Self-managed Abortion Care in a Legally Restrictive Environment

Vitala Global y IBP Network y OMS
Sep 26, 2023
3 min read

Updated: May 17, 2024

"I don't have a stable job. I don't have a steady income. Since abortion here is legally restricted, even access to medication was quite complicated. Very complicated. The information provided by the Aya Contigo mobile app helped me prepare for the abortion process, and gave me more confidence in what I was doing." User of Aya Contigo .

Download

Lessons Learned

Even in humanitarian contexts, it is possible to apply people-centered research and design thinking to the development and implementation of digital solutions for sexual and reproductive health and rights (SRHR). Using a localized, community-driven approach, it is possible to achieve quality solutions, even for the most stigmatized sexual and reproductive health problems and in the most difficult and legally restrictive contexts.

Tips to Make It Happen

Listen to and learn from women and local community organizations. Close collaboration with end-users improves understanding of the gaps and barriers to accessing sexual and reproductive health services, as well as the challenges to implementing these services in real situations. In this way, inclusive and non-fragmented SRHR interventions that scale up and improve existing local initiatives can be supported.
Design solutions together with the end users. This approach generates a feeling of ownership, as opposed to externally imposed solutions. The end result is a solution created by the community itself.
Have patience in building trust. It is crucially important to take the time to build strong relationships with local grassroots organizations. This process will be strengthened if we base our work on the evidence provided by the WHO guidelines.
Be reactive and willing to change plans. Engaging with new stakeholders, exploring alternative approaches and reformulating strategies can help avoid delays in the process. Flexibility is particularly valuable in legally restrictive contexts and in complex humanitarian crisis situations, as well as in unexpected situations such as the emergence of a pandemic.

Background and Context

As in other Latin American countries, the Bolivarian Republic of Venezuela has highly restrictive abortion laws. Induced abortion is legal only to save the lives of pregnant women, and persons who perform or facilitate abortion in any other case are liable to imprisonment (1). Estimates indicate that 10% of all maternal deaths in the country can be attributed to unsafe abortion. However, given the criminalization of abortion in the country, this figure is believed to be significantly higher (2). A complex humanitarian crisis

The Venezuelan population is facing a complex humanitarian crisis. The management of foreign exchange reserves, the drop in oil revenues in 2013, and the imposition of economic sanctions in 2017 have contributed to a context in which many people in 2019 had a monthly minimum wage of just USD 2.20 (3). The health system has been deteriorating since 2013, with shortages of medical supplies, health personnel leaving the country due to low salaries, and interruptions in the supply of water and electricity services, events that affect hospital infrastructure (2). Moreover, women are often stigmatized in the formal health system. The fear of being judged or treated abusively by health workers, or of not being considered legally entitled to an abortion for vital reasons, keeps women from seeking an abortion in the formal health system. Estimates indicate that, as a consequence of this humanitarian crisis in the Bolivarian Republic of Venezuela, the rate of unplanned pregnancies, as well as maternal health complications and maternal deaths from unsafe abortions, is reaching unprecedented levels (2). The country has one of the highest rates of adolescent pregnancy among 15-19 year olds in the region (95 births per 1000 adolescents in 2019, compared to an average of 62 per 1000 in the region) (2). Moreover, within just one year, from 2015 to 2016, maternal mortality increased by 66% (2). These circumstances, together with the vicious cycle of poverty (2), make the situation of women and girls in Venezuela particularly alarming. Reducing harm in a legally restrictive environment with clandestine abortion markets

Many Venezuelan women and girls migrate to neighboring countries to access sexual and reproductive health services, such as childbirth care (4) or abortion, as well as to purchase contraceptive products and/or escape gender-based violence (4). In the Bolivarian Republic of Venezuela, there is an extensive clandestine market for medical abortion products. In the context of a legally restrictive environment, and despite the risk of legal prosecution, local grassroots organizations promoting access to safe abortion care in the country focus their efforts on harm reduction, i.e., reaching women seeking abortion with information on how to safely self-administer a medical abortion. This may include information about the abortion process, where to find quality abortion drugs at low cost, or how to use the drugs, but without providing those drugs or participating in the intervention. These grassroots organizations are often small teams of volunteer staff with limited resources, who cannot physically accompany all the women who need assistance.

