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International organizations and NGOs: An example of international collaboration to improve women's health by preventing unsafe abortion
International Journal of Gynecology and Obstetrics 110 (2010) S30–S33
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
FIGO INITIATIVE FOR THE PREVENTION OF UNSAFE ABORTION
International organizations and NGOs: An example of international collaboration to improve women's health by preventing unsafe abortion Shahida Zaidi a,⁎, Ezzeldin Osman Hassan b, Stelian Hodorogea c, Robert J.I. Leke d, Luis Távara e,f, Marina Padilla de Gil g a
Institute of Ultrasonography and Ultrasound Clinic, Karachi, Pakistan Egyptian Society of Gynecology and Obstetrics, Cairo, Egypt Department of Obstetrics and Gynecology, State Medical University, and Reproductive Health Training Centre, Chisinau, Republic of Moldova d University of Yaounde 1, Cameroon e Universidad Nacional Federico Villarreal, Lima, Perú f Peruvian Medical College, Lima, Perú g Social Security Institute, El Salvador b c
a r t i c l e
i n f o
Keywords: International collaboration International organizations NGOs Prevention of unsafe abortion Women's health
a b s t r a c t International collaboration with organizations and agencies is a basic requirement for the success of the FIGO Initiative for the Prevention of Unsafe Abortion and its Consequences. Many activities being carried out by the organizations form a part of the plans of action of all countries participating in the Initiative. It was, therefore, not difficult to obtain their collaboration in implementing the plans of action. The many ways in which they have collaborated and continue to do so are described in this article. This collaboration has saved time, avoided duplication of effort, and has also satisfied the Accra Agenda of Action by reducing fragmentation of funding. It has already contributed toward preventing unsafe abortion and reducing abortion-related maternal deaths and morbidities, and is expected to contribute even more significantly in the coming months and years. © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The preceding articles in this Supplement have described how the FIGO Initiative for the Prevention of Unsafe Abortion was devised, the responsibility of the FIGO Working Group, the mandate received from the FIGO Executive Board, the process to be followed to achieve the preestablished goals, and the objectives of the plans of action as defined by the countries involved [1–3]. This article discusses the importance of international and national collaboration in the planning and implementing the interventions aimed at preventing unsafe abortion. From the very start, the need for international collaboration was understood to be a prerequisite for the FIGO initiative. FIGO was aware that many other organizations and agencies shared the same objectives of preventing unwanted pregnancy and unsafe abortion, and its consequences. These organizations were logical allies since their programs already included activities necessary for reducing unsafe abortions. It was also recognized that reduction in maternal mortality and achievement of other Millennium Development Goals (MDGs) would
⁎ Corresponding author. Institute of Ultrasonography and Ultrasound Clinic, 140 R, Block 2, PECHS, Karachi 75400, Pakistan. Tel.: +92 21 3455 2129/3455 1455; fax: + 92 21 3431 2525. E-mail address: [email protected] (S. Zaidi).
not be possible without greater national ownership, less fragmentation of funding, and more effective partnerships, as recommended in the Accra Agenda for Action [4]. Based on these premises, the initiative sought the commitment of governments and emphasized national ownership of the plans of action, while simultaneously involving all international organizations working in the area and improving communication among them. The generous and effective response of many international agencies and non-governmental organizations (NGOs) in the planning and implementation of the FIGO initiative at country level is described below. 2. Preliminary steps As soon as the Working Group was created and the Chair had been nominated, several organizations, principally International Planned Parenthood Federation (IPPF) and Ipas, offered to collaborate in defining the FIGO initiative. Indeed, the original letter of invitation to all member societies of obstetrics and gynecology was also sent to all associations affiliated with IPPF and was signed by the presidents of both FIGO and IPPF. The first activity carried out as part of the initiative—a technical consultancy meeting held in New York in May 2007—represented a prime example of collaboration. The consultancy was supported financially by Ipas and logistically by the IPPF/Western Hemisphere
0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2010.04.007
S. Zaidi et al. / International Journal of Gynecology and Obstetrics 110 (2010) S30–S33
