YANAA WORKSHOP: VALUES CLARIFICATION and ATTITUDE TRANSFORMATION  

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CONDUCTED BY
THE YOUNG ACTIVISTS NETWORK FOR ABORTION ADVOCACY (YANAA)  

Report by Shruti Arora, YANAA Coordinator 

This year for International Safe Abortion Day, on 25 September 2021, five YANAA committee members conducted a 3-hour Values Clarification and Attitude Transformation (VCAT) workshop on Zoom. Participants were youth advocates from sub-Saharan Africa, Europe, Asia and the USA. We used interactive activities to facilitate discussion in the sessions. A combination of Google Jam board and PowerPoint slides were used. We discussed multiple barriers that young people face in accessing abortion in different countries and regions, both those that are similar and different. We also delved into parental consent and mandatory reporting as key barriers in accessing abortion, and how paternalistic ideas regarding young people’s sexuality make it difficult for providers and policymakers to understand young people’s realities. We agreed that advocacy with these actors to change paternalistic mindsets and conservative legal frameworks so that all young people can exercise their right to safe abortion is essential.

 

THE TRAINERS 

CHRISTINA BOATENG is part of the Coordination team at the Campaign. She has worked on abortion rights for four years, and has been previously involved in migrant rights work. Christina is from the UK.

KARELL JO ANGELIQUE C CALPITO is a medical doctor, public health practitioner and researcher. She has been involved in various programmes and research studies that promote and advocate for universal access to health services, especially for marginalised populations. She currently works as a Programme Officer for Monitoring and Evidence Generation for Change at the Asian Pacific Resource & Research Centre for Women (ARROW).

SHRUTI ARORA is a feminist activist and SRHR advocate from India. She holds a Master’s in Gender Studies. She has over 8 years’ experience of working with diverse feminist and youth organisations, including Nirantar- A Center for Gender and Education and the YP Foundation. She is a co-founder of YANAA and currently its Coordinator, and works independently on SRHR issues.

WAFA MUDAWI IBRAHIM ADAM is an independent sexual and reproductive health and rights (SRHR) and gender-based violence expert, and reproductive justice activist from Sudan. She has an MSc in Reproductive Science and Women’s Health from University College London and was an SRHR fellow at Lund University. She is a founding member of Amplify Change and a Youth Committee member of YANAA.

ZANELE MABASO is a feminist policy advisor, social justice activist and and advocate for young women’s and adolescent girls’ sexual, reproductive and abortion rights from South Africa. She holds a Masters in HIV/AIDS Management from the University of Stellenbosch and is currently completing a Masters in Sexual and Reproductive Rights in Africa at the University of Pretoria. She’s a member of South Africa’s Sexual and Reproductive Justice Coalition, has extensive experience working with civil society, government and international development partners in championing SRHR advocacy and influencing reproductive rights policies in her country.

 

THE WORKSHOP 

Young people have the right to access the full spectrum of reproductive health services, including comprehensive sex education, maternity care, contraception, safe abortion and post-abortion care. There should also be recognition and respect for young people’s bodily autonomy and choice. Young people across the world face barriers to accessing safe abortion, more in some countries than others. They are disproportionately affected by legal barriers, judgmental attitudes and behavior of providers, as well as long waiting periods for services and other restrictions such as third-party (e.g. parental) consent, cost and stigma.

The workshop aimed to provide rights-based information on access to abortion, with a focus on transforming prevalent negative attitudes and belief systems, especially African and Asian countries, though not exclusively, and work towards building the capacities of the participants to advocate on these issues.

Values clarification and attitude transformation is both a theory and an intervention, originating from humanistic psychology, based on the belief that people are responsible for discovering their values through a process of open-minded self-examination, in this case by  examining personal values, attitudes and actions related to abortion. Evidence suggests that when conducted with stakeholders such as service providers, trainers and policy makers, it results in overcoming misinformation, stigma, and personal biases, and led to improvements in participant knowledge, attitudes and behaviours regarding abortion. For example, a pre-post assessment study conducted in 12 countries suggests that the providers’ positions on second-trimester abortion shifted from being obstructionist to supportive.ᶦ

THE PARTICIPANTS 

AATISH GURUNG, from the USA, recently graduated with a Masters in Public Health from the University of South Wales. They are working as a Communications Coordinator at a human rights and social justice organisation in NYC, organising and campaigning on abortion rights in their home country, Bhutan, and part of the Women Deliver Young Leaders Class of 2020.

HANNAH FERNANDES (pseudonym) is from Italy and is with an organisation working for youth sexual and reproductive rights. She has experience of working in Europe and Brazil on youth advocacy and engagement with youth-friendly and rights-based approaches.

EPHRAIM CHIMWAZA is from Malawi and works as a Programmes Director for the Centre for Social Concern and Development, a reproductive health rights organisation.

