Objectives: The objectives of this study are to describe the health sector's role in establishing or expanding abortion services following legal or policy reform, and to compare strategies used in order to generate practice-based options for the implementation of abortion services. Method: This is a comparative case study of six countries that recently changed abortion laws: Colombia, Uruguay, Portugal, Ghana, Ethiopia, and South Africa. For each, we completed a desk review of published and unpublished data, and conducted in-depth, semi-structured interviews with key stakeholders involved in the implementation of abortion services. Interview guides were tailored to each country, and stakeholders identified through a network of in-country partners.
Results: We conducted 58 interviews with healthcare providers, public health officials, academics, and members of advocacy groups. We found that specifics of the laws did not predict their successful implementation. Ministry of Health involvement was key. Collaborations with UN agencies and international NGOs helped establish clinical and training protocols. Integration of abortion into existing public facilities led to more rapid and broader access. Key strategic decisions included a focus on medical rather than surgical abortion; the expansion of midlevel providers' role; and integration of contraception into abortion care.
Conclusions: We observed a range of approaches to the implementation of abortion services in response to varying legal and policy frameworks.
Public sector commitment and early involvement was key to the successful establishment of services, and thoughtful adaptations to local contexts can significantly reduce logistical and financial barriers to the equitable provision of services.