"I started researching on the Internet and found many people in the city of Caracas who sold abortion drugs, but each pill cost $20 and I needed $12. I didn't have that much money, plus I had heard that they could be fake products and that many people had died from using those products."User of Aya Contigo.

Given the situation, there is an urgent need in the Bolivarian Republic of Venezuela for a wider range of options for access to safe and timely induced abortion, with person-centered care, as well as improved access to effective contraceptives to reduce the risk of unwanted pregnancies.

WHO GUIDELINES AND TOOLS ON ABORTION

Implementation of WHO recommendations on self-management of abortion

In response to the need for more options for accessing safe and comprehensive abortion care, the Canadian non-profit organization Vitala Global developed an evidence-based mobile application based on WHO guidelines. It is an application that accompanies Venezuelan women and girls in the self-management of medical abortion, in addition to providing information on contraceptives after abortion. This digital tool was named Aya Contigo, because in many languages the word "Aya" has the meaning of caregiver, while "Contigo" confers the idea of accompanying.

One of the principles on which the development of Aya Contigo was based was the WHO recommendation that during the early stages of pregnancy, it is the pregnant women themselves who can safely and effectively perform a medical abortion, provided that they have a source of accurate information and quality medicines, as well as access to health personnel if needed.

Aya Contigo provides step-by-step guidelines across the continuum of self-managed abortion care. Included are self-assessment of eligibility for medical abortion, medication administration, self-assessment of successful abortion outcome, and possible post-abortion contraceptive methods. The app also seeks to care for women's psychological well-being by providing ongoing support, as needed, for up to 30 days after the abortion, e.g., through WhatsApp chats and notifications.

"As a woman going through this process, you have a thousand questions in your head that are overwhelming. Aya Contigo answers them with total clarity." User of Aya Contigo .

Using WHO guidelines to build trust and confidence

To guide and inform the design and development of the tool, including the recommendations provided through the application, the WHO Medical Treatment of AbortionandHealth care provider roles in safe abortion care and contraceptive methods after abortion. Moreover, the use of WHO publications helped Vitala Global build relationships with local partners and build trust among them. Many of the Venezuelan grassroots organizations working on risk reduction for people seeking abortion are guided by the WHO guidelines, as they are evidence-based guidelines that bring legitimacy to the work of these organizations. Because Aya Contigo is both based on the evidence highlighted by WHO and tailored to the local context, Vitala Global had full confidence in referring women to existing service providers who had the capacity to provide personal accompaniment if needed.

HOW THE IMPLEMENTATION WAS CARRIED OUT

Development of an application with women and local grassroots organizations

The development of Aya Contigo was based on a localized, community-driven approach and the idea of co-developing the product together with the people it was intended for. Key partners in the project were Fòs Feminista, PLAFAM, and the grassroots feminist organizations Faldas-R and Entre Nosotras. All of these organizations work to promote safe and dignified abortion care using harm reduction models, through telephone services, accompaniment or information models, and in-person counseling at clinics. The project followed rigorous principles of people-centered research and design thinking, keeping the values, preferences and needs of Venezuelan women at the core.

With the help of a grant from Grand Challenges Canada's OPTions Initiative, Vitala Global conducted a three-phase study to gather input from local women and grassroots organizations. In the first phase, interviews with a dozen organizations found that partners would benefit from a digital tool that would enable them to provide information and support during self-managed abortion processes to women in hard-to-reach areas where organizations lack a physical presence.

Inputs from women were collected through surveys and interviews. For the selection of participants, a social media campaign was designed and disseminated through the Facebook and Instagram accounts of PLAFAM, the main provider of sexual and reproductive health services in the Bolivarian Republic of Venezuela. A total of 1148 women participated in the online survey, and in-depth interviews were conducted with an additional 12 women who had undergone abortion.

