Nego-feminism as a strategy to improve access to abortion in sub-saharan Africa

Abstract

Background

Abortion is partially legal in 48 of 54 countries in Sub-Saharan Africa (SSA); however, abortion laws are generally weakly implemented, and evidence suggests that extending abortion rights does not necessarily improve abortion access.

Objective

Reflecting on the implementation challenges faced by the laws extending rights to abortion in SSA, and enriching this approach by considering complementary avenues to overcome barriers in access to abortion.

Argument

Reproductive justice is a theory that emphasizes the importance of contexts and different levels of societal forces in shaping reproductive freedom. From a reproductive justice perspective, we suggest that the successful implementation of abortion laws is hampered by discrepancies between legal frameworks and socio-cultural contexts in many SSA countries. In many SSA contexts, the legalization of abortion has not been accompanied by a modification of socio-cultural contexts regarding abortion. Until these contexts are more receptive to abortion, implementation issues may persist and access to abortion may remain hindered. Since increasing social acceptability of abortion can be a lengthy process, exploring complementary strategies to improve abortion access can be beneficial. Nego-feminism, an African feminist theory rooted in African values of negotiation and relationships, may be an effective strategy to navigate societal forces to improve abortion access, in the meantime, until greater acceptability and enforcement of abortion laws. An illustration of this promising strategy can be found in abortion accompaniment models such as MAMA network which provide safe access to medication abortion in the informal sector.

Conclusion

Nego-feminism could potentially improve access to abortion in legally and socially restricted settings. However, the continued fight for the legalization of abortion is essential, while using nego-feminism as a complement.

Background

Abortion is partially legal in 48 of 54 Sub-Saharan Africa (SSA) countries [1]; however, legal frameworks allowing abortion are generally weakly implemented, and evidence suggests that increasing legal rights to abortion does not necessarily improve access to abortion [2,3,4,5]. The present comment reflects on the implementation challenges faced by laws extending rights to abortion in SSA. It aims to enrich this approach by considering complementary avenues to overcome societal barriers hindering abortion care access. To do so, reproductive justice is utilized to analyze societal forces influencing the implementation of said laws. Then, Nego-feminism, an African feminist theory, is suggested as a complementary strategy to improve access to abortion in restrictive settings. In doing so, the example of abortion accompaniment models such as MAMA network, is discussed.

A brief history of the fight for abortion rights

A historical analysis of the fight for abortion rights suggests an evolutionary trajectory stemming predominantly from North America and Europe and gradually expanding across the globe. The global fight for abortion rights was initiated in the 1960s by second-wave feminist movements based largely in the United States. This fight became a unifying issue for feminist movements across Western countries, leading many Western countries to legalize abortion during the 1960s and 1970s [6]. The global influence of these movements led to the prioritization of women’s rights and reproductive health at the 1994 International Conference on Population and Development (ICPD) in Cairo [7]. This spurred a turning point on the African continent: Within 5 years, almost all SSA countries had partially legalized abortion [8]. The next step was taken in 2003, when the need for further access to abortion was recognized by the African Union in the Maputo Protocol. In this policy, all signatories were encouraged to allow abortion in case of sexual assault, rape, incest, and where the continued pregnancy endangered the mental and physical health of the mother or the life of the mother or the fetus [9]. While second-wave feminism undeniably contributed to the advancement of reproductive rights for women worldwide, multiple implementation studies reveal that these rights face significant challenges in many SSA countries [2,3,4, 10,11,12].

Implementation challenges in abortion laws

The relationship between abortion laws and access to safe abortion care is complex and highly dependent on proper implementation. Studies conducted in Tanzania, Zambia, Ethiopia, South Africa, the Democratic Republic of Congo (DRC) and Ghana have revealed a generally low implementation of abortion laws [2,3,4, 10,11,12]. Although several roadblocks have been identified, the most important may be a general confusion and lack of knowledge about the legality of abortion amongst women, providers, and law enforcement officials. Some governments also failed to create or disseminate operational guidelines on the new laws. Without a clear understanding of these laws, women and healthcare workers are reluctant or even fearful to seek or provide abortion care [2,3,4, 10, 11]. [4] Attitudes and values of providers sometimes negatively impact implementation; for example, many clinicians invoke “conscientious objection” to abortion care [4, 11, 12]. Laws are often designed to make access to abortion services difficult, like those that require three medical doctors to formally approve the procedure before it can be carried out [3, 4]. These implementation issues result in access to abortion care remaining low, despite its partial legalization [2,3,4, 10,11,12].

