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

labirasumaya@gmail.com

+256750009675.