Facilitating women’s access to misoprostol through community-based advocacy in kenya and tanzania

International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i j g o Facilitating women’s access to misoprostol through community-basedadvocacy in Kenya and Tanzania Francine Coeytaux ,Leila Hessini Nondo Ejano Albert Obbuyi Monica Oguttu Joachim Osur , Kristen Shuken a Public Health Institute, Oakland, USAb Ipas, Chapel Hill, USAc Women’s Promotion Centre, Kigoma, Tanzaniad Centre for Study of Adolescence, Nairobi, Kenyae KMET, Kisumu, Kenyaf Ipas, Nairobi, Kenya Objective: To explore the feasibility of educating communities about gynecologic uses for misoprostol at the community level through community-based organizations in countries with restrictive abortion laws. Methods: In 2012, the Public Health Institute and Ipas conducted an operations research study, providing small grants to 28 community-based organizations in Kenya and Tanzania to disseminate information on the correct use ofmisoprostol for both abortion and postpartum hemorrhage. These groups were connected to pharmacies selling misoprostol. The primary outcomes of the intervention were reports from the community-based organizations regarding the health education strategies that they had developed and implemented to educate their communi- ties. Results: The groups developed numerous creative strategies to reach diverse audiences and ensure access to misoprostol pills. Given the restrictive environment, the groups attributed their success to having addressed the use of misoprostol for both indications (abortion and postpartum hemorrhage) and to using a harm reduction approach to frame the advocacy. Conclusion: This initiative proves that, even where abortion is legally restrictedand socially stigmatized, community-based organizations can publicly and openly share information aboutmisoprostol and refer it to women by using innovative and effective strategies, without political backlash.
Furthermore, it shows that communities are eager for this information.
2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
continues to be restricted . Public policies; legal, regulatory, andadministrative barriers; and general discomfort with abortion have com- Misoprostol, a drug sold around the world to treat gastric ulcers, has bined to keep misoprostol a best-kept secret Believing that proven to be very effective in preventing 2 of the leading causes of ma- women everywhere have the right to information about and access to ternal mortality—postpartum hemorrhage (PPH) and unsafe abortion this lifesaving drug, the Public Health Institute and Ipas conducted an op- Since the 1980s, when women in Brazil discovered that misopros- erations research study to explore strategies for introducing misoprostol tol could help them safely end unwanted pregnancies, women have been for gynecologic uses at the community level through community-based passing on this knowledge by word of mouth, woman to woman. We organizations in countries with restrictive abortion laws.
now have global evidence that misoprostol is being used by women inmany countries with restrictive abortion laws to end unwanted pregnan- cies, without talking to or seeing a healthcare provider In addition,community-based studies have shown that women can also use this life- The present study was conducted in early 2012 in Kenya and saving drug to prevent hemorrhaging at birth—safely, by themselves, in Tanzania—2 countries where abortion is restricted and stigmatized, and where maternal mortality is still relatively high. In partnership Unfortunately, despite the tremendous potential of this relatively with 4 local organizations—the Center for the Study of Adolescence inexpensive and widely available drug, knowledge about its various in- (Kenya), KMET (Kenya), Ifakara Health Institute (Tanzania), and the dications is extremely sparse, particularly in countries where abortion Women's Promotion Centre (Tanzania)—we trained community groupson gynecologic uses of misoprostol and provided them with funding toimprove access to misoprostol in their communities. Small grants ⁎ Corresponding author at: Public Health Institute, 1512 Stearns Drive, Los Angeles, CA (averaging US $2000 per group) were awarded to 28 community- based organizations: 9 based in Kigoma, Tanzania; 7 in Nairobi, Kenya; 0020-7292/$ – see front matter 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Coeytaux F, et al, Facilitating women’s access to misoprostol through community-based advocacy in Kenya andTanzania, Int J Gynecol Obstet (2014), F. Coeytaux et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx and 11 in Kisumu, Kenya. By supporting strategies that emerged from and PPH prevention to convey the information. Another group in Kigoma local groups that work directly with women and adolescents, we distributed simple information cards with a message to encourage girls hoped to strengthen communities’ understanding of the multiple uses to seek support and guidance from trained teachers and peer educators of misoprostol, create a favorable community context in which miso- in schools. In Kisumu, messages written inside the reusable sanitary prostol and abortion could openly be discussed, increase the buy-in towel packages distributed by the Kenyan Medical Educational Trust in and commitment for access to safe abortion within a diverse array of rural communities included what to do if worried about a missed period community organizations, and help build women’s skills to manage and the number of a helpline to call.
