Building Safe Spaces to Talk About Abortion: RAWSA MENA Network

The mission of Women on Web is to provide safe, accessible, and affordable online abortion care to women and people around the world. People who need safe abortion can make an online consultation at Women on Web website. After being reviewed by medical doctors, medical abortion pills are provided via mail. Women on Web’s service is open to countries in the MENA region that have restricted or criminalized abortion laws. We talked with Dr. Selma Hajri, project manager of the RAWSA MENA Network, on sexual and reproductive health rights and the future of medical abortion in the Middle East and Northern Africa.

Interview by Efekan Sadak*

Could you please tell us a bit more about yourself? How did you start to work on reproductive rights and especially the right to access safe abortion?

My name is Selma Hajri and I am a Tunisian doctor [endocrinologist]. I am still working and still providing medical services for endocrinology. Back in time, at the end of my specialization, I was assistant researcher and I started to train at the family planning research center in Tunisia. I spent around 5-6 years working on family planning methods, introduction to family planning and hormonal contraceptive methods. End of the nineties, I started introducing the medical abortion by pills. I thought it would be really interesting to introduce medical abortion in Tunisia as abortion is legal upon request, but unlike in Tunisia, it is really difficult for countries in the Middle East and North Africa (MENA), which has restrictive laws on abortion. They didn’t believe me when I said, “No, in Tunisia it is really cheap, available and legal”. Finally, I succeeded in introducing the first studies on medical abortion with a first successful introductory trial in 1997. Since this period, I have been deeply involved in medical abortion. It was a real pioneer experience because nobody had done that in the region and neither in other countries of the region, even some countries in Europe, had not started. That is why I started to be much more involved in safe abortion and I had to face all the barriers on the access to abortion, and realized how many women faced barriers to access. I started to be an advocate on access to safe abortion in general and in Tunisia more specifically. At that stage, I started to be involved in several training groups for safe abortion and also for value clarification for attitude transformation. I have been involved in international organizations and groups advocating for safe abortion. Lastly, after the Tunisian Revolution (the Jasmine Revolution) we created a new Tunisian NGO called Group TAWHIDA BEN CHEIKH; I was the founding president at that time, now I am the general secretary. We started the work on all different aspects of sexual and reproductive health and rights and access to services. Not only on abortion but also on contraception, sexual education, information and sensitization. Recently (2018-2019) we made a survey in order to understand the knowledge of young people on sexual health was, and we conducted research on barriers to young people’s access to reproductive and sexual health services. During those 10 years, we were strongly involved in advocacy for all the aspects of sexual and reproductive rights, developed trainings, developed new partnerships with all feminist NGOs.

Last years, I started to think about barriers on sexual and reproductive health in conservative and Islamic countries, specifically in the MENA region. In Tunisia we have seen new barriers in terms of access, mainly for abortion. Abortion is available since 1974 in Tunisia, and it was really difficult to understand the new barriers. I started to think that this problem is not only Tunisia’s problem, it is really the problem of the region. If we have legal abortion, accessible why do we have exactly the same barriers, the same stigmatization, the same negative attitude of providers like countries in the region? We started to build this new network (RAWSA MENA) to understand the situation, try to develop specific advocacy strategies, and think about the region. What have been done in the last 2 years is to develop contacts to build this network.

Let’s start by going from the general to the specific: let’s first talk about access to abortion in the Middle East in general, and then Tunisia specifically. Could you please tell us what is RAWSA?

Concerning the situation of legal abortion in the region, nothing has changed for the past 15 years. Tunisia and Turkey are the only countries where there is legal indication for abortion. In Tunisia, it is legal during the first three months of the pregnancy and legal for every woman, married or unmarried. We do not have spousal consent. The second interesting point in Tunisia is there are legal/official structures. National Organization of Family and Population (ONFP) is completely dedicated to services for family planning, and it involves contraceptive methods, abortion (surgical and medical), Sexual infection treatments, information, education of young people for better knowledge of sexual information, and prevention of gynecological cancers (uterus and breast). This situation has existed since 1973 and the services are free for all women. In Turkey, I know that abortion is allowed until the 10th week of pregnancy. I know that unfortunately medical abortion is not available in the best conditions. I do not know about the cost and if it is free on the public sector or not. So, this is the situation in the two countries and in all the other countries in MENA region abortion is illegal. Best to say, abortion is completely illegal in 50% of countries, even in situations that endanger women’s lives. This is an unacceptable situation.

