Expanding access to safe abortion in DRC: charting the path from decriminalisation to accessible care

Abstract

Access to safe and comprehensive abortion care has the potential to save thousands of lives and prevent significant injury in a vast and populous country such as the Democratic Republic of the Congo (DRC). While the signing of the Maputo Protocol in 2003 strengthened the case for accessible abortion care across the African continent, the DRC has grappled with de jure ambiguity resulting in de facto confusion about women’s ability to access safe, legal abortion care for the past two decades. Conflicting laws and the legacy of the colonial penal code created ambiguity and uncertainty that has just recently been resolved through medical and legal advocacy oriented towards facilitating an enabling policy environment that supports reproductive healthcare. A study of the complex – and frequently contradictory – pathway from criminalised abortion to legalisation that DRC has taken from ratification of the protocol in 2008 to passage of the 2018 Public Health Law and subsequent Ministry of Health guidelines for abortion care, is an instructive case study for the international sexual health and reproductive rights community. Through this analysis, health and legal advocates can better understand the interdependence of law and public health and how a comprehensive approach to advocacy that includes legal, systems, and clinical accessibility can transform a country’s system of care and the protection of women’s rights. In DRC, new legislation and service delivery guidelines demonstrate a path forward towards concrete improvements for safe abortion care.

Résumé

L’accès à des soins d’avortement sûrs et complets a le potentiel de sauver des milliers de vies et d’éviter de graves lésions dans un pays vaste et peuplé comme la République démocratique du Congo (RDC). Si la signature du Protocole de Maputo en 2003 a renforcé les arguments en faveur de soins d’avortement accessibles dans l’ensemble du continent africain, ces vingt dernières années, la RDC s’est trouvée aux prises avec une ambiguïté de droit, entraînant une confusion de fait quant à la capacité des femmes d’accéder à des soins d’avortement sûrs et légaux. Des lois contradictoires et l’héritage du code pénal colonial ont créé une ambiguïté et une incertitude qui ont été récemment résolues grâce à un plaidoyer médical et juridique visant à faciliter la création d’un environnement politique favorable aux soins de santé reproductive. Une étude du chemin complexe, et souvent contradictoire, parcouru par la RDC depuis la criminalisation de l’avortement jusqu’à sa légalisation, depuis la ratification du Protocole en 2008 jusqu’à l’adoption de la loi sur la santé publique de 2018 et la publication ultérieure des directives du Ministère de la santé en matière de soins liés à l’avortement, est une étude de cas instructive pour la communauté internationale de la santé sexuelle et des droits reproductifs. Avec cette analyse, les défenseurs de la santé et du droit peuvent mieux comprendre l’interdépendance du droit et de la santé publique, et comment une approche globale du plaidoyer incluant le volet juridique, les systèmes et l’accessibilité clinique peut transformer le système de soins d’un pays et les protections des droits des femmes. En RDC, une nouvelle législation et des directives sur la prestation des services montrent la voie à suivre vers des améliorations concrètes en matière de soins d’avortement sûrs.

Resumen

El acceso a servicios seguros de atención integral al aborto tiene el potencial de salvar miles de vidas y evitar lesiones significativas en un país vasto y poblado como la República Democrática del Congo (RDC). Aunque la ratificación del Protocolo de Maputo en 2003 reforzó los argumentos a favor de la accesibilidad de servicios de aborto en todo el continente africano, en las últimas dos décadas, la RDC ha lidiado con la ambigüedad de jure, lo cual ha generado confusión de facto sobre la capacidad de las mujeres para acceder a servicios de aborto seguro y legal. Leyes conflictivas y el legado del código penal colonial crearon ambigüedad e incertidumbre, que se resolvieron recientemente mediante incidencia política médica y legislativa orientada a facilitar un entorno político favorecedor que apoye los servicios de salud reproductiva. Un estudio de la compleja, y a menudo contradictoria, trayectoria de la RDC desde la penalización hasta la legalización del aborto, desde la ratificación del protocolo en 2008 hasta la aprobación de la Ley de Salud Pública en 2018 y directrices posteriores del Ministerio de Salud para los servicios de aborto, es un estudio de caso instructivo para la comunidad internacional de salud sexual y derechos reproductivos. Mediante este análisis, promotores sanitarios y legislativos pueden entender mejor la interdependencia de la ley y la salud pública, y cómo un enfoque integral de incidencia política que abarca accesibilidad legislativa, sistémica y clínica, puede transformar el sistema de salud de un país y las protecciones de los derechos de las mujeres. En RDC, la nueva legislación y directrices de prestación de servicios demuestran el camino hacia adelante para lograr mejoras concretas en los servicios de aborto seguro.