FREDRICK OMUTITI is from Kenya and works as a research analyst. The personal loss of a friend who passed away from complications of an unsafe abortion got him thinking and challenging the harmful social norms that deny young people abortion access.

INDAH TANGENTE (pseudonym) is from Indonesia and is the director of a leading women’s rights organisation.

INNOCENT INDEJE is from Kenya and works with AMREF Health Africa, and is a Steering Committee member of Youth in Action (Y-ACT).

ALOUCH SAMANTA (pseudonym) is a college student and a member an SRHR advocacy organisation in Kenya with safe abortion as one of the key issues of their work.

REHEMA PATRICKS is from Malawi and founded and runs a social movement aimed at promoting economic development among youth while challenging normalised habits that perpetrate multifaceted forms of violence.

TERESA LOCH is from Kenya and is a volunteer at Zamara Foundation where she is in charge of website content creation and management. She does advocacy work in sexual and reproductive health rights and media, and is the contact person for Zamara’s engagements with the Generation Equality Forum and partnership with Girls Not Brides Kenya.
THE SESSIONS 

Each session included a powerpoint presentation and interactive discussion, including work with the Jamboard. The Powerpoint slides can be seen here.

Session 1: Why did Mia die?ᶦᶦ

We started with the basics of unsafe abortion and non-availability of safe abortion being one of the root causes of maternal death. This session was facilitated by Wafa Adam. A vignette/case study was used (see slides 6 and 7). The questions posed elicited the following responses from the group.

Why did Mia (the abortion seeker) die?

  • Lack of information about pregnancy.
  • Misinformation about SRH, lack of support, abortion stigma, lack of help from the clinic staff, lack of popular knowledge about abortion and where to find support.
  • Lack of access to information about the full range of medical options available.
  • Stigma and ignorance.

Who is responsible for Mia’s death?

  • The State, for not having proper public policies and trained medical staff, not providing comprehensive public health information on safe abortion, and making access to healthcare difficult.
  • The service provider who refused to give her services.
  • The staff at the two clinics because they took the conscious decision of denying her the information on where to find access to safe abortion at 14 weeks.
  • Abortion stigma as structural reason for misinformation for providers and abortion seekers

What could have been done to prevent Mia’s death? Who could have helped prevent her death?

  • A well-prepared, welcoming and informed staff.
  • More information about safe abortion.
  • Provision of comprehensive sexuality education.
  • Access to healthcare/safe abortion.
  • Laws and policies aimed at preventing abortion-related deaths.

What are the consequences of restricting access to safe abortion?

  • Unsafe abortion and its risks and complications.
  • Preventable deaths.

The session established the fact that there are many negative consequences of restricting access to safe abortion and who the important actors for changing these situations are.

Session 2: Busting the myths 

This session was facilitated by Zanele from South Africa. The participants were asked to identify some commonly known myths. The responses from the participants were as follows:

  • Only women need abortions.
  • A transperson seeking abortion is “less of a woman” or is not considered as possibly needing an abortion.
  • People who seek abortion can never have kids again.
  • Abortion is a sin.
  • Abortion can kill.
  • Abortion is murder.
  • All abortions are in young people who are unmarried.
  • All abortions are dangerous.
  • If you have an abortion you will not be able to get married.

Zanele provided clarification on the four most commonly mentioned myths by presenting facts, figures and examples to the participants (see slide 9), along with some examples from the Africa region to drive home the following points:

  • Safe abortion is an essential healthcare need.
  • Abortion is a safe and simple procedure due to technological advances. Childbirth carried greater risks than abortion. There are more risks the longer the number of weeks of pregnancy, but even then, the risks of abortion are far less than the risks of childbirth.
  • Safe abortion does not affect women’s fertility.
  • Abortion does not cause depression or make women regret it. This narrative is used a lot by anti-choice actors to discourage women from getting an abortion, but most women in fact express relief afterwards.

Session 3: Safe abortion: a public health and human rights issue

The third session was facilitated by Karell, whose presentation was about a rights-based approach to safe abortion. She elaborated the human rights framework that states that the right to decide whether or not to continue a pregnancy is a basic human right. Not all pregnancies are planned and not everyone who becomes pregnant wishes to continue with the pregnancy. Non-consensual sex, contraceptive failure and/or personal circumstances that make having a(nother) child difficult are some common reasons why women decide not to continue with a pregnancy.

The latest available data show that globally, there were roughly 25 million unsafe abortions each year. Irrespective of whether or not abortion is restricted, women will seek to terminate a pregnancy if they decide it is not possible for them to continue it. The legal status and accessibility of safe abortion for everyone who requests it in each country make a crucial difference to the percentage of safe abortions.

Death and disability from complications of unsafe abortion represent a serious public health tragedy because they are almost always completely preventable. Historical experience shows that when abortion services are available on broad legal grounds or on request, deaths  and complications from unsafe abortion are very rare, making abortion one of the safest medical procedures.

