Perceptions of misoprostol among providers and women seeking post-abortion care in Zimbabwe

Abstract

In Zimbabwe, abortions are legally restricted and complications from unsafe abortions are a major public health concern. This study in 2012 explored women’s and providers’ perspectives in Zimbabwe on the acceptability of the use of misoprostol as a form of treatment for complications of abortion in post-abortion care. In-depth interviews were conducted with 115 participants at seven post-abortion care facilities. Participants included 73 women of reproductive age who received services for incomplete abortion and 42 providers, including physicians, nurses, midwives, general practitioners and casualty staff. Only 29 providers had previously used misoprostol with their own patients, and only 21 had received any formal training in its use. Nearly all women and providers preferred misoprostol to surgical abortion methods because it was perceived as less invasive, safer and more affordable. Women also generally preferred the non-surgical method, when given the option, as fears around surgery and risk were high. Most providers favoured removing legal restrictions on abortion, particularly medical abortion. Approving use of misoprostol for post-abortion care in Zimbabwe is important in order to reduce unsafe abortion and its related sequelae. Legal, policy and practice reforms must be accompanied by effective reproductive health curricula updates in medical, nursing and midwifery schools, as well as through updated training for current and potential providers of post-abortion care services nationwide. Our findings support the use of misoprostol in national post-abortion care programmes, as it is an acceptable and potentially life-saving treatment option.

Résumé

Au Zimbabwe, les avortements sont limités par la loi et les complications dues aux avortements à risque représentent un grave problème de santé publique. Cette étude de 2012 a analysé les perspectives des femmes et des prestataires au Zimbabwe sur l’acceptabilité de l’utilisation du misoprostol comme forme de traitement des complications de l’avortement dans les soins post-avortement. Des entretiens approfondis ont été menés avec 115 participants dans sept centres de soins post-avortement. Ont participé 73 femmes en âge de procréer qui avaient reçu des services pour avortement incomplet et 42 prestataires, notamment des médecins, des infirmières, des sages-femmes et des généralistes. Seuls 29 prestataires avaient déjà utilisé le misoprostol avec leurs propres patientes et à peine 21 avaient reçu une formation formelle sur son utilisation. Presque toutes les femmes et les prestataires préféraient le misoprostol aux méthodes d’avortement chirurgical car il était jugé moins invasif, plus sûr et plus abordable. En général, les femmes préféraient aussi la méthode non chirurgicale, lorsqu’elles avaient le choix, car l’acte chirurgical et les risques suscitaient de nombreuses craintes. La plupart des prestataires étaient favorables à la levée des limitations légales à l’avortement, en particulier l’avortement médicamenteux. L’approbation de l’utilisation du misoprostol pour les soins post-avortement au Zimbabwe est importante afin de réduire les avortements à risque et ses séquelles. Les réformes juridiques, politiques et pratiques doivent s’accompagner de mises à jour probantes du programme des études en santé génésique dans les écoles de formation des médecins, des infirmières et des sages-femmes, ainsi que d’une formation actualisée des prestataires actuels et potentiels de services de soins post-avortement dans l’ensemble du pays. Nos conclusions appuient l’utilisation du misoprostol dans les programmes nationaux de soins post-avortement, puisqu’il s’agit d’une option de traitement acceptable, qui a le potentiel de sauver des vies.