Other aspects of the MENA region are that not only you cannot advocate about abortion, you cannot even talk about it! Indeed, some countries penalize talking about and advocating abortion. This situation makes it very difficult to find activists who are willing to take the risk. This is a really big problem. The second aspect is that safe abortion by medical method is not available in private clinics, even if it is legal. And this means that we cannot exactly know the situation and we cannot compare the situation within the MENA region. Likewise, we cannot evaluate in Africa or in some countries in Asia, where we know mortality is very high.

In the MENA region, we do not know anything, we do not know if women are dying from unsafe abortion. We have the mortality rates, but we do not have any data that we could link with unsafe abortion. Probably, even if it is something everybody talks about there is no proof. It is well known that abortions are done in a safe way by doctors but women have to pay and they have to keep quiet, no one talks about it. This is the context of the MENA region. One aspect for me is that abortion is a proof of your sexual intercourse. Mostly for unmarried women, it is something unacceptable; you cannot talk about this. It is considered like a shame and women cannot talk about their sexual intercourse. That is why there is no progress in the region.

We know that there is significative progress in several countries in Africa, that are changing their dialogues on abortion. There is also big progress in Latin America where religion is strong but sexual intercourse is accepted. Our problem in the MENA region is that sexual intercourse outside of marriage is not accepted. You cannot even think about it or express any idea about this.

“Building RAWSA perhaps will help us first create a safe space to talk about abortion but also talk about sex”

This is why we thought that building RAWSA perhaps will help us first create a safe space to talk about abortion but also talk about sex. This is what we want: to create a safe space to talk. Secondly, reach out to the activists. Trying to give them maximum knowledge of safe abortion and also how to argue, how to advocate and understand what is happening in their country. We’re trying to collect stories, to collect testimonies, any type of data that we can collect. To really build a network and a platform, our efforts are focusing on always trying to have all the documentation in three languages. Always in Arabic, in English, and also in French because North Africa is more francophone. RAWSA was built in a really difficult situation because we started work on it in the times of Covid-19: we started 6 months before the pandemic. Everything is right now going through the website, through webinars, through online meetings and it is not easy to maintain implications and enthusiasm. It is very difficult, but we are trying. We are also trying to develop training for better knowledge of advocacy strategies. We are always trying to think about what could be done from our side. RAWSA is like a baby: we see it’s growing and we’re trying to educate it. We are trying to develop a good strategic plan and trying to give more visibility to the network.

Can we talk about RAWSA’s action plan? What did you do in the past? What are your current actions? And finally, what are your plans for the future? What should we expect from RAWSA?

We had to first identify what we have locally through focal points. In different countries, focal points are representing their countries. We have focal points covering Tunisia, Morocco, Algeria, Palestine, Lebanon, Jordan, Egypt, Oman, Libya, Iraq, Syria, and Turkey. We have a coordination team in Tunisia, and I am the manager of the network. We are trying to build contact between focal points and the coordination team. We organize regular meetings with specific objectives: First, create a very comprehensive, large mapping of the organizations and the activities in the region. Second, to build a website. The challenge for the website was to make it very safe. It is a closed website, not an open one. You have to be registered to reach all the documents on the website. It was not easy to make it. We are still moving slowly but we have now developed a good range of documentation (presentations on Abortion, mini videos etc..). These are the main objectives, but we have several other objectives too. For instance, to develop advocacy training and information. We realized webinars dedicated to journalists and media; it has been clear that is really important to build an efficient relationship with the media. What is the key information to be convinced of and how to disseminate it through media? We have done three webinars for journalists and two of them are media conferences. We also aim to hold annual webinars and trainings for providers on advocacy for safe abortion. We just finished the cycle of training for advocates and health providers to give them the capacity to provide abortion and develop value clarification for attitude transformation (VCAT) and a good advocacy plan for the region.