Understanding implementation issues through reproductive justice

Reproductive justice is a critical theory that connects reproductive rights with social justice. It emerged in the 1980s, in response to the dominant rhetoric around abortion, mostly reflecting white middle-class women’s experiences of choice. Reproductive justice places the contextual nature of women’s lives at the center of reproductive rights. It recognizes the role of economic, social and political power dynamics in shaping reproductive autonomy [5, 13]. Using reproductive justice at a macro and meso-level can shed light on how power dynamics between and inside countries impact implementation of abortion laws. On a macro-level, as demonstrated in the historical analysis above, the fight for abortion rights remains mainly rooted in Western mental models. Despite their deep investment and commitment, African stakeholders have had to contend with a Western approach that is ill-suited to the sociocultural realities of Africa. For second-wave feminist movements in Western societies, success in making abortion legal and accessible was fueled by intense social movements emerging from grassroots activist organizations [6]. These social movements not only resulted in policy changes but also contributed to changes in social norms in Western societies.

Many SSA countries face entirely different contexts. Abortion laws have largely been modified despite generally restrictive contexts, and social norms and values regarding abortion have been resistant to change. Studies describe abortion laws being implemented in relatively conservative contexts, in which public opinion is generally unfavorable toward abortion regardless of its legal status [2,3,4, 10]. Abortion is often opposed on moral and religious grounds [2,3,4, 12], and in contexts where traditional gender roles are predominant, abortion is seen as a violation of expected behaviors of women as mothers and caregivers [10]. Fear and stigma around abortion are common [2, 4, 11, 12], and a study carried out in DRC reported that even when legal abortion services were available, women preferred clandestine abortion care to avoid societal exclusion [10].

On a meso-level, the existence of a discrepancy between legal and sociocultural frameworks regarding abortion in SSA could explain the challenges in implementing abortion law. This discrepancy could be amplified by the emphasis placed on social frameworks in SSA: relationships and communities are placed in high importance in many SSA societies, as outlined by multiple decolonial authors [14, 15]. This phenomenon is similar to what others have observed for the case of female genital mutilation and child marriage, for example. Although they have been banned in many SSA countries, the deep sociocultural roots of these practices cause them to persist [16, 17]. While laws can usually be changed relatively quickly, social norms evolve much more slowly. As opposed to social norms, laws can also be objects of power and be subject to pressure from external actors, agendas, and norms. The main issue is that even with legalization, access to safe abortion remains limited until socio-cultural contexts are modified. With these obstacles in mind, it can be useful to look at nego-feminism for strategies to improve access to abortion more promptly.

Navigating societal forces using nego-feminism

Nego-feminism is an African feminist theory developed by Obioma Nnaemeka, a Nigerian feminist scholar. As like other decolonial feminist theories, nego-feminism opposes the presumed universalism of the female experience and emphasizes the importance of contexts in understanding women’s oppression. However, Nnaemeka goes further by defining how African feminism is rooted in African mental models. She introduces nego-feminism as a theory grounded in African values of negotiation and relationships. The framework strives for gender equality, but unlike Western feminism, which seeks to dismantle or deconstruct patriarchal oppression, it focuses on negotiation, compromise, and navigation around oppressive forces. Nego-feminism relies on “gives and takes” with the dominant culture as a way to survive. As well, nego-feminism revolves around sisterhood, as Nnaemeka points out that “ African women do feminism as an act of altruism towards other women” [18]. While Western feminism created a social movement resulting in extended rights to abortion, nego-feminism might instead aim to navigate oppressing forces to improve access to abortion care.

Nego-feminism and medication abortion accompaniment models

Medication abortion (MA) consists in the administration of misoprostol (a synthetic prostaglandin analog) with or without mifepristone (a progesterone blocker) to expel the product of conception [19, 20]. The use of misoprostol as an abortifacient was first discovered by Brazilian abortion activists in the 1980s. Originally used to treat gastric ulcers, this drug rapidly became an essential tool in increasing access to abortion and resulted in a small revolution in the field of reproductive health [19,20,21]. MA has long been proven to be as safe, effective, and acceptable as procedural abortion methods [22]. Compared to procedural abortion methods, MA holds certain advantages: it is simple, inexpensive, non-invasive, and unlikely to cause complications. Additionally, MA’s discreetness contributes in increasing access to abortion where it is legally or socially restricted, namely by reducing the need for stigmatizing interaction with healthcare providers [19, 20, 23,24,25]. It is worth mentioning that although MA holds many advantages, it can still have downsides that vary in magnitude depending on women’s preferences. MA requires space and privacy to self-administer and can cause side effects such as pain and light bleeding [31, 32].