Resumen

En Zimbabue, el aborto es restringido por la ley y las complicaciones del aborto inseguro son un grave problema de salud pública. Este estudio en 2012 exploró las perspectivas de las mujeres y profesionales de la salud en Zimbabue respecto a la aceptabilidad del uso de misoprostol como una forma de tratamiento de las complicaciones del aborto en la atención postaborto. Se realizaron entrevistas a profundidad con 115 participantes en siete centros de atención postaborto. Los participantes fueron 73 mujeres en edad reproductiva, que recibieron servicios por aborto incompleto, y 42 prestadores de servicios, entre ellos médicos, enfermeras, parteras y médicos generales. Solo 29 prestadores de servicios habían usado misoprostol anteriormente en sus pacientes, y solo 21 habían recibido formación académica en su uso. Casi todas las mujeres y profesionales de la salud prefirieron el misoprostol a los métodos de aborto quirúrgico porque fue percibido como menos invasivo, más seguro y más asequible económicamente. Por lo general, las mujeres prefirieron el método no quirúrgico, cuando se les dio la opción, ya que tenían muchos temores en torno a la cirugía y el riesgo. La mayoría de los prestadores de servicios favorecieron eliminar las restricciones jurídicas referentes al aborto, particularmente el aborto con medicamentos. En Zimbabue, es importante aprobar el uso de misoprostol para la atención postaborto a fin de reducir el aborto inseguro y las secuelas relacionadas con éste. Las reformas de leyes, políticas y prácticas deben ir acompañadas de actualizaciones eficaces de currículos sobre salud reproductiva en facultades de medicina, enfermería y partería, así como de capacitación actualizada para actuales y futuros prestadores de servicios de atención postaborto a nivel nacional. Nuestros hallazgos respaldan el uso de misoprostol en programas nacionales de atención postaborto, ya que es una opción de tratamiento aceptable, que tiene el potencial de salvar vidas.

Keywords:

• unsafe abortion
• misoprostol
• post-abortion care
• Zimbabwe

The World Health Organization estimated that in 2008 21.6 million women worldwide had unsafe abortions, nearly all of them in developing countries, with an overall unsafe abortion rate at about 14 per 1,000 women aged 15–44 years. In sub-Saharan Africa, unsafe abortion rates are about 31 per 1,000 women aged 15–44 years.¹

In Zimbabwe, unsafe abortions account for 10% of all maternal deaths,^2–4 and post-partum haemorrhage and unsafe abortion are two of the five main causes.⁵ The Ministry of Health and Child Welfare has long expressed concern about the high level of deaths, and as part of its support for reproductive health care, it has supported the development of post-abortion care services.

Currently, abortion in Zimbabwe is only legally permissible on three grounds: in circumstances of rape and/or incest, when the pregnancy endangers the health of the woman and where there is a risk that the child will be born with serious mental or physical disabilities (Termination of Pregnancy Act of 1977. No. 29). Despite the law, Harare Hospital records show that the number of admissions for abortion complications has increased over time, along with high rates of maternal mortality.^2,5 Unwanted pregnancy in Zimbabwe appears to be increasing due to the erosion of traditional cultural values in the wake of rural–urban migration, the increased desire to limit family size, delay in the age at marriage given increased educational opportunities for women, and the fact that contraceptives are not readily available to women under age 18.⁴

Post-abortion care in Zimbabwe consists of a package of services designed to address complications from incomplete abortion and miscarriage. Since 2006, the Ministry, with the University of Zimbabwe, has established three post-abortion care referral and training centres, located in the capital Harare and Chitungwiza, an adjacent peri-urban area. The main objective of this programme has been to train health care providers to use manual vacuum aspiration (MVA) instead of dilatation and curettage (D&C), with the goal of abolishing D&C in Zimbabwean health care facilities.^* The World Health Organization also recommends mifepristone plus misoprostol, or misoprostol alone, as a safe and effective treatment for incomplete abortion,⁶ based on a substantial body of evidence, including from sub-Saharan Africa.^7–16 Some of these studies have also documented women’s satisfaction with misoprostol for abortion-related care.^7–9,13,14

Mifepristone is not registered in Zimbabwe, however, and misoprostol is registered through the Medicines Control Authority of Zimbabwe only to treat gastric ulcers. Manual vacuum aspiration (MVA) is also recommended by WHO for post-abortion care.⁶ Because misoprostol is inexpensive, easy to use, and can be administered through several routes (oral, sublingual, buccal, and vaginal), it is well suited for use in resource-constrained settings.¹⁷ However, in Zimbabwe, as in many countries in sub-Saharan Africa, the use of misoprostol in the management of post-abortion complications is restricted, due to registration delays with the relevant regulatory body.