“To talk about safe abortion in the MENA region”

Now we have to go deeper on our action plan. We have to be less Tunisian-centric, and we have to involve people from countries in the region. We should give them more responsibilities to advocate in their region. We start developing (this is really new) a board of expert for RAWSA, for a more efficient advocacy on safe abortion process to talk about safe abortion in the MENA region. Tunisia is really different from other countries. There are lots of differences on what has been already done in the cultural context of safe abortion. Turkey also has a really different historical context that makes it different from other countries in the region. What we realize for Tunisia is that Tunisian people who are advocating for sexual and reproductive rights have to be less radical and to maintain the situation and try to develop women rights. This is the lesson we learn from other countries; we have to be really careful. Tunisia can be in some aspects, an example for the other countries in the region.

Can we talk a little bit about Tunisia? What is the current status of access to safe abortion in Tunisia?

“Right to abortion was one of the visible successes in Tunisia as a modern country in the region and it was always encouraged”

Legal abortion has existed in Tunisia since 1965, a few years after the independence, with restricted indications, then upon request since 1974. It was legalized for two reasons: willingness of the president and government to give more rights and more independence for women; and second, it was a natalist political strategy until the 90s’. Still, abortion access was easy and free. Because the political will was very strong until the end of 90s, it was one of the visible successes in Tunisia as a modern country in the region and it was always encouraged. There were no difficulties for abortion service.

Things started the change, after September 11, when Libya and other Arabic countries started to develop religious identity for Arabic countries. They had to strategize to give a religious context to countries. Conservative populations have been growing since 2004-2005. In 2008, I was one of the people who said that we need to do something because midwives and providers started to refuse to make abortions, considering it as haram. It was criticized and stigmatized women, especially young women who have desire to have contraception or ask for abortion. The barriers started at that time and refusal of abortion started before the revolution. But with the revolution, political will to preserve barriers and encouraged to family planning disappeared completely. At that time, the financial fund of the Family Planning decreased dramatically. They had to negotiate on less medical abortion and choose less expensive contraceptive methods. So, we had a strong drop in services for family planning. In 2015, the Tunisian MICS (Multiple Indicator Cluster Surveys, UNICEF statistics) studies show that fertility rights were growing and a need for abortion and contraception was growing too. Services decreased in a really dramatic way. This is related not only to conservative opinion in the country but also the government was not preserving services at all.

What is the process for women seeking abortion in Tunisia?

Regarding medical abortion, it is not regulated with law; law didn’t change on abortion. There is a directive on medical abortion. It says that medical abortion is authorized in Tunisia through central pharmacy; it is not distributed in the pharmacies. It authorized for distribution in family planning clinics, hospitals, and private clinics in theory. In practice, family planning clinics are the only ones providing medical abortion. They are providing until the 9th week of the pregnancy with a very well-structured protocol. We had several international publications on this protocol. The protocol is to take one pill of Mifepristone -200 mg than the second or third day, two pills of Misoprostol 200 mcg/pill. Further misoprostol pills are necessary if there is no expulsion. Pills of Misoprostol are taken by sublingual, or buccal route. Mifepristone is always given in the clinic and the woman can go home with two pills Misoprostol. All the studies we have done show that until the 9th week, we have a really great success rate, around 96-97%. If needed, we add the second dosage in case of non-expulsion. What we see is women do not come back easily for controls. But also, we know that they don’t go anywhere, they are staying home, and this is okay. Studies have shown that around 40% of women don’t come back. When we go to these women and try to explore what happened to them, we see that they are okay with the situation: they had bleeding and the bleeding has stopped. They are not pregnant anymore. In Tunisia, surgical abortion is mostly provided in private clinics. In some hospitals, if they do not have the option for medical abortion, the hospitals refer women to family planning clinics where they have medical abortion. In the public sector, I think 90% of abortion is done by medical abortions. But in the private sector, it is mostly surgical abortion.

