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Midwife Tembi Mugore answers four questions about bias, shame, and what it takes to overcome them in health services for young people.
At least 8% of maternal deaths worldwide are from unsafe abortions. And almost all abortion-related deaths occur in low- and middle-income countries, mostly in Africa.
“But there is a stigma attached to unsafe abortion, and because of that there is a bias against clients,” says IntraHealth International midwife and public health professional Stembile Mugore. That bias prevents many clients—particularly young ones—from getting the services they need.
I talked with Mugore about her commitment to high-quality reproductive health care and how we can make services better, especially for young people. The following interview has been edited for length and clarity.
[Note: Postabortion care is the term used for a package of services—including medical treatment, counseling, family planning/reproductive health services, and community partnerships—that prevent unwanted pregnancies and unsafe abortions. These services are provided after both induced unsafe abortions and incomplete spontaneous abortions (often called miscarriages).]
Because abortions happen every day, and unsafe abortion is one of the leading causes of maternal mortality. Among young people, there are a lot of misconceptions about abortion, and if it was an unsafe abortion, they are typically unlikely to seek services immediately.
In Togo, for instance, we found that all client records for young unmarried people with no children were coded as self-induced abortions, and that these patients were often seen by health workers as promiscuous, undeserving of pain medication, and happy to have gotten rid of their pregnancy.
Whether their abortion was spontaneous, or if it was unsafe, the only way we can save lives is if they come to seek services. We want to break the cycle of repeat unintended pregnancies and repeat unsafe abortions, and youth-friendly services can address that. They can help young people feel confident coming to a health facility.
I am a midwife. I believe that a lot of maternal deaths are preventable and that we could be doing more to stop them. For every woman that dies, there are many more who survive and live with irreversible morbidities: chronic infections, fistula, infertility.
We want to not only improve the quality of services and get more women seeking services early in pregnancy, but also to make sure women receive good care should the pregnancy result in a miscarriage or an incomplete abortion. A lot of young people die because they aren’t able to get those services, whether it’s because they don’t know where to go or because they fear being judged or mistreated, so they wait until the situation is really severe.
A lot of that has to do with the quality of the service that is provided, and how health workers treat those young people. That’s what drives me.
My biggest success is changing health worker attitudes. I’m very proud of the work we did in Togo with health workers, and getting to hear them say, “We used to do that, but now we do this.” They were very candid and very open about how they used to provide poor care and how their behavior had changed.
The training we provide instills a sense of empathy and really makes the work personal. When you ask one of those health workers what they would do if the patient was someone they knew—their sister’s child or their brother’s child—you can see the reaction immediately: “Yes it could happen, and yes this person would need help. I would go out of my way to help them.”
I am very aware that behavior change takes a while, and attitude change takes a while, but just from talking with them, there was a change. And for me, that’s a great success.
You need to change the whole culture where services are provided.
But challenges will always remain. When you are creating youth-friendly services, it’s not just about training a certain number of health workers. You need to change the whole culture of everybody working in the area where services are provided—security guards, janitors, record clerks. You don’t want to have a security guard tell a young person, “No, you can’t come in here.”
The person who receives a patient in admission is not likely to be the midwife that you trained, so you need to provide continuous support so that the entire facility is youth-friendly. You need to include everybody.
First and foremost, we need to train more health workers to provide adolescent-friendly services. Whether it’s for family planning, pregnancy care, or postabortion care, we know that young people want services that are anonymous, confidential, and private. It doesn’t work to have them sit on a bench in a waiting room when they’re sitting next to their neighbor or someone who knows their parents.
We also need to make sure that youth have access to all the reproductive health information they need. This includes information about contraception—if they’re sexually active and don’t want to be pregnant, they should be confident they can come and receive services. Age alone should not be a barrier to contraception. We also need to increase awareness around related issues like sexual coercion and what constitutes gender-based violence.
Communication is a key issue here. The communication between health workers and adult clients should look different from communication between health workers and young people. Just because a person is pregnant does not mean that they are mature. They may be only 15 or 16 years old, so they need different care with a lot more sensitivity.
And that comes down to the health worker. You can have youth-focused posters and everything in a clinic, but if the health worker is biased toward young people, those young people will not access the services.
Since 2013, the Evidence to Action (E2A) Project, the US Agency for International Development’s flagship project for strengthening reproductive health and family planning services, has been supporting Togo’s Division of Family Health to offer high-quality postabortion care services that include family planning counseling and access to a range of contraceptives at points of treatment for incomplete abortion to break the cycle of repeat abortions. As a partner in the project, IntraHealth International focuses on gender, capacity building, performance improvement and quality improvement.
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