Increasing Access by Increasing Understanding: Developing Picture-Based Medical Abortion Materials for Women

Background: Most countries’ laws permit abortion to save the life of a woman, and many permit abortion on broader grounds. However, abortion remains highly stigmatized, and marginalized women become more vulnerable when faced with an unwanted pregnancy. Medical abortion – the use of drugs to end pregnancy – has recently become more widely available. Women can use this noninvasive method in a range of settings, often in their own homes. Medical abortion is especially promising for women most at risk of turning to dangerous abortion methods. Unlike in abortion with instruments, women using medical abortion are more involved in administering the medication, monitoring the abortion process, managing side effects and assessing outcomes. It is therefore imperative that women obtain clear and accurate information on the dosage, timing, possible side effects, and signs indicating the need for further care.

Program background: Picture-based materials were developed to guide women with low literacy through the medical abortion process. A design firm expert in visual health communication was contracted to create a guide using a sequence of frames to depict the core concepts of the medical abortion process.

Evaluation Methods and Results: Focus groups were conducted in Nicaragua, Cambodia, Nepal and Pakistan to field test the tools. Ten focus groups were conducted with approximately 75 participants total, most of whom could not read. Discussions with lay and formally-trained healthcare providers were conducted separately. Participants discussed their understanding of the content and offered suggestions for improving the materials’ clarity and appearance. Across settings, the most clearly understood concept was postabortion contraception; side effects and information about when to seek care were generally well understood. The authors determined that some accompanying text or verbal communication was necessary to explain the concepts. The depiction of time – necessary to explain the scheduling of doses of medicine – proved to be the most challenging concept. Thought-bubbles were well-understood in some settings and poorly understood in others. Depictions of the female anatomy were the most controversial element, however many participants felt their inclusion necessary to illustrate key points.

Conclusions: Several reactions were common across countries and literacy levels, and variations also resulted. Materials were modified based on participant feedback. In some settings, the materials can be used without adaptation, however, programs should have autonomy in adapting and creating materials, using the guide as a model.

Implications for research and/or practice: Revised guides were burned onto CDs and distributed to programs across Asia, Africa and Latin America. The CDs contained illustration files and instructions for using and adapting the materials. Medical abortion has enormous advantages for increasing access to safe abortion for some of the world’s most vulnerable women. However, it typically relies on the woman’s ability to take medicines as instructed and identify signs indicating additional care, underscoring the need for effective health communication materials. Ensuring that such materials are available will give healthcare providers confidence to offer medical abortion to more women, including women with limited literacy, thus increasing equity of access. Additional research will evaluate cultural appropriateness, clarity and acceptability by women and healthcare providers.