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Expanding Access

Advancing the Roles of Midlevel Providers in
Menstrual Regulation and Elective Abortion Care

2 -6-December 2001

Kwa Maritane Lodge

Pilanesberg National Park

South Africa

Conference Summary

Ipas/IHCAR Conference report

The conference Expanding Access: Advancing the Role of Midlevel Providers in Menstrual Regulation and Elective Abortion Care was co-organized by Ipas and IHCAR.

During the conference, 50 participants from 17 countries shared a wealth of energy, experience and commitment toward the common goal of improving women’s reproductive health and lives through expanded access to safe abortion services through midlevel service providers. This summary presents conference highlights.

Opening sessions

In his welcoming remarks on Sunday, Abe Nkomo, Member of Parliament, Republic of South Africa, gave an impassioned review of events leading up to South Africa's Choice on Termination of Pregnancy Act (CTOP), emphasizing the critical importance of access at the community level. The Amakhosi Theatre Group from Zimbabwe presented "Making a Difference," an energetic and poignant drama depicting familial, community and provider reactions to an adolescent girl's unwanted pregnancy. The drama presentation, and the role of the midwives in the play, provided a common reference point for discussions throughout the conference.

On Monday morning Eunice Brookman-Amissah, Ipas’s vice-president for Africa, officially opened the conference, and Staffan Bergstrom of IHCAR introduced Mozambique's Prime Minister, Pascoal Mocumbi.

The Prime Minister spoke of his own experience supporting the enhanced training of midlevel providers (MLPs) in Mozambique when his country was ravaged by war in the 1980s and there were virtually no ob-gyn doctors. He characterized the training and involvement of MLPs as a practical and effective strategy for providing care to those who need it most, a sentiment echoed by Eddie Mhlanga, from the Department of Health for South Africa, who welcomed the Prime Minister and all the conference participants to his country.

Working sessions

Three working sessions followed the conference inauguration. In session 1, participants from Mozambique, Vietnam and Kenya presented the case for midlevels providing abortion services and discussed barriers that prevent such care by midlevels.

In session 2, participants from South Africa, Bangladesh and Sweden presented case studies on the role of midlevel providers in improving the quality of abortion care. Small group work followed the presentations. Discussion groups focused on the three main topics of: skills necessary for providing high-quality abortion care; the service delivery requirements necessary for midlevel providers to offer abortion care; and the client perspective on quality of care.

In session 3 participants from Zambia, Cambodia, India and the United States presented case studies on health system and policy strategies to overcoming barriers to MLPs providing abortion services. The small group discussions following the presentations focused on the three main topics of: health system policies and regulations governing the training and practice of MLPs; policies governing existing and potential abortion service delivery sites; and the involvement of local community stakeholders in linking women to safe abortion services.

Recommendations from the small groups were presented in plenary. Participants divided into small groups to prioritize the recommendations in the areas of training and education, service delivery, policy and research.

Post-conference workshop

Participants drew on recommendations from the conference and in small groups deliberated four thematic areas that had surfaced as priority concerns. These final sessions culminated in thematic recommendations for action in four areas: networking; expanding access to high quality abortion services where the law is restrictive; medical abortion; and values clarification education.

In addition, Della Sherratt, from the World Health Organization, gave a special presentation on work underway at WHO that is relevant to the theme of the meeting. She emphasized WHO’s firm commitment to women’s health and the need to address all causes of pregnancy-related death, notably unsafe abortion.

Conference statement

To capture the enthusiasm that characterized discussions at the conference, as well as their key themes, and to give participants a tool that they could take back and use to advance work in their own settings, conference organizers drafted a statement on the penultimate day of the meeting. The statement was distributed to all meeting participants on the final morning and then discussed in a special plenary session.

Comments focused on ensuring that the language was not unnecessarily proscriptive, that it would be acceptable and useful in as many countries and policy environments as possible, and that it would include a clear, compelling call to action.

Ipas staff revised the statement in accordance with that discussion and distributed it to all meeting participants by the end of the meeting. The final version is presented on the website. In the weeks following the meeting, the statement was posted on Ipas’s and the conference’s websites as well as disseminated to selected media outlets, including newspapers and medical journals. The editor of Reproductive Health Matters has agreed to publish the conference statement or a brief summary of the conference. In addition, a conference report is being prepared for wide distribution.


