Medical AbortionMedical Abortion Public Policies and Public Policies and Provision in TunisiaProvision in Tunisia

Selma HAJRISelma HAJRI11-13 March 2009 11-13 March 2009

-Johannesburg--Johannesburg-

General introduction

The introduction, of The introduction, of medical abortion in medical abortion in

TunisiaTunisia Background Background Population:Population:10,383 10,383

millionmillion GNP: $2,000GNP: $2,000 98% Muslim98% Muslim CPR: 60%CPR: 60% MMR:70 MMR:70 TFR:1.73TFR:1.73 Abortion ratio: 7.8 per Abortion ratio: 7.8 per

100 pregnancies100 pregnancies

Historical context of Historical context of abortion legalityabortion legality

One of few MENA countries with legal One of few MENA countries with legal abortionsabortions

Liberalization of the traditional Islamic law Liberalization of the traditional Islamic law or or “sharia”“sharia” on family issueson family issues – Polygamy abolishedPolygamy abolished– Minimum age of marriage set at 17 yearsMinimum age of marriage set at 17 years– Women granted rights to divorce, work, voteWomen granted rights to divorce, work, vote– Abortion legalizedAbortion legalized– National FP program organized. National FP program organized.

1965: 1965: permitted up to 3 months for high fertilitypermitted up to 3 months for high fertility 1973: 1973: permitted up to 3 months for any reason.permitted up to 3 months for any reason. Abortion rates: increased till early 1990; stable Abortion rates: increased till early 1990; stable

till 2000, declining since 2000till 2000, declining since 2000. .

Tunisian Tunisian characteristicscharacteristics

Modern approach from more than 50 Modern approach from more than 50 yearsyears

3 cultural specificities : African, arabo-3 cultural specificities : African, arabo-islamic, méditerranean .islamic, méditerranean .

The cultural et religious context source of The cultural et religious context source of barriers , and contradictions in attitudes and barriers , and contradictions in attitudes and strategical choicesstrategical choices

The process of medical The process of medical abortion introductionabortion introduction

The integration of medical The integration of medical abortion in Tunisia : abortion in Tunisia :

MA MA IntroductionIntroduction to to ExpansionExpansion 19941994: Site in WHO multi-site trial: Site in WHO multi-site trial 19981998: First clinical trials with Population : First clinical trials with Population

CouncilCouncil 20012001: Mifepristone-misoprostol approved: Mifepristone-misoprostol approved Since 1998: Ongoing Since 1998: Ongoing research and research and

innovationinnovation with Pop Council and Gynuity with Pop Council and Gynuity– First series of 5 clinical studies(2000-2007), First series of 5 clinical studies(2000-2007),

with continuous development of new studies with continuous development of new studies allowing integration of changes in protocolallowing integration of changes in protocol

– Qualitative Qualitative studies studies in ONFP sites with married and in ONFP sites with married and unmarried women.unmarried women.(2006-2007)(2006-2007)

PUBLIC POLICYPUBLIC POLICY

CH UMATERNITIES

Internatioinal Center for Training and ResearchCIFR

ClinicsM o b ile C lin ics

National O ffice of Fam ily and Population(O NFP)

M INISTERY O F HEALTH

Motivated investigators

Key personsNGO/donors

Promoters

Local leaders

Providers in clinical trials (ObGyn,Generalists,midwifes)Providers in clinical trials (ObGyn,Generalists,midwifes)

ONFP/CHUONFP/CHU

ADVOCATESADVOCATES TRAININGTRAINING

PROVIDERS-TRAINERSPROVIDERS-TRAINERSDOCTORSDOCTORS MID WIFESMID WIFESMedical and scientific Medical and scientific social aspects andsocial aspects andBackground councellingBackground councellingof trainingof training

TRAINING SESSIONSTRAINING SESSIONSDeveloping Bookets, Developing Bookets,

brochures brochures and service delivery and service delivery programmsprogramms

Future providersFuture providersMidwifes,nurses,Midwifes,nurses,Social workersSocial workersothersothers

Provision of MA Provision of MA To dateTo date

– Over 20,000 medical abortions across 14 (of 24) Over 20,000 medical abortions across 14 (of 24) regions.regions.