In line with the goal of expanding post-abortion care services in Zimbabwe to include misoprostol for treatment of complications, this study aimed to: 1) explore women’s and provider’s perspectives and knowledge of misoprostol in urban Zimbabwe; 2) explore the existing and potential use of misoprostol in the management of abortion complications as part of existing guidelines in Zimbabwe; and 3) inform discussions and advocacy around increasing access to safe abortion and improving policy in Zimbabwe with the goal of saving women’s lives.

Methods

The study employed a primarily qualitative approach, using semi-structured interview guides with open-ended questions — one for women and another for providers. Data were collected in seven facilities in Harare and Chitungwiza, from June to December 2012. They were chosen both based on the mix of institution types providing post-abortion care services and because they are among the best nationwide and typically attract women from around the country. They were comprised of two privately owned hospitals, three government- or state-owned tertiary level (referral) hospitals, and two non-governmental organization-supported (NGO) facilities, which taken together are typical of the framework of the health care system in Zimbabwe. General practitioners and casualty providers were also part of the provider sample, giving a more comprehensive assessment of the landscape of practitioners offering post-abortion care services in Zimbabwe.

In-depth interviews were conducted with 73 women and 42 service providers. We used a consecutive recruitment strategy for the women, within a purposive sample of consenting women. The criteria for inclusion were to have been admitted with a diagnosis of incomplete abortion or another pregnancy-related complication requiring treatment at one of the facilities.

Providers included doctors (n = 7), nurses (n = 15) and midwives (n = 10), who were recruited from among emergency reproductive health care providers (n = 21) evenly divided among the seven study sites, as well as general practitioners and casualty staff (n = 21) practising in the greater Harare area. Nine of the 42 providers were male and 33 were female, with a mean age of 41 years. They had been working in the field of reproductive health for a mean of 9.8 years (range 1 month to 38 years) and had been based at their current medical facility for a mean of 7.2 years (range 1 month to 27 years).

In an effort to be even more inclusive, ten other ‘practitioners’ (n = 10) such as clerks, a monitoring and evaluation specialist and other non-clinical staff were also included in the provider sampling frame, but in the end their narrative was neither substantial nor robust enough to be included in the analysis.

The two interview guides were developed from a similar study in Mexico¹⁸ and adapted through pre-testing to the local context. Interviews explored key thematic areas such as stigma, values clarification and interpretation of the law. Women were asked about their access to, and awareness and knowledge of methods for pregnancy termination, their reproductive histories (pregnancies and the use of contraceptives), their experience with pregnancy termination, their views on medical methods of pregnancy termination, and on information received after the procedure. The interviews with providers focused on their perceptions and use of misoprostol versus surgical methods as a means of post-abortion care and to ascertain interest in using misoprostol should it be approved by the Medicines Control Authority of Zimbabwe. When the interviewer arrived at the designated site, she asked which providers were performing post-abortion procedures that day. If there were more than three providers, each provider was assigned a number and she randomly chose three for interview from a bowl.

Oral informed consent was obtained from the women and providers. Participants were assured of confidentiality. Interviews lasted 45–60 minutes and were conducted in Shona or English in a private location at the research site. All interviews were audio-taped and later transcribed and translated from Shona to English. Ethical approval was obtained from the Ethical Review Board of the World Health Organization and the Medical Research Council of Zimbabwe. Participants were reimbursed for transportation and time at a rate approved by the Medical Research Council of Zimbabwe.

Names were not used to ensure anonymity of those enrolled in the study, with personal identifiers removed from transcripts before they were entered into Nvivo 8 (QSR International, Melbourne, Australia), a qualitative data storage and retrieval programme. Two researchers read through the transcripts and independently identified emerging ideas, which were then collectively grouped into codes. Discrepancies were resolved by discussion. Codes were grouped into categories and emerging themes were then identified iteratively following the general principles of grounded theory. We present verbatim quotes in order to illustrate the major themes that emerged from the interviews.