The survey found that one in three participating women had had an abortion at some point in their lives, and among those who had not, one in three knew someone who had. The survey further revealed that, given that misinformation about abortion is widespread in the country, there is a pressing need for accurate information about abortion, and that a common way of accessing such information is by using WhatsApp, Facebook and Instagram groups and Google searches via cell phones. Women pointed to the need for a reliable tool that, in one place, provides all the empirical information they might need before, during, and after an abortion. Given the frequency of power outages, the tool would need to function without an internet connection. In addition to accurate information, women pointed out the need for emotional support and accompaniment during the abortion process.

A collaborative and iterative design process

In this highly collaborative development process, the focus on women's empowerment in the local community was integrated throughout the application design and co-development process, including in the contracting of providers. Following the second phase of the research process, during which the design concepts were evaluated by 10 of the participating organizations and tested by five women users who had had an abortion, AnnieCannons was contracted to manage the development of the software. AnnieCannons, a women-led organization that provides programming training to victims of gender-based violence, coded what would become Aya Contigo: a web application with the ability to run offline and the option to receive notifications via WhatsApp.

"The Vitala Global team came to AnnieCannons with an impressive set of designs, demonstrating the enormous dedication they had put into the process to achieve participatory design, collaborating with local design professionals, service providers and community members. This laid the groundwork for a highly collaborative process among stakeholders from different disciplines, integrating input from users, design based on user experience, and knowledge of sexual and reproductive health and product development. The Aya Contigo app is one of the most rewarding collaborations I have been involved in throughout my professional life." Grace McCants, Project Manager, AnnieCannons.

A companion even in the most isolated areas

The next step in the Aya Contigo development process was to test the acceptability and ease of use of the application, as well as the feasibility of the women themselves conducting a self-assessment of their eligibility for a medical abortion and the success of the abortion procedure. Throughout the process, 40 women who had self-managed one or more phases of a medical abortion with the help of Aya Contigo shared their observations through a variety of methods, including surveys, chat conversations, and interviews. The women felt that the Aya Contigo application was reliable, easy to use, and essential for a positive abortion care experience. They also valued Aya Contigo's ability to act as a companion throughout the process.

"I read all the information on the application to make sure I got it right. My sister didn't know anything. I told her later, but she had to be absent from the house. Since I knew I was going to be alone during the whole abortion process, Aya Contigo helped me a lot, clarifying all my doubts."User of Aya Contigo .

Vitala Global's internal research shows that Aya Contigo plays a crucial role in Venezuela's current landscape of medical abortion self-management, including contraceptive self-administration after abortion. The app serves to empower the work of organizations by connecting women in need of care with existing services, thereby helping these women obtain earlier abortion care. The digital nature of the product also allows organizations to reach more women, with the possibility of guiding several users at once - something that would not be possible face-to-face - and to reach more women in isolated areas.

"I'm thankful I turned to PLAFAM, because if I hadn't, I wouldn't know about Aya Contigo. And if it weren't for Aya Contigo, I wouldn't know of the existence of Entre Nosotras."User of Aya Contigo.

Reconciling global recommendations with local realities

Throughout the development process, Vitala Global faced numerous challenges that highlighted the importance of agility and a willingness to reformulate initial plans. For example, the outbreak of COVID-19 forced the organization to redesign the survey and interviews to be conducted entirely virtually. The importance of flexibility was also highlighted by a legal case that occurred in the country during the development phase of Aya Contigo. A 12-year-old girl, pregnant as a result of rape, underwent an abortion with the help of an activist who was subsequently sentenced to prison. Fearing possible legal implications, local organizations working with Vitala Global were forced to discontinue their services. To continue the development of the application without endangering its local partners, Vitala Global established temporary partnerships with international organizations such as Safe2Choose and Women on Web.

The most difficult challenge encountered in implementing Aya Contigo was the continued lack of access to affordable, quality-assured medical abortion drugs and contraceptive products faced by women in the Bolivarian Republic of Venezuela. Even when women receive empirical guidance on the medications they can use to perform a safe abortion, those medications are often not available in the country, given the prevailing legal context.