Region (IPPF/WHR). It was attended by representatives of the United Nations Population Fund (UNFPA), the World Health Organization (WHO), Ipas, IPPF, the International Women's Health Coalition (IWHC), the Center for Reproductive Rights (CRR), Columbia University, EngenderHealth, and representatives of FIGO member societies from Asia, Europe, Africa, and Latin America. The process of identifying candidates for the Regional Coordinator positions was also conducted by consulting with key people in several agencies. In addition, the generous collaboration of colleagues from Ipas was crucial in preparing a project proposal for presentation to a potential donor. Therefore, from its very inception, this FIGO initiative was able to count on the generous and unconditional support of several agencies and organizations. 3. Situational analysis and preparation of the plans of action Although preparation of the situational analysis was principally the responsibility of the focal points, who in some countries performed the task with no further assistance, all countries counted on the collaboration of the Alan Guttmacher Institute to provide them with internationally available data. Data from studies carried out by the WHO, the Population Council, and the Population Reference Bureau were used, as well as those available from the Guttmacher Institute and from other organizations. In addition, the local representatives of international organizations and NGOs such as UNFPA, WHO, Ipas, and IPPF among others, worked with the focal points and government officials in each country to prepare the situational analysis. Several organizations collaborated with the societies of obstetrics and gynecology in publishing and distributing the reports and providing support for holding the national workshops. The principal organizations involved at this stage were the IPPF member associations, the local offices of UNFPA and Ipas, and the Packard Foundation. Often, the same organizations also assisted in preparing the plans of action of several countries participating in the initiative.
S31
To identify agencies and organizations with aims and objectives similar to those in the interventions proposed, the general coordinator carried out a systematic search and shared this information and all relevant correspondence with the regional coordinators. He also provided these agencies and organizations with information about the FIGO Initiative, the list of participating countries, and the plans of action of the countries in which each organization was operational. In addition, all the organizations were invited to attend a series of follow-up regional workshops, held in July and August 2009. Twenty organizations subsequently participated in one or more of these regional workshops. These organizations and the regions in which they operate are listed in Table 1. Some, including Gynuity Health Projects, IPPF, UNFPA, and WHO, were active in all 7 regions in which the initiative was being conducted, while others were limited to one or more regions (Table 1). Participation of these organizations in the workshops promoted integration of their country programs with the national plan of action for the prevention of unsafe abortion in that country. It also provided information about what the other organizations/agencies were doing in the same sphere, and with whom they were collaborating, thereby preventing duplication of effort. It resulted in “less fragmentation of funding and more effective partnerships,” as recommended in the Accra Agenda for Action to achieve the MDGs [4]. While there is a broad overlap of objectives and activities between some of the organizations and the plans of action, the mandate of other agencies may be limited, sometimes by their own rules, to certain specific elements of the plans. Table 2 lists areas in which the organizations are collaborating or intend to do so in the future. The areas in which most organizations have collaborated are sensitizing policy makers and health professionals (n = 18) followed by provision of postabortion care (n = 15), which encompasses a wide ambit of activities ranging from using improved technology and the humanization of care to the inclusion of postabortion contraception. A total of 13 organizations assist in improving access to contraception, whereas 12 facilitate access to safe abortion services within the full extent of the law, and 11 work in the field of abortion research. The areas in which the fewest organizations are involved are advocacy for laws
4. Regional workshops The organizations that had collaborated in the early phases of the initiative were invited to participate in the first series of regional workshops held between June and August 2008. Those participating in one or more of the workshops were Ibis Reproductive Health, the International Consortium for Medical Abortion, Ipas, IPPF, Marie Stopes International, the Packard Foundation, the Pathfinder Foundation, the Population Council, Population Services International, UNFPA, and WHO. They were given the opportunity of presenting their programs for the respective regions, and were provided the plans of action if they were not aware of these; in turn, their representatives made suggestions and commitments for possible future collaboration. 5. Implementation of the plans of action FIGO allocated no funds to support the activities included in the plans of action, the rationale being that the end of the project (and cessation of funding) would not herald the end of the activities. The best way of guaranteeing continuity of the activities incorporated in the plans of action would be to have them included in the government's general plans. It was understood, however, that the Initiative encompassed countries in which budgets were limited and demands manifold, meaning that they would require external support for some time. Once again, the collaboration of international organizations and agencies was expected to fill this gap, because many of the proposed activities already formed a part of their program in these countries.