Others came up with innovative and effective strategies to ensure The initiative set out to test whether groups could, in a restrictive en- access to the drug—a particular challenge for women living in rural vironment, talk openly about misoprostol for both indications: abortion communities. The use of community pharmacies and traditional birth and prevention of postpartum hemorrhage. Abortion is legally restrict- attendants to distribute the drug proved to be effective approaches ed in both countries but access to medical information is not prohibited; that attracted no backlash but increased coverage and drug availability in fact, the constitutions of both countries guarantee the right to infor- at the community level. For example, 14 traditional birth attendants mation for consumers of services: Article 46 (b) of the Kenyan Bill of and herbalists in Kisumu asked KMET to train them to provide miso- Rights and Article 18 (b) of the Tanzanian Constitution. Discussing prostol directly to women. KMET contracted with matatu (public trans- misoprostol freely is, therefore, lawful and the initiative set out to test port) drivers to deliver misoprostol to women in rural communities in the feasibility of sharing this information at the community level.
which pharmacists either had not stocked the drug or were unwilling Before implementing the program, we met with national and interna- to dispense it without a doctor’s prescription. The community-based tional organizations working in the 2 countries and identified local organizer or the woman in need calls the KMET helpline to ask for community-based organizations interested in partnering. These organiza- misoprostol, waits for the matatu driver to deliver the drug, and con- tions helped us disseminate the open call for proposals and participated in firms receipt via text message. The partnership with matatu drivers— both the review of the proposals and the follow-up of the ones awarded which facilitated same-day deliveries—greatly improved access to grants. The request for proposals entailed a very simple process: requesting ideas that could be implemented in a 9-month timeframe In Kigoma, because no pharmacies were selling misoprostol in the and for a maximum of the local equivalent of $2000. The proposals rural community, a grantee organization decided to provide the drug di- were judged according to creativity, feasibility, and replicability. Follow- rectly. Using its own resources, the organization trained staff to provide ing the implementation of the activities for which they received funding, counseling and support, formed an alliance with like-minded doctors to the community-based organizations submitted reports, which were then help women with any complications, and established a small pharmacy analyzed; phone interviews were conducted when needed to clarify the as an alternate model for supporting women’s access to safe pregnancy reports further. Because this was strictly a funding initiative that involved and family planning. The competition that resulted from the organiza- disseminating information to communities, informed consent and ethics tion’s lower prices has driven down the cost from other private drug sellers, making these medicines more affordable for women who needthem.
Overall, we found that most groups felt emboldened to advocate for the prevention of maternal deaths in their communities. They showed The groups that received funding were extremely varied and served courage in reaching out and vocalizing the needless deaths and suffer- diverse constituencies, including women with disabilities, youth, busi- ing of women in their communities from unwanted pregnancies, and ness groups, religious leaders, and assorted health professionals. With did this in spite of a difficult legal and social environment. As one of the exception of 1 group—a medical student organization in Nairobi, the groups reported, women and mothers are dying because of a lack which met resistance from anti-choice students—all found that the of information; the group was thankful for the initiative because, in initiative greatly assisted them in their advocacy work. For example, their words, knowledge is power. Another group expressed outrage at some reported that the approach gave women and youth opportunities not having been given this information earlier, saying that women con- to speak their views on abortion and maternal deaths, and helped break tinued to die in their communities while this “magic drug” was being silence and taboos surrounding abortion and safe motherhood by kept a secret; the group urged those in authority to disseminate this sharing very sensitive testimonies about unsafe abortion and its effects.
good news to all women in rural communities in order to save lives.
Others said that the initiative cleared misconceptions and myths aroundabortion, challenging religious fundamentalism, and created awareness that women can perform abortions safely and prevent PPH themselves,using medical back-up only if needed. Still others reported increased The misoprostol initiative in Kenya and Tanzania provides practice- empathy and support from local leaders and various stakeholders for based evidence that local community-based groups operating under the campaign on reducing maternal deaths and the creation of a social and legal sanctions or restrictive abortion laws and policies can network of like-minded advocacy groups that drew synergy from each openly and publicly disseminate information about misoprostol to pre- vent both unsafe abortion and PPH. The groups we funded in Kenya and The strategies that the groups implemented were diverse and Tanzania showed that, with very small sums (approximately $2000), reached many different audiences in creative ways. For example, an or- they could simply and effectively (and without political backlash) ganization that was uncomfortable addressing abortion directly did not inform their communities that misoprostol is available; that women specifically mention the word, instead using phrases on flyers such as can be empowered to use it safely, on their own, without going to a “Have you missed your period? Are you worried? Come talk to us, we provider; and that it can prevent maternal deaths. They also showed that, while diversified strategies are needed to reach diverse audiences, Many grantees developed materials that could be used by the com- information on the correct use of misoprostol can be spread very effec- munity groups to increase information on managing expected effects, tively and inexpensively by community groups.
prevention of PPH, and signs and symptoms of incomplete abortion.