Keywords:

• abortion
• Maputo Protocol
• Democratic Republic of the Congo
• family planning
• legalisation

Introduction

Unsafe abortion causes an estimated 5.1–17.2% of maternal deaths in Sub-Saharan Africa.¹ In recognition of the significance of unsafe abortion as a key driver of maternal mortality worldwide, the World Health Organization (WHO) includes comprehensive abortion care, provided to the fullest extent allowed by law, as one of its essential health care services.^2,3 In 2003, the African Union passed the “Protocol to the African Charter on Human and People’s Rights on the rights of Women in Africa,” now commonly shortened to the “Maputo Protocol” (Maputo).⁴ Maputo has provided a basis for liberalisation of abortion laws across the continent of Africa. Liberalisation of abortion laws has been associated with improved reproductive health outcomes,⁵ including decreases in maternal mortality in Ethiopia,⁶ Mexico,⁷ and Chile.⁸

The issue of abortion affects millions of women* in the Democratic Republic of the Congo (DRC). Approximately 16,000 Congolese women die each year during their pregnancy, childbirth, or in the six weeks following the end of their pregnancy.^1,9–11 Across the region, approximately one in ten maternal deaths can be attributed to unsafe abortion; improving the safety of abortion care is a central strategy for reducing maternal mortality.¹ In a recent study, Médecins Sans Frontières (MSF) reported that across all 75 countries where MSF works, 13% of all abortion-related complications that they treated in 2017 occurred in DRC; in total, MSF-DRC treated 2,800 cases of abortion-related complications in 2017.¹² The high rates of maternal mortality and abortion-related complications in DRC have myriad drivers, including low contraceptive prevalence and regional conflicts that have driven up rates of sexual and gender-based violence.^12–15 Nearly three quarters (74%) of Congolese women aged 15–49 have an unmet need for modern contraception.¹⁶ The rate of unplanned pregnancy in DRC is 117 per 1000 women aged 15–49, and an estimated 28% of these unplanned pregnancies in DRC end in abortion.¹⁶ High rates of unplanned pregnancy, limited access to quality primary and maternity care, and high incidence of sexual assault all underscore the urgency to strengthen access to safe abortion care across this vast country.

Access to safe abortion in the DRC has historically been constrained¹⁷ by multiple factors: conflicting laws¹⁸ that have caused confusion over its legal status, a lack of trained clinicians and equipment¹⁹ to perform the procedure, insufficient knowledge²⁰ among potential clients on locations that perform abortion, and public stigmatisation¹² of the procedure. Ratification of the Maputo Protocol and publication in the National Gazette in 2018 should have decriminalised abortion and resolved its legal status once and for all. Yet a Public Health Law, also passed in 2018, included discrepant language on the conditions under which abortion can be legally performed. The uncertainty and ambiguity around the legal status of abortion under different conditions among law makers, clinicians, and potential patients has stymied access to safe abortion in the DRC.^18,21 Limited resources and geographic differences in health facility readiness have also created disparities in access to care.¹⁹

This paper aims to describe the status of safe abortion in the DRC in terms of the evolution of policy, rates of abortion, availability of abortion services, and public attitudes towards the practice. As a first step to reconciling discrepancies in key legal documents that govern abortion, it is essential for lawmakers, advocates, and clinicians to understand what documents exist, how they differ, and what legal standard takes current precedence to guide practice on the ground. If the legal status of abortion remains murky – including the conditions under which it is legal – many providers and institutions will shy away from providing the procedure out of abundance of caution or as a convenient excuse for not providing a procedure they don’t condone. As has been observed in similar contexts, provider uncertainty around the legal status of abortion further perpetuates the already considerable barriers to accessing safe abortion care.^22,23

The DRC provides a useful case study of the history of the liberalisation of abortion policy in this francophone African country, and the experience of the DRC in navigating a legally ambiguous health policy environment has correlates in countries around the world, across regions and all levels of country income.^5,22 This article outlines implications for health practice and outcomes, and it proposes a future research and practice agenda for DRC to further expand access to safe abortion care in this populous country.