Findings

Characteristics of women and providers

The women had a mean age of 29 years; two-thirds of them were married. About 7% reported that their partners were in polygamous relationships, and 24% said they did not participate in decision-making in their households. One-third (34%) were employed in the informal sector but were barely earning an income; only 26% were employed in the formal sector.

Sixty-eight (93%) of the women had a diagnosis related to incomplete abortion. Four had other diagnoses: one molar pregnancy, two anembryonic pregnancies, and one IUD complication. One woman’s record was incomplete. All five of these women qualified for the study as per protocol, since all needed some method of abortion for their treatment. Seventeen women reported a history of previous abortions. Available hospital data showed that 13 women (19%) were treated using misoprostol, 19 (28%) were treated with MVA and 36 (53%) with D&C (five cases had missing data). No complications from post-abortion treatment were reported from any of the medical facilities in the study, based on annual statistics kept by the University of Zimbabwe.

Women’s understanding of the risks of unsafe abortion

Women understood the risks of unsafe abortion and knew they were at risk of complications, including life-threatening loss of blood. When asked about reasons for presenting and being admitted in the hospital or clinic, not all women directly disclosed this information. Among those who did, 15 said they had voluntarily terminated their pregnancy, including five who used misoprostol and ten through MVA or D&C at a health facility. Eleven other women had self-induced the abortion at home, among whom one woman used traditional herbs; the rest had used an unnamed medication.

Fear of the legal and social repercussions resulting from the abortion was noticeable. Outside the confines of the law, women can be (and, in some cases are) imprisoned for abortion. Moreover, the anti-abortion lobby is strong in Zimbabwe, evidenced by placards and signs hung in public places and morally reproaching women who seek post-abortion care. Religiously and culturally, abortion is widely regarded as murder, even though this information was not confirmed by those in our study.

In addition to the fear of being reported to the police and/or suffering public humiliation, the hospital setting and the medical procedures can be overwhelming.

“ . . .ah it’s going to be painful you know with these instruments and all, l [would] just rather have a pill at home and l rest… “ (Woman, NGO)

While women admitted to private hospitals (where fees are considerably higher) openly requested treatment for an incomplete abortion, in contrast, most women presenting at the state-owned hospitals expressed their needs in more indirect ways, without admitting to having induced an abortion. For example, when asked “Why did you come to the hospital/clinic?”, one woman responded:

“I was referred to Harare by my doctor in Chegutu. The doctor could not remove my uterus [perform an abortion] because they wanted $60 upfront and a current pay slip [proof of monthly income], which my husband refused to provide. I was [then] referred to another private clinic and . . . they requested $350 upfront for treatment. I did not have the money and decided to come here. . .” (Woman, public hospital)

By the time most women presented at the health care institutions, they were often gravely ill with extremely heavy bleeding or septic wounds.

“I just felt like l want to go to the ladies [room], l was feeling pain in my stomach then that is when l started bleeding with heavy clots and everything . . . the bleeding was . . . not normal . . . it was scary.” (Woman, private hospital)

“The abdominal pain continued, together with backache. I was expelling blood clots. That is how I went to hospital. It was then explained to me that since my visit, I was having a miscarriage. Blood clots started 7 days after I started bleeding.” (Woman, private hospital)

Women’s knowledge of misoprostol

We asked women their views on post-abortion care methods, comparing medical abortion, involving a single drug or combination of drugs to cause what is similar to a miscarriage, to surgical methods, whereby a minor operative procedure is performed to evacuate the uterus (with mild sedation or local or general anesthesia). 56% of the women had heard of surgical methods of abortion. Two-thirds had heard of medical abortion. However, the majority of women were unclear about proper dosing or how the medical method actually worked. Those who did know something about misoprostol were largely informed by friends or colleagues. When probed about where misoprostol could be obtained or how it was used, most were unsure.