One of the biggest barriers to the introduction of misoprostol for use Young people from the slum areas of Nairobi relied on social media at the community level is its association with abortion . Most of the platforms to educate each other and create linkages to increase access international non-governmental organizations we met with when to the drug. In Kigoma, a group printed and disseminated handkerchiefs we first introduced the initiative in Kenya and Tanzania were wary, with pictorial indications on the use of misoprostol for both safe abortion warning us that—because of the sensitivity of abortion in these 2 Please cite this article as: Coeytaux F, et al, Facilitating women’s access to misoprostol through community-based advocacy in Kenya andTanzania, Int J Gynecol Obstet (2014), F. Coeytaux et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx countries—we might not be able to openly discuss the use of misopros- their obligation because the drug can significantly reduce harms and tol to end pregnancy. Some warned us that we might be “endangering” the groups by funding them. Yet, when we approached national and A particular strength of the initiative was joint accountability; we local organizations, we found that we had no shortage of interested partnered with the organizations by providing financial support, and partners. In both countries, we easily found organizations willing to trusted them to develop their approaches and to implement the pro- work with us, to help spread information about the initiative, and to dis- grams. The strategies the groups developed emanated from lived expe- tribute our request for proposals. In all 3 locations we decided to focus rience and were concrete, doable, and creative. Furthermore, because on—Nairobi, Kisumu, and Kigoma—we received many more proposals the groups embedded these strategies into their ongoing work and existing networks, the approaches were inexpensive and will, hopefully, The funding model proved to be key; each group/organization de- cided how much political risk it could or would undertake. And, because What really matters to the people closest to the communities is that the groups were so well networked and had legitimacy in their commu- women are dying. They will do what they need to do in order to meet nities, they managed the political risk. As the director of a community- their communities’ needs. The funded organizations viewed misopros- based organization confirmed, “political risk management is something tol as a right to information and understood that women need to know about its potentially lifesaving properties and be empowered to Why were so many groups able to accomplish what many feared obtain and use it correctly. Indeed, the simplicity and effectiveness of could not be done: that is, publicly disseminate information about a misoprostol produced outrage in several communities over the fact drug that can be used to terminate a pregnancy in countries where that they had not been informed about this “good news pill” sooner.
abortion is restricted? Our partners pointed to 2 strategies that they For most, direct access to misoprostol was about a woman’s agency felt made this “emboldened advocacy” possible. The first, and most im- and her ability to help herself by preventing possible hemorrhage portant, strategy was that they addressed the use of misoprostol for while giving birth or by safely ending an unwanted pregnancy of her both indications—abortion and the prevention of PPH; the second was own accord. The misoprostol initiative grew into the beginnings of a that they used a harm reduction framework to introduce the work.
movement—one in which women help themselves and then help others Focusing on several indications at once was the sole requirement we by sharing information. By putting access to misoprostol in the hands of had when we announced the request for proposals. Given that we were women in their communities, these groups are breaking the silence that focusing on community mobilization, we thought it best to impart infor- so often surrounds abortion and are assisting women in becoming the mation about both of the indications for which women can safely and shapers and users of this promising technology.
effectively use misoprostol without having to go to a facility. We knewthat there was already interest at the community level about a drug for abortion and thought it best not to skirt around that fact, but rathershare the complete knowledge with the women and the communities.
The authors have no conflicts of interest.
Talking about both uses had additional benefits: it gave cover for thework on abortion for those who needed it; more players became in- volved because it included organizations that focused on maternal health as well as those that tackled the problem of unsafe abortion; and, because misoprostol can reduce maternal deaths in several ways, it provided a very effective advocacy message. Maternal mortality as a public health issue is receiving a tremendous amount of attention in both countries, and the fact that a single inexpensive and available drug can significantly prevent 2 of the major causes of maternal mortal- ity is a powerful advocacy message. In addition, the fact that misoprostol is used for prevention—of unsafe abortion and hemorrhaging at birth— was compelling for community-based organizations that do not nor- mally see themselves as health providers but as educators.
Using a harm reduction framework to introduce the lifesaving quali- ties of misoprostol shifted the conversation about abortion from its legal status to protecting women’s health. Harm reduction is an evidence- based public health and human rights framework that prioritizes strate- gies to reduce harm and preserve health in situations in which policies and practices prohibit, stigmatize, and drive common human activities underground In this context, the harm reduction framework [9] Family Care International. Mapping Misoprostol for Postpartum Hemorrhage: Orga- enabled discussions about how reducing the harms associated with nizational Activities, Challenges, and Opportunities. unsafe abortion and home delivery could promote the rights to health, life, information, empowerment, and participation, in addition to women’s human rights in general. In Kenya and Tanzania, where abor- tion is legally and socially restricted, the framework freed the communi- ty groups from the political and legal constraints they usually operate under and allowed them to devise ways to help prevent women in their communities dying from unsafe abortion and from hemorrhage [13] Coeytaux F, Wells E. Misoprostol Is a Game-Changer for Safe Abortion and Maternal during home deliveries. Once it was understood that the harms associat- Health Care. Why Isn’t it More Widely Available? ed with both activities could be significantly reduced with the dissemi- nation of accurate information on misoprostol use as well as access to the drug, many eagerly submitted proposals to improve both informa- tion about and access to misoprostol. Most of the groups came to view the sharing of information about the multiple uses of misoprostol as Please cite this article as: Coeytaux F, et al, Facilitating women’s access to misoprostol through community-based advocacy in Kenya andTanzania, Int J Gynecol Obstet (2014),

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