Maputo: a rights-based agreement for sexual and reproductive health

African nations formed the African Union through the African Charter of the Organization of African Unity (OAU). The Charter, signed in 1963, gave preference to national self-determination and non-interference over the individual human rights of the citizens of member states. The massive human rights violations on the continent during the middle part of the twentieth century prompted the OAU to adopt the African Charter on Human and Peoples’ Rights and proclaim October 21 as “International Human Rights Day in Africa” in 1981.²⁴

In 1995, African heads of state utilised Article 66 of the African Charter to begin work fulfilling the African Commission on Human Rights’ recommendation to draft a protocol on women's rights in Africa.²⁴ In 2000, the Organization of African Unity (OAU) became the African Union (AU) with a focus on human rights²⁵ and gender equality and provided legal remedy for enforcement by the AU to intervene in cases of human rights violations or genocide.^26.

The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa was adopted in July 2003 at the 2nd African Union Summit in Maputo, Mozambique, and came into force in 2005, known thereafter as the “Maputo Protocol.” The Maputo Protocol is the first regional treaty developed and endorsed by African governments that formally recognises sexual and reproductive rights, particularly the right to safe abortion.²⁷ Given the African Union’s emphasis on the sovereignty and self-determination of member states, individual states adopted Maputo through national legal processes. Due to varying degrees of political support within nation-states for sexual and reproductive health and rights, some countries have chosen not to sign and ratify (3) or to sign and not to ratify (15), while 42 states signed and ratified.²⁸ To clarify the circumstances for which Maputo was intended to provide for the legal provision of abortion care, the African Union issued guidance in the form of general comment N° 2: “Under Article 14 (2) (c) of the Maputo Protocol, States Parties are called upon to take all appropriate measures to protect the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus.”^29.

Reproductive health in DRC before Maputo

The penal code of the DRC restricted access to contraception and abortion since colonial times.³⁰ The penal code included provisions that criminalised abortions performed under any circumstances; abortion providers and patients convicted of this offence could spend 5–15 years in prison.³⁰ In the last 50 years, a number of legislative and presidential policy actions have chipped away at reproductive health restrictions established in 1940 by the Penal Code, including the Medical Code of Ethics, Public Health Law of 2018, and integration of the Maputo Protocol into DRC statute.

In 1970, 10 years post-Independence, President Mobutu Sese Seko issued an order through the Medical Code of Ethics providing limited circumstances where an abortion could legally be performed, which stated: “the Penal Code prohibits abortion. In exceptional cases, when the mother’s life is seriously threatened, and therapeutic abortion appears to be the only way to save her life, the legitimacy of this intervention remains under discussion.”³¹ While this provision opened a limited circumstance where a woman could seek a legal “therapeutic” abortion procedure, it established other barriers to accessing care, such as requiring agreement of the necessity of the abortion from at least three doctors. It also provided clinicians with the opportunity to opt out of providing abortion care through conscientious objection. The prohibition on contraception went unquestioned until 1973 when President Mobutu signed Presidential Ordinance No. 73/089 creating the Conseil National pour la Promotion des Naissances Desirables (National Council for the Promotion of Desirable Births), which authorised the advertising, sales, and use of contraception.³² While still technically banned by the penal code until 2018, contraception was made available in DRC through this presidential decree for nearly 45 years.

