(2020) Implementing the liberalized abortion law in Kigali, Rwanda: Ambiguities of rights and responsibilities among health care providers
Jessica Påfs, Stephen Rulisa, Marie Klingberg-Allvin, Pauline Binder-Finnema, Aimable Musafili, Birgitta Essén et al
Midwifery, Vol 80, 102568
Objective: Rwanda amended its abortions law in 2012 to allow for induced abortion under certain circumstances. We explore how Rwandan health care providers (HCP) understand the law and implement it in their clinical practice.
Findings: HCPs express ambiguities on their rights and responsibilities when providing abortion care. A prominent finding was the uncertainties about the legal status of abortion, indicating that HCPs may rely on outdated regulations. A reluctance to be identified as an abortion provider was noticeable due to fear of occupational stigma. The dilemma of liability and litigation was present, and particularly care providers’ legal responsibility on whether to report a woman who discloses an illegal abortion.
Conclusion: The lack of professional consensus is creating barriers to the realization of safe abortion care within the legal framework, and challenge patients right for confidentiality. This bring consequences on girl’s and women’s reproductive health in the setting. To implement the amended abortion law and to provide equitable maternal care, the clinical and ethical guidelines for HCPs need to be revisited.
Our findings point at a lack of professional consensus when consulting persons seeking advice or care for an unwanted pregnancy. The HCPs consult women differently depending on their personal values and interpretation of the law. This bring thoughts to the ‘Professional Code of Ethics’ as nurses and midwives have the right to “refuse to participate in activities contrary to his/her personal moral and professional convictions.” (Rwanda Ministry of Health 2009). This is an issue raised within reproductive health care, as the allowance for personal values among HCPs leads to an inequitable provision of care (Rehnström Loi et al., 2015 ; Fiala and Arthur, 2014). For physicians, the ethical guidelines do state that it is in their duty to provide abortion within the law ( Rwanda Ministry of Health 2009 ), in line with what one of the participants said. Yet, the physicians in our study also claimed they lack proper training to implement this in practice. This argument of not possessing the skills needed may though be a cover up for their actual attitudes of not being willing to provide abortion services. Similar reasoning has been seen among nurses and midwives in other sub- Saharan countries (Rehnström Loi et al., 2015). The lack of skills cannot be an acceptable argument anymore, given the possibility of medical abortions, that can be carried out by midlevel providers and women themselves and are in line with WHOs recommendations (Klingberg-Allvin et al., 2015; Cleeve et al., 2016; Kim et al., 2019). Not only could such task-shifting significantly reduce cur rent costs of PAC and diminish current workload of health care providers in Rwanda (Vlassoffet al., 2015) – it may also facilitate for HCPs in their ethical dilemma seen in our findings. However, HCPs attitudes play an important role in the implementation of task-shifting (Kim et al., 2019). Additionally, our findings highlight the concern of stigma connected to the implementation and usage of Misoprostol in the clinical practice. The controversial status of Misoprostol is worthy of attention. This does not only have implications for abortion-related care, but also for the quality of maternal health care.