Background

Most PAC program efforts approach PAC from the service delivery perspective, with emphasis on operations research, training of service providers and service delivery strategies. Community perspectives, such as knowledge and attitudes about unsafe abortion and health-seeking behavior among those who experience complications of abortion, are sorely lacking. Yet such information is critical for designing client-oriented services that will have maximum impact on reducing morbidity and mortality and break the cycle of repeat abortion.

The public health community recognizes that stakeholder commitment is critical for expanding, improving and sustaining PAC programs and services. Communities, however, often are ignored as stakeholders. At the same time, in this age of scarce healthcare resources, communities are being called upon to play a more active role in tackling health problems, including those arising from unsafe abortion. Yet only limited information is available on how communities view that role and what they believe they can do.

Difficulty in collecting information on community perspectives on abortion is one of the reasons that research in this area has been overlooked. Traditional methods of data collection such as surveys have proved inadequate to gather valid data on this sensitive topic. The illegality of abortion³ and the social stigma attached to it contribute to people’s reluctance to provide information to researchers. Nevertheless, in 1997, Amakhosi Theatre Group, a leading professional theater company in Zimbabwe, produced a play on adolescent pregnancy, unsafe abortion and PAC titled "Don’t—Ungaqali."^4,5 Audiences who previewed performances of the play commented freely on the issues presented in the play in discussions following the performances. They also recommended that the play be shown to others to promote dialogue.

Recognizing the potential of the play as a research and dialogue tool, the POLICY Project and Amakhosi Theatre Group began a collaborative project in October 1998 to conduct research on community perspectives on unsafe abortion and PAC. Using the methodology of social theater, the project also aims to promote community dialogue and actions. The project continues until June 1999.

This paper summarizes research findings from the first phase of the project, which focused on collecting information on community perspectives. The second phase focuses on measuring the impact of the play and social theater methodology to mobilize community actions. A forthcoming Phase Two report will present results from that component of the project. Additionally, a "lessons learned" guide to the use of social theater for research and community mobilization and a documentary video on the entire project will be produced.

Methodology

Performances were held in nine rural and urban locations in Hwange and Bulawayo Districts in Matebeleland North. Following each performance, the audience was invited to stay for a discussion of the issues raised by the play. The author of the play and a public health nurse led the discussions while two researchers documented what was said.

Altogether, approximately 2,500 people attended the performances. Post-performance discussions ranged in size from 18 to 100 participants. Efforts to recruit members of specific stakeholder groups to the performances and discussions were successful. Participants included elected city officials, traditional chiefs, healthcare professionals, traditional healers, teachers and education administrators, clergy and religious leaders, police, court magistrates, business leaders, military officials, representatives of national- and community-level NGOs and civil society organizations, and community members-at-large.

Researchers also conducted key informant interviews with representatives of these stakeholder groups before and after the performances. Fifty-three interviews were conducted with 61 informants. Most, but not all, interviewees also attended a performance.

Results

• Abortion is a well-known problem, although most abortions are done secretly. It’s often only when someone dies or gets sick that the problem becomes known. Sources of information about the size of the problem are both personal and public: through rumors, through personal observation, in healthcare and social services settings, and in the media. Infanticide is sometimes associated with abortion. Comments on specific infanticide incidents suggest these are publicized in the media and discussed throughout the community.

• Young girls are at highest risk of unwanted pregnancy and unsafe abortion. However, women of all ages induce abortions. Older women who induce abortions are often married women who have become pregnant from extramarital affairs.

• Causes of unwanted pregnancy are many. They include economic hardship that leads to sex for income, poor parenting, ignorance about sex and RH, early physical maturity and experimentation with sex, promiscuity, unprotected sex, peer pressure to have sex, shift from traditional to modern societal values, inaccessibility of contraceptives, women’s lack of control of their sexuality, inadequate family accommodation, boys and men cheating girls into having sex by promising marriage, and lack of respect between a man and woman.

• Men’s denial of responsibility for the pregnancy and fear of family members finding out about the pregnancy are major causes for abortion.

• Abortions are obtained from a variety of sources, including traditional healers, community members (often female elders) and medical doctors. They also are self-induced with assistance from friends and other community members. Most abortionists are unskilled, although some are more qualified than others. Abortion methods used outside the formal healthcare system include oral administration of traditional medicine or herbs, overdoses of malaria tablets or contraceptive pills, and inserting knitting needles or roots into the vagina.

• Women who experience spontaneous abortion seek medical attention although they are sometimes unaware that they are aborting. They are treated respectfully by nurses and doctors, although difficulty in determining whether a client is suffering from complications of induced or spontaneous abortion may affect the quality of treatment that is given. Traditional healers also provide treatment for spontaneous abortion.

• Girls and women who experience complications of induced abortion often delay or do not seek medical treatment. Fear of being reported to the police by clinic or hospital staff, fear of harsh treatment and exposure by nurses, and fear of parents’ reactions are the primary reasons for avoiding medical attention. Other reasons include financial constraints, difficulty with transport and "mild" symptoms.