– 60-70% of women select for abortion, where 60-70% of women select for abortion, where offered and when available.offered and when available.

– 20082008: approx. 18,500 abortions performed, : approx. 18,500 abortions performed, including 7800 MA.including 7800 MA.

– Midwives perform most MAs (prescribed by Midwives perform most MAs (prescribed by doctors).doctors).

– Private sector limited access.Private sector limited access. 20092009: Plan to expand in private sector: Plan to expand in private sector

Medical Abortion Medical Abortion ProtocolProtocol

For pregnancies up to For pregnancies up to 56 days* beyond LMP56 days* beyond LMP

Day 1 Mifepristone Day 1 Mifepristone 200mg orally200mg orally

Day 3 Misoprostol Day 3 Misoprostol 400400µg orally (home µg orally (home use some sites)use some sites)

Day 15 Follow-up visitDay 15 Follow-up visit

*In some sites only

Innovation thru Innovation thru researchresearch

Simplified regimen Simplified regimen authorized since authorized since introductionintroduction

Use to 56 days and now Use to 56 days and now to 63 daysto 63 days

Midwives provide MAsMidwives provide MAs

Home use of Home use of misoprostol misoprostol

Mobile servicesMobile services

Misoprostol routes: Misoprostol routes: Oral; recently Oral; recently sublingual, buccal in sublingual, buccal in next studiesnext studies

Introduction into the Introduction into the private sector (20%)private sector (20%)

The expansion of medical abortion in Tunisia

With the ongoing studies extension of MA to peripheral clinics

•Evaluation data of outcomes (2002-2004 and 2005-2006)

•Ongoing provider training and research dissemination.

Innovations in Clinical Innovations in Clinical ResearchResearchStudy (yr)Study (yr) nn InnovationInnovation Efficacy Efficacy

(%)(%)Ongoing Ongoing

(%)(%)

Elul et al Elul et al (2000)(2000)

205205 200 mife, 200 mife, midwives, home midwives, home use+ 56 days use+ 56 days

91.191.1 1.61.6

Blum et Blum et al (2004)al (2004)

222222 All above+ new All above+ new sitessites

94.494.4 1.91.9

Hajri et al Hajri et al (2004)(2004)

321321 All above+ new All above+ new sitessites

96.096.0 1.81.8

Mobile Mobile clinicclinic

4040 All above + All above + mobile clinicmobile clinic

95.095.0 5.05.0

Oral vs Oral vs sublinguasublingual l (ongoing)(ongoing)

500500**

All above + All above + sublingual route sublingual route +private sector+ +private sector+ thru 63 days LMPthru 63 days LMP

96.6*96.6* 1.4*1.4*

*Of 377 cases analyzed

Evaluation dataEvaluation data

EvaluatioEvaluation periodn period

nn SitesSites EfficacyEfficacy* (%)* (%)

Ongoing Ongoing (%)(%)

Unknown/ LFU Unknown/ LFU (%)(%)

2002-2002-20042004

(ESC (ESC 2007)2007)

29329399

10 10 ONFPONFP

93.293.2 2.32.3 high high

(of 6000)(of 6000)

2005-2005-20062006

(Tunis (Tunis 2007)2007)

37237244

10 10

ONFPONFP97.397.3 1.11.1 16.0%16.0%

*Of known outcome cases

Complications: 1 blood transfusion, 3 cases of infection noted

Unmarried womenUnmarried women

Unmarried women represent 21% Unmarried women represent 21% of usersof users

Interviews with married and Interviews with married and unmarried women reveal similar unmarried women reveal similar reasons for choosing the method reasons for choosing the method and high satisfaction (>90%).and high satisfaction (>90%).

Women’s Experiences Women’s Experiences and Acceptabilityand Acceptability

High satisfaction and satisfaction(98,45%).High satisfaction and satisfaction(98,45%). Discomfort for prolonged bleeding : 91,6%Discomfort for prolonged bleeding : 91,6% Second choice : 90,9%Second choice : 90,9%

Where offered, most offered (60-70%).Where offered, most offered (60-70%).