There are two main types of abortion method – surgical or medical. Medical abortion is abortion carried out using medication without surgery. A combination of two medicines, mifepristone and misoprostol, used sequentially, is on the WHO Essential Medicines List. In places where mifepristone is not available, misoprostol alone can be used.

When used with the recommended dosage and regimen, medical abortion is highly effective. It can be provided at the primary care level for use at home up to 12 weeks, and thus has the potential to make abortion more accessible. After that, it can be provided in an outpatient clinic up to 20-24 weeks.

Surgical abortion is the use of a minor surgical procedure called vacuum aspiration in the first 14-16 weeks and a more complicated one, dilatation and evacuation (D&E), in the later second trimester. Dilatation & curettage (D&C) is still widely used in some countries, but because it has higher complication rates and requires general anaesthetic and a hospital stay, it is no longer recommended by the World Health Organization, and its use should be stopped.

Wherever possible, depending on the length of pregnancy, there should be a choice of method, as there is with contraception.

Where abortion is legally restricted or inaccessible, post-abortion care ensures appropriate care to prevent further morbidity and mortality is provided, as a harm reduction strategy. In such a context, post-abortion care that is provided should be of good quality, humane, and non-judgmental, and the treatment should include treatment of complications from spontaneous and induced abortion, counselling, contraceptive services, and referral if required to other reproductive health services.ᶦᶦᶦ

Session 4: Exploring the barriers to abortion for young people 

The fourth session was facilitated by Christina and focused on identifying, with the participants, added disadvantages and vulnerabilities experienced by younger people in accessing abortion, especially when they are minors. The responses were as follows:

  • Lack of comprehensive sexuality education in schools and pregnancy testing kits.
  • Restrictive abortion laws heavily influenced by the religion of the country that has a socio-psychological impact on young people. Restrictive abortion laws also mean that abortion is legal only when it is to save the life of the woman, e.g. in Malawi.
  • Parental consent requirements.
  • Lack of youth-friendly health services, including absence of youth-friendly language, attitudes and behavior of the providers.
  • Stigma associated with young people’s sexuality.
  • Unaffordable services for young people as they can be dependents or students.
  • Prejudice associated with young people’s decision-making capabilities.
  • Barriers due to long distances to services, e.g. locations such as rural communities where availability of services is limited and young people have to walk or travel long distances to access services.

Christina presented the following points in summarising the session:

Parental involvement laws 

  • There are laws that require a young person to notify or obtain consent from one or both parents before they can receive abortion care
    • There may be issues with getting consent from parents
    • What happens if they cannot do so?
  • Lack of privacy.

Financial barriers 

  • Likelihood of being financially independent is low
  • Fewer financial resources
  • Health insurance access and coverage limited.

Medical barriers 

  • Lack of knowledge of signs of pregnancy
  • Lack of knowledge on where to access an abortion and existing methods
  • Seeking an abortion later in pregnancy
  • Requiring an abortion provider to approve the abortion, in addition to parental consent.

Social barriers (community) and stigma 

  • Premarital sexual activity not acknowledged or accepted
  • Not allowed to independently visit medical services
  • Shame around sexual activity or accessing abortion services
  • Gendered forms of judgement from the community
  • Lack of information about safe abortion and methods
  • Marginalised groups experience additional difficulties (based on race, disability, sexuality, ethnicity, etc)
  • Religion and other faith or cultural beliefs.

Risk of harm 

  • Being criminalised
  • Complications from unsafe abortion
  • Putting themselves or their family in danger for accessing an abortion
  • Being rejected by family or community for having an abortion.

Session 5: All the reasons why…ᶦᵛ

This session was facilitated by Wafa.

All the reasons why women have sex:

  • To fulfill conjugal duties
  • To express love
  • For procreation
  • For sex work
  • Being forced or raped.

All the reasons why women become pregnant:

  • Influence, to be like other women
  • Society an families demand that married women bear children, e.g. for continuity of the lineage
  • Birth control did not work
  • They were sexually assaulted
  • Lack of contraceptives, failed contraception
  • They may want a child of a specific sex, so keep getting pregnant until that is realised.

All the reasons why women terminate a pregnancy:

  • They do not what to have a baby (at that time)
  • They have just had a child
  • Incest or rape
  • Do not want to have a child from a sexual assault
  • Health reasons
  • For work
  • The country doesn’t allow having more than 1 or 2 children.

All the reasons why women continue an unintended pregnancy:

  • To not be judged
  • Do not have access to information about other options
  • Societal stigma, internalised stigma
  • Not aware of being pregnant
  • It’s not ok to abort a pregnancy
  • Pregnancy too far along
  • No available services for an abortion.

