MEETING REPORT Open Access

Harmonizing national abortion andpregnancy prevention laws and policies forsexual violence survivors with the MaputoProtocol: proceedings of a 2016 regionaltechnical meeting in sub-Saharan AfricaJill Thompson1, Chi-Chi Undie2*, Avni Amin3, Brooke Ronald Johnson3, Rajat Khosla3, Leopold Ouedraogo4,Triphonie Nkurunziza4, Sara Rich5, Elizabeth Westley6, Melissa Garcia6, Harriet Birungi2 and Ian Askew3

From Harmonizing National Abortion and Pregnancy Prevention Laws and/or Policies for Survivors of Sexual Violence withthe Maputo ProtocolLusaka, Zambia. 11-13 April 2016

Abstract

In April 2016, the Population Council, in partnership with the World Health Organization (WHO) and the InternationalConsortium for Emergency Contraception, convened a regional meeting in Lusaka, Zambia, geared toward supportingcountries in East and Southern Africa in meeting their obligations under the Maputo Protocol. These obligationsinclude expanding access to women’s reproductive health services – especially women survivors of sexual violence.Government and civil society representatives from six countries participated: Botswana, Ethiopia, Kenya, Malawi,Rwanda, and Zambia. Countries were selected based on to their being priority settings for the projects that sponsoredthe meeting, coupled with the fact that they were each far enough along in addressing post-rape care to be able todevelop concrete policy, programming, and/or legal action plans by the end of the meeting.The meeting was the first activity in a joint project of technical assistance by the conveners, aimed at strengtheningaccess to comprehensive post-rape care for survivors of sexual violence. It aimed to sensitize Member States to theirobligations under the Maputo Protocol to expand women’s access to emergency contraception (EC) and safe abortionservices, and to inspire them to do so by providing information, research evidence, and a platform for discussion.The meeting deliberations fostered a better understanding of opportunities to broaden access to EC and safe abortionfor survivors in the region. Discussions on EC in this regard centered on strengthening EC delivery in the clinicalcontext, decentralizing EC services, increasing community awareness, and overcoming policy barriers. Safe abortiondiscussions focused primarily on legislation, policy, and integrating these services into existing services for sexualviolence survivors. Country-specific action plans were developed to address gaps and weaknesses.The regional technical meeting concluded with a discussion of practical steps that participants could take to facilitatelegal, policy, and program reform with respect to pregnancy prevention and safe abortion in their respective countries.The steps revolved around three mainly areas, namely: establishing an evidence base to inform action; creating forumsfor discussing the issues; and drafting action points to carry the momentum from the meeting forward. This paper(Continued on next page)

* Correspondence: cundie@popcouncil.org2Population Council, P.O. Box 17643-00500, Nairobi, KenyaFull list of author information is available at the end of the article

BMC Proceedings

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Thompson et al. BMC Proceedings 2018, 12(Suppl 5):0https://doi.org/10.1186/s12919-018-0101-5

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details the proceedings from this regional technical meeting – proceedings that are of interest to the field of sexualand gender-based violence (and reproductive health, more broadly) as challenges faced by countries in implementingthe Maputo Protocol are outlined, and evidence-informed and practice-based strategies for addressing thesechallenges are provided.

IntroductionThe risks of pregnancy and the potential for morbidity,mortality, and grave social consequences are relativelyhigh for female rape survivors [1]. Despite this reality,markedly less attention and investment have beengranted to pregnancy prevention and management ser-vices – namely, access to pregnancy testing, emergencycontraception (EC), and safe abortion – compared toother forms of post-rape care (PRC) [2].In recognition of this gap, in April 2016, the Population

Council, in partnership with the World Health Organization(WHO) and the International Consortium for EmergencyContraception (ICEC), convened a regional meeting inLusaka, Zambia, geared toward supporting countries in Eastand Southern Africa in meeting their obligations under theMaputo Protocol (described in further detail below) to ex-pand access to women’s reproductive health services – espe-cially women survivors of sexual violence (SV). Meetingparticipants included representatives of national Ministries ofHealth, Ministries of Justice, and/or Non-Governmental Or-ganizations from six countries: Botswana, Ethiopia, Kenya,Malawi, Rwanda, and Zambia. Also in attendance were tech-nical experts from the ICEC, Ipas, Population Council, UN,WHO, and the Zambia Police Service.These six countries were selected for the following rea-

sons: 1) they were priority countries under the PopulationCouncil programs that sponsored the meeting [3], 2) theyall had national guidelines on the medical management ofsexual violence, 3) the national sexual violence guidelines inthese countries all mentioned abortion, and/or the coun-tries had statutes allowing for post-rape abortion, and/or 4)the countries were undergoing legal reforms at the time ofthe meeting. These first three factors were considered as anindicator of the readiness of the six countries to participatein such a convening, but also of the fact that the countrieswere far enough along in addressing post-rape care to beable to tackle additional policy or legal issues following themeeting.

The Maputo protocolThe 2003 Protocol to the African Charter on Human andPeoples’ Rights on the Rights of Women in Africa (the‘Maputo Protocol’: http://www.achpr.org/instruments/women-protocol/) is the main legal instrument for the pro-tection of the rights of women and girls in Africa [4]. Art-icle 14 of the Maputo Protocol guarantees women’s right tohealth, including sexual and reproductive health. Women’s

rights to sexual and reproductive health include: the rightto control their fertility and make decisions regarding whenand whether to have children, the right to choose theirmethod of contraception, the right to affordable and access-ible reproductive health services, the right to informationand education, and the right to be free of violence and coer-cion. The Maputo Protocol is also the only international in-strument that specifically recognizes access to safe, legalabortion as a woman’s human right. Under Article 14 (2)(c), State Parties agree to “protect the reproductive rights ofwomen by authorizing medical abortion in cases of sexualassault, rape, incest, and where the continued pregnancyendangers the mental and physical health of the mother orthe life of the mother or the foetus”.More than ten years since the agreement went into ef-

fect, many countries in Africa have still not adopted thenecessary laws and policies to effectively domesticate orimplement the rights established by the Protocol. A 16-country review of rape survivors’ access to pregnancyprevention and management services in sub-Saharan Af-rica [1] unveiled a variety of gaps and inconsistencieswhich contribute to a violation of survivors’ rights andof good medical practice as outlined in internationalprotocols. A major gap highlighted in this study centredon the fact that, with a few exceptions, pregnancy man-agement and safe abortion for survivors do not featureprominently in national sexual violence guidelines in theregion. Existing provisions for pregnancy managementand abortion also tend to lack detailed, country-specificguidance on laws and procedures that would facilitateaccess to these services.Five of the six countries participating in the regional

meeting had signed and/or ratified the Maputo Protocol.Nonetheless, in many countries in the region, women andgirls still have limited information about, and access to,EC; abortion remains criminalized; and women are effect-ively prevented from accessing safe abortion services, evenin cases where abortion is legally permitted [1]. For survi-vors of SV, ensuring timely access to emergency preg-nancy prevention and safe, legal abortion for unwantedpregnancy remains a critical and urgent challenge [1].

2014 Guidance to member statesIn May 2014, the African Commission on Human andPeoples’ Rights adopted General Comment No. 2 onArticle 14 (1) (a), (b), (c) and (f ) and Article 14 (2) (a)and (c) of the Maputo Protocol (http://www.achpr.org/

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instruments/general-comment-two-rights-women). ThisGeneral Comment provided interpretive guidance on thespecific obligations of States Parties to promote and pro-tect the sexual and reproductive health of women andgirls. Adopting a broad, rights-centered interpretation ofthe Protocol’s requirements, the General Commentmade clear that the State obligation to protect and pro-mote women’s reproductive rights extends beyond de-criminalizing abortion in a few narrow cases.The General Comment specifically calls on State Parties

to:

■ Domesticate Article 14 (2)(c) to authorize legalabortion in all cases of sexual violence or risk tothe life, mental or physical health of the mother orfetus;

■ Eliminate restrictive laws, policies, procedures andpractices that impede access to pregnancy preven-tion services and/or safe, legal abortion, includinglaws and policies that require women to travel longdistances to obtain services, overcome onerous ad-ministrative obstacles, present evidence to “prove”rape or incest, or obtain judicial or other third-party approval for the procedure;

■ Implement measures to facilitate access to repro-ductive health services, and to address social, eco-nomic, and institutional obstacles;

■ Allocate sufficient resources to promote and ex-pand reproductive health services; and

■ Create an enabling legal and political frameworkthat promotes access to pregnancy prevention andsafe abortion for women and girls, including butnot limited to, survivors of sexual violence.