“I do not know on that, but because I only know that they use pills. It has not been explained to me how they work or were obtained.” (Woman, private clinic)

“I don’t know, l thought maybe it’s like it is forcing a woman to… deliver like a normal delivery. It’s like speeding up the process, l don’t know. That’s what l think and maybe the woman is not yet contracting. So they put the pills that make the woman contract.” (Woman, private hospital)

Perceived benefits of misoprostol: the women’s perspective

The abortion process and possible side effects were also described for both types of termination. Following this, most of the women reported that, given the choice, they would prefer medical over surgical termination. The most commonly cited reason, besides the omnipresent fear of authorities and the law, was the fear of surgery. The use of pills was also regarded as safer and cheaper than other methods, even though the costs of either type of termination were not provided to women.

“The benefit is that it leaves a person with good health after the abortion, compared to the herbalist from the community who claims to know other methods.” (Patient, public hospital)

“. . .it’s cheaper and safer because the drugs are not costly and also you do not need to go out and be taken to theatre so you avoid the risk of anaesthesia and the risk of surgery. I think it’s cheap and relatively safe for the patient.” (Patient, private hospital)

While the women understood from the interviewer that, in some cases, medications can be taken at home, they expressed a general reluctance to use misoprostol in the household setting.

“I think if you do not have a doctor’s supervision, at home it’s a bit risky…” (Woman, private hospital)

Providers’ perspectives on the acceptability and legality of abortion

Overall, most of the providers felt that abortion should be legalized under all circumstances, based on basic principles of human rights and the belief that every woman has the right to terminate an unwanted pregnancy. Providers were concerned about the well-being of their patients and attested to the fact that most women will seek abortions for unwanted pregnancies — legal or not. Providers discussed the significant number of Zimbabwean women who undergo “backyard” abortions in conditions that raise their risk of morbidity and mortality.

“ . . .there have been a lot of underground or backyard abortions, that itself is an indication that there is really a gap. The backyard abortions have led to maternal deaths at times… The backyard market is very risky and in the end we are having lots of death with regards to abortion.” (Doctor, private hospital)

“An abortion, if done medically, can save hundreds of thousands of lives of women, but if done in the backyard it can cause complications that might result in death of the woman.” (Doctor, NGO)

Providers view safe abortions as life-saving for many of their patients. They discussed this in the context of opportunities, and provided examples of young women who will still in secondary school or university, or who were HIV positive, for whom an infant could present considerable challenges.

“I personally feel that if there is something in the laws that can be done to legalize abortion in Zimbabwe, that this will really save a lot of lives. [Now] when a woman doesn’t want a pregnancy, no matter how you deny her in the medical facilities she will go to the backstreet abortionists… and then [eventually] come here when they have complications.” (Nurse-midwife, private hospital)

“Well, . . . since in this country it’s being done in the backyards and not legally allowed, I would say for the benefit of reducing maternal mortality, I think it should be legalized and those patients may go to any site which has been licensed to do… medical abortions.” (Nurse-midwife, private hospital)

Providers’ rights-based narratives were largely reflected in their actual medical practice, with the majority of providers choosing not to record if an abortion was self-induced when women were admitted with complications. Instead, they typically recorded all abortions as spontaneous or incomplete in order to evade the legal issues.

In Zimbabwe, the doctors' first duty is to treat women for post-abortion complications. They are expected to write up clinical notes. However, there is also an obligation to respect confidentiality. When asked in court or by the police if there was a suspicion of induced abortion, challenges arise between the professional confidentiality required and the legal requirement not to pervert the course of justice, given the restrictive law on abortion. Conflict can thus occur if providers are compelled to give evidence against their patients. Providers in Zimbabwe respect their obligation not to disclose information under their oath of confidentiality and so there is a common, yet unspoken, understanding that it is best to avoid judicial processes that may lead to the imprisonment of women if they provide evidence of an abortion.