Table 1 Collaborating organizations and the regions in which they collaborated with the FIGO Initiative (cut-off date September 2009). Agency/organization
Region SA CA&C WCA ECSA NAEM SSEA ECE
Amnesty International Asia Safe Abortion Partnership Concept Foundation DKT International EngenderHealth Global Doctors for Choice Guttmacher Institute Gynuity Health Projects Ibis Reproductive Health International Consortium for Medical Abortion Ipas International Planned Parenthood Federation Marie Stopes International Packard Foundation Pathfinder Population Council Population Services International Population Reference Bureau UNFPA WHO
√ √
√ √ √ √
√ √
√ √
√ √ √ √ √ √ √
√ √
√ √
√ √
√
√ √
√ √
√ √ √
√ √
√
√
√ √
√
√ √
√ √
√ √
√ √
√
√ √
√ √
√ √
√ √ √ √ √ √ √ √
√ √
√ √ √
√ √
√ √
√
Abbreviations: SA, South America; CA&C, Central America and the Caribbean; WCA, Western and Central Africa; ESCA, Eastern Southern and Central Africa; NAEM, North Africa and Eastern Mediterranean; SSEA, South-Southeast Asia; ECE, Eastern and Central Europe.
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S. Zaidi et al. / International Journal of Gynecology and Obstetrics 110 (2010) S30–S33
Table 2 Areas in which the organizations are collaborating or may collaborate with the plans of action. Agency/organization
Sensitize policy makers
Abortion research
Access to contraception
Amnesty International Asia Safe Abortion Partnership Concept Foundation DKT International EngenderHealth Global Doctors for Choice Guttmacher Institute Gynuity Healthcare Ibis Reproductive Health International Consortium for Medical Abortion Ipas International Planned Parenthood Federation Marie Stopes International Packard Foundation Pathfinder Population Council Population Research Bureau Population Services International UNFPA WHO
√ √
√
√ √ √ √
√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √ √ √
that permit greater access to safe abortion (n = 7) and sexuality education (n = 5). The different areas in which the organizations are collaborating with the country teams are discussed in some detail below. 5.1. Sensitizing policy-makers and health professionals Almost all agencies and organizations have been willing to collaborate with this objective, which was included in many of the plans of action. The WHO, which is not listed in the table, could also be included since it is a frequent source of information and “expert opinion” that helps sensitize policy makers and health professionals on the relevance of the issue of unsafe abortion. Global Doctors for Choice, Gynuity Health Projects, EngenderHealth, Ipas, IPPF, Marie Stopes International, and UNFPA have been active in sensitizing policy-makers about unsafe abortion in several regions of the world. Amnesty International is active in South America and Global Doctors for Choice in South America and Africa. The Population Reference Bureau was active in South-Southeast Asia through its ENGAGE Project, as was the Packard Foundation.
Sex education
Safe abortion services √ √ √ √
Advocate for safe abortion √ √
Postabortion care √ √ √ √
√
√
√
√ √ √ √
√ √
√ √
√ √
√ √ √
√
√ √ √ √
√ √ √
√
√
√ √
√ √ √ √ √ √ √ √ √ √
such as Marie Stopes International and the Concept Foundation have been operating in several, but not all, regions (Table 1). The Pathfinder Foundation and Ibis International are providing family planning services in South America, Eastern Southern and Central Africa, and in South-Southeast Asia, while Population Services International provides family planning services in South-Southeast Asia. 5.4. Providing safe abortion services Marie Stopes International, IPPF member associations, and Ipas collaborate in providing legal services related to safe abortion, particularly in countries in which laws are less liberal. Gynuity Health Projects and the Concept Foundation promote access to medication abortion in almost all regions, while the International Consortium for Medical Abortion has provided this support to North Africa and the Eastern Mediterranean region, and to Eastern and Central Europe. Its counterpart in Asia, the Asia Safe Abortion Partnership (ASAP), and Population Services International operate in South-Southeast Asia. The Concept Foundation make the abortion drugs mifepristone and misoprostol available at an affordable price through its “Access-toMedicines” program.