When we started introducing medical abortion in Tunisia around 2004-2005, Tunisian women did not trust the method of medical abortion. However, when it started to become widespread, women and providers saw that it is not actually a dangerous method. This opinion was disseminated by providers. Women do not see what is the danger. Frequently, when medical abortion started to be introduced, the providers consider that as a dangerous method. With high risk of hemorrhage. But it is completely wrong, and it is not the reality. Medical abortion is a very easy and very safe method. Of course, women are bleeding but they are bleeding in the surgical abortion as well. This is something that has to be part of the training process for providers to explain to them how easy the method is and how safe, so they will be able to explain that to women. We know that less than 0.5% of the women have heavy bleeding and they have to go to the hospital to have the adequate treatment. So, it is very few of them.

When we compare Turkey and Tunisia in terms of access to abortion, what are your impressions of Turkey?

Based on my experience in this area, for countries like ours (Turkey and Tunisia), what has worked in Tunisia, is promoting medical abortion from the cost aspect. Also, the fact that medical abortion does not need the expertise of doctors. In that way, doctors and gynecologists have more time for illness, pregnancies, etc. The cost of medical abortion is low compared with surgical procedure. Midwives and nurses, when they are trained, will be totally able to provide a medical abortion. It should be shown that medical abortion is really safe, easy to provide, and it will be an option to pay less for abortion. Surgical abortion is more costly in terms of it needing an operating room, an experienced doctor, materials etc. For Medical Abortion, you do not need these kinds of things. Ultrasound before a medical abortion is indicated in some specific cases but not necessarily after and nothing more. Second thing is that you give more time to doctors. They really need time for complicated cases, for surgical and medical actions, and put abortion process in the hands of non-medical health providers (midwifes and nurses). The third point, medical abortion preserves the intimacy and the integrity of the women, and gives women the power to decide and organize for her abortion. And now, using telemedicine is really useful and really safe for providing abortion; Covid-19 has shown that. For countries like Turkey where it is really big, telemedicine will be a really good option and it is only possible through medical abortion.

What are your thoughts on the future of medical abortion and telemedicine?

I think that the future of medical abortion is to be available over the counter. My presumptions on the MENA region are it will be close to the rest of the world. Pills will be readily available one day. Not today, perhaps not tomorrow, but really soon. Women will always find them over the counter, maybe on the black market. You cannot ever know what is on the black market and I hope it won’t be on the black market. This happened in Latin America where unsafe abortion was really one of the recognizable causes for mortality rates. With the provision of Misoprostol - only Misoprostol - women were taking Misoprostol over the counter, sometimes alone, sometimes with very little information and they were bleeding. They have to go to the hospital for emergency situation. As a consequence, there has been a decrease in mortality This will be probably the situation in the MENA region. It is already there. Misoprostol is there and it is used. Soon, with Mifepristone & Misoprostol combined, it will be in the area.

I think what we have to do as activists and as advocates, is give the maximum knowledge to people: how to use it, how to control it, where to find it, etc. It has to be more in the hands of NGOs and less in the hands of doctors and hospitals. This is the possibility of the medical abortion. It is not possible with the surgical one. I know that it is a little bit provocative and perhaps it is not going to happen tomorrow but it is on the way. Everybody is using smart phones, the internet, etc. They will find Women on Web** on the internet really easily. And we have to develop something like this in the region. It is more something that has to be done by NGOs and activists more than governments or official organizations. I know that it is not easy and could be dangerous for activists and organizations because it is not legal, but it is going to happen. We have to produce data: data on unsafe abortion and data on safe abortion that is already provided in secrecy. We need maximum information, and we have to publish it. Also, that is why we are developing a good relationship with media within the region.

*Efekan Sadak is a LL.M. Candidate, Project Assistant at Women on Web and Advocacy Focal Point for Turkey within RAWSA MENA Network.

** Women on Web is to provide safe, accessible, and affordable online abortion care to women and people around the world. MENA countries consist of Algeria, Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, Turkey, United Arab Emirates and Yemen. Please note that Women on Web service is open for MENA Region except for Israel, Lebanon, Syria. Women on Web’s help desk operates in 16 languages, including Arabic, English, French, German, Japanese, Korean, Hungarian, Indonesian, Italian, Persian, Polish, Portuguese, Russian, Spanish, Thai, and Turkish. Our help desk team accompanies women and pregnant people during all stages of the process and responds to any questions that may arise within 24 hours.