Project Dates: March 2015 – August 2015
Rwanda has made considerable progress toward reaching Millennium Development Goal 5 (MDG5) to reduce its maternal mortality ratio (MMR) of 1,071 per 100,000 live births in 2000 to 268 deaths per 100,000 live births by using an integrated approach to strengthen maternal health programs.1 By 2013, the MMR had fallen dramatically to 320 per 100,000 live births and is on track to decline further by the end of 2015. Demonstrating steadfast commitment, the Ministry of Health (MOH) fostered these improvements by prioritizing the systematic development of rigorous policies and implementation of evidence-based programs to address all causes of maternal mortality, including deliberate targeting of maternal deaths due to unsafe abortion.
Several crucial legal and policy changes have paved the way to the current success. In 2012, Rwanda revised their decades-old, highly restrictive penal code, which only allowed abortion to save the life and/or health of the mother, and introduced legal exemptions for fetal impairment and non-medical criteria including rape, incest, and forced marriage. The MOH also produced a pair of key policy documents to provide a road map2 for the acceleration of the reduction of maternal mortality and guidance for the operationalization of these exemptions.3,4 Despite legal and policy reforms, a myriad of obstacles to implementation and access persist, owing largely to enduring traditional views, cultural norms, social behaviors related to sexuality, the continuing practice of forced marriage, and abiding stigma related to rape, incest, abortion, and illegal behavior. Furthermore, several new criteria for eligibility under expanded exemptions in the penal code involve criminal conduct related to gender-based violence (GBV). Recourse through the criminal justice and court system can be quite challenging, potentially involving daunting police investigation, and, has to date, rarely resulted in a court order. The complex and sensitive nature of these issues warrant a deliberate and concerted effort to increase institutional capacity, awareness, and evidence regarding the operationalization of the law.
To address these challenges, in collaboration with the Rwandan MOH, Venture Strategy Innovations (VSI) initiated a pilot project to operationalize the exemptions in the Revised Penal Code of 2012 with successful components including capacity building, community awareness, and data generation. Through retrospective record review in the 2 years following the legal reform and throughout prospective data collection during the last 5 months in 2014, the VSI pilot found around 5,000 women sought GBV services. However, of those GBV clients who were pregnant at the first or follow up visit, only one pregnant GBV client successfully navigated the criminal justice system and obtained the abortion she sought.
These findings called into question whether or not the criminal justice system facilitated access based on legal exemptions or posed insurmountable barriers to actual abortion access for eligible women. Recommendations for further action based on findings from pilot research included continuing to work with communities to raise awareness, incorporating information into medical and nursing school curriculum as well as training existing providers, strengthening ties between relevant ministries, agencies, and provider and facility capacities, and further clarifying child defilement and the process for referrals for medical and judicial services.
Building on these initial efforts, the Bixby Center assumed international NGO leadership of the project after the closure of VSI in March 2015. The work was supported by transitional funding from the David and Lucile Packard Foundation and additional Bixby funds. During this phase of the project, the Bixby Center continued VSI’s collaboration with the MOH including on-going data collection from eight initial sites and expansion of implementation to six new sites. As part of project scale up, the Bixby Center worked with the MOH to prioritize the recommendations from pilot research while supporting and expanding existing efforts and also designed and implemented new ones.
In moving forward, the Bixby Center seeks to further identify potential bottlenecks in the process and highlight persistent ones, study the practical application of the revised code and feasibility of using the new exemption to access services, and identify the implications for access to legal, safe abortion and impact on maternal mortality and morbidity in Rwanda due to unsafe abortion.
As with the pilot project, program implementation for the scale-up efforts involved three core components, including, capacity building, community sensitization, and evidence generation.
Overview of key themes & recommendations emerging from pilot research for follow up during the scale up project and beyond:
- World Health Organization (WHO), UNICEF, UNFPA, World Bank, and UN World Population Division (2014). Trends in Maternal Mortality: 1990 to 2013. Geneva.
- Rwanda Road Map to Accelerate the Reduction of Maternal and Neonatal Morbidity and Mortality 2013-2018 (ARMNM Road Map)
- Guidance Document to Operationalize the Exemptions for Abortion in the Penal Code of 2012 (2014-2018)
- The Operationalization of Exemptions for Abortion in the New Penal Code of 2012: Evidence for Action