Meeting objectives and structureThe regional meeting was the first activity in a joint projectof technical assistance by the Population Council, WHO, andthe ICEC, aimed at strengthening access to comprehensivePRC (including EC and safe abortion) for survivors of sexualviolence. The principal objectives of the meeting were to:

■ Provide up-to-date information on State obliga-tions under the Maputo Protocol to expandwomen’s access to EC and safe abortion services;

■ Foster awareness among participants of how preg-nancy prevention and management feature in PRCprotocols and services in their countries, usingWHO guidance as a benchmark for analysis;

■ Support and inspire participating countries to ad-dress legal and policy gaps by sharing technicalguidance, best practices, and examples of enabling,survivor-centered laws and policies in the region;and

■ Deliver initial technical assistance to participatingcountries to identify and address key legal andpolicy issues.

The three-day meeting provided participants with anopportunity to share information and experiences, critic-ally review national laws, policies and guidelines with re-spect to EC, abortion, and sexual assault management,and develop action plans for addressing specific gapsand weaknesses. Structured around plenary presenta-tions, team exercises, and moderated panel discussions,the meeting drew on the following 4 topics to stimulatediscussion and learning:

1. EC and Safe Abortion as Essential Components ofComprehensive SV Care;

2. The current Situation in Participating Countrieswith Respect to National Guidelines, Laws, Policiesand Practice;

3. Opportunities to Expand Access to EmergencyContraception; and

4. Opportunities to Expand Access to Safe Abortion.

These themes are discussed in further detail in theremainder of this paper.

EC and safe abortion as essential components ofcomprehensive SV careA key theme of the meeting was the importance of fullyintegrating reproductive health into the services rou-tinely provided to SV survivors, and of ensuring that thereproductive rights of survivors are protected in nationallaws, policies, and clinical guidelines. To this end, a pri-mary emphasis of the expert presentations was onhighlighting evidence and/or international guidance(from the Population Council, WHO, and the ICEC) on:the impact of SV and IPV, the importance of compre-hensive care for survivors, medical facts on EC, preg-nancy management, and access to safe abortion.Subsequent to setting the stage with the evidence andavailable guidance, the current situation in participatingcountries (with regard to survivors’ access to EC and safeabortion) became the subject of focus, coupled with dis-cussions around modalities for expanding such access.

Global research evidenceImpact of SV and IPV on women’s health The WHOdefines intimate partner violence (IPV) as ‘any behaviorwithin an intimate relationship that causes physical, psy-chological or sexual harm to those in the relationship’ [5].IPV includes acts of physical aggression, psychologicalabuse, sexual coercion, and various controlling behaviors.SV and IPV have significant long-term consequences for

women’s physical, mental, and reproductive health [6]. Re-gional experts presented evidence of the consequences of

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sexual and intimate partner violence for health outcomessuch as unintended pregnancy, infectious diseases, mentaldisorders, depression, alcoholism, and suicide, as well ascomplications from unsafe abortion. Unsafe abortion re-mains one of the most common and avoidable causes ofmaternal mortality and morbidity in Africa. According toWHO research, 14% of maternal deaths of African womenresult from unsafe abortion [7]. Meeting participants alsonoted that women and girls who become pregnantthrough violence (as well as their children and families)experience long-term social, economic and health conse-quences when forced to carry an unwanted pregnancy toterm. Presenters noted the lack of research on rape- andincest-related pregnancy, and called for more Africa-specific research to provide evidence on both the fre-quency and impact of such pregnancies on survivors, theirchildren, and families.With respect to the Maputo Protocol’s grounds for

abortion, General Comment 2 states that:“The Protocol provides for women’s right to terminate

pregnancies contracted following sexual assault, rape orincest. Forcing a woman to keep a pregnancy resultingfrom these cases constitutes additional trauma which af-fects her physical and mental health...”In terms of reproductive health consequences, WHO ex-

perts noted that women who experience physical, sexual,and/or emotional IPV are at even greater risk of unintendedpregnancy (and unsafe abortion) than survivors of non-partner or “one-off” sexual violence. Women experiencingIPV not only are victims of sexual coercion, they also fre-quently lack control over contraception and family plan-ning (FP) decisions. Nevertheless, most countries thatpermit abortion in cases of sexual violence do not recognizea need for access to safe abortion for women experiencingIPV, nor is IPV explicitly identified as a basis for legal abor-tion in the Maputo Protocol (although some cases may becategorized as rape in countries where spousal rape is rec-ognized). According to WHO estimates, IPV survivors aretwice as likely to induce abortions (often in settings wherethere is no access to safe abortion) as other women.

Need for comprehensive services WHO has developeddetailed policy and clinical guidance on the care of survi-vors of sexual assault and intimate partner violence [8].According to this guidance, female survivors of sexual vio-lence need comprehensive, woman-centered services thatmeet their physical, psychosocial, and reproductive healthneeds. Comprehensive PRC includes physical and psycho-logical care, EC, PEP for HIV prevention, treatment forsexually transmitted infections (STIs), collection of foren-sic evidence, access to safe abortion services, psycho-social counseling, and follow up care.While post-rape services initially focused on medico-legal

aspects of SV, and later, on prevention of HIV, there is a

growing consensus on the importance of preventing un-wanted pregnancy from sexual assault through provision ofEC. This is reflected in national guidelines and PRC proto-cols: Management of pregnancy from rape, including preg-nancy counseling and referral, remains a neglected area ofcare.Participants at the regional meeting agreed that preven-

tion and management of pregnancy are essential aspectsof comprehensive post-rape care. Care and support to pre-vent and manage pregnancy should be offered in the con-text of comprehensive care for the overall management ofSV and IPV, rather than in isolation. Effective psychosocialsupport that includes “first line” response or psychologicalfirst aid, is critical [9]. As a WHO expert noted, “Somesurvivors will need EC, some will need safe abortion, butall survivors will need and should be offered ‘first line sup-port’ to address psychological trauma.” Psychological firstaid should form part of a complementary, initial mentalhealth and psychosocial response, though it is not the onlymental health service that survivors receive as part ofcomprehensive care.In addition to offering specialized post-rape care, pre-

senters also identified the health sector as a key entrypoint for addressing sexual and intimate partner violencemore broadly. WHO presenters noted that the majority ofwomen and girls who experience SV/IPV do not report orseek specialized care for such violence. Those that do ac-cess health services may enter via delivery points thatseem unrelated to SV/IPV care, present with non-violencesymptoms, or not reveal that they are experiencing vio-lence. However, most women will receive sexual and re-productive health services at some time in their life. Ifhealth workers are sensitized about SV, they can identifywomen based on the consequent symptoms or conditions,educate women on their rights, provide information towomen about their and options, provide referrals, assist inaccessing social and legal services, and manage some ofthe clinical aspects. They can also avoid the harm that re-sults to survivors when health workers do not respond ad-equately or sensitively to SV. The health sector can alsoplay an essential role in collecting data on the incidence,risk factors and consequences of SV, inform SV policy andprogram development, and advocate for more integrationand prioritization of SV as an issue within the sector.WHO’s health sector guidelines and tools based on

services for women subjected to intimate partner vio-lence or sexual violence, the clinical management of rapesurvivors, and technical and policy guidelines for safeabortion [10] should be used to strengthen health ser-vices and also to advocate for policy change.

A technical update on emergency contraception AnICEC representative delivered a presentation focusing ona technical update on EC. The presentation revealed that

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EC is one of the safest forms of contraception and worksby preventing fertilization, not implantation. Thus, manyof the reasons given for not providing EC reflect misin-formation and provider bias rather than medical fact. ECis both safe and effective. EC pills are more effective thesooner they are taken after unprotected sex, but can beeffective at preventing pregnancy for up to five days.Dedicated EC pills (those packaged and labeled specific-ally for use as emergency contraception) have no estro-gen, have few side effects, and are not associated withinfertility, cancer, or stroke. If a pregnant woman takesEC, it will not cause harm to her or to the fetus. It is nota form of abortion. EC pills are safe to be used repeat-edly within the same menstrual cycle, and, while not rec-ommended for long-term family planning because otherongoing methods are more effective, there are no restric-tions on repeated use.