5.2. Improving comprehensive postabortion care 5.5. Abortion research Many organizations are collaborating in different aspects of comprehensive high-quality postabortion care. Many of them are collaborating in introducing new, improved, and safer technology such as manual vacuum aspiration (MVA) and medication abortion, while Ipas was foremost in promoting the substitution of sharp curettage (D&C) by MVA. In addition, Ipas provided training for doctors and, more recently, for midwives in the use of MVA, a safer method than D&C for removing products of conception. Several other organizations/ agencies are collaborating: UNFPA has included MVA equipment in its list of essential commodities; Gynuity Health Projects has introduced misoprostol as a medical alternative to MVA for the management of incomplete abortion. Other organizations support postabortion contraception, a basic instrument for preventing unwanted pregnancy and abortion. 5.3. Improving access to contraception to reduce the number of unplanned/unwanted pregnancies Some organizations such as IPPF and UNFPA have been active for several decades in providing family planning services globally. Others
The WHO and the Alan Guttmacher Institute have both done an outstanding job in making available the best global statistics on induced abortion and unsafe abortion rates and abortion-related maternal mortality for each region and subregion. Other organizations such as the Population Council have contributed data that are more limited in their geographical scope. Several others have contributed with research in other abortion-related areas, ranging from operational to biomedical research. 5.6. Advocacy for safe abortion Only one-fifth of the countries incorporated this objective in their plans of action [3]; few organizations are actively working in this sensitive area despite the recommendation of the Fourth World Conference on Women, held in Beijing in 1995, which states that countries should consider reviewing laws containing punitive measures against women who have undergone illegal abortions [5]. Amnesty International, Global Doctors for Choice, the International Consortium for Medical Abortion, ASAP, Ipas, IPPF, and Pathfinder are
S. Zaidi et al. / International Journal of Gynecology and Obstetrics 110 (2010) S30–S33
all willing to collaborate in promoting this objective within the limits of their own internal regulations, if so requested by the country in question. 5.7. Imparting sexuality education and establishing adolescent-friendly reproductive health services Adolescents constitute an important group for whom sexuality education and contraceptive advice are required to prevent unwanted pregnancy; however, few organizations include sexuality education within their scope of work. IPPF, Pathfinder Foundation, and UNFPA have established adolescent-friendly clinics in several regions, and the Population Council provides this service for indigenous girls in Guatemala.
S33
those in Western Central Africa and Eastern Central Europe. The FIGO initiative needs to dedicate significant effort to filling these gaps during the coming months to ensure optimal utilization of all available resources in implementing interventions that will effectively contribute to preventing unsafe abortion. To prevent the human suffering and deaths that result from unintended pregnancies and unsafe abortion will require the concerted effort of all these organizations and agencies. Acknowledgment The authors acknowledge the collaboration of Dr Florence Mirembe representing Eastern Central Southern Africa for providing regional information included in this article, and the General Coordinator, Dr Anibal Faúndes, for careful review of the manuscript.
6. Comments and conclusions Conflict of interest As predicted, the collaboration of the several agencies working in this field has been fundamental for the success of this FIGO initiative at the country level. One of the main achievements of the FIGO initiative has been to successfully bring together a relatively large number of organizations to discuss what each one is doing, especially with regard to the components of the plans of action being implemented by societies of obstetrics and gynecology and the government. These dialogues and assistance with implementation represent a constructive example of international collaboration aimed at improving women's health. It is important to recognize, however, that some limitations have occurred. The initiative has failed to attract several organizations and agencies working in key interventions aimed at helping prevent unsafe abortion and its consequences; further, there are few agencies willing to work in some of the participating countries, particularly
The authors have no conflict of interest to disclose. References [1] Shaw D. The FIGO initiative for the prevention of unsafe abortion. Int J Gynecol Obstet 2010;110(Suppl 1):S17–9. [2] Leke RJI, de Gil MP, Távara L, Faúndes A. The FIGO Working Group on the Prevention of Unsafe Abortion: Mandate and process for achievement. Int J Gynecol Obstet 2010;110(Suppl 1):S20–4. [3] Mirembe F, Karanja J, Hassan EO, Faúndes A. Goals and activities proposed by the countries in seven regions of the world toward the prevention of unsafe abortion. Int J Gynecol Obstet 2010;110(Suppl 1):S25–9. [4] 3rd High Level Forum on AID Effectiveness. Accra Agenda for Action. September 2–4, 2008, Accra, Ghana. Available at: http://www.undp.org/mdtf/docs/Accra-Agenda-forAction.pdf. Accessed March 3, 2009. [5] United Nations. Report of the Fourth World Conference on Women. Beijing: United Nations, September 4–15, 1995.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