According to the constitution of the DRC, a presidential order (such as the medical code) cannot override a law (such as the penal code) passed by Parliament.^33,34 While these two regulations coexisted, abortion providers did not have legal protections. The arbitrary application of the conflicting laws depended on prosecutorial interpretation and philosophy.³⁵ Starting in 1970, a Congolese woman could seek a therapeutic abortion under very limited circumstances, but the provider of the procedure risked potential prosecution under the penal code. Other administrative barriers, such as the lack of specific standards and guidelines for the provision of abortion care, the omission of mifepristone as an essential medication, and the exclusion of abortion care in health provider training curricula, also limited meaningful access to this medical procedure.

Maputo: a decade of transition to legal abortion in DRC

In the wake of the Second African War in the late 1990s that involved multiple countries in the region and led to new levels of violence in the eastern region of the country, the DRC was anxious to project an image of its commitment to promoting human rights.³⁶ In 2006, the DRC adopted a new constitution after the “Sun City Dialogue” that promoted and protected human rights with a significant focus on women’s rights and gender-based violence.^37,38 The major innovation in this new constitution was the attempt to formalise parity between men and women.³⁹

In line with this new emphasis on gender equity, in 2006 Parliament also passed a law authorising the DRC to ratify the Maputo Protocol,⁴⁰ which would decriminalise abortion. According to a member of the DRC parliament, ratifying the protocol aligned with its commitment to bring justice to individuals who survived sexual violence during the rebellion and support their access to comprehensive reproductive health, including safe abortion care.⁴¹

On June 9, 2008, the DRC parliament ratified the Maputo Protocol in its entirety, including the articles on abortion. However, the protocol could only be considered a law and applied in the country if published in the National Gazette. The Catholic Church was steadfastly opposed to the Maputo Protocol and succeeded in significantly delaying its publication in the National Gazette.⁴² Ten years after the ratification, on March 24, 2018, the cabinet of the presidency published the Maputo Protocol in the Journal officiel édition spécial du 5 Juin 2018 (National Gazette).⁴³

Independently of the Maputo Protocol, in 2012 a group of reproductive health advocates began a protracted process to obtain a new reproductive health law that would override the outdated penal code prohibiting contraception and ensure access to safe abortion in the DRC. After several dead ends, the reproductive health advocates agreed to subsume their key issues into a larger public health law to increase the likelihood of its passage. Thus the Parliament passed the Public Health Law of 2018, including language that authorised access to contraception for all persons of reproductive age and provided for legal abortion care to preserve the life of the mother or due to fetal malformations that are incompatible with carrying a healthy pregnancy to term.⁴⁴ The publication of the Maputo Protocol in the National Gazette and the passage of the Public Health Law occurred in the same year, but the two laws contained conflicting language on the conditions under which abortion can be legally performed. Table 1 provides a timeline of this policy history and summarises the conditions under which abortion is legal according to the different documents in effect in the DRC over the past 80 years.

Table 1: Status of abortion and conditions under which it is legal, according to regulations from 1940 to 2022

Law / Policy	Enacted	Circumstances where abortion is legally indicated
		Mother’s life	Fetal malformation	Mother’s physical health	Mother’s mental health	Rape	Incest	Any reason
DRC Penal Code; Livre II, titre VI, Section I, Art. 165-166, 178, Section IV	1940	No	No	No	No	No	No	No
Code of Medical Ethics	1970	Yes	Yes	No	No	No	No	No
Law on Public Health	2018	Yes	Yes	No	No	No	No	No
Maputo Protocol	Published in DRC National Gazette in 2018	Yes	Yes	Yes	Yes	Yes	Yes	No

According to the DRC Constitution (Art. 215), “lawfully concluded treaties and agreements, once published, have legal superiority over domestic statute.” Therefore, the 2018 ratification and publication of the Maputo Protocol in the National Gazette took precedence over the Public Health Law of 2018.⁴⁵ This being the case, in 2018 abortion became legal for the indications listed in the Maputo Protocol: sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the fetus.^{4, 40, 43} This policy development drove the establishment of a steering committee to take charge of the monitoring of the implementation of Article 14 of the Maputo Protocol. The steering committee was set up by the Supreme Council of the Judiciary, composed of judges, magistrates, and experts from the Ministry of Health (MOH), and it called for updating the internal laws to align them with international commitments.⁴³ As part of the implementation of the Maputo Protocol, in 2020 the MOH developed standards and guidelines for comprehensive woman-centred abortion care following the request of the Supreme Court. These standards and guidelines, aligned with those of the WHO, determine who may perform abortions, where the procedures can be performed, what technology and methods may be used, and to whom safe abortion care can be offered.^46.