Pregnancy management and access to safe abortionAccording to WHO guidelines, survivors who experiencerape-related pregnancy should be counseled on their op-tions and referred for abortion where legally available.This guidance is consistent with the Maputo Protocol andstatements by the UN Commission on the Status ofWomen calling for access to EC and safe abortion for sex-ual violence survivors [11]. Nevertheless, national sexualviolence guidelines tend to be silent, or at best, vague onthe law with respect to abortion and on counseling survi-vors who become pregnant regarding their legal options.Expert presentations also highlighted the health and

human right aspects of access to safe, legal abortion, thesafety of medical abortion (when performed accordingto WHO guidelines), and the consequences of unsafeabortion for millions of women globally. According toWHO (in 2008), half of the 44 million abortions ob-tained annually across the world are unsafe. WHO alsoemphasized that “highly restrictive abortion laws are notassociated with lower rates of abortion – just higherrates of unsafe abortion.” Where states have legalizedabortion, abortion-related mortality has declined dra-matically (73% in the USA, 91% in South Africa). OneWHO presenter reported that, because safe, legal abor-tion is rarely permitted in Africa, an abortion on the Af-rican continent in 2008 was 767 times more likely toend in death than an abortion in the United States [7].The Maputo Protocol requires that States not only

decriminalize abortion in certain circumstances – it alsorequires that States create an enabling environment thatpromotes safe abortion care. To achieve this environ-ment, countries must ensure legal access to safe abor-tion, availability of services, and good quality of care.Experts also noted that the African Commission has

adopted the broader WHO definition of “health” forpurposes of the Maputo Protocol:

“When assessing the risks to a pregnant woman’shealth, health must be interpreted according to theWHO definition, namely: a ‘state of complete physical,mental and social well-being and not merely the absenceof disease or infirmity.”According to this guidance, any laws, policies or practices

that restrict legal abortion to narrowly defined medicalgrounds do not meet State obligations under the Protocol.The Comment also states that the unavailability of safeabortion is in itself a threat to women’s life and health, dueto the high risk of injury and death from abortion by unsafeor illegal procedures, methods and providers [12]. Giventhe General Comment interpretation, it is clear that safe,legal abortion should be far more available in the regionthan is currently understood or implemented.Drawing a parallel between restrictive abortion laws and

policies and those relating to HIV, regional experts stressedthe need to address unsafe abortion first and foremost as ahealth and human rights issue. In the case of HIV, punitivelaws that criminalized HIV transmission, sex work and drugpossession did not reduce HIV, but in fact created barriers tohealth service access and had a negative impact on utilizationoverall. To change this, policy makers and health careproviders (HCPs) had to “withhold judgment and prioritizeaccess to services.” A similar approach is needed now to re-duce unsafe abortion and its negative health consequences.Participants recognized the difficulty of advocating for

EC and abortion with policy makers and in communities,because of the “moral or religious issues” and stigma at-tached to abortion, rape and incest. WHO presenters en-couraged participants to focus on the “health imperative” ofpreventing unwanted pregnancy and reducing the numberof unsafe abortions in Africa, and to frame the debatearound reproductive health and SV as a fundamental hu-man rights issue. A Population Council representative alsospoke of the human cost of SV and unsafe abortion, callingon participants to be “bold” in the face of resistance, and tochampion the “rights of the voiceless.”

Current situation in participating countries with respectto national guidelines, laws, policies, and practiceA key objective of the meeting was to encourage delegatesto look closely and critically at the laws, policies and prac-tices that currently exist in their countries and to comparethese with the requirements of the Maputo Protocol andWHO evidence-based guidelines for safe abortion andPRC/IPV. This was achieved through: 1) a PopulationCouncil presentation of the key findings from its 2014study of sixteen African countries, entitled “Access toEmergency Contraception and Safe Abortion Services forSurvivors of Rape: A Review of Policies, Programmes andCountry Experiences in Sub-Saharan Africa” [1], and 2) areview of WHO guidelines, facilitated team exercises, andsharing of information in plenary.

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Pregnancy preventionAll of the six countries represented at the meeting havedeveloped national guidelines for the care and managementof rape and sexual assault. In each of these guidelines,prevention of pregnancy through EC is included as anessential element of care.National Post-Rape Care (PRC) guidelines on EC are

generally consistent with WHO guidance. However, re-view of the national guidelines identified some gaps and/or inconsistencies, such as information on determiningeligibility for children and adolescents, and the informa-tion to be provided to survivors when administering EC.Participants also found that in some cases their guidelineson EC were not fully consistent with the most recent 2013WHO guidance. Several countries noted the need to up-date their guidelines to include the following information:

■ Pregnancy testing is not necessary before adminis-tering EC. EC should never be delayed or refused iftesting is not available;

■ EC should be given to all survivors presentingwithin 5 days (not 72 h, per prior guidance) whowish to prevent pregnancy;

■ Children and adolescents should be offered EC ifthey have begun menstruating or have secondarycharacteristics;

■ EC works by preventing fertilization, notimplantation;

■ EC is completely safe and does not interfere withexisting pregnancy;

■ EC should be administered as soon as possiblewithin the post-rape care regimen;

■ Dedicated emergency contraceptive pill (ECP) [levo-norgestrel (LNG)] may be taken as a Stat dose [13];

■ Children and adolescents should be offered EC ifthey have begun menstruating or have secondarycharacteristics;

■ EC should be offered regardless of where thewoman is in her menstrual cycle, as it is difficultto predict the timing of ovulation;

■ Prophylactic administration of anti-emetics is notneeded when patients are given dedicated ECPs(LNG);

■ Survivors should be offered a longer-term contra-ception option after being given EC.

WHO and ICEC guidelines recommend the use ofdedicated ECP (1.5 mg of LNG) for emergency contra-ception. This is not always possible, however, as manycountries in Africa do not stock dedicated ECP in publichealth facilities, or they experience frequent stock-outs.Participants therefore noted the need to include moreinformation for health providers in national and clinicalguidelines on how to use regular contraceptive pills(progestogen-only contraceptive pills or combined oral

contraceptive pills) for EC. “Customizing” guidelines toreflect the specific brands and regimens available canalso be helpful for providers, but may require frequentupdating. WHO representatives at the meeting recom-mended that these details be provided in training orclinical instructions rather than the national guidelines.Discussions revealed that the majority of countries rep-

resented at the meeting do not stock dedicated ECP (levo-norgestrel) in their public health facilities or pharmaciesin practice. Kenya is an exception in this regard, as allpublic facilities are provided dedicated ECP, in part bydonor organizations. Dedicated EC is also readily availablefrom the private sector. Other countries, such as Rwanda,provide dedicated EC in specialized PRC facilities such as“one-stop centers,” however most public clinics only haveregular contraceptive pills to use for EC. In some coun-tries, participants stated that dedicated EC is available inpublic sector pharmacies and family planning clinics butmay not be stocked in emergency rooms or other placeswhere PRC services are provided. In Botswana, dedicatedECP is only available from private pharmacies - public fa-cilities, including those designated for PRC- are currentlylimited to offering combined oral contraceptive pills. InEthiopia, EC is available in public facilities - according toone participant, no prescription is required, there is noage restriction for access and even men can come in andask for it for their wives and girlfriends.According to participants, EC is available over the

counter in pharmacies without a doctor prescription inthree of the six countries at the meeting - Ethiopia,Kenya, and Malawi [14]. In the other three, it may beobtained at private pharmacies, but a prescription is re-quired [15]. According to ICEC, there is no medical rea-son why EC should not be available over-the-counter.Requiring a prescription reduces access because manywomen, especially young, poor, and rural women, do nothave the time, opportunity or resources to see a doctoror to access EC from a clinic during regular hours. Forwomen in urban areas, over the counter EC substantiallyincreases opportunities for access, without having to seea doctor or report to a public facility offering post-rapecare. Access is even more challenging for women andadolescents in rural areas, where private-sector EC isnot always an option: there are fewer pharmacies, phar-macies may not carry it, it is too expensive, or there areno doctors at the clinics to prescribe it.The findings from the Population Council study regard-

ing the policy framework for EC were generally consistentwith the presentations by country teams, particularly interms of coverage of EC in national PRC guidelines. Thestudy found that national guidelines consistently identifypregnancy prevention as an essential element of sexualviolence care, and all countries with national guidelines in-cluded provisions on EC. Population Council also found,

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however, gaps and inconsistencies in the EC provisions, aswell as a disconnect between PRC guidelines and nationalguidelines for reproductive health and family planning.The study found, for example, that although many RHpolicies contained general provisions on EC, EC was notgiven much attention compared to other FP methods.Moreover, most national RH/FP guidelines tended to bevague or silent on the specific reproductive health needsof rape and incest survivors and the need to integrate ECinto both PRC and regular RH/FP services in order to en-sure that all eligible survivors have access to EC. Duringthe regional meeting, several countries identified the needto align the language in their RH/FP guidelines with thelanguage in the PRC guidelines, particularly in terms of of-fering EC to all SV survivors and the information to givepatients prior to administering EC.