FIGO INITIATIVE FOR THE PREVENTION OF UNSAFE ABORTION
International organizations and NGOs: An example of international collaboration to improve women's health by preventing unsafe abortion Shahida Zaidi a,⁎, Ezzeldin Osman Hassan b, Stelian Hodorogea c, Robert J.I. Leke d, Luis Távara e,f, Marina Padilla de Gil g a
Institute of Ultrasonography and Ultrasound Clinic, Karachi, Pakistan Egyptian Society of Gynecology and Obstetrics, Cairo, Egypt Department of Obstetrics and Gynecology, State Medical University, and Reproductive Health Training Centre, Chisinau, Republic of Moldova d University of Yaounde 1, Cameroon e Universidad Nacional Federico Villarreal, Lima, Perú f Peruvian Medical College, Lima, Perú g Social Security Institute, El Salvador b c
a r t i c l e
i n f o
Keywords: International collaboration International organizations NGOs Prevention of unsafe abortion Women's health
a b s t r a c t International collaboration with organizations and agencies is a basic requirement for the success of the FIGO Initiative for the Prevention of Unsafe Abortion and its Consequences. Many activities being carried out by the organizations form a part of the plans of action of all countries participating in the Initiative. It was, therefore, not difficult to obtain their collaboration in implementing the plans of action. The many ways in which they have collaborated and continue to do so are described in this article. This collaboration has saved time, avoided duplication of effort, and has also satisfied the Accra Agenda of Action by reducing fragmentation of funding. It has already contributed toward preventing unsafe abortion and reducing abortion-related maternal deaths and morbidities, and is expected to contribute even more significantly in the coming months and years. © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The preceding articles in this Supplement have described how the FIGO Initiative for the Prevention of Unsafe Abortion was devised, the responsibility of the FIGO Working Group, the mandate received from the FIGO Executive Board, the process to be followed to achieve the preestablished goals, and the objectives of the plans of action as defined by the countries involved [1–3]. This article discusses the importance of international and national collaboration in the planning and implementing the interventions aimed at preventing unsafe abortion. From the very start, the need for international collaboration was understood to be a prerequisite for the FIGO initiative. FIGO was aware that many other organizations and agencies shared the same objectives of preventing unwanted pregnancy and unsafe abortion, and its consequences. These organizations were logical allies since their programs already included activities necessary for reducing unsafe abortions. It was also recognized that reduction in maternal mortality and achievement of other Millennium Development Goals (MDGs) would
⁎ Corresponding author. Institute of Ultrasonography and Ultrasound Clinic, 140 R, Block 2, PECHS, Karachi 75400, Pakistan. Tel.: +92 21 3455 2129/3455 1455; fax: + 92 21 3431 2525. E-mail address: [email protected] (S. Zaidi).
not be possible without greater national ownership, less fragmentation of funding, and more effective partnerships, as recommended in the Accra Agenda for Action [4]. Based on these premises, the initiative sought the commitment of governments and emphasized national ownership of the plans of action, while simultaneously involving all international organizations working in the area and improving communication among them. The generous and effective response of many international agencies and non-governmental organizations (NGOs) in the planning and implementation of the FIGO initiative at country level is described below. 2. Preliminary steps As soon as the Working Group was created and the Chair had been nominated, several organizations, principally International Planned Parenthood Federation (IPPF) and Ipas, offered to collaborate in defining the FIGO initiative. Indeed, the original letter of invitation to all member societies of obstetrics and gynecology was also sent to all associations affiliated with IPPF and was signed by the presidents of both FIGO and IPPF. The first activity carried out as part of the initiative—a technical consultancy meeting held in New York in May 2007—represented a prime example of collaboration. The consultancy was supported financially by Ipas and logistically by the IPPF/Western Hemisphere
0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2010.04.007
S. Zaidi et al. / International Journal of Gynecology and Obstetrics 110 (2010) S30–S33