Ratification of the Maputo Protocol and the MOH guidelines for its implementation facilitate the implementation of clinical guidelines, in place of executive orders with ambiguous legal standing, to govern the provision of abortion care in DRC. The new legal environment provides an unprecedented opportunity for women and girls to access safe abortion, and they enable providers to meet women’s reproductive health needs based on globally accepted clinical standards. Provisions for the repeal of marital consent for married women and parental approval for adolescent girls reinforce women's bodily autonomy and agency. Any sexual intercourse before the age of 18 is rape, following the provisions of Law No. 06/018 of July 20, 2006, on rape.⁴⁷ Any minor's pregnancy is automatically eligible for a safe abortion if the minor so wishes. Proof of rape is not required, and healthcare providers are the only ones who can determine mental health issues according to the WHO definition. Any trained health care provider (nurse, midwife, general practitioner, or gynaecologist) can provide safe abortion care according to WHO guidelines on task sharing.⁴⁸ Safe abortion care can be offered at any level of the healthcare pyramid as long as the health facility, whether primary, secondary, or tertiary, has trained staff and an adequate technical capacity.

Attempts to monitor a common unsafe procedure prior to legalisation

Due to the only recent liberalisation of abortion care access, DRC does not conduct regular surveillance on abortion care or track provision of abortion services in regular health statistics, and the estimated abortion rate varies widely based on estimation methods used. One of the key ways that decriminalisation of abortion care improves safety and health outcomes is through improved transparency and health surveillance; once a service can be legally provided, it can be legally counted, researched, and monitored.

In 2022, Guttmacher released national figures for DRC estimating an abortion rate between 2015 and 2019 of 33 per 1000 women aged 15–49.¹⁶ The disparate numbers outlined below reflect an era in DRC when safe abortion care was inaccessible, with unwanted pregnancies terminated through unsafe and dangerous methods that resulted in high rates of injury and mortality.⁴⁹ Rather than utilising safe, evidence-based self-managed or facility-provided abortions, scores of women presented to hospitals suffering from complications from unsafe procedures, and abortion rates were estimated via hospital records of complications.^49,50.

Two methods have been used to estimate an abortion rate for Kinshasa, the capital city of DRC. The Abortion Incidence Complications Method (AICM) is an indirect estimation method that uses abortion-related complications presenting to health facilities and health professionals. Using AICM, Chae et al. estimated that 37,865 women were treated for complications resulting from unsafe abortion in health facilities in Kinshasa in 2016 – the equivalent of an abortion rate of 56 per 1000 women aged 15–49.⁵⁰ Using data from this study, Bankole et al. estimated the severity of post-abortion complications presenting in Kinshasa health facilities and found that 16% constituted cases of “severe morbidity,” a category including haemorrhage requiring blood transfusion, generalised peritonitis, hypothermia with signs of infection, organ failure, shock, and death.⁴⁹ AICM has also been used to estimate an adolescent-specific abortion rate in Kinshasa using these same data.⁵¹ When comparing across age groups for only those women who are sexually active, Fatusi et al. found that adolescents (age 15–19) in Kinshasa have the highest abortion rate at 167.2 per 1000 women (2021).^51.