“In Zimbabwe abortion is only permissible under certain circumstances. As for me, I think saving a woman’s life comes first at whatever cost.” (Doctor, private hospital)

“Some people use some concoctions… and usually these [end up as] septic abortions… because these people will not go to the hospital to seek medical attention. These are illegal according to this government but medically if the patient has a septic abortion or a criminal abortion, we don’t interrogate them. We just note it as a spontaneous abortion, then we take necessary measures to treat them so that they stay alive.” (Doctor, state-owned hospital)

Provider knowledge and use of abortion methods

We also asked providers about various post-abortion care methods. Nearly all of them knew of D&C; only one doctor and one nurse had no knowledge of this method. In contrast, while 15% had not heard of MVA, all medical staff had knowledge of medical abortion. The vast majority (95%) knew the treatment by the brand name Cytotec or as misoprostol. However, only ten of the 15 general nurses, five of the seven doctors and one of the ten midwives had actually been trained in the use of misoprostol specifically for post-abortion care. Those who had been trained were able to cite indications for the drug use in PAC, gestational age when it is used, dosage, effects and side effects. However, half of the providers had never been trained and their primary sources of information regarding misoprostol were largely informal — colleagues, family members, the internet, newspapers and pamphlets. Indeed, their understanding was often unclear:

“I have heard that it is used sometimes for treatment of stomach ulcers. The other indications, l am forgetting now, but l think those are some of the indications for post-partum hemorrhage.” (Nurse, state-owned hospital)

78% indicated that their institutions used medical abortion and most of the providers (69%) had used it for their own patients. However, among those who had used misoprostol with their patients, 41% did not know the correct dosage.

Perceived benefits of misoprostol: the providers’ perspectives

Overall, providers welcomed medical abortion as a treatment option for post-abortion services in their institutions. Numerous advantages of misoprostol over other pregnancy termination methods were noted. In public hospitals, providers often have to schedule post-abortion care patients for the operating theatre either very early in the morning or very late at night, and some women have been left to bleed for long periods while awaiting procedures. While the referral hospitals have alleviated some of these problems, there are not always providers on call who can/will perform a surgical procedure. Providers generally felt that misoprostol was risk-free, or at least less risky than surgical procedures. They also associated the non-invasive nature of misoprostol with minimal risk of infection. Another perceived advantage was the low cost and ease of administration.

“Sometimes, sharp curettage may damage the vagina or the wall of the uterus, it might cause infection. Since misoprostol is administered in the hospital the risk of infection is very low because antibiotics are used after the procedure.” (Doctor, state owned hospital)

“In my experience with medical abortion, I have noticed that there is less haemorrhage, less bleeding and also I think there will be less trauma if you use medical abortion….” (Doctor, private hospital)

Providers’ perspectives on barriers to misoprostol use

We asked about barriers to post-abortion care services, specifically institutional, administrative, technical and regulatory barriers. 68% felt significant barriers existed to this use of misoprostol at their institutions. The administrative barriers noted were difficulties in obtaining and stocking the medication. Providers commented that while it is relatively easy to obtain misoprostol in Zimbabwe, since it is registered for the treatment of gastric ulcers, it is not approved for pregnancy termination, and its use is strictly controlled by the Medicines Control Authority of Zimbabwe, which makes it challenging for an institution to obtain. Access to mifepristone is another barrier:

“Because abortion is illegal in Zimbabwe, you can’t register mifepristone because it’s only meant for abortion, unlike methotrexate and misoprostol. Methotrexate can be used for [other] treatment.” (Doctor, private hospital)

“I am sure the medication might be difficult to get but even if we got it, it’s also the issue of legislation. We still go back to the legislation part.” (Nurse-midwife, NGO)

Technical barriers cited included the lack of training for clinical personnel on misoprostol. Over 90% of providers mentioned the need for more information on medical abortion. Requests for training included more information on the advantages and disadvantages of misoprostol, its mode of action, safety, dosage and effectiveness, women’s perspectives about different abortion options, and how other countries are using misoprostol successfully. Information about the role of mifepristone in combination with misoprostol was also requested. Briefings on legality were pre-eminent among the training requests. Providers were quick to suggest how training and standardization of medical abortion in Zimbabwe could be achieved through advocacy, electronic media, conferences, workshops, organized courses, and print materials such as pamphlets. Doctors requested informal trainings, while nurses wanted to be better informed of the potential implications of the use of medical abortion.