In addition, Vitala Global found that the local situation leads many organizations to adopt measures that do not conform to WHO guidelines, but are considered necessary to avoid misuse of services and waste of scarce medicines. For example, most Vitala Global partner organizations require an ultrasound scan to confirm pregnancy before abortion care is provided. This is because some women come to the organizations to request abortion drugs without being pregnant, in order to obtain pills that they can then sell clandestinely. The limited availability of drugs also leads organizations to use guidelines different from those recommended by WHO.

Vitala Global's ongoing communication with stakeholders laid the foundation for a transparent, safe and trusted space in which partners could assess local adaptations and the underlying causes of such adaptations. While the complex situation in the Bolivarian Republic of Venezuela highlights the vital need for access to evidence-based abortion care, it also served as a learning opportunity for Vitala Global, as the organization had to strike the right balance between global recommendations and the goal of safeguarding women's access to accurate care in a complex practical context.

From application to crucial actor in the feminist movement

Aya Contigo was officially introduced to the Venezuelan population in March 2022. By July 2022, more than 1,500 women had accessed the application. It is estimated that at least one third of these women self-managed a therapeutic abortion with the help of the Aya Contigo platform.

Aya Contigo demonstrates the power of involving vulnerable local women throughout the process of developing solutions to improve sexual and reproductive health. Their participation in the project as market research respondents, testers, programmers and marketers empowered women who are often marginalized, such as migrant women, women who have experienced gender-based violence, or women who suffer the financial and psychological stress of not having access to respectful, timely and safe abortion. Aya Contigo contributed to improving access to safe abortion, supported organizations that provide income to marginalized groups, and undoubtedly prevented much of the financial and emotional suffering that comes with continuing an unwanted pregnancy in the context of an economic and humanitarian crisis.

"We are delighted to work with Vitala Global and our wonderful partners in Venezuela in this participatory process of creating Aya Contigo. Digital solutions and feminist solidarity together contribute to the powerful impact that this project represents: putting information about safe abortion in the hands of women, in the most adverse national contexts and in a very difficult global situation." Susana Medina Salas and Nina Zamberlin, Fòs Feminista

What began as a product idea aimed at addressing the lack of access to abortion care has, in Vitala Global's view, become an integral part of the feminist movement in the Bolivarian Republic of Venezuela. Aya Contigo empowers women to exercise their right to physical and mental health, autonomy and privacy, enabling them to thrive, both socially and economically, despite the difficult socioeconomic context.

REFERENCES

Penal Code of Venezuela. Caracas: Comisión Legislativa Nacional; 2000 (https://www.oas.org/dil/esp/Codigo_Penal_Venezuela.pdf, accessed August 10, 2021).
Mujeres al Límite 2019: Urgent implementation of plans and policies that guarantee the dignified life of women and girls in Venezuela. Caracas: Center for Justice and Peace (CEPAZ); 2019 (https://cepaz.org/noticias/mujeres-al-limite-2019-urge-implementacion-de-planes-y-politicas-que-garanticen-la-vida-digna-de-mujeres-y-ninas-en-venezuela/, accessed February 2, 2021).
Venezuela raises minimum wage in fourth year of hyperinflation [Venezuela sube el sueldo mínimo en el cuarto año de hiperinflación]. Caracas: Reuters; May 1, 2021 (https://www.reuters.com/world/americas/venezuela-raises-minimum-wage-fourth-year-hyperinflation-2021-05-01/, accessed January 24, 2022).
Evaluation of the unmet needs in sexual health and reproductive health of the Venezuelan migrant population in four cities of the Colombian-Venezuelan border: Arauca, Cúcuta, Riohacha and Valledupar. Bogotá: Profamilia Colombia and IPPF (International Planned Parenthood Federation), 2019.

For more information and recent WHO resources on abortion care, see the WHO webpage on abortion.

This story was written by Vitala Global, in collaboration with the IBP Network and the Prevention of Unsafe Abortion (PUA) Unit of the WHO Department of Sexual and Reproductive Health and Research (including the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme for Research, Development and Research Training in Human Reproduction [HRP]). This document does not necessarily represent the decisions, policies or opinions of WHO or HRP. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by WHO or HRP in preference to others of a similar nature that are not mentioned.

Are you looking for safe and confidential support and accompaniment?

Download the app Aya Contigo.