The Anonymous Third-Party Reporting (ATPR) method collects information through population-based surveys where women are asked about the abortion experiences of their close confidantes; this is another method that can be used in settings where there may be legal ramifications punishing women who disclose their own abortion experiences. Using ATPR, Ishoso et al. estimated an abortion incidence for 2015 of 55 per 1000 women of childbearing age in Kinshasa.¹⁷ Studies in DRC using the ATPR also revealed high rates of injury resulting from complications of unsafe abortion procedures. Half (50.6%) of the abortion procedures reported in 2015 through the ATPR method were performed using “high doses of drugs,” and 31.6% were performed through a physically invasive method such as curettage or aspiration; however, this study could not verify if these surgical methods were conducted by trained providers, following clinical guidelines, and/or in appropriate settings using sanitary instruments.¹⁷ This study also did not specify the types of drugs used for these unsafe procedures. Just over half (51.9%) of reported abortions resulted in complications requiring medical treatment, with haemorrhage making up the majority of presenting complications (65.8%), followed by infection at 14.6%.¹⁷ Genital trauma and uterine perforation/intestinal necrosis each comprised 9.8% of presenting complications. Akilimali et al. updated these estimates using data collected in late 2021 and early 2022 and calculated an abortion rate of 105.3 per 1000 women of reproductive age in Kinshasa and 44.3 in Kongo Central using an ATPR method.⁵² This study found that an estimated 17% of abortions performed in Kinshasa used a non-recommended (and likely unsafe) method of termination, such as non-indicated medications or other traditional/surgical methods that are not evidence-based or performed by a trained health provider.^52.

Readiness of facilities to perform safe abortion

Despite the restrictive abortion laws in DRC, abortions were performed in most public hospitals prior to the ratification of Maputo. An assessment conducted by the MOH in 2017, shortly before the Maputo Protocol came into force in the DRC, showed that four out of five hospitals provided abortion care. However, an assessment of commodities and facility readiness to provide safe abortion care conducted using the 2017 Service Provision Assessment (SPA) demonstrated significant resource limitations, with just a third of facilities reporting readiness to perform pregnancy terminations, as well as stark variation in facility readiness to provide care by province.¹⁹ Misoprostol was included in the essential medicine list and available in hospitals prior to Maputo due to its uses in treating postpartum haemorrhage and managing post-abortion complications.⁵³ Despite its status as an essential medicine, the 2017 SPA showed that just 13.4% of health facilities in DRC had misoprostol on hand at the time of the assessment.^19.

This facility assessment also revealed that health facilities, such as primary care health centres which are much more widespread and accessible to the population than hospitals, that should have the capacity to provide pregnancy terminations, do not have the resources to do so. Safe pregnancy terminations could be performed by just 24% of these health centres according to this assessment.¹⁹ Since the 2017 assessment was conducted, and following the ratification of Maputo in DRC, the MOH has authorised mifepristone-misoprostol medical abortions, added mifepristone to the essential medication list, and authorised providers to give prescriptions for Mifepak (the combination package of mifepristone 200 mg and misoprostol 200 mcg tablets) that women can access at pharmacies. Currently in DRC, NGOs, healthcare providers, as well as certain community agents, such as doulas and Mashujaa^54,55 (a referral network of community leaders and advocates set up by Ipas), can provide access to medical abortion due to the expanded legal availability of mifepristone and misoprostol. Medical abortion, which can be provided in a broader array of settings such as ambulatory health centres, pharmacies, and other community providers, rather than hospitals, has significant potential for expanding access to safe abortion care.

In addition to disparities in the availability of services, studies show that the quality of abortion care needs improvement in DRC to bring procedures up to accepted international clinical standards. While WHO has declared dilation and curettage (D&C) to be an obsolete method, two out of three abortions are performed using this method in public facilities that are required to follow WHO guidelines, indicating a need for greater attention to quality and safety protocols.¹⁹ In response to this identified need, systems updates have been rolled out that aim to improve the quality of and access to safe abortion care.⁵⁶ Examples of these improvements include the development of training curricula and tools such as guide sheets and wall posters for providers; enhanced accessibility of medical abortion in pharmacies, health centres, and through community-based organisations; and the establishment of centres of excellence for continuous learning in safe abortion care. Prior to Maputo, medical and nursing schools did not include clinical training in safe abortion care in their curriculum, but this has been recently added.^53.

