Male involvement in unsafe and safe abortion in Zambia

by Emily Freeman

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Emily Freeman is Assistant Professorial Research Fellow at the London School of Economics and Political Science and Co-Principal Investigator of the “Termination of pregnancy in rural Zambia” project. Her work on men’s involvement in unsafe abortion uses data from “Pregnancy termination trajectories in Zambia: the socio-economic costs”, a collaborative study of the socio-economic causes and costs of abortion for women, their households and the Zambian health system. 

When the world’s policymakers moved their focus from mass family planning programmes to the sexual and reproductive health (SRH) needs and rights of individuals in the early 1990s, attention turned to men.  Men began to be included in SRH programming not only as individuals with their own SRH needs but also as actors who influence women’s SRH outcomes. In the quarter-century since then, policymakers have attempted to tackle significant global SRH challenges – HIV, unskilled care for pregnancy and childbirth, early pregnancy, female genital cutting to name a few – in all of which recognising that a woman’s risk of morbidity and mortality is – to a greater or lesser extent – bound-up with what her sexual partner, husband, boyfriend, father, uncle is doing. However, one of the leading – and most easily addressed – causes of maternal morbidity and mortality hasn’t seen much focus on men at all.
Unsafe abortion is a massive public health challenge. It accounts for around 13% of maternal deaths around the world, but in the regions where it’s most common – low- and middle-income countries in Africa and Asia – it accounts for around a third of all maternal deaths (WHO, 2018). 
Some interventions for addressing the problem are apparently obvious: making safe abortion legal and having adequate healthcare facilities licensed to provide abortion services in the areas people need them for instance. But in some countries like Zambia, South Africa, Cambodia, Nepal with these structures in place, policy makers and researchers have struggled to identify why some women receive safe abortions and others don’t. 
Take the example of Zambia.  Here the question is understanding what influences women’s pathway to either safe and legal abortion in one of 75+ licensed Government facilities, or unsafe abortion outside of the legal system. Our research suggests at least one answer must be to consider the influence of men.
We spoke to women who came to a large urban hospital for either safe abortion services or for post-abortion care following an unsafe abortion. We wanted to know how they had ended up in the study hospital. We didn’t ask them about the men in their lives particularly, but men’s roles formed a significant part of their stories.

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The women told us about men who had influenced not only whether or not they sought safe or unsafe abortion, but also how complex their trajectories from pregnancy to the hospital were – how many twists and turns there had been on their journey. Men shaped the women’s trajectories both in the things they did, the things women’s expected them to do, and in the things they didn’t do. The cases of Thandi, Bulongo and Gertrude, as outlined in the following, are illustrative of these influences.
21-year old Thandi and her boyfriend ended their relationship a month before she realised she was pregnant. She had hoped the pregnancy would reunite them but instead he “denied” her, telling her to abort or raise a child on her own. She felt she was out of options: “I cannot raise a child on my own. Though I needed my child, I never had a choice.”
There were two ‘absent yet present’ men in 28-year old Bulongo’s decision-making about abortion: her abuser and her husband. Bulongo became pregnant after being raped at work. She explained that she might have continued the pregnancy and presented the child as belonging to her husband, but the perpetrator looked so different from her husband she did not think she would be believed. Fearing that her account of rape would be doubted and she would be condemned for adultery by her husband and her faith community, she had told no one about her ordeal. Bulongo ran the gamut of methods for terminating the pregnancy from unsafe drugs to finally post-abortion care and a surgical abortion in hospital.
17-year-old Gertrude had more support, directly accessing safe abortion with her uncle’s help. When she discovered she was pregnant with her boyfriend of three years, she did not tell him about the pregnancy, but went to her uncle. Knowing what was possible, her uncle recommended abortion so that she could finish school. He guided her through the healthcare system, accompanying her during treatment and paying for everything.

Gender inequity was the vein running through all the women’s stories. 

The trajectories a woman went on, and how involved men were in those, was a product of men and women’s different economic and social power, different norms about father- and motherhood, differences in what pregnancy and childbearing meant for men and women’s lives (e.g. future opportunities for education, career and relationships), as well as the extent to which women were regarded as able decision-makers by the significant men in their lives. Men’s abandonment of women or denial of paternity, and women’s desire to avoid disclosing pregnancy to men (e.g. husbands and fathers) through fear of their reactions, were both significant influences on some women’s decision to seek abortion and on the secrecy, urgency and risk with which they sought out an abortion. Ultimately in these cases, delays in care-seeking and desperation to clandestinely abort using ever-escalating methods resulted in unsafe abortions.

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However unequal and inequitable access to social and economic resources meant that men were also able to facilitate access to safe abortion or to care following unsafe abortion. When directly involved in women’s pathways from pregnancy to obtaining an abortion, men were most commonly the providers of financial assistance, providing the money for examinations, treatments and travel to the hospital. However, in Zambia’s context of low general awareness about the legality and availability of abortion, and lack of the easily accessed public information available in other countries (e.g. education programmes, leaflets in healthcare facilities, information online), men’s ability to seek information about where safe abortion could be accessed was especially influential in shaping the course of women’s trajectories to safe abortion. 
What can be done? Clearly broad, far-reaching strategies to increase gender equity in society will ultimately have a positive impact on specific problems, like unsafe abortion. Until gender equality is reached, interventions to address unsafe abortion should be aimed at a much wider audience than women at risk of unwanted pregnancy. It is clear from our research and research in other African settings that a range of male actors are directly and indirectly involved in abortion decision-making and care-seeking. Knowledge about the legality and availability of safe abortion is vital for those seeking abortion and for the men and women those seeking abortion confide in. The next step for researchers, policy makers and communications practitioners might usefully be work to identify how best to equip women and men with knowledge about effective contraception and the provision of safe and legal abortion where they live (23 February 2018).