“The best way [is] information on paper. We can have the handouts or books with the information…. it’s easy to understand that way; it’s the easiest way of getting information. Conferences too – if time allows.” (Nurse, state-owned hospital)

“…I can’t say we need to go for a course for that, but just informal, not formal training.” (Doctor, private hospital)

“…We carry out doctors’ orders, if they say give the patient that, we will just give, we are well trained to do that. But… knowing the drug itself, seminars, even literature, will just update us. It’s more of the update that we need.” (Nurse-midwife, private hospital)

Providers’ views on home vs. clinic use of misoprostol

Most providers interviewed (82%) felt that misoprostol should be administered under the supervision of clinicians in hospitals, because this would reduce the risk of potential complications.

“I am not for [home-based] medication, because patients may not have access to transport or easy access to a medical institution and they may have complications and by the time they come to the hospital it might be too late.” (Doctor, private hospital)

“I think that after assessing the level of understanding of a patient… maybe you can say ‘okay, let’s involve your taking this at home’, but then there is the issue of compliance. I think it will be better if we start doing it in the hospitals first rather than at home.” (Doctor, state owned hospital)

A few providers remarked that women from remote areas might benefit from the provision of misoprostol for post-abortion care at accessible levels of the health system, from hospitals to rural health centres.

“Some service users may be coming from far away rural areas so to give them medication to take at home and come back may be a hassle and not attainable…” (Nurse midwife, NGO)

One of the reasons they mentioned to discourage home-based use of misoprostol would be missing the opportunity of providing holistic care, including quality counselling. Several providers also felt that women generally needed social support and might be reluctant to reveal or discuss the abortion with relatives, due to sensitivity around the subject. In such cases, providers saw hospital admission as an advantage to these women.

Discussion and recommendations

This study adds to a growing body of evidence for the introduction of misoprostol as treatment for post-abortion care, based on the views of both medical providers and women patients, and of the demand for safer and simpler post-abortion care methods. We believe misoprostol use could be successfully integrated into a revised edition of the National Guidelines for Comprehensive Abortion Care in Zimbabwe. There are currently discussions about improving programmatic efforts (including training and quality of service provision), and the study participants too have expressed the need for improved policy and practice.

The introduction of misoprostol as a post-abortion care method is a critical step for improving women’s reproductive health and quality of care in Zimbabwe. Our findings make clear that both women who need these services and the providers who care for them are overwhelmingly supportive of the supervised use of misoprostol within a health care setting.

The registration of misoprostol for post-abortion care is important, however, not only to abate fear of repercussions from providing or receiving it, but also because women and providers interviewed considered its use as safer, simpler, more affordable and more convenient than surgical methods, and may not necessarily require hospital admission. Formal training would serve to enforce proper practice and ensure positive health outcomes, as well.

An operations research study conducted concurrently with this study from 2012 to 2013 by the Zimbabwe Ministry of Health and Child Welfare and the University of Zimbabwe Medical School, assessed the acceptability and feasibility of introducing misoprostol for the treatment of incomplete abortion and miscarriage into four districts in Zimbabwe and within a range of health care facilities–from referral hospitals to rural health care centres.¹⁹ That study was designed to offer women presenting for post-abortion care with misoprostol (or, if possible, a choice of methods) along with the package of services currently promoted including post-abortion contraceptive counselling and a modern method of contraception. The study included training of providers and considerable post-abortion care prevention and response messaging in the community. Participants in that study with complications were referred to higher-level facilities using the existing referral system.

Their results corroborate our findings. Not only is misoprostol perceived to be acceptable and feasible as a post-abortion care method, but it also proved to be a highly effective form of treatment. The number of women receiving misoprostol for post-abortion care at rural health care centres increased fourfold in just four months — a strong indication of both demand and required supply. Further, according to the researchers, it “dramatically” reduced the number of women presenting at rural health care centres and rural and mission hospitals who needed to be referred to higher-level facilities for further treatment due to complications. These are powerful findings in a country like Zimbabwe, with its overworked and underpaid health care providers and the many women seeking services from them.