Expanding access to safe abortion care in DRC should also emphasise the quality of abortion care, both for pregnancy terminations as well as for the management of abortion complications occurring from unsafe abortion methods. Quality healthcare is care that is safe, effective, patient-centred, timely, efficient, and equitable.⁵⁷ Some research has been done in abortion care quality in DRC in the equity and patient-centred domains. DRC participated in the WHO Multi-Country Survey on Abortion (MCS-A) study in late 2017, which has helped to highlight geographic disparities in the availability of quality post-abortion care that are driven by ongoing conflict and insecurity in certain DRC regions.⁵⁸ Facilities located in secure areas are more likely to provide quality clinical care for post-abortion complications; however, women report similar levels of satisfaction with the care they receive in facilities located in both secure and insecure regions in DRC.⁵⁸ Qualitative data corroborates the findings from the MCS-A; women in North Kivu report generally positive experiences receiving post-abortion care and would advise other women to seek these facility services when in need.⁵⁹ A recent study on midwives’ use of manual vacuum aspiration⁶⁰ and a study on improving post-abortion care in Kinshasa⁶¹ provided some attention to the safety domain of healthcare quality. The healthcare quality of timeliness is also especially important in safe abortion care, where earlier terminations can be self-managed safely and effectively. Future studies examining the expansion of medical abortion and abortion accessibility can also study the impact of expanded access to care in terms of improving the timeliness of these procedures and associated improved care quality.

Further challenges: public opinion and stigma

In the DRC, some communities have expressed bias against women who have violated norms around fertility and morality: both getting pregnant while unmarried as well as having an abortion can be extremely stigmatising and harmful for a woman’s quality of life and acceptance in society.¹² To keep their procedure a secret, women who have terminated a pregnancy may avoid seeking potentially life-saving post-abortion care.⁶² In DRC, studies have documented that women pursue potentially unsafe abortion procedures to avoid societal exclusion, the loss of marriage prospects, or the risk of being abandoned by their spouses and families.^12,63,64

The perceived criminality of induced abortion is a major reason for community disapproval. Some community members go so far as to propose criminal sanctions against women who induce abortion. Some communities think that inducing abortion violates the social norms and behaviours expected of women in their culture, and undermines the role of mother and care-giver attributed to female community members.^63.

Studies have been conducted on abortion care in eastern DRC in the context of armed conflict and sexual violence. Respondents in these communities have reported that the health consequences of unsafe abortion are compounded by women’s reluctance to seek care for complications due to stigma and concern for both criminal and familial repercussions for seeking to terminate their pregnancy.⁶³ Community members also report that this fear of stigmatisation and social alienation likely causes women to turn to unsafe, clandestine measures for pregnancy termination rather than seeking abortion care from facilities, as it is “better dead than being mocked,” making potential health consequences worth the risk.^12.

Despite these social stigmas around abortion, a recent survey conducted in Kinshasa suggested a shift in attitudes towards abortion. The latest round of the Performance Monitoring for Action (PMA) survey found that among women of reproductive age, over half (55.0%) felt that abortion was a very or somewhat common occurrence in their community.⁶⁵ Just 15.6% felt that there weren’t any circumstances where a woman should be able to get a legal abortion, and a majority felt that abortion should be legal in cases where the woman’s life is at risk (60.8%), where the pregnancy was not developing properly and would not result in a healthy birth (54.7%), and in cases of incest (52.1%).⁶⁵ Notably, this survey was conducted in 2022, and represents the most recent available public opinion data on abortion in DRC, but only refers to Kinshasa. Given the rapidly changing policy landscape, social mores may be changing as safe abortion care becomes integrated into medical care.

Recommendations and opportunities for expanded access to care

The decriminalisation of pregnancy termination in DRC has opened the door for several opportunities to expand access to and strengthen the capacity for safe abortion care, which will ultimately improve health outcomes by reducing morbidity and mortality caused by unsafe abortion procedures. These opportunities fall under the categories of service delivery, workforce, health information, and research.

First, through public institutionalisation of safe abortion care procedures, the MOH can improve service delivery by working towards eliminating terminations conducted through sharp curettage, considered obsolete by WHO.⁶⁶ This can be undertaken through communication with clinics and provision of manual and electric vacuum aspirators. Through this effort, the country can also work towards broader access to medical abortion in both pharmacies and facilities, following WHO guidelines.⁶⁶ Increasing access to medical abortion in pharmacies will also improve access to evidence-based self-managed abortion care, a practice that has demonstrated efficacy and safety in other settings.