Key challenges to EC access

Participants’ perspectives on barriers to EC accessDuring the meeting, participants were asked to identifywhat they felt were the major challenges to EC access.The results of this group exercise were then analyzedand summarized by an ICEC expert as follows:

■ At the Personal Level, low awareness of EC amongsurvivors and the public generally was the mostfrequently identified obstacle, followed by stigmaassociated with rape or pre-marital sex;

■ At the Provider Level, lack of knowledge regardinghow EC works and how to administer it correctly,was the primary barrier identified by participants,followed by provider biases, misconceptions andattitudes toward EC and survivors;

■ At the Policy Level, participants identified supplychain management and logistics as the biggestchallenge, resulting in frequent “stock-outs” of ECproducts in public facilities.

The findings closely mirror results from the PopulationCouncil study on access to EC for survivors in the region[1]. This study highlighted low awareness of EC amongsurvivors and other community members; failure to reportor seek health services following rape; ‘late reporting’(reporting past the timeframe for EC); providers’ unfamili-arity with their national protocols or the details of how toadminister EC, including to rape victims.

Pregnancy counseling, management, and safe abortioncareWHO’s most recent guidance on Responding to IntimatePartner Violence and Sexual Violence Against Women(2013) states that if a survivor presents after the time re-quired for EC, if EC fails, or if she presents with a preg-nancy as a result of rape or incest, she should be offered

safe abortion in accordance with national law. Survivorswho decide to maintain the pregnancy should be advisedof all available options (including adoption and fostercare), and referred to pre-natal care.WHO’s guidance on Safe Abortion [16] further states

that women who are pregnant as a result of rape:“have a special need for sensitive treatment, and all

levels of the health system should be able to offer appro-priate care and support. Standards and guidelines forprovision of abortion in such cases...should not imposeunnecessary administrative or judicial procedures suchas requiring women to press charges or identify the rap-ist ... and should ideally be part of comprehensive stan-dards and guidelines for the overall management ofsurvivors of rape.”Further:“[p]rompt, safe abortion services should be provided

on the basis of the woman’s complaint rather than re-quiring forensic evidence or police examination. Admin-istrative requirements should be minimized and clearprotocols established for both police and health-careproviders as this will facilitate referral and access tocare” [16].Similar standards for safe abortion for survivors are re-

quired under the Maputo Protocol, as articulated in theAfrican Commission’s General Comment 2.Consistent with the findings of the Population Coun-

cil’s 2014 study [1], the meeting confirmed that fewcountries in the region provide safe abortion for sexualviolence survivors as required by the Maputo Protocol.With the exception of Ethiopia, none of the six countriesrepresented at the meeting had clear guidelines on abor-tion for sexual violence survivors. Ethiopia was also theonly country of the six participating in the meeting thatfeatures access to safe abortion in its national protocolas an essential element of post-rape care.Like Ethiopia, Botswana and Rwanda have national

laws permitting legal abortion in the case of rape and in-cest, as well as in cases where the pregnancy presents arisk to the life or health of the mother, or in cases of se-vere fetal abnormality. However, of these three countries,only Ethiopia was found to have an “enabling” legal andpolicy framework in which survivors of sexual violenceare referred for abortion if requested, and can actuallyaccess safe abortion in practice. Due to judicial and/oradministrative requirements contained in the law or im-plemented in practice, safe abortion is almost as in-accessible to sexual violence survivors in Botswana andRwanda as in countries where abortion is illegal.In two of the participating countries - Kenya and

Zambia - the legality of abortion for sexual violence sur-vivors is unclear, and therefore tends to be interpretednarrowly. Neither country explicitly allows legal abortionin case of rape or incest. However, both countries have

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adopted provisions (in the constitution and by statute,respectively) that allow for legal abortion to protect thelife and health of the mother. If interpreted expansively,according to General Comment 2, these current exceptionsare sufficient to allow legal abortion where pregnancy is theresult of sexual violence. In practice, however, abortion isnot generally offered to SV survivors and is considered bymost to be a criminal offense. Zambia has reportedly initi-ated a process to update its 1972 termination of pregnancylaw to meet the requirements of the Maputo Protocol. Atpresent, however, only child survivors of sexual violence areexpressly permitted to obtain abortion (per an amendmentto the penal code). The procedure for accessing abortion inthese cases remains unclear.In Malawi, participants explained that abortion re-

mains illegal except to save the life of the mother, andthat in practice, this provision is interpreted narrowly.Pregnancy is not addressed in the national PRC guide-lines, and survivors of sexual violence who become preg-nant are not offered abortion as part of post-rape care.Participants from Malawi reported that the Malawi

Law Commission has proposed amended legislation thatwould broaden the law to include all the exceptions re-quired by the Maputo Protocol, including a specificrape/incest exception. However, little progress has beenmade in enacting the law since it was proposed in 2009.In contrast, participants from Ethiopia explained that

according to their law, safe abortion is available in allcases required by the Maputo Protocol, as well as to anyyoung woman under the age of 18 by virtue of her mi-nority status. Ethiopia is also one of the few countries inthe region that has developed national clinical and policyguidelines for safe abortion care, establishing a clear pol-icy framework for safe abortion in addition to clinicalprotocols for practitioners [17]. Of note was the fact thatEthiopia’s law, consistent with WHO guidelines andGeneral Comment 2, allows abortion services to be pro-vided at the woman’s request, if her reason is one of thereasons allowed by the statute. She is not required toprovide “proof” of eligibility or obtain a doctor or judge’spermission in order to access the service. As onepresenter explained, “If the woman says she was raped,that is enough ... Nothing further is required.”

Treatment of pregnancy and safe abortion in nationalguidelinesAs with EC, participants at the meeting conducted an in-depth review of provisions in their national PRC guide-lines regarding pregnancy testing, counseling and manage-ment. According to WHO guidelines, pregnancy testing isnot required prior to giving EC, as it will not harm anexisting pregnancy and any pregnancy from rape couldnot be detected at that stage. Rather, pregnancy testingshould be conducted at the recommended two-week

follow up visit if the survivor is at risk for pregnancy, or atthe first visit if a survivor presents too late for EC.The participant review confirmed that pregnancy test-

ing features in all of the national PRC guidelines. All sixrecommend a baseline pregnancy assessment [18] (al-though not required by WHO guidelines) and re-testingfor pregnancy at some stage after the survivor’s initialvisit (ranging from two weeks to six weeks). However,participants generally agreed that their guidelines couldbe strengthened by specifically addressing the needs of“late reporters” and by providing clear guidance and anadapted flow-chart for these patients. For example, par-ticipants noted that late reporting survivors should betested for pregnancy at their initial visit and managedaccordingly, regardless of when they report for care. Par-ticipants also pointed out the need to ensure that survi-vors who receive EC are routinely tested for pregnancyafter two weeks - per WHO guidelines - rather thanwaiting for a 4 to 6 week follow-up. At minimum, theynoted that survivors should be informed to return im-mediately for testing in the event of a missed period.With few exceptions, the review showed also that preg-

nancy counseling and management does not featureprominently in national PRC guidelines. Where discussedat all, national provisions tend to be vague or stated ingeneral, boilerplate terms, with little in the way of detailedguidance or country-specific information. This is particu-larly true with respect to access to abortion. In countrieswhere abortion after rape is not specifically allowed, theprotocols are silent. In others, the provisions are unclearand provide little guidance to health care providers or pa-tients in terms of their rights or options. Ethiopia’s na-tional PRC guidelines [19] provide the clearest guidanceon pregnancy, focusing on the following needs of survi-vors of rape: emotional support to foster understanding oftheir options if pregnant, antenatal care for those that optto keep the pregnancy, adoption and foster care as op-tions, and abortion services.Most participants agreed that their guidelines could be

strengthened with respect to pregnancy counseling andmanagement, although some noted the difficulty ofdoing so before the laws and policies on abortion intheir countries are changed or clarified. Others noted,however, that there was room for clearer and more fa-vorable interpretations of existing laws to be incorpo-rated into PRC guidelines. Such a process would behelpful in expanding survivors’ access to safe abortionwithin the framework permitted by law. According toone expert, “If the law is vague, then we need to play arole in interpreting them. If interpretation is at the dis-cretion of health care providers, then we need to em-power them to interpret the law more expansively.”With respect to counseling, WHO experts noted the

importance of providing accurate and evidence-based

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information to women to allow them to make their owndecision regarding their pregnancy. Pregnancy counsel-ing should be client-centered and non-directive, focusedon the woman and her needs rather than the counselor’spersonal views and opinions.Participants and experts also noted the importance of

identifying specific referral services for survivors who be-come pregnant, particularly at facility level, and ensuringthat survivors are able to access them [20]. Whether forabortion, adoption/foster care, further counseling andsupport, or PMTCT/pre-natal care, identifying availableservices and putting formal referral arrangements inplace, can help ensure that survivors receive the carethey need.

