Self-managed abortion: Barriers and opportunities in humanitarian settings

What did the study set out to achieve?

This study aimed to document the abortion experiences of displaced women and girls with a focus on self-managed abortion and information access.  The research focused on:

• examining the differences in abortion experience based on displacement, humanitarian setting, and legal context.
• estimating the abortion incidence, rate, and ratio using respondent-driven sampling (RDS) and an innovative adaptation of the abortion incidence complications methodology.

The team planned to use the findings to develop community-informed strategies to improve access to information and use of abortion medication in humanitarian settings. The goals of the research were to:

• provide critical evidence to inform the type and magnitude of resources that are needed, identify necessary service delivery improvements, and inform recommendations on how best to support women who self–manage abortions in humanitarian settings.
• provide data to serve as an advocacy tool to encourage governments, UN agencies, and donors to prioritise safe abortion care in humanitarian programmes and policies, and to include humanitarian populations in reproductive health programmes and policies.
• inform the development of effective interventions to improve access to self-managed abortion in humanitarian settings.

What were the key findings?

• The majority (84%) of participants with recent abortion experiences used non-recommended methods, including: traditional herbs; misuse of pharmaceuticals, and ingestion of toxic substances.
• Very few participants used WHO-recommended methods for abortion, such as medication abortion (misoprostol alone or in combination with mifepristone), or procedural abortion methods (manual vacuum aspiration or dilation and evacuation). Only 5% of participants sought care from the formal healthcare system.
• Economic concerns and having an unsupportive partner were primary reasons participants wanted to terminate their pregnancy.
• Experiencing signs of potential complications, such as heavy bleeding and signs of infection, was common. Despite this, some avoided seeking care, due to fear of stigma, mistreatment, or arrest.
• Of the 28 health facilities surveyed, only two reported offering abortion care.
• While a quarter of participants knew about medication abortion, only 1% could name misoprostol.

What does this mean for policymakers and practitioners?

These findings demonstrate that despite the need for abortion services among displaced women and girls, there is a severe lack of access to WHO-recommended methods of abortion in humanitarian settings. Practitioners and policy makers should dedicate resources to training providers on provision of safe abortion, as well as building trust and awareness of the availability of these services for those living in refugee contexts.

Increased access and availability of WHO-recommended medication abortion methods (misoprostol alone or in combination with mifepristone), as well as programs to increase medication abortion knowledge and support, can expand the cadres of providers who can offer safe abortion care, and expand opportunities for self-managed medication abortion use.

Initiatives to increase information and support for self-managed medication abortion should occur in tandem with efforts to strengthen facility-based abortion care. Humanitarian agencies and advocates should renew and strengthen their efforts to make facility-based abortion care accessible, as individuals not only deserve the right to have an abortion, but to decide where, how, and with what support their abortion takes place.