Ipas is coordinating the creation of a video to capture the energy of and further advocate the themes of the Expanding Access conference. A video team interviewed at least 20 conference delegates who represented a range of geographic and functional perspectives (i.e., service providers, health system officials, parliamentarians, representatives of international NGOs, etc.). The video team filmed all conference presentations, primarily for archival purposes.

To supplement the interviews, the video team also shot in and around Johannesburg and visited several service-delivery settings, where they filmed interviews with service providers and clients. These sites included a private clinic run by two midwives in Central Johannesburg, a more upscale clinic in a Johannesburg suburb, and a tertiary-level hospital in South Africa’s Northwest Province.

The video will be ready to show and discuss at the April 2002 annual conference of the International Confederation of Midwives in Vienna. The video should be a useful advocacy tool at other conferences of professional associations, as well as in trainings. Additionally, the video will be made available to all participants in the Expanding Access conference.

Conference evaluation

We received 17 completed conference evaluation forms. An analysis indicates overwhelmingly positive feedback. Notably, all but one respondent said that it was "likely" or "very likely" that their future work would address issues surrounding midlevel providers offering MR or abortion care.

Participants appreciated the opportunity to learn from and exchange information with their counterparts and others in different countries, and also expressed a strong commitment to carry the work forward in their own contexts.

Participants reported that the conference was focused and well organized. The intended flexibility of post conference workshop was viewed by many as a useful opportunity to address issues that surfaced as of greatest concern to participants, although some participants wanted additional clarity in the goals, and guidance for developing follow-up activities. Several participants expressed wanting to leave the conference with more clearly defined next steps, and others recognized the need to develop next steps specific to their own contexts.

According to conference evaluations, critical next steps in the area of expanding access to MR and elective abortion care include:

  • coordinating training and research efforts; developing curricula;
  • integrating MVA training into basic nursing training;
  • integrating abortion care into reproductive health service delivery;
  • generating data comparing the quality of abortion services from MLPs and physician providers;
  • involving MLPs to reduce numbers of unsafe abortions (by counseling and provision of elective abortions);
  • advocating for legislative liberalization where MLPs are not allowed to provide MR or elective abortion care; and
  • continued sharing of experiences from countries where MLPs do provide abortion services to countries where MLPs are not allowed to provide abortion services.
In the evaluations, participants noted that subsequent conferences and workshops on the role of midlevel providers in MR and elective abortion care need to engage providers, policy makers, researchers, and others who are not convinced of the need for MLPs to provide MR and elective abortion care. It is particularly critical to include policy makers who have decision-making authority, and to engage participants from countries where the need for decentralized abortion care is greatest. In the evaluations participants identified the need to follow-up the conference with activities that advance the role of MLPs in MR and elective abortion care, and to disseminate widely lessons learned.

Initial follow-up activities

The momentum generated during the conference is being maintained through a number of activities. The report generated from data presented at the conference will be published in time for dissemination at the Triennial Congress of the International Confederation of Midwives in April 2002, where conference organizers also hope to arrange a showing and discussion of the advocacy video discussed above.

Both the conference report and video will also be disseminated through other channels, including meetings, workshops and conferences, and made available for training sessions and other advocacy opportunities. Multiple copies of the conference report will be sent to each conference participants for their own use and distribution. The Conference Statement will be printed in journals, newsletters, and other print media. Results of the conference have already been presented at the 2001 meeting of the Africa Midwives Research Network, and several participants have written reports of the conference for publication in professional newsletters.

Participants are currently using contacts developed at the conference to explore means of improving services offered by midlevel providers. Participants are building on the contacts and experiences gained at the conference to develop research, policy, advocacy, and training and service delivery opportunities. Delegates from most participating countries have expressed interest in conducting conference follow-up activities. The conference website – which is continually updated with new reports, links and references – and e-mail list will continue to facilitate the sharing of ideas regarding project development and regular updates of implementation.

Ipas/IHCAR Conference report