Key challenges to safe abortion access

Legal provisions The most significant challenge to safeabortion is the legal and policy framework in the majorityof countries represented at the meeting. As mentionedpreviously, with the exception of Ethiopia, none of theparticipating countries currently have a clear and enablingpolicy allowing safe abortion for survivors of sexual vio-lence – not even in countries such as Botswana andRwanda where abortion after rape or incest is legally per-mitted. In some countries, the challenge lies in vague and/or conflicting laws or the narrow interpretation of theselaws. In others, the law requires onerous third-party ap-proval processes to obtain an abortion, which significantlyimpede timely access to the procedure. In Zambia, for ex-ample, the law requires three doctors, including one spe-cialist, to give their approval before an abortion may beprovided. In a country with very few doctors, thisprovision is prohibitive, particularly in rural areas. Expertsalso noted with concern how few countries in Africa allowabortion at the request of the survivor, and instead placethe decision-making in the hands of third parties.

Lack of policy guidance Few countries in the regionhave developed clear policy guidance interpreting existinglaw or setting out the procedures for accessing safe, legalabortion. The result is that few health care providers, po-lice, or members of the public understand what is and isnot legally permitted, or what survivors must do to obtainlegal abortion services. Concerns about criminal penaltiescause practitioners to err on the side of caution, refusingabortion in situations arguably permitted under the law.Moreover, in the absence of clear policy, too much discre-tion rests with the individual health care providers or facil-ities, and the “policy” becomes what is done in practice,rather than the other way around. During the meeting, itbecame evident that some countries are interpreting thelaw more strictly than necessary- in practice, imposingevidentiary burdens and approval processes above and

beyond the requirements of the law in the absence of aclear policy framework. An example is Botswana wheremany hospitals require a panel of doctors to approve abor-tion for SV survivors even though not required by law.Participants also stated that, in practice, pregnant survi-vors seeking abortion must prove not only that they wereraped (i.e., by providing evidence of a police report ormedical exam), but that they became pregnant because ofrape (i.e., they were not sexually active before or after thesexual assault) before they can be referred for abortion.Even children, who are by definition victims of defile-ment/statutory rape, must provide evidence and gothrough these approval procedures. Participants notedthat while all of the participating countries have protocolson post-abortion care (PAC), only Ethiopia has a nationalhealth policy on safe abortion. Rwanda reported that it isin the process of developing guidelines in connection withits new abortion law.

Low awareness Limited awareness of abortion laws inthe country or confusion regarding their interpretationcan result in survivors not accessing abortion even whereit is legal under the law. As the primary “gate-keepers,”health care providers play a critical role in informingwomen of their rights and the options available to them. Itis important, therefore, that HCPs are well-trained to pro-vide accurate, un-biased information on abortion andabortion procedures, and to understand the law and Min-istry of Health policy regarding the right to access. As oneparticipant explained, “Moving forward, there is a criticalneed to interpret the law and educate the public so thatpeople understand what the law says. At the moment, law-makers don’t know. Service providers don’t know. Andthe people who need these services don’t know. Most as-sume [abortion] is illegal even when it’s not.”

Capacity and training Capacity to provide accessible,high quality abortion services is currently limited, evenin countries where abortion is legally available. In orderto expand access to abortion, participants noted theneed to increase the number of trained providers and fa-cilities offering the procedure, and to more fully inte-grate safe abortion into post-rape care. Training alsoneeds to address moral objections to abortion.Of additional concern are laws which only allow doc-

tors to perform abortions, or require abortions to beperformed only in hospitals. These create unnecessarybarriers to access in areas where doctors are rare andhospitals are far away. WHO guidance is clear that abor-tion should be accessible at all levels of the health caresystem and that lower level HCPs can be trained tosafely provide medical and non-surgical abortions.

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Age of consent A few participants expressed concernthat minors are not able to access abortion without paren-tal consent, even where they are above the age of consentfor sex. This creates a barrier, because many do not wantto reveal sexual violence or sexual activity to their parentsand wait until it is too late to obtain abortion safely.Ethiopia was the exception among participating countries,as minors are allowed to access abortion without consent.

Legal challenges by conservative/religious groups Inseveral countries, “pro-life” groups have vigorously op-posed expansion of abortion rights. In Kenya, there iscurrently a case in the Supreme Court challenging thedissemination and implementation of health ministryclinical protocols on safe abortion. Participants fromZambia also reported that a proposed constitutionalprovision stating that life begins at conception could ef-fectively eliminate legal abortion in the country, at thesame time that key stakeholders in Zambia are workingto expand access to safe abortion.

Opportunities to expand access to emergencycontraceptionTo date, efforts to strengthen access to EC for survivors ofsexual violence have focused primarily on including EC inthe package of PRC services offered in health facilities andone-stop centers. As reflected in the national protocols,EC is increasingly recognized as an essential componentof comprehensive post-rape care. The challenge remains,however, that in many settings a majority of sexual assaultsurvivors do not report to law enforcement or seekfacility-based treatment. For these women and girls,knowing that EC is an option to prevent pregnancy andbeing able to obtain it through other avenues is critical.During the meeting, participants explored various

ways to improve access to EC both within and outsidethe clinical context. Discussion focused on four mainareas: strengthening delivery of EC in the clinical con-text, decentralization of EC services, increasing aware-ness in the community, and overcoming policy barriers.

Enhancing clinical contexts

Training Participating countries need to ensure that ECis integrated into HCP training on family planning (FP)and SV. It should be part of the regular curriculum forpre-service as well as in-service training. The trainingshould focus on the safety, side effects, and mechanism ofaction of EC, along with how to provide EC, includinghow to use regular contraception pills for EC. This is acritical component since many facilities do not yet supplyor have a regular supply of dedicated EC pills. As one par-ticipant explained, “Women should not be turned awaybecause dedicated EC products are not available.”

Access to products Countries need to strengthen accessto supplies and management of the supply chain. Somecountries procure dedicated ECPs while others do not.Even in countries where the government procures it, theremay be other barriers to ensuring its availability. InZambia, for example, EC is not included on the EssentialMedicines List. As a result, EC is not automatically sent tolower level facilities such as clinics, and even dedicated SVfacilities experience stock-outs. Countries need to procureEC and then ensure that it is distributed regularly to everyhealth care facility without the need to special order.Countries should also be sure to include EC on facility-level order forms and reporting forms to request EC andkeep track of EC usage. According to ICEC, including ECon such forms can be very helpful in improving country-level procurement and distribution.

Availability 24/7 Saying EC is available in the “publicsector” is not sufficient, as that often only means thatEC can be obtained from a FP clinic or pharmacy duringregular business hours. Given the narrow timeframe forEC and the impact of timing on efficacy, women, and es-pecially SV survivors, need to be able to access EC atany health facility - from local clinic to emergency room,on weekends and after hours, and without having totravel long distances to regional hospitals or specialtycenters. Facilities also need to ensure that the staff onduty can provide EC (and have access to ECP) even if adoctor is not available.

Facility-level protocols To improve access at facility-level,facilities offering care to sexual violence survivors should in-corporate the following into their service protocols:■ EC should be provided as early as possible in the

treatment flow.■ EC must be available and accessible to HCPs 24/7.■ EC must be physically available in the place where

SV services are provided, including during offhours, so that patients do not have to wait at thepharmacy, travel to other wards or off-site facil-ities, or wait for services to open for business inorder to obtain EC.

