Applying the WHO Strategic Approach to unsafe abortion: Experience in five sub-Saharan African countries

The World Health Organization's Strategic Approach to Strengthening Reproductive Health Policies and Programmes is a country-owned, participatory, interdisciplinary methodology designed to assist countries identify and prioritize sexual and reproductive health service needs, test appropriate interventions and scale up successful programs. Five African countries (Ghana, Zambia, Malawi, Guinea and Senegal) have used the Approach to examine unsafe abortion-a significant cause of maternal morbidity and mortality worldwide and accounting for a third of maternal mortality in some sub-Saharan countries. In these five countries, this methodology has helped document the extent and impact of unintended pregnancy and unsafe abortion, shed light on underlying causes, and facilitated consensus among key stakeholders, including Ministries of Health, on strategies for addressing these significant public health problems. Factors contributing to high levels of abortion-related mortality have included: barriers in availability and accessibility of contraceptives and safe, legal abortion services; legal restrictions on abortion; incomplete implementation of post-abortion care services; and countries' religious, institutional and cultural contexts. In addition to describing countries' research, policy and programmatic responses to assessment findings, we discuss and evaluate facets of the Approach that facilitate countries' ability to address the sensitive issue of unsafe abortion, including use of a systems framework, multi-disciplinary team approach, qualitative field-oriented process, research capacity strengthening and flexibility to address both national priorities and local concerns. While addressing limitations of this methodology, and lessons learned during its application, we confirm the value of the Strategic Approach in stimulating improvements in health systems, programs and policies concerning abortion.