title: Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia.
abstract: BACKGROUND
  Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation.
  
  
  METHODS
  An intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country's abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships.
  
  
  RESULTS
  After 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides.
  
  
  CONCLUSIONS
  These findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa.
authors.affiliation: Ipas, 300 Market St., Suite 200, Chapel Hill, NC, USA. fetterst@ipas.org.
authors.forename: Tamara
authors.identifier: http://orcid.org/0000-0002-1921-1313
authors.initials: T
authors.lastname: Fetters
authors.affiliation: Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Ghazaleh
authors.initials: G
authors.lastname: Samandari
authors.affiliation: Regional program Manager, Francophone Africa, Lusaka, Zambia.
authors.forename: Patrick
authors.initials: P
authors.lastname: Djemo
authors.affiliation: Department of Obstetrics and Gynecology, Consultant Obstetrician and Gynecologist University of Zambia School of Medicine, Lusaka, Zambia.
authors.forename: Bellington
authors.initials: B
authors.lastname: Vwallika
authors.affiliation: National Reproductive Health Specialist, UNFPA, Lusaka, Zambia.
authors.forename: Stephen
authors.initials: S
authors.lastname: Mupeta
mesh_terms: D000028:Abortion, Induced / Q000331:legislation & jurisprudence* / Q000592:standards*; D000029:Abortion, Legal / Q000592:standards*; D000349:Africa; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006284:Health Plan Implementation; D006297:Health Services Accessibility; D006806:Human Rights; D006801:Humans; D011247:Pregnancy
keywords: Abortion; Implementation science; Medical abortion; Postabortion care; Reproductive health; Scale up; Zambia