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Medical Abortion Public Policies and Provision in Tunisia

Medical Abortion Public Policies and Provision in Tunisia. Selma HAJRI 11-13 March 2009 -Johannesburg-. General introduction. The introduction, of medical abortion in Tunisia. Background Population: 10,383 million GNP: $2,000 98% Muslim CPR: 60% MMR:70 TFR:1.73

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Medical Abortion Public Policies and Provision in Tunisia

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  1. Medical Abortion Public Policies and Provision in Tunisia Selma HAJRI 11-13 March 2009 -Johannesburg-

  2. General introduction

  3. The introduction, of medical abortion in Tunisia Background • Population:10,383 million • GNP: $2,000 • 98% Muslim • CPR: 60% • MMR:70 • TFR:1.73 • Abortion ratio: 7.8 per 100 pregnancies

  4. Historical context of abortion legality • One of few MENA countries with legal abortions • Liberalization of the traditional Islamic law or “sharia”on family issues • Polygamy abolished • Minimum age of marriage set at 17 years • Women granted rights to divorce, work, vote • Abortion legalized • National FP program organized. • 1965: permitted up to 3 months for high fertility • 1973: permitted up to 3 months for any reason. • Abortion rates: increased till early 1990; stable till 2000, declining since 2000.

  5. Tunisian characteristics Modern approach from more than 50 years • 3 cultural specificities : African, arabo-islamic, méditerranean . • The cultural et religious context source of barriers , and contradictions in attitudes and strategical choices

  6. The process of medical abortion introduction

  7. The integration of medical abortion in Tunisia : MA Introduction to Expansion • 1994: Site in WHO multi-site trial • 1998: First clinical trials with Population Council • 2001: Mifepristone-misoprostol approved • Since 1998: Ongoing research and innovation with Pop Council and Gynuity • First series of 5 clinical studies(2000-2007), with continuous development of new studies allowing integration of changes in protocol • Qualitative studies in ONFP sites with married and unmarried women.(2006-2007)

  8. PUBLIC POLICY Motivated investigators Key persons Promoters Local leaders NGO/donors

  9. ONFP/CHU Providers in clinical trials (ObGyn,Generalists,midwifes) ADVOCATES TRAINING PROVIDERS-TRAINERS DOCTORS MID WIFES Medical and scientific social aspects and Background councelling of training TRAINING SESSIONS Developing Bookets, brochures and service delivery programms Future providers Midwifes,nurses, Social workers others

  10. Provision of MA • To date • Over 20,000 medical abortions across 14 (of 24) regions. • 60-70% of women select for abortion, where offered and when available. • 2008: approx. 18,500 abortions performed, including 7800 MA. • Midwives perform most MAs (prescribed by doctors). • Private sector limited access. • 2009: Plan to expand in private sector

  11. Medical Abortion Protocol • For pregnancies up to 56 days* beyond LMP • Day 1 Mifepristone 200mg orally • Day 3 Misoprostol 400µg orally (home use some sites) • Day 15 Follow-up visit *In some sites only

  12. Innovation thru research • Simplified regimen authorized since introduction • Use to 56 days and now to 63 days • Midwives provide MAs • Home use of misoprostol • Mobile services • Misoprostol routes: Oral; recently sublingual, buccal in next studies • Introduction into the private sector (20%)

  13. 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.

  14. Innovations in Clinical Research *Of 377 cases analyzed

  15. Evaluation data Complications: 1 blood transfusion, 3 cases of infection noted *Of known outcome cases

  16. Unmarried women Unmarried women represent 21% of users Interviews with married and unmarried women reveal similar reasons for choosing the method and high satisfaction (>90%).

  17. Women’s Experiences and Acceptability • High satisfaction and satisfaction(98,45%). • Discomfort for prolonged bleeding : 91,6% • Second choice : 90,9% • Where offered, most offered (60-70%). • Lack of data about women’s choice of method and its socio-cultural context.

  18. Tunisia has a relatively high CPR (>60%) and a continuing trend towards decrease in the number of abortions performed annually. • The proportion of medical abortions is a growing part of abortion, with 50 and 70% of women seeking abortion choose medical over surgical methods in select sites

  19. Influence of existing policies programmes and services on access to MA • The success of MA, as part of the Family Planning • programm, was tributary of: • 1) The political will  Importance of the legal and institutionnal • mechanisms •  mobilisation of resources (disponibility and access • to information and services ) • -Access to MA in Public /private sectors , interactions • -Strategies to improve these influences • 2) The Socio-cultural environnement • Status of women (education , work, Health….) • procreative attitude of a population influenced by • the social and religious briddles( opinion leaders)

  20. PUBLIC POLICY Political resistance ObGyn Midwifes/nurses Motivated investigators Key persons Promoters Local leaders NGO/donors

  21. The Choice of Medical Abortion • Separate & secondary to decision to abort. • Lessened guilt due to belief in fate or “maktub” and the “natural” almost “miscarriage-like” process of MA. No “tbarbiche” or instruments. • Provider driven: • access denied due several reasons (perceived contra-indications ( diabetes, etc), religious barriers etc… Or • strongly recommended over surgical: nulliparous, unmarried or “virgins”, low GA, recent c-section, chronic medical conditions. • Excess of control: home use, visits, US , control visit

  22. Looking Forward • Expansion of clinical research (1st/ 2nd tim, miso sublingal, buccal) • alternatives to routine US and FU) • Study Provider KAP • Training of new providers in 16 new regions • Introduce value clarification in trainings and refreshing trainings

  23. Expansion to private sector Develop networks Foster new leaders and experts Looking Forward

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

  25. Questions still adressed • Why do women choose the method? How do they experience the process and what are women’s experiences with MA? • What are the implications of use and women’s experiences within their socio-cultural context? • What are the potential facilitating factors to use and barriers faced? • What are women’s views of abortion and contraceptive counseling and the quality of care received?

  26. THANK YOU

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