■ EC should be given to patients free of charge.■ Survivors should not be required to report to

police in order to receive EC.■ Provision of EC should be included in staff moni-

toring/evaluation/supervision and oversight.

Youth-friendly services Countries need to make ECmore accessible to young people, including throughyouth-friendly services at local clinics. In Botswana, forexample, some public clinics have created a “youth cor-ner” staffed with younger nurses (male and female),which has improved access to EC in this context. Young

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people also need to have access to more complete andaccurate information about sexuality, contraception andSV to counteract the stigma and “culture of silence”around EC and SV. HCPs can play a role in promotingmore open discussion around these issues, as can cre-ative use of social media.

Confidentiality FP protocols for EC distribution must besensitive to women’s privacy concerns and protect theirconfidentiality. In Kenya and Botswana, for example,women requesting EC from public sector clinics have torecord their names in a register, as with other forms of FP.Given the circumstances under which women seek EC,countries should amend these requirements to permit re-cording of EC distribution without identifying informationso as not to inhibit women and girls from seeking ECfrom the public sector, especially after rape.

Sensitization The health profession in general needs tobe more open and sensitized regarding SV, sexuality, re-productive health, and rights, “so that people - and espe-cially young people - can go and get help, feel free totalk, and ask questions without judgment,” including,but not limited to, questions about EC.

Decentralization of services A second way to improveaccess is to make EC available in a broader range of pub-lic and private settings, and to assure access, regardlessof whether sexual violence is reported. Making ECwidely known and available can help survivors access EC– especially those who choose not to report or seek ser-vices at a health facility.

Recommendations from the meeting include:

Over-the counter access/private pharmacies Countriescould enter into public/private partnerships with phar-macies to improve information on the safety of EC andthe appropriateness of OTC purchase of EC at pharma-cies and drug stores. Such actions would help enhanceaccess to services. In Vietnam, for example, certain pri-vate pharmacies have been selected and trained as desig-nated “Youth-Friendly Pharmacies” [21] to improveaccess to young people.

Make EC available to SV survivors at the first pointof contact Participants from Zambia indicated thatZambia-based research showed that 90% of rape survi-vors who reported their rape incident, went first to thepolice, not to health care facilities. In response, Zambiaimplemented a pilot project to provide EC at police sta-tions through the Victim Support Unit (VSU) [22].These officers were trained to provide EC, provide infor-mation about PRC, and refer survivors for further

services. The project also included a community out-reach component in which officers went out to commu-nities and told people about the services available. As aresult of the project, the number of women reporting topolice, obtaining EC, and being referred to hospitals forcomprehensive PRC all increased. It also helped improvethe public’s perception and attitudes toward police. Thisrole of EC provision to survivors by VSU police officersis now also stipulated in Zambia’s national guidelines forthe management of survivors.

Make EC available in schools and workplaces InBotswana, for example, EC is available in clinics based attertiary educational institutions, as well as some publicsector workplaces such as the Botswana Defense Force.Use Community Health Workers/Volunteers to expand

access to EC, especially in rural communities.In Zambia, the ministry is currently using community

health workers (CHWs – also referred to as ‘communityhealth volunteers in some countries) to expand access tohealth services, especially in rural areas where there arefew clinics, few professional nurses, and no doctors. Ifproperly trained, CHWs could also be used to providefamily planning services and EC. In Kenya, communityhealth volunteers are already allowed to distribute regularcontraceptive pills. At minimum, these same volunteersshould be trained on how to use regular contraception forEC. With additional training, community health volun-teers could also distribute dedicated ECP and refer womenin their communities for longer-term family planning ser-vices and/or comprehensive IPV or SV care [23].Some participants noted a potential downside of de-

centralizing services and increasing access to EC outsideof health facilities or specialized PRC centers, namelythat SV survivors may choose to take EC without obtain-ing other essential services, such as psycho-social coun-seling and PEP to prevent HIV infection. As a result,some participants argued that efforts should focus onstrengthening access to comprehensive PRC, and identi-fying and addressing the barriers that prevent survivorsfrom seeking health services. Some also expressed con-cern about community workers providing services tosurvivors of violence, noting sensitivity, ethical and priv-acy concerns. According to one expert, communityhealth workers can be used to raise awareness, but arenot qualified to provide counseling and other services tosurvivors, and risk causing further harm. There was con-sensus among participants on this point, however- ifcommunity workers are allowed to provide EC, it is es-sential that they be trained to provide correct informa-tion, protect survivor privacy and confidentiality, andrefer survivors to health care facilities for comprehensiveservices. As one participant stated, “EC should not bestand-alone response.”

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Increasing awarenessParticipants in the meeting agreed that low awareness ofEC is a major challenge to increased access. Accordingto DHS data, less than 40% of women have ever heardof EC in five of the six countries that participated in themeeting (Kenya is the exception). Those that have heardof EC may not know how it works, the timeframe forusing EC or how and where to access it. Increasing pub-lic awareness of EC, and SV services generally, is thus anurgent need. SV services should include a communityawareness and outreach component so that survivorswill be informed of the services available to them andencouraged to access those services in a timely fashion.Some specific recommendations (made based on existingapproaches) and suggestions were outlined to help pro-mote EC awareness:

School-based education and outreach Countries needto integrate information about EC and SV into the regu-lar health education curricula. Various role players canalso conduct outreach in schools. In Zambia, for ex-ample, the police have a “school zone” unit, which goesout to schools and raises awareness about SV and ser-vices available to SV survivors, including EC.

Integrate EC into FP visits Raising awareness about ECshould be part of regular family planning and counseling.If EC is explained during routine appointments, womenwill be more aware of their options if and when they orsomeone they know needs EC. Integrating EC into FPcounseling and information materials is also important forother reasons. As explained by ICEC, there is an urgentneed to “set the facts straight” about EC, as many peoplehave been given inaccurate information or have miscon-ceptions about EC. Women also need to understand thatEC is not the most effective method of birth control. Theyneed to be aware of its limitations and the importance ofregular contraception/FP strategies for longer-term pro-tection against pregnancy and HIV. Government fromacross sectors, including but not limited to health, shouldteam with civil society to raise awareness of EC, availableSV services, and the need for a multi-sectoral response toaddress sexual violence and IPV.

Advocacy and information campaigns using multipleapproaches In the DRC ICEC is working on a projectwith Population Media Center. PMC produces soap op-eras and radio shows that are very popular with women.ICEC is working with PMC to incorporate EC-relatedmessages into the program story lines to raise awarenessabout EC. This is an example of how large audiencesmight be reached by leveraging existing media platforms.In Kenya, LVCT Health (a non-governmental organization)

has partnered with Safaricom (a leading communications

company) to provide a caller information line focused on re-productive health issues. According to members of the Kenyadelegation, this strategy has been very effective and benefitedthousands.Community health workers can also be used to dis-

seminate information about EC and SV services, particu-larly in rural areas. Traditional leaders are alsoimportant in rural culture and are very influential intheir communities. As one panelist explained, “If we cantrain the leaders and get them on board, the people willget the information.”

Social marketing Countries need different approachesfor rural and urban populations and various age groups.Strategies must be appropriate and effective for the targetaudience. As one panelist explained, “Working with chiefsis a good strategy in rural areas but a different approach isneeded to reach young people in the cities.” Marie Stopes,for example, recommends creating youth-friendly spacesoutside the clinical setting, where young people can obtaininformation and speak openly about sexuality and repro-ductive health. Social media and mHealth campaigns arealso effective ways to reach young people, provide infor-mation and improve uptake of services.The social marketing sector is a natural fit for EC: Re-

search shows that women like to buy EC from pharma-cies and often are willing to pay for it. Social marketingprograms have effectively distributed EC in a number ofcountries, including a large program in Ethiopia; yet asof 2012, only a third of social marketing family planningprograms in Africa included EC.

Addressing policy barriers

Improve supply and distribution of dedicated ECP Asdiscussed above, there is a need to improve supply-chainlogistics and management so that health care facilitiescan properly estimate their needs and ensure uninter-rupted supply. Including dedicated EC on the EssentialMedicines List is an important step, and ensures that allhealth facilities, including local clinics, have a supply ofECP. To the extent possible, governments should pro-cure and distribute dedicated EC products; however,where dedicated ECPs are not available, protocols shouldbe in place for supplies of regular oral contraception tobe used as EC.

Over-the counter access EC should be available over-the-counter without a prescription and without restric-tions as to age.

