How to leverage innovation to increase access to self-managed medical abortion in restrictive settings

A growing body of evidence from across the globe affirms that lack of access to safe, timely, affordable and respectful abortion care is a critical public health problem and a human rights issue. Millions of women and girls with unintended pregnancies continue to face access barriers, often pushing them to resort to unsafe abortion. Indeed, unsafe abortion is a leading, yet preventable, cause of maternal deaths and morbidities. Of the estimated 73 million induced abortions that take place globally every year, 45% are unsafe and they account for up to 13% of preventable maternal deaths worldwide. Developing countries bear the burden of 97% of all unsafe abortions .

These statistics are both appalling and unacceptable, especially given that abortion is a simple health care intervention that can be safely and effectively provided even within contexts of limited resources. Numerous barriers continue to hinder access to safe and respectful abortion. They include restrictive laws that criminalise abortion, high costs, social stigma, negative attitudes of providers, poor quality of services, lack of access to accurate information, among others.

These barriers are not insurmountable. Self-care, within the context of a safe and supportive enabling environment, is emerging as one of the ways to circumvent a number of these barriers. Specifically, self-managed medication abortion (MA) is proven to be a highly acceptable and safe option during the first 12 weeks of pregnancy. The approach is supported by World Health Organisation recent guidelines on abortion care and self-care interventions.

Drawing from Options’ experience in advancing the right to safe abortion in numerous countries around the world, we commemorate this year’s International Safe Abortion Day (28 November) by reflecting on how leveraging innovation can increase access to self-managed medical abortion in restrictive settings. Specifically, we turn the spotlight on how two of our programmes delivered innovative and potentially game changing solutions.

Supporting Access for Adolescents to Integrated Sexual and Reproductive Health Services (Safire)

Safire aimed to reduce unsafe abortion among adolescent girls in two high-burden countries in sub-Saharan Africa. In both countries, access to safe abortion care was constrained by a number of barriers, including restrictive laws and policies. We recognised that these barriers were more pronounced for adolescent girls who found themselves in situations of unintended pregnancy.

Taking a human centred design (HCD) approach, we used in-depth research and analysis to gather insights from girls on what ‘girl-approved’ safe abortion services meant to them. We learnt what sources and channels of information they preferred, and what service delivery approaches suited their needs and circumstances. We applied these insights to design an integrated delivery model through a process of testing, seeking feedback, iteration and adaptation.

Our integrated model consisted of three pathways: reaching girls with accurate information, community engagement focusing on creating a stigma-free conducive social environment, and providing quality services through a network of trained, supervised and supported private sector vendors and referral centres.

The Safire model was ground-breaking in many ways but perhaps what stood out as most innovative was the support the so-called ‘Big Sisters’ offered to girls during their entire process of seeking and engaging in abortion self-care. Big Sisters were ‘near peer’ cohort of girls (slightly older than the target group of 10 to 19-year-old adolescent girls) that we trained, supported and supervised to deliver group education session and non-judgemental individualised counselling and referrals, including accompaniment to the vendor where needed. The partnership of trust created between a Big Sister, a vendor, and their client was the key to unlocking safe, affordable access to quality MA services for adolescent girls. Big Sisters supported girls to navigate the system with confidence, including by leverage ICT platforms and interpersonal networks to improve access to services and information.

On the supply side of the Safire ecosystem was a network of private sector providers (vendors) who provided safe and discrete services, including quality and affordable abortion medication and links to referral services (including higher level health care services and psychosocial support). In addition, we worked with local civil society organisations (CSOs) and champions to foster more supportive community norms that enabled girls to take control over their reproductive health choices.

By the end of the programme we:

• Reached over a quarter of a million girls (263,148 in total) with sexual and reproductive health information through a network of 243 Big Sisters and other information pathways, including social media.
• Enabled 371 Safire vendors to serve over 36,000 girls (36,548 in total) with quality MA services, with over 70% of the girls being referred by the Big Sisters.The programme taught us that self-managed MA can be successfully and safely integrated into adolescent sexual and reproductive health (ASRH) initiatives, even in highly restricted settings. The programme model addressed the major barriers faced by girls in accessing safe abortion and other ASRH services by building a solution with girls and communities, working with local organisations, and adapting to reflect what was working, and emerging needs.

OPTions Learning Platform: Intersecting innovation and safe abortion

Options is currently hosting the Grand Challenges Canada-funded “OPTions Learning Platform” (OLP) for the Options for Pregnancy Termination Innovation (OPTions) Initiative. OLP’s goal is to accelerate the impact of OPTions Initiative innovator organisations from across the globe by providing technical support along the innovation journey from achieving proof of concept through to transition to sustainable impact at scale.

The focus of the OPTions Initiative is to support the testing and development of new approaches to increase early access to existing safe abortion products and services in low- and middle-income countries and the development of next-generation methods for safe abortion. OPTions innovator organisations are pioneering new strategies in telemedicine, digital health literacy and self-care, testing new service delivery models through the public and private sector, and exploring new devices for quality of care and medication.

Under this initiative, Options provides technical assistance to the innovators – who include national CSOs, international organisations, academic institutions and social entrepreneurs – to develop effective, quality and scalable transformative solutions to support reproductive choices. To date, we have supported over 40 innovators to strengthen their innovation design through mentorship in technical areas including monitoring and evaluation, safeguarding, quality of care, and scaling strategies through small workshops, webinars, solution dialogues and mentorship. Moving forward, we will continue providing tailored technical support to innovators with a focus on improving quality and helping them to navigate their scaling pathway.

The OPTions Learning Platform is teaching us useful lessons on how innovation can catalyse breakthroughs that enable more women and girls to access safe abortion services. Among the insights we and the innovators have gained are:

• Innovating with scale in mind: We are learning that the innovation-learning-scaling up process is not a linear process but rather one with numerous turns and twists that can easily dim the innovator’s vision. And that venture advisory and business development mentoring to help innovators deepen their understanding of the market and positioning for various forms of growth financing is critically important. Given the unlikelihood of securing continuous flow of external funding, innovators, we have also understood the relevance of thinking ahead and exploring how each successive grant could systematically build on the preceding one to create a cumulative series of leaps towards the long-term goal of their innovations.
• Nurturing next generation methods: Developing, testing and proofing new methods of pregnancy termination is a long and daunting journey. Innovators often struggle with designing robust pre-clinical and clinical trials, as well as navigating regulatory landscape. Next generation methods innovators are eager to receive expert technical support, but it needs to be tailored and, more importantly, confidential.
• Flexible funding models are needed: The portfolio of innovations funded under the OPTions Initiative goes to prove that there is no shortage of innovative ideas and local solutions to help extend access to safe abortion for underserved users. However, the lack of available funding to develop, test and scale such solutions is a major drawback. There is need for more funding through flexible models that acknowledge contextual complexities and that are bold enough to deal with inherent risks. The OPTions Initiative demonstrates the pivotal role that funders can play in supporting innovators to expand the frontiers of access to safe abortion.
• Collaborative knowledge sharing can enable innovators to secure quicker wins: Innovators often face similar challenges. Thus, providing a platform for networking and sharing of best practices within a collaborative innovator community and network is essential. Based on this lesson, OLP is facilitating the crafting of a value-based community of practice that will enable peer-to-peer connections and a safe space for sharing and nurturing complimentary initiatives.

The insights shared in this blog underline that it’s not only possible but also imperative for stakeholders to integrate safe abortion as a critical component of the sexual and reproductive health and rights (SRHR) programming. It is the right thing to do. It is at the core of the tenet of bodily autonomy and a fundamental ingredient of gender equality.