The discovery of MA led to a movement aiming to democratize access to abortion. With MA, medical professionals were no longer gatekeepers of abortion and with the appropriate medication, abortion could be carried out safely outside of the formal sector. In the early 2000s in Latin America, a movement of women reclaiming abortion as an autonomous act led to the development of abortion accompaniment models (AAM) [26]. AAM aim to increase access to safe abortion methods, even where abortion is illegal, by supporting women in the self-management of their medication abortion. Formed of feminist activist collectives, AAM exist in over 50 countries and use strategies to increase access to safe abortion, such as abortion hotlines, medication-by-mail services, online sources of detailed instructions, mobile apps [27]. The effectiveness of AAM has been demonstrated, notably in Argentina and Nigeria where evidence suggests that abortions completed through accompaniment models had similar outcomes from those completed with medication abortion in clinical settings (for pregnancies of less than 9 weeks) [28].

The Mobilizing Activist for Medication Abortion (MAMA) network is an African abortion accompaniment network present in 21 countries across SSA. This network believes that MA is an opportunity to provide universal access to safe abortion, regardless of national abortion laws. MAMA’s focus is on sharing knowledge and expanding access to MA at the community level in SSA countries. To do so, they train pharmacists to safely provide MA, create hotlines where women can get advice on their self-managed MA, and develop resources to provide women with accurate information on MA.

The strategies put forward by MAMA network can be viewed through a nego-feminist lens. MAMA strives for universal access to abortion, but rather than seeking to advocate for the legalization of abortion, it works around limitations to offer access to abortion in a more discreet way. The set of strategies offered by MAMA circumvent the restrictions that society placed on abortion (both legal and social). MAMA’s strategies can be viewed as a form of social compromise: their activities remain outside of the formal sector and outside of the public space, but this enables them to continue providing women with access to safe MA. The altruistic aspect of nego-feminism is also present in these strategies. Women helping other women access safe MA is clearly an example of doing feminism as an act of altruism towards other women. AAM such as MAMA challenge the traditional path towards increased abortion access which involves legalizing abortion. If legalizing abortion does not necessarily succeed in granting further access to abortion in some contexts, can other models succeed in doing so, even when abortion access through formal channels remains hindered? AAM provide an interesting nego-feminist strategy to promptly improve access to abortion until legal abortion becomes legally and socially accessible.

Conclusion

By examining abortion in SSA through a reproductive justice perspective, we suggest that the unsuccessful implementation of abortion laws often results from discrepancies between legal and sociocultural frameworks regarding abortion. Where socio-cultural contexts surrounding abortions remain restrictive, nego-feminism offers insights into navigating societal forces rather than opposing them, offering a practical solution to rapidly improve access to abortion. An interesting usage of nego-feminism was demonstrated through abortion accompaniment models such as the MAMA network, which makes MA accessible despite restrictive contexts. It is noteworthy that nego-feminism and Western feminism can and should be used complementarily. Decolonial authors in global health stress the importance of stepping away from a false “Western versus African” dichotomy to develop new and integrated mental models [14, 29]. We encourage a hybrid approach, in which nego-feminist strategies, such as AAM, would be used alongside Western feminist strategies, such as advocating for the legalization of abortion. Latin American feminism provides an interesting example of combining activism (e.g. the ni una menos movement) with negotiation strategies such as abortion accompaniment models [30]. Continued advocacy towards the legalization of abortion is essential, as relying only on AAM could have shortcomings. For some women, the downsides of MA (requiring space and privacy and causing side effects such as pain and light bleeding) can be significant and procedural abortion may be a better fit [31, 32]. It is important to make progress in both directions to enable women to choose from a range of abortion methods and select the one that suits them best. Safe and legal access to all abortion methods is the ideal; however, knowing and understanding the constraints of achieving this goal, nego-feminism provides a strategy to improve access to safe abortion in the meantime.