Region (IPPF/WHR). It was attended by representatives of the United Nations Population Fund (UNFPA), the World Health Organization (WHO), Ipas, IPPF, the International Women's Health Coalition (IWHC), the Center for Reproductive Rights (CRR), Columbia University, EngenderHealth, and representatives of FIGO member societies from Asia, Europe, Africa, and Latin America. The process of identifying candidates for the Regional Coordinator positions was also conducted by consulting with key people in several agencies. In addition, the generous collaboration of colleagues from Ipas was crucial in preparing a project proposal for presentation to a potential donor. Therefore, from its very inception, this FIGO initiative was able to count on the generous and unconditional support of several agencies and organizations. 3. Situational analysis and preparation of the plans of action Although preparation of the situational analysis was principally the responsibility of the focal points, who in some countries performed the task with no further assistance, all countries counted on the collaboration of the Alan Guttmacher Institute to provide them with internationally available data. Data from studies carried out by the WHO, the Population Council, and the Population Reference Bureau were used, as well as those available from the Guttmacher Institute and from other organizations. In addition, the local representatives of international organizations and NGOs such as UNFPA, WHO, Ipas, and IPPF among others, worked with the focal points and government officials in each country to prepare the situational analysis. Several organizations collaborated with the societies of obstetrics and gynecology in publishing and distributing the reports and providing support for holding the national workshops. The principal organizations involved at this stage were the IPPF member associations, the local offices of UNFPA and Ipas, and the Packard Foundation. Often, the same organizations also assisted in preparing the plans of action of several countries participating in the initiative.
S31
To identify agencies and organizations with aims and objectives similar to those in the interventions proposed, the general coordinator carried out a systematic search and shared this information and all relevant correspondence with the regional coordinators. He also provided these agencies and organizations with information about the FIGO Initiative, the list of participating countries, and the plans of action of the countries in which each organization was operational. In addition, all the organizations were invited to attend a series of follow-up regional workshops, held in July and August 2009. Twenty organizations subsequently participated in one or more of these regional workshops. These organizations and the regions in which they operate are listed in Table 1. Some, including Gynuity Health Projects, IPPF, UNFPA, and WHO, were active in all 7 regions in which the initiative was being conducted, while others were limited to one or more regions (Table 1). Participation of these organizations in the workshops promoted integration of their country programs with the national plan of action for the prevention of unsafe abortion in that country. It also provided information about what the other organizations/agencies were doing in the same sphere, and with whom they were collaborating, thereby preventing duplication of effort. It resulted in “less fragmentation of funding and more effective partnerships,” as recommended in the Accra Agenda for Action to achieve the MDGs [4]. While there is a broad overlap of objectives and activities between some of the organizations and the plans of action, the mandate of other agencies may be limited, sometimes by their own rules, to certain specific elements of the plans. Table 2 lists areas in which the organizations are collaborating or intend to do so in the future. The areas in which most organizations have collaborated are sensitizing policy makers and health professionals (n = 18) followed by provision of postabortion care (n = 15), which encompasses a wide ambit of activities ranging from using improved technology and the humanization of care to the inclusion of postabortion contraception. A total of 13 organizations assist in improving access to contraception, whereas 12 facilitate access to safe abortion services within the full extent of the law, and 11 work in the field of abortion research. The areas in which the fewest organizations are involved are advocacy for laws
4. Regional workshops The organizations that had collaborated in the early phases of the initiative were invited to participate in the first series of regional workshops held between June and August 2008. Those participating in one or more of the workshops were Ibis Reproductive Health, the International Consortium for Medical Abortion, Ipas, IPPF, Marie Stopes International, the Packard Foundation, the Pathfinder Foundation, the Population Council, Population Services International, UNFPA, and WHO. They were given the opportunity of presenting their programs for the respective regions, and were provided the plans of action if they were not aware of these; in turn, their representatives made suggestions and commitments for possible future collaboration. 5. Implementation of the plans of action FIGO allocated no funds to support the activities included in the plans of action, the rationale being that the end of the project (and cessation of funding) would not herald the end of the activities. The best way of guaranteeing continuity of the activities incorporated in the plans of action would be to have them included in the government's general plans. It was understood, however, that the Initiative encompassed countries in which budgets were limited and demands manifold, meaning that they would require external support for some time. Once again, the collaboration of international organizations and agencies was expected to fill this gap, because many of the proposed activities already formed a part of their program in these countries.
