/PRY/CO/6, para.31(a)

[130] - LC v. Peru (CEDAW 2009)

[131] - K.L. v. Peru (Human Rights Committee)

[132] - K.L. V. Peru (Human Rights Committee); L.M.R. v. Argentina (UN Human Rights Committee)

[133] - See, e.g., ICPD Programme of Action paras, 7.8, 8.25, 13.14(b), 1994; K.L. v. Peru, Human Rights Committee, No. 1153/2003, U.N. Doc. CCPR/C/85/D/1153/2003 (2005); L.M.R. v. Argentina, Human Rights Committee, No. 1608/2007, U.N. Doc. CCPR/C/101/D/1608/2007 (2011); L.C. v. Peru; Rep. of the Special Rapporteur on the right to health CEDAW Committee, General Recommendation No. 24, supra note 12, 12(d) (identifying violations of medical confidentiality as a form of discrimination against on women); Convention on the Elimination of All Forms of Discrimination against Women, art. 2(b), G.A. Res. 34/180, U.N. GAOR, 34th Sess., Supp. No. 46, at 193, U.N. Doc. A/34/46 (1981) [hereinafter CEDAW] (requiring States to "adopt appropriate legislative and other measures, including sanctions where appropriate, prohibiting all discrimination against women.").