Access to safe abortion remains a dream for many women in Uganda-Universal Health Coverage Must Include Access to Medical Abortion!
As we mark the International
Universal Health Coverage day, December 12, under the theme “Keep the Promise”, it is crucial to highlight
the World Health Organization (WHO)’s policy incoherence regarding misoprostol
and mifepristone. Is the WHO keeping the promise of delivering universal health
for all? WHO’s policy incoherence regarding the status
of misoprostol and mifepristone constitutes a significant barrier to wider
access to safe medical abortion. WHO must keep the promise of UHC and
unequivocally endorse prompt low cost access to misoprostol and mifepristone
including appropriate advice on usage and precautions. This comment addresses
the global issue taking Uganda as a case study.
Access
to essential health care is the ‘promise’ of Universal Health Coverage (UHC).
It is also a fundamental human right. The mortality burden globally associated
with unsafe abortion is horrendous and could be dramatically reduced if prompt
low cost access to safe medical abortion was guaranteed. Globally, about
25 million abortions carried out annually are unsafe. Uganda registers about
2.3 million pregnancies a year. Over 48% are intended pregnancies which end in
miscarriage or birth, and 14% unintended ending in abortion. These statistics
are alarming given new developments in research in this area. Noticeably,
almost all complications from unsafe abortion are preventable only if medical
abortion is accessible, affordable, available and of good quality, thereby,
promoting and protecting a woman’s right to life and dignity.
Complications
from unsafe abortion remain a leading cause of maternal mortality in Uganda
(UDHS, 2013). The Guttmacher Institute (2017) reported that over 800 abortions
happen every day in Uganda most of the time in unsafe conditions. This is
partly attributed to the cultural and religious disapproval of abortion. This phenomenon
is further exacerbated by the exclusion of abortion discussions from the mainstream
national policy agenda- deliberating on making abortion safe and legal in
Uganda.
The United Nations
Commission on Human Rights (UNHCR) affirms that access to safe and affordable
abortion facilities is part of the sexual and reproductive health rights of
women and young girls. The 1995 Uganda constitution guarantees the right to
life, directs that power belongs to the people, that the Parliament has the
power to make laws for the social good of people, the obligation of the state
to protect women’s human rights taking into account their maternal functions
and duties in society. A careful unpacking of this provision (Article 33 (2))
includes provision of medical abortion. Women and girls of reproductive age are
born with those rights. For example, the landmark case of Roe V. Wade (1973) was emphatic on promoting and protecting the
freedom of choice when it highlighted abortion as a constitutional right.
However, it remains a dream to many women facing unwanted pregnancy in Uganda.
Therefore, the
primary question is whether it is possible to advance universal health coverage
without addressing issues of access to medical abortion, and to what extent?
Despite a few
adverse effects associated with the combination drugs, latest evidence confirms
the safety and efficiency of the medication, and that it does not require close
medical supervision. WHO expert committee report
(2017), restricts the use of misoprostol and mifepristone to “close medical
supervision” and further highlights that their use must be permitted under
“national law and [be] culturally acceptable”, which imposes a barrier to
access and perpetuates abortion stigma. This same position is maintained in the
current WHO 21st model list of essential medicines (2019). Consequently, both
drugs are listed under WHO’s complementary essential medicines list. Usually,
medicines on the complementary list require specialized health care facilities
and services.
Presently, the
outstanding issue is whether WHO’s policy incoherence regarding misoprostol and
mifepristone, align with the commitments adopted by world leaders at the
high-level United Nations Political Declaration on universal health coverage
(September 2019)- implement high-impact health interventions to protect women’s
and children’s health? In fact, many
national regulatory bodies adopt such restrictions. For example, Section
20 of the National Drug and Authority Act, of Uganda, categorize misoprostol and
mifepristone as restricted/classified drugs- thereby
limiting over-the-counter access which is a barrier to access for low-income
women and those living in resource-limited areas. This lack of policy coherence
is affecting efforts aimed at reducing unsafe abortions which is key to
achieving Sustainable Development Goal 3 (target
3.1 “by 2030, reduce the global maternal mortality ratio by less than 70 deaths
per 100,000 live births”). Also, it puts pressure on the already
constrained health system and consumes a great portion of women’s productive
time as they have to wait in queues, and sometimes walk long distances just to
consult a doctor. This however, disproportionately affects young girls and
women who often resort to clandestine methods as a means to circumvent the law.
Yet, the means used to terminate an unintended pregnancy are disturbing- from
inserting coat hangers, and consuming bleach among others. Especially in
countries with restrictive abortion laws like Uganda.
In light of the
above, a serious dilemma in which the struggle for universal health coverage
and access to life-saving medicines, remains a dream to many women seeking medical
abortion in Uganda and beyond. It seems that WHO’s policy incoherence maintains
health inequities.
My question is: Has
WHO kept its promise to advance universal health for all? Is the notion of
indivisibility and inalienability of human rights just floating on air? Or,
something we cannot implement?
A closer analysis
of ongoing debates and advocacy campaigns on access to medical abortion across
the globe, highlights some common features: universality and indivisibility of
human rights, intersectionality of human rights, respect of bodily autonomy,
choice when, how and if to have a baby, among others. Post- Trump’s Global Gag
Rule (GGR), all these grounds have sparked off protests in a number of counties
(both with liberal and restrictive abortion laws) such as, Morocco, Brazil,
Britain, and Poland, among others.
In
light of evidence supporting the safety and effective use of misoprostol and
mifepristone, WHO must reclassify the drugs as core essential medicines on the
model list of essential medicines; remove the asterisk that states ‘close medical supervision is required for
the administration of misoprostol-mifepristone for medical abortion’; and delete
the statement ‘where permitted under
national law and where culturally acceptable’
So again, I ask, if WHO restricts
access to safe abortion by restricting it to close medical supervision and
national laws, will it stop women and young girls from terminating unintended
pregnancies? NO, it will only stop safe, legal abortion. Then, how do we reduce
maternal mortality and ensure universal health for all?
By: Labila Sumayah Musoke
PHM-Uganda
Women’s Health and Justice Initiative
+256750009675.
Comments
Post a Comment