We have three broad recommendations, based on our findings and years of work dedicated to Zimbabwe’s reproductive health sector. First, while Zimbabwe has a proud history of progressive reproductive health interventions, its legal system lags behind. Since achieving independence in 1980, Zimbabwe invested heavily in its infrastructure with a large share of that investment allocated to the provision of social services, particularly in health. The country's family planning programme, which was integrated into the public health system in the 1980s, was a unique outlier of success in sub-Saharan Africa. Knowledge of contraception is virtually universal, and the level of use of modern methods, 57% of currently married women aged 15–44, is among the highest in sub-Saharan Africa.²⁰ Access to safe abortion should be seen to sit alongside the use of contraception, as related aspects of holistic reproductive health care.

However, the provision of safe abortion remains an intractable challenge in Zimbabwe. While Zimbabwe’s independence ushered in one of Africa’s most viable and sustainable community health systems, including community-based distribution of modern family planning methods, it failed to liberate the law on abortion. Prior to the 1977 Termination of Pregnancy Act, abortion legislation in Zimbabwe was governed by Roman-Dutch common law, which permitted abortion to be performed only to save the life of the pregnant woman. While the 1977 Act extended the grounds under which a legal abortion could be obtained in Zimbabwe, they remain restrictive. For women in need of emergency obstetric services for serious unsafe abortion complications, the law still fails to offer adequate protection.

Second, we recommend dissemination of the WHO guidance on medical abortion and MVA as two treatment options for incomplete and post-abortion care.⁶ It is encouraging that the Zimbabwe Ministry of Health and Child Welfare is using evidence from this study as well as service-based evidence from the larger operations research study in four districts²⁰ to advocate for both misoprostol and the misoprostol/mifepristone combination to be registered with the Medicines Control Authority of Zimbabwe for both post-abortion care and therapeutic abortion under current abortion laws. We recommend that all efforts to accelerate this advocacy and policy and practice change be encouraged. Providers in this study were clear that abortion at the request of women should be free and fair, unburdened by fears of imprisonment or other negative legal or social sanctions. We support this view and suggest that women’s reproductive health concerns and needs are recognized and placed at the forefront of Zimbabwe’s reproductive health reforms.

Third, as legal and policy reforms are achieved, several types of provider training need to be implemented or enhanced. In medical, nursing and midwifery schools, training on the use of misoprostol should be incorporated into the current curricula to ensure proper understanding of the medication and its uses. Equally important, when women are not eligible for misoprostol, training on the use of MVA should continue as the best surgical alternative. It is critical that Zimbabwe continues to train and promote these best practices not only at its three national referral centres but also throughout the health care system.

Finally, even before any of these changes occur, information about the correct use of misoprostol for post-abortion care at different stages of pregnancy should be provided immediately to every hospital and clinic providing post-abortion care services. As job aids are developed to accompany training and community-based prevention and promotion of these services, it is essential that the WHO Safe Abortion Guidance⁶ and information about abolishing the use of D&C are also widely circulated. Medical, nursing and midwifery schools will need to set and keep the pace for these reforms.

Denied access to high quality services, women will continue to seek abortions under poor conditions, putting their lives at risk. Providing misoprostol under safe medical conditions and within clinical standards that both regulate and ensure consistency of practice will be an important step forward for Zimbabwe, and help to break down the legal, economic and knowledge barriers that prevent African women from being able to access life-saving medical abortion.

Acknowledgements

The authors acknowledge the technical and financial support from HRP (UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction). We thank the women and providers who consented to participate in the study, as well as the hospital administrators who allowed us to implement the study in their hospitals. We also benefitted from ongoing support from the Zimbabwe Ministry of Health and Child Welfare.

Notes

* D&C is no longer recommend by the WHO or the University of Zimbabwe School of Medicine, but the practice still persists, despite national efforts to institutionalise MVA.