Table 1 Collaborating organizations and the regions in which they collaborated with the FIGO Initiative (cut-off date September 2009). Agency/organization
Region SA CA&C WCA ECSA NAEM SSEA ECE
Amnesty International Asia Safe Abortion Partnership Concept Foundation DKT International EngenderHealth Global Doctors for Choice Guttmacher Institute Gynuity Health Projects Ibis Reproductive Health International Consortium for Medical Abortion Ipas International Planned Parenthood Federation Marie Stopes International Packard Foundation Pathfinder Population Council Population Services International Population Reference Bureau UNFPA WHO
√ √
√ √ √ √
√ √
√ √
√ √ √ √ √ √ √
√ √
√ √
√ √
√
√ √
√ √
√ √ √
√ √
√
√
√ √
√
√ √
√ √
√ √
√ √
√
√ √
√ √
√ √
√ √ √ √ √ √ √ √
√ √
√ √ √
√ √
√ √
√
Abbreviations: SA, South America; CA&C, Central America and the Caribbean; WCA, Western and Central Africa; ESCA, Eastern Southern and Central Africa; NAEM, North Africa and Eastern Mediterranean; SSEA, South-Southeast Asia; ECE, Eastern and Central Europe.
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S. Zaidi et al. / International Journal of Gynecology and Obstetrics 110 (2010) S30–S33
Table 2 Areas in which the organizations are collaborating or may collaborate with the plans of action. Agency/organization
Sensitize policy makers
Abortion research
Access to contraception
Amnesty International Asia Safe Abortion Partnership Concept Foundation DKT International EngenderHealth Global Doctors for Choice Guttmacher Institute Gynuity Healthcare Ibis Reproductive Health International Consortium for Medical Abortion Ipas International Planned Parenthood Federation Marie Stopes International Packard Foundation Pathfinder Population Council Population Research Bureau Population Services International UNFPA WHO
√ √
√
√ √ √ √
√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √ √ √
that permit greater access to safe abortion (n = 7) and sexuality education (n = 5). The different areas in which the organizations are collaborating with the country teams are discussed in some detail below. 5.1. Sensitizing policy-makers and health professionals Almost all agencies and organizations have been willing to collaborate with this objective, which was included in many of the plans of action. The WHO, which is not listed in the table, could also be included since it is a frequent source of information and “expert opinion” that helps sensitize policy makers and health professionals on the relevance of the issue of unsafe abortion. Global Doctors for Choice, Gynuity Health Projects, EngenderHealth, Ipas, IPPF, Marie Stopes International, and UNFPA have been active in sensitizing policy-makers about unsafe abortion in several regions of the world. Amnesty International is active in South America and Global Doctors for Choice in South America and Africa. The Population Reference Bureau was active in South-Southeast Asia through its ENGAGE Project, as was the Packard Foundation.
Sex education
Safe abortion services √ √ √ √
Advocate for safe abortion √ √
Postabortion care √ √ √ √
√
√
√
√ √ √ √
√ √
√ √
√ √
√ √ √
√
√ √ √ √
√ √ √
√
√
√ √
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such as Marie Stopes International and the Concept Foundation have been operating in several, but not all, regions (Table 1). The Pathfinder Foundation and Ibis International are providing family planning services in South America, Eastern Southern and Central Africa, and in South-Southeast Asia, while Population Services International provides family planning services in South-Southeast Asia. 5.4. Providing safe abortion services Marie Stopes International, IPPF member associations, and Ipas collaborate in providing legal services related to safe abortion, particularly in countries in which laws are less liberal. Gynuity Health Projects and the Concept Foundation promote access to medication abortion in almost all regions, while the International Consortium for Medical Abortion has provided this support to North Africa and the Eastern Mediterranean region, and to Eastern and Central Europe. Its counterpart in Asia, the Asia Safe Abortion Partnership (ASAP), and Population Services International operate in South-Southeast Asia. The Concept Foundation make the abortion drugs mifepristone and misoprostol available at an affordable price through its “Access-toMedicines” program.