• The law requires healthcare facilities to report abortion cases to the police. The practice of reporting, however, appears to vary among service delivery sites and individuals. Parents and community members also report cases to authorities. Frequently, they file these reports because they are concerned with arresting the abortionist.

• Nurses’ attitudes and behavior toward postabortion clients have an impact on client decisions to seek care. In particular, community members are concerned about gossip, harsh treatment, and unfriendliness to youth. On the other hand, nurses are often frustrated by the client’s failure to explain the reason for her condition and delay in seeking treatment until complications are severe.

• Community dialogue and mobilization are needed to solve the problems of unwanted pregnancy and unsafe abortion. Recommended actions include: sensitize and educate on the dangers of unsafe abortion and the need for prompt medical attention for complications and PAC; encourage church attendance and dialogue at church on unsafe abortion; establish and support programs for youth; facilitate networking among community organizations and families; engage elected officials and politicians; and improve and expand PAC services.

• Better parenting would reduce the problems of unwanted pregnancy and unsafe abortion. Parents should provide more support to their children, improve parent-child communication, teach their children about sex, exercise more discipline over their children and be better role models. Sex education, with a focus on abstinence, should be taught in schools.

• Legalization of abortion is a controversial issue. Some community members support legalization, believing it would reduce the incidence of unsafe abortion and its consequences. Others are opposed to legalization or support stricter penalties and law enforcement, believing that legalization would promote prostitution, encourage abortions and increase mortality.

• FP helps to prevent unwanted pregnancy, but there are constraints. Since the government began selling contraceptives at higher prices, people can no longer afford them. Also, many people are concerned about side effects. Youth have limited access to FP services, and opinions are mixed with regard to whether or not they should have better access.

Recommended Actions

• Educate community members.

• Network among organizations.

• Broadcast information on the radio and in newspapers.

• Host drama performances and workshops.

• Establish youth centers for counseling and employment development.

• Seek prompt medical treatment.

• Expand and improve PAC services: confidentiality, counseling, support.

• Sensitize traditional healers to the dangers of abortion.

• Continue dialogue on policy issues.

• Be better parents.

• Teach sex education in schools.

Discussion

To increase the use of PAC services among those who need them, quality of care needs to be improved and these improvements need to be defined from a client perspective. This task, however, is not straightforward.

Offering clients the confidentiality, support and counseling that they want, for example, could create for some service providers a dilemma arising from conflicts in their moral and professional values. Furthermore, improving the quality of services from a client perspective is not enough. Community perceptions of services also would have to change in order to increase the use of PAC services. This, too, presents challenges because many members of the community think confidential and supportive treatment of clients would lead to an increase in the incidence of abortion.

Community perspectives also raise issues about the PAC strategy of providing FP services at the time of emergency treatment for abortion complications. Many community members commented on FP in general. These comments were both supportive and critical. FP was not necessarily considered the best approach to prevention of unwanted pregnancy and abortion. A particular challenge for postabortion FP services is the legal restriction on and community opposition to provision of contraceptives to girls and youth. In Zimbabwe, the FP policy restricts provision of contraceptives, and allows them to be provided only to those 16 years of age and older. Thus, contraceptives are unavailable at the time of emergency treatment to those at highest risk of unsafe abortion.

Improving PAC services from the client perspective would go a long way toward strengthening the impact of PAC on morbidity, mortality and repeat abortion. But more than provision of high quality PAC services is needed to curb the problem of unsafe abortion. Community members are motivated to act and have specific ideas about what needs to be done. The health community can strengthen its role by linking with other community action organizations to sensitize community groups and promote dialogue on FP, PAC services and the dangers of unsafe abortion.

Notes

2. The POLICY Project is a 5-year project funded by USAID under Contract No. CCP-00-95-00023-04, beginning 1 September 1995. It is implemented by The Futures Group International in collaboration with Research Triangle Institute (RTI) and the Centre for Development and Population Activities (CEDPA).

3. Abortion is illegal in most African countries. In Zimbabwe, abortion is permitted only to save the life of the mother, to preserve physical health, in cases of rape or incest and in cases of fetal impairment.

4. The University of Zimbabwe Medical Library commissioned Cont Mhlanga, Artistic Director of Amakhosi Theatre Group, to write and produce the play. The Library, through support from the USAID-funded Support to Analysis and Research in Africa (SARA) Project, had established a Task Force on Unsafe Abortion, and the play was one of its featured advocacy activities. It premiered in Harare in April 1997.

5. The play is based on Amakhosi’s community research on unsafe abortion and the policy guidelines published by the Commonwealth Regional Health Community Secretariat in conjunction with: Kinoti S et al. 1995. Monograph on Complications of Unsafe Abortion in Africa. Reproductive Health Research Programme of Commonwealth Regional Health Community Secretariat (CRHCS) for East, Central And Southern Africa, JHPIEGO Corporation and IPAS: Baltimore, Maryland.

6. These views are those of the respondents. They do not necessarily represent those of the authors or USAID.

References

Settergren S et al. 1999. Community Perspectives on Unsafe Abortion and Postabortion Care. POLICY Project: Research Triangle, North Carolina. Draft. (14 April).