Session 6: Involving young people in decision-making 

The sixth session was facilitated by Shruti. A case study was used (see slide 30) and the following questions were raised and answered by participants:

  • Do you think Lalita was capable of taking a decision regarding having an abortion?
    Everyone in the group agreed that Lalita had the capacity to take an autonomous decision regarding the abortion and that parental consent was not needed.
  • How do you think the legal framework impacted Lalita’s decision?
  • Everyone agreed that the law became a barrier for her to access a safe abortion. Participants said:
    • It was due to the Protection of Children from Sexual Offences Act that her autonomous decision was not considered by the doctor. The provider did not provide any information to her but insisted on parental consent, thereby denying abortion.
    • It made her vulnerable and she might have gone for an unsafe abortion or to a quack.
    • Shruti added that the law ends up compromising the confidentiality of the abortion seeker as the provider is mandated to report the request to the police. Filing a medico-legal case with the police ends up putting the abortion seeker and her partner in a very vulnerable position. Moreover, setting the age of consent at 18 is not based on any evidence from the country.
  • What is the age of consent for young people in your country? Do you think it is appropriate? Why or why not?

    In Bhutan, Malawi and Kenya, the age of consent is 18 years. In Brazil, it is 14 years. Everyone agreed that 18 was too high as young people, especially in some global South countries, get married (and have sex) much earlier. There were some differences amongst participants if it should be as low as 14 as young people aged 14 may not be able to assess their situation.

Shruti said that in many contexts, young people are considered “mature enough” when it comes to marrying them off before age 18, but not for exercising their right to choose, sexual health, or seek an abortion. The age of consent should be determined only after considering certain parameters of development and the lived experiences of young people. Since these vary from context to context, setting a universal age of consent may not be the right solution to the problem.

  • How can service providers consider young people’s autonomy and evolving capacity to consent while providing abortion services? Responses included:

    The service provider could have made more of an effort to provide an abortion for the young woman — in a more understanding and appropriate way (instead of scaring her), but the service provider may have been limited by the law too.

    It is not necessary to punish the girl.

    The doctor should have given her information even if providing an abortion was illegal. Perhaps the doctor should break the law, although it may be asking too much (but in Brazil, for example, there is a protocol on how to handle such cases of seeking abortion).

Shruti introduced the concept of the evolving capacity of young people to consent.ᵛ This refers to individuals developing the ability to take responsibility for their actions and make autonomous decisions as they grow older. Development varies from context to context, and hence setting a universal age of consent may not be the solution for young people’s access to abortion. There are international frameworks that may help in advocating at the national level for young people’s access to abortion. Articles 5 and 12 of the UN Convention on the Rights of the Child (1989) state that children are active agents in the exercise of their rights, as they mature and gain competency, there is a reduced need for adults to intervene in decision-making for them.ᵛᶦ

The session was concluded by providing potential strategies for the participants for including young people in decision-making. As youth advocates, we can support young people in taking informed and autonomous decisions related to SRHR by providing and advocating for comprehensive sexuality education, youth-friendly services and participatory approaches to service-provision.ᵛᶦᶦ

THE WAY FORWARD 

The session was concluded by sharing the link to join the International Campaign for Women’s Right to Safe Abortion. As a way forward, the facilitators and participants agreed that we need to organise such sessions more regularly to learn practice-based strategies and share advocacy lessons with each other across regions. The resources that were referred to during the workshop were later shared with the participants.

References 

I. Katherine L Turner, Alyson G Hyman, Mosotho C Gabriel. Clarifying values and transforming attitudes to improve access to second trimester abortion. In: Second Trimester Abortion: Public Policy, Women’s Health. Reproductive Health Matters 2008;16:Suppl.31, 2 Sept. pp.108-116. https://www.tandfonline.com/doi/pdf/10.1016/S0968-8080%2808%2931389-5?needAccess=true

II. The activity was adapted from Ipas. Abortion Attitude Transformation: Values clarification activities adapted for young women. 2011. https://www.ipas.org/wp-content/uploads/2020/06/VCATYTHE13-VCATAbortionAttitudeTransformationActivities.pdf

III. TK Sundari Ravindran & Subha Sri B. An Advocate’s Guide: Rights-Based Safe Abortion Policies, Programmes and Services. ARROW, 2021. https://arrow.org.my/wp-content/uploads/2021/05/ARROW-Advocates-Guide-2021_Safe-Abortion_WEB_28-May-2021-3.pdf

IV. Op cit. Ipas Ref 2.

V. IPPF. Keys to youth-friendly services: Understanding evolving capacity. 2012. https://www.ippf.org/sites/default/files/key_evolving_capacity.pdf

VI. UN Convention on the Rights of the Child, 1989. https://downloads.unicef.org.uk/wp-content/uploads/2010/05/UNCRC_united_nations_convention_on_the_rights_of_the_child.pdf

VII. Op cit. IPPF, Ref 5.