5.2. Improving comprehensive postabortion care 5.5. Abortion research Many organizations are collaborating in different aspects of comprehensive high-quality postabortion care. Many of them are collaborating in introducing new, improved, and safer technology such as manual vacuum aspiration (MVA) and medication abortion, while Ipas was foremost in promoting the substitution of sharp curettage (D&C) by MVA. In addition, Ipas provided training for doctors and, more recently, for midwives in the use of MVA, a safer method than D&C for removing products of conception. Several other organizations/ agencies are collaborating: UNFPA has included MVA equipment in its list of essential commodities; Gynuity Health Projects has introduced misoprostol as a medical alternative to MVA for the management of incomplete abortion. Other organizations support postabortion contraception, a basic instrument for preventing unwanted pregnancy and abortion. 5.3. Improving access to contraception to reduce the number of unplanned/unwanted pregnancies Some organizations such as IPPF and UNFPA have been active for several decades in providing family planning services globally. Others
The WHO and the Alan Guttmacher Institute have both done an outstanding job in making available the best global statistics on induced abortion and unsafe abortion rates and abortion-related maternal mortality for each region and subregion. Other organizations such as the Population Council have contributed data that are more limited in their geographical scope. Several others have contributed with research in other abortion-related areas, ranging from operational to biomedical research. 5.6. Advocacy for safe abortion Only one-fifth of the countries incorporated this objective in their plans of action [3]; few organizations are actively working in this sensitive area despite the recommendation of the Fourth World Conference on Women, held in Beijing in 1995, which states that countries should consider reviewing laws containing punitive measures against women who have undergone illegal abortions [5]. Amnesty International, Global Doctors for Choice, the International Consortium for Medical Abortion, ASAP, Ipas, IPPF, and Pathfinder are
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all willing to collaborate in promoting this objective within the limits of their own internal regulations, if so requested by the country in question. 5.7. Imparting sexuality education and establishing adolescent-friendly reproductive health services Adolescents constitute an important group for whom sexuality education and contraceptive advice are required to prevent unwanted pregnancy; however, few organizations include sexuality education within their scope of work. IPPF, Pathfinder Foundation, and UNFPA have established adolescent-friendly clinics in several regions, and the Population Council provides this service for indigenous girls in Guatemala.
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those in Western Central Africa and Eastern Central Europe. The FIGO initiative needs to dedicate significant effort to filling these gaps during the coming months to ensure optimal utilization of all available resources in implementing interventions that will effectively contribute to preventing unsafe abortion. To prevent the human suffering and deaths that result from unintended pregnancies and unsafe abortion will require the concerted effort of all these organizations and agencies. Acknowledgment The authors acknowledge the collaboration of Dr Florence Mirembe representing Eastern Central Southern Africa for providing regional information included in this article, and the General Coordinator, Dr Anibal Faúndes, for careful review of the manuscript.
6. Comments and conclusions Conflict of interest As predicted, the collaboration of the several agencies working in this field has been fundamental for the success of this FIGO initiative at the country level. One of the main achievements of the FIGO initiative has been to successfully bring together a relatively large number of organizations to discuss what each one is doing, especially with regard to the components of the plans of action being implemented by societies of obstetrics and gynecology and the government. These dialogues and assistance with implementation represent a constructive example of international collaboration aimed at improving women's health. It is important to recognize, however, that some limitations have occurred. The initiative has failed to attract several organizations and agencies working in key interventions aimed at helping prevent unsafe abortion and its consequences; further, there are few agencies willing to work in some of the participating countries, particularly
The authors have no conflict of interest to disclose. References [1] Shaw D. The FIGO initiative for the prevention of unsafe abortion. Int J Gynecol Obstet 2010;110(Suppl 1):S17–9. [2] Leke RJI, de Gil MP, Távara L, Faúndes A. The FIGO Working Group on the Prevention of Unsafe Abortion: Mandate and process for achievement. Int J Gynecol Obstet 2010;110(Suppl 1):S20–4. [3] Mirembe F, Karanja J, Hassan EO, Faúndes A. Goals and activities proposed by the countries in seven regions of the world toward the prevention of unsafe abortion. Int J Gynecol Obstet 2010;110(Suppl 1):S25–9. [4] 3rd High Level Forum on AID Effectiveness. Accra Agenda for Action. September 2–4, 2008, Accra, Ghana. Available at: http://www.undp.org/mdtf/docs/Accra-Agenda-forAction.pdf. Accessed March 3, 2009. [5] United Nations. Report of the Fourth World Conference on Women. Beijing: United Nations, September 4–15, 1995.