Eliminate reporting requirements In policy and/or inpractice, many countries require survivors to report topolice and/or provide a police report before they can

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access PRC services – including free EC – at publichealth facilities. These policies should be reviewed andamended, and staff at facilities trained, to ensure thatsurvivors of sexual violence and IPV can obtain essentialhealth services without reporting to law enforcement.

Opportunities to expand access to safe abortionExpanding access to safe abortion is a multi-step processwhich requires an enabling legal and policy framework,awareness of rights, availability of services and trainedservice providers, and quality of care. Given the limita-tions of the current legal framework in most countries,discussions around access focused primarily on legisla-tion and policy, as well as on integrating safe abortionmore specifically into services for SV survivors.

LegislationIn terms of legislation, several participating countriesthat have not updated their abortion laws post-Maputoidentified a need to enact legislation or amend existingstatutes to bring them into compliance with Article14(2)(c). At a minimum, the Maputo Protocol requires thatnational laws authorize legal abortion in all cases of rapeor incest, risk to the life, mental or physical health of themother, and serious fetal abnormality. Some countries inthe region also allow abortion on other grounds, such associo-economic circumstances (Zambia) or the age ofthe pregnant woman (Ethiopia).Countries in the region that already permit abortion in

certain circumstances need to revisit existing or proposedlegislation in light of the new interpretive guidance pro-vided by the African Commission General Comment 2. Inparticular, the General Comment states that countriesshould eliminate or revise any provisions in the law thatmay impede access to safe, legal abortion where autho-rized, or that run contrary to the idea of an “enabling en-vironment.” These include, for example: evidentiaryrequirements; third-party authorization requirements andprocedures; and overly restrictive requirements regardinghow and where abortions may be performed, and by whatlevel of HCP.General Comment 2 also adopts a broad definition of

the terms “life” and/or “health” of the pregnant woman,per the WHO definition of “health,” which arguably en-compasses a much wider range of circumstances forlegal abortion beyond those currently permitted by lawor in practice.

Interpretation/implementation of existing lawBeyond enacting or amending legislation, opportunitiesalso exist for line ministries to interpret and implementexisting law in a way that is more expansive and favor-able to SV survivors. For example, countries can makeclear through policy and/or policy directives that any

pregnancy of an underage girl is by definition statutoryrape, and therefore automatically subject to theprovision allowing abortion in the case of rape or incestwithout the need for any further evidence or approvalprocess. Countries can also allow SV and IPV survivorsto access legal abortion on the grounds that it is neces-sary to protect their mental and physical health. Such aprovision is consistent with WHO guidance and GeneralComment 2, as well as with the British case Rex v.Bourne. Countries can also reduce administrative andevidentiary burdens by allowing survivors to obtain asafe abortion based on their statement alone, or in con-junction with a statement by a SV service provider orsurvivor advocate, without having to provide a police re-port or medical evidence to prove sexual violence orpregnancy from sexual violence. Similar opportunitiesfor interpretation through policy and program measuresexist in terms of other allowable grounds for abortion,including reasons of maternal or fetal health. As a corol-lary to all of this, working to address underlying socialnorms that work against prohibit women’s access toabortion services would be critical.Where the statute contains specific requirements, stake-

holders can work together to design and implement moresurvivor-friendly procedures while still complying withthe law. In Rwanda, for example, the law requires a “courtorder” for abortion in the case of rape and incest, but doesnot dictate any particular process for obtaining one. Upuntil now, survivors have had to navigate the courtprocess alone and very few have succeeded in obtainingcourt approval. In response, members of a sexual andgender-based violence working group in the country arelooking at possible ways to facilitate the process for survi-vors, i.e. by allowing the HCP or police officer at one-stopfacilities to submit a request to the court on behalf of thesurvivor and obtain court approval without the survivorhaving to appear or present evidence in court. They arealso looking at ways to streamline the approval process re-quired for abortion based on a health condition.Participants also discussed the possibility of bringing a

test case to challenge the narrow interpretation of exist-ing law. In Malawi, for example, attorneys are consider-ing bringing a test case based on Rex v Bourne – aBritish case that broadly interpreted the same penal codeprovision on abortion that still exists in many of thecommonwealth countries. In this case, the court foundthat protecting the “life of the mother” included protect-ing physical and mental health, and that terminating anunwanted pregnancy from rape was justified to protectthe mother’s health. The court thus held that a girl whohad become pregnant from sexual assault was entitled tolegal abortion, even where the law allowed abortion onlyto save the life of the mother. Several legal experts, in-cluding those from the Center for Reproductive Rights,

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have argued that in the absence of conflicting law, Rex vBourne provides a legally valid interpretation of theabortion law in countries such as Malawi, Tanzania andUganda.

Awareness of and access to quality servicesExperts also pointed to State obligations in the MaputoProtocol and in General Comment 2 to ensure thatrights protected by law are promoted and fulfilled inpractice. This requires not only that abortion is autho-rized in the circumstances allowed by law, but thatpeople are informed of their rights and have access toquality services in the communities where they live.

Integration of safe abortion into national guidelinesIn terms of national guidelines, participants agreed thatPRC guidelines need to incorporate clear and accurateinformation on the law and women’s right to accessabortion in the context of rape and incest, includingstatutory and marital rape. The information should pro-vide clear guidance for survivors and for HCPs on whatis and what is not legally possible and how survivors canaccess available services. The guidelines should also inte-grate clear guidelines for non-directive pregnancy coun-seling, including available options and referralmechanisms to facilitate access to available services.

Moving forwardThe regional technical meeting concluded with a discus-sion of practical steps that participants could take to fa-cilitate legal, policy, and program reform with respect topregnancy prevention and safe abortion in their respect-ive countries. The steps revolved around three areas:

� establishing an evidence base to inform actionswithin countries;

� creating forums for discussing the issues; and� drafting action points to carry the momentum from

the meeting forward in individual countries.

Establish an evidence basePanelists agreed on the need to conduct research and es-tablish an evidence base to inform policy decisions, im-prove programming, and support advocacy efforts. Asone panelist stated, presenting evidence from researchhelps to frame the issue as a medical one. It can also beused to “start the conversation” with others. Reliablehealth data - including on maternal mortality and otherconsequences of unsafe abortion – is needed to drivethe discussion around abortion reform and counter“emotive arguments” made by pro-life advocacy groups.With respect to abortion, panelists recommended con-

ducting an impact assessment of current laws and policies,as was undertaken in Rwanda. In Rwanda, facilities began

collecting data on the number of survivors becoming preg-nant from rape and the number of rape survivors whowere able to access legal abortion. From this study, Rwandalearned that since the new law came into effect allowingabortion in cases of sexual violence (including statutoryrape), only one survivor was able to obtain an abortion.This evidence is now being used to advocate for a changein the way the law is interpreted and implemented.Evidence can also be used to make changes on the

ground, even where change is slow at the legislative andpolicy level. In Zambia, for example, Population Councilis collecting evidence on such issues as quality of abor-tion care and the availability of medical abortion. Popu-lation Council also called for more research on theimpact on women of unwanted, rape-related pregnancyto inform advocacy in this area.

Create forums for discussing issuesIn Kenya, Zambia, and Malawi, interested stakeholdershave formed working groups specifically focused onexpanding access to safe abortion, the problem of unsafeabortion and the lack of quality abortion services. InKenya, members of the Safe Abortion Working Groupare primarily from the private sector, but the group isled by the maternal health division of the Ministry ofHealth. In Zambia, the Safe Abortion Action Group is apartnership between non-governmental organizationsand the Ministry of Health. Malawi also has establisheda Coalition for Prevention of Unsafe Abortion (COPUA).In contrast to other technical working groups dealingwith family planning and reproductive health more gen-erally, having a forum specifically for abortion has facili-tated frank discussion and helped to focus the group’sefforts. It has also helped build partnerships amongstakeholders and between the private and public sector.