Lack of data about women’s choice of Lack of data about women’s choice of method and its socio-cultural context.method and its socio-cultural context.

Tunisia has a relatively high CPR Tunisia has a relatively high CPR ((>>60%) and a continuing trend 60%) and a continuing trend towards decrease in the number of towards decrease in the number of abortions performed annually. abortions performed annually.

The proportion of medical abortions is The proportion of medical abortions is a growing part of abortion, with 50 and a growing part of abortion, with 50 and 70% of women seeking abortion 70% of women seeking abortion choose medical over surgical methods choose medical over surgical methods in select sitesin select sites

The success of MA, as part of the Family Planning programm, was tributary of:1) The political will1) The political will

Importance of the legal and institutionnalmechanisms

mobilisation of resources (disponibility and access to information and services ) )

-Access to MA in Public /private sectors , interactions-Access to MA in Public /private sectors , interactions-Strategies to improve these influences-Strategies to improve these influences

2) 2) The Socio-cultural environnementThe Socio-cultural environnement Status of women (education , work, Health….)

procreative attitude of a population influenced by the social and religious briddles( opinion leaders)

Influence of existing policies programmes Influence of existing policies programmes and services on access to MA and services on access to MA

PUBLIC POLICYPUBLIC POLICY

CH UMATERNITIES

Internatioinal Center for Training and ResearchCIFR

ClinicsM o b ile C lin ics

National O ffice of Fam ily and Population(O NFP)

M INISTERY O F HEALTH

Motivated investigators

Key persons

NGO/donors

Promoters

Local leaders

Political resistance

ObGynMidwifes/nurses

The Choice of Medical The Choice of Medical AbortionAbortion Separate & secondary to decision to abort.Separate & secondary to decision to abort. Lessened guilt due to belief in fate or “Lessened guilt due to belief in fate or “maktubmaktub” and ” and

the “natural” almost “miscarriage-like” process of MA. the “natural” almost “miscarriage-like” process of MA. No “No “tbarbichetbarbiche” or instruments.” or instruments.

Provider driven:Provider driven:– access denied due several reasons access denied due several reasons

(perceived contra-indications ( diabetes, (perceived contra-indications ( diabetes, etc), religious barriers etc… etc), religious barriers etc… OrOr

– strongly recommended over surgical: strongly recommended over surgical: nulliparous, unmarried or “virgins”, low GA, nulliparous, unmarried or “virgins”, low GA, recent c-section, chronic medical conditions.recent c-section, chronic medical conditions.

– Excess of controlExcess of control : home use, visits, US , : home use, visits, US , control visit control visit

Looking ForwardLooking Forward Expansion of clinical Expansion of clinical

research (1research (1st/st/ 2 2nd timnd tim, , miso sublingal, buccal)miso sublingal, buccal)

alternatives to routine alternatives to routine US and FU)US and FU)

Study Provider KAP Study Provider KAP Training of new Training of new

providers in 16 new providers in 16 new regionsregions

Introduce value Introduce value clarification in trainings clarification in trainings and refreshing trainingsand refreshing trainings

Looking ForwardLooking Forward

Expansion to Expansion to private sector private sector

Develop Develop networksnetworks

Foster new Foster new leaders and leaders and expertsexperts

conclusionconclusion

The lessons learned from the The lessons learned from the introduction and expansion of introduction and expansion of medical abortion services in Tunisia medical abortion services in Tunisia could be important for future could be important for future expansion and for other countries expansion and for other countries wishing to effectively integrate the wishing to effectively integrate the method to broaden women’s access method to broaden women’s access and choice to safe abortion and choice to safe abortion services. services.

Questions still Questions still adressed adressed

Why do women choose the method? How do Why do women choose the method? How do they experience the process and what are they experience the process and what are women’s experiences with MA?women’s experiences with MA?

What are the implications of use and What are the implications of use and women’s experiences within their socio-women’s experiences within their socio-cultural context?cultural context?

What are the potential facilitating factors to What are the potential facilitating factors to use use and barriers facedand barriers faced? ?

What are women’s views of abortion and What are women’s views of abortion and contraceptive counseling and the quality of contraceptive counseling and the quality of care received?care received?

THANK YOUTHANK YOU