Second, DRC can prioritise training for the healthcare workforce in the provision of safe abortion care. Recent studies with providers have found hesitancy to perform abortions due to a lack of awareness of the law. In North Kivu, for example, where cases of rape are prevalent due to the ongoing war, health-care providers are still reluctant to assist women in need of safe abortion, citing legal restrictions. Some providers continue to view abortion as a criminal act and condemn any form of termination of pregnancy, citing legal ramifications or personal reasons (moral and religious arguments).¹² In Ituri, another war-torn province, providers are sometimes forced to refer women with abortion-related complications (who had previously sought an abortion and used unsafe methods) to other facilities.¹² As medical and nursing schools implement new clinical curricular standards, training can be provided in understanding DRC abortion law to address issues related to provider fears and uncertainties around their rights and protections in providing this care.

Third, DRC can take advantage of the legalisation of abortion by improving national statistics monitoring the provision of quality abortion care, towards the ultimate end of ensuring that pregnancy terminations are conducted by trained professionals, in safe settings, and that safe self-managed abortion care is available – all following international guidelines. These statistics should include types of terminations performed by gestational age, type of provider and facility in which the procedure was performed, and the provision of care for post-abortion complications. Post-abortion family planning services should also be tracked. As described previously in this paper, current estimations of the abortion rate in DRC vary widely depending on methodology. The necessity to approximate the incidence of abortion in these settings, through tools like AICM and ATPR, underscores the need to demarginalise abortion and bring it into mainstream reproductive healthcare, where it can be measured and provided as quality healthcare. Improved health surveillance will allow the country to target health interventions and ensure that maternal mortality and morbidity related to unsafe abortion are minimised.

Fourth, improved health information availability across the health system and legal systems of DRC should also be followed with improved understanding across the population about the legal protections that abortion seekers have, in order to to reduce the demand for abortion procedures conducted by untrained providers using unsafe methods.

Finally, the new policy environment in DRC can provide an enabling environment for research aimed at improving care from the supply side through focused studies that assess readiness and the availability of abortion care services and medications in DRC facilities and pharmacies, the accessibility of quality abortion care through process-oriented quality data, and health improvement outcomes resulting from these service improvements and better understanding at the provider and population level of the expanded opportunities for care.¹⁹ These quality-oriented studies can drive service delivery improvements as well as a better understanding of demand for services.

As public understanding of the decriminalisation of abortion spreads, researchers should be better equipped to assess public opinion and stigma around abortion care – a phenomenon that has already been observed to be complex with vast heterogeneity across the population. Future research can measure the prevalence of abortion, including both safe and unsafe procedures, and assess the circumstances and factors that lead women to have unplanned pregnancies that end in abortion, which may help to identify and perfect interventions around preventing unplanned pregnancies from occurring.^67–69

The ratification of the Maputo protocol in 2008 and the passage of the Public Health Law in 2018 represent monumental changes in policy that could allow the DRC to reap health benefits like those observed in other countries that have also relaxed abortion restrictions. Ensuring the safety of abortion care – that women receive abortion care from trained providers in an appropriate setting – has the potential to significantly decrease maternal deaths in a country such as DRC with high unplanned pregnancy, maternal mortality, and incidence of unsafe abortion.

Author contributions

Conceptualisation – ALG, J-CM, PA, DK, JTB; methodology – ALG, J-CM, PA, JTB; data collection – J-CM, PA, DK; Formal analysis – ALG, J-CM, PA, DK, JTB; writing-original draft – ALG, J-CM; writing-review and editing – ALG, J-CM, PA, JTB.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This project was supported by NIH Research Training grant D43 TW009340 funded by the NIH Fogarty International Center, NINDS, NIMH, NHBLI and NIEHS. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. AG was a postdoctoral fellow with this grant programme when the research was conducted. This work was also supported by grants from the David and Lucile Packard Foundation [grant numbers 2022-73375 and 2021-72174].

Notes

* The authors recognise that individuals who need access to abortion care may have diverse gender identities. The use of “woman” in this article reflects context-specific language used in population-level systems and policy documents.