The ICMA Information Package on Medical Abortion
Information for women’s health advocates, abortion rights organizations and other NGOs that support women’s sexual and reproductive rights / Updated in 2013
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.
|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.  
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. 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  while an estimated 5 million women are hospitalized due to such complications each year.
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%.  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”. 
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).
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. 
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.  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. 
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.   
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. 
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.  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,  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. 
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. 
The international and regional human rights systems have a growing legal and political importance.   UN human rights bodies and consensus documents have directly and indirectly recognized the connection between high rates of unsafe abortion and maternal mortality.  And have clearly indicated that denying women the right to a therapeutic abortion can violates her right to life, and the rights to health,  privacy  and to be free from cruel, inhumane and degrading treatment. 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. 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. 
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. 
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.  
|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.   
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.  
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. 
Medical abortion has been noticeably acknowledged by international scientific organizations
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.  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.
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.   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
|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. 
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.  
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.
|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.   
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”. 
Advocates can play various roles: to educate, to represent and to persuade
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:   
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.      
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.
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:
Based on the analysis, additional advocacy priorities, e.g. for reforming current laws, might be identified, such as:
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:
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 
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: 
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: 
|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:
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.  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:
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.
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.  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. 
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.
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.  
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.     
Some ways to involve and engage health professionals:
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:
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. 
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.
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.
|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.
 - IPAS. (2005). Ensuring women's access to safe abortion: Essential strategies for achieving the Millennium Development Goals. (2005). Chapel Hill: IPAS.
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