Draft an action strategyFinal discussions from the meeting focused on develop-ing country-specific action points to improve access toEC and safe abortion services, particularly for survivorsof sexual violence. Key action points from participantsincluded:■ Increasing public education around pregnancy pre-

vention, EC, safe abortion, and accessing availableSV services (while framing these as public healthissues)

■ Updating SV guidelines and training to reflectmost recent WHO guidance

■ Integrating EC and safe abortion issues into exist-ing SV and FP training, protocols, and documents

■ Decentralizing EC services to expand access toyoung people and rural communities

■ Expanding public sector procurement and distri-bution of dedicated ECP in health facilities

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■ Improving forecasting and management of ECsupplies

■ Educating line ministries and policy makers re-garding their obligations under Maputo, as inter-preted in the African Commission’s comments

■ Advocating for favorable interpretation of existingabortion law, or using Ministry of Health policy tointerpret and clarify the law relating to safe abor-tion rights and procedures

■ Organizing partners and like-minded individuals toadvocate for reform and address gaps in services

As a follow-up to the meeting, the Population Council,WHO, and the ICEC committed to providing technicalsupport to selected participating countries to facilitatedistinct action points as outlined in the draft actionplans to help bring countries’ national laws, policies,and/or programming into compliance with the MaputoProtocol and with WHO technical guidelines for safeabortion and comprehensive post-rape care.

FundingThe publication of this article was made possible through funding from theRegional Team for Sexual and Reproductive Health and Rights, Embassy ofSweden, Lusaka, Zambia.

Availability of data and materialsMaterials related to the regional technical meeting on which this article isbased are available at the Population Council. These materials includePowerPoint presentations given by meeting participants.

Authors’ contributionsJT co-conceptualized the regional technical meeting and developed the firstdraft of the meeting report that informed this article. CU co-conceptualized theregional technical meeting, refined drafts of the meeting report that informedthis article, and prepared the article for publication. AA, BRJ, RK, LO, TN, SR, EW,and HB co-conceptualized the regional technical meeting, gave input intodrafts of the meeting report that informed this article, and reviewed the finalversion of the article prior to publication. MG gave input into drafts of the meet-ing report that informed this article, and reviewed the final version of the articleprior to publication. IA conceptualized the 2014 Population Council study citedin this article, the findings of which culminated in the regional technical meet-ing. He also reviewed drafts of the meeting report that informed this article,and reviewed the final version of the article prior to publication. All authors readand approved the final manuscript.

Ethics approval and consent to participateN/A.

Competing interestsThe authors declare that there are no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Public Counsel, 610 South Ardmore Avenue, Los Angeles, CA 90005, USA.2Population Council, P.O. Box 17643-00500, Nairobi, Kenya. 3Department ofReproductive Health and Research, World Health Organization, Avenue Appia20, 1211, 27 Geneva, Switzerland. 4Regional Office for Africa, World HealthOrganization, BP 06 Brazzaville, Republic of Congo. 5Women’s RefugeeCommission, 15 West 37th Street, 9th Floor, New York, NY 10018, USA.6International Consortium for Emergency Contraception (hosted byManagement Sciences for Health), 45 Broadway, Suite 320, New York, NY10006, USA.

Published: 23 April 2018

References1. Thompson J, Undie C, Askew I. Access to emergency contraception and

safe abortion services for survivors of rape: a review of policies, programmesand country experiences in sub-Saharan Africa. Nairobi: Population Council;2014.

2. ICEC, SVRI. EC for rape survivors: A human rights and public healthimperative. ICEC & SVRI; 2003. http://www.cecinfo.org/custom-content/uploads/2013/10/SexAssault_FactSheet-Revised.pdf.

3. The regional technical meeting in Lusaka was sponsored by two PopulationCouncil programs: the Expanding the Evidence Base and Networks for SexualViolence Response and Management program, funded by the Regional Teamfor Sexual and Reproductive Health and Rights, Embassy of Sweden, Lusaka,Zambia; and the Strengthening Evidence for Programming on UnintendedPregnancy (STEP UP) Research Programme Consortium, funded by the U.K.Department for International Development.

4. The “Maputo Protocol” went into effect in November 2005 followingratification by 15 out of the 53 African Union Member States. To date, theMaputo Protocol has been signed by 46 of 53 Heads of State and ratifiedand deposited by 28 Member States including Angola, Benin, Burkina Faso,Cameroon, Cape Verde, Comoros, Democratic Republic of the Congo,Djibouti, Gambia, Ghana, Guinea-Bissau, Kenya, Libya, Lesotho, Liberia, Mali,Malawi, Mozambique, Mauritania, Namibia, Nigeria, Rwanda, Senegal,Seychelles, South Africa, Tanzania, Togo, Uganda, Zambia, and Zimbabwe.

5. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report onviolence and health. Geneva: World Health Organization; 2002.

6. World Health Organization. Understanding and addressing violence againstwomen: health consequences. Geneva: World Health Organization; 2012.

7. World Health Organization. Global and regional estimates of the incidenceof unsafe abortion and associated mortality in 2008. Geneva: World HealthOrganization; 2011.

8. World Health Organization. Responding to intimate partner violence andsexual violence against women: WHO clinical and policy guidelines. Geneva:World Health Organization; 2013.

9. For WHO guidance on psychosocial support, see. World HealthOrganization. In: Health care for women subjected to intimate partnerviolence or sexual violence: a clinical handbook (parts 2 and 4). Geneva:World Health Organization; 2014.

10. See, for example: World Health Organization. Responding to intimatepartner violence and sexual violence against women: WHO clinical andpolicy guidelines. Geneva, Switzerland: World Health Organization; 2013;World Health Organization. Safe abortion: technical and policy guidance forhealth systems. Geneva, Switzerland: World Health Organization; 2012;World Health Organization. Health care for women subjected to intimatepartner violence or sexual violence: a clinical handbook. Geneva: WorldHealth Organization; 2014.

11. See agreed conclusions 22 and 34 in: United Nations Commission on theStatus of Women. Report on the 57th session (4-15 March 2013). New York:United Nations. http://undocs.org/E/2013/27.

12. African Commission on Human and Peoples Rights, General Comment No.2 on Article 14.1 (a), (b), (c) and (f) and Article 14. 2 (a) and (c) of theProtocol to the African Charter on Human and Peoples’ Rights on theRights of Women in Africa. Clauses 37–39. http://www.achpr.org/instruments/general-comment-two-rights-women/.

13. Women can take LNG ECPs as a single dose of 1.5 mg. When using thetwo-pill product, women can take both pills at the same time.

14. Although this information was derived from meeting participants, it isnoteworthy that the ICEC currently lists Ethiopia, Kenya, and Malawi asallowing for the provision of EC over the counter. Botswana and Zambiaare listed by the ICEC as requiring a prescription for EC. The ICEC has noofficial data on prescription status for Rwanda but their fact sheet on EC inRwanda notes that “it appears that EC can be purchased without aprescription” (http://www.cecinfo.org/custom-content/uploads/2013/09/Rwanda_2013.pdf).

15. The ICEC notes that, in practice, access to EC may not always align with thelaw regarding prescription status – i.e., in policy, it may be available onlywith a prescription, but in practice, women can obtain it over-the counter;or, in policy, it may be over-the-counter, but in practice, some pharmacistsrequire a prescription.

Thompson et al. BMC Proceedings 2018, 12(Suppl 5):0 Page 15 of 16

16. World Health Organization. Safe abortion: technical and policy guidance forhealth systems. Geneva: World Health Organization; 2012.

17. Republic of Ethiopia. Technical and procedural guidelines for safe abortionservices in Ethiopia. Addis Ababa: Family Health Department; 2006.

18. Participants provided various rationales for a baseline test. Although notmedically necessary prior to providing EC, some suggested that baselineevidence was required to “prove” that a pregnancy was caused by rape forpurposes of obtaining abortion or for use in other legal proceedings.Others felt it merely reflected the (misplaced) concern that EC couldnegatively impact a pre-existing pregnancy.

19. Republic of Ethiopia. National guideline for the management of survivors ofsexual assault in Ethiopia. Addis Ababa: Ministry of Health; 2009.

20. See the ‘Referrals’ section on pages 30–31 of: World Health Organization.Health care for women subjected to intimate partner violence or sexualviolence: A clinical handbook. Geneva: World Health Organization; 2014.

21. Beitz J, Srimuangboon H, Lion-Coleman A, Transgrud R, Hutchings J, WeldinM. Youth-friendly pharmacy program implementation kit: guidelines andtools for implementing a youth-friendly reproductive health pharmacyprogram. Seattle: PATH; 2003.

22. Keesbury J, Zama M, Shreeniwas S. The Copperbelt model of integratedcare for survivors of rape and defilement: testing the feasibility of policeprovision of emergency contraceptive pills. Lusaka: Population Council;2009.

23. CHWs already distribute EC in some South Asian countries, such as India,Pakistan, and Bangladesh.

Thompson et al. BMC Proceedings 2018, 12(Suppl 5):0 Page 16 of 16