The role of midwives in first‐trimester abortion care: A 40‐year experience in Tunisia

Abstract Objective To review the relevant literature on abortion and summarize interviews with key stakeholders to assess the role of midwives in the evolution of abortion‐related care in Tunisia. Methods Interviews with eight stakeholders from different organizations based on a guide developed for the study, focusing on policies, strategies used for implementation, capacities used for expansion, user opinions and experience, obstacles and facilitators, and control and evaluation. Results Task‐sharing for midwifes was encouraged in the family planning program from the beginning and when medical abortion was introduced. It allows midwifes to contribute widely, develop good skills and performance for several tasks, and helps reduce regional disparities in human resource allocation. Success and safety of home use of medical abortion confirms the ability of women to manage their own abortion. Yet, obstacles to accessing abortion still exist for several reasons. Conclusion This study, based on interviews with personnel with significant experience and solid knowledge of sexual and reproductive health services, allowed us to consider proposals for a future strategy to integrate task‐sharing into abortion care and address the barriers to legal and safe abortion access for all women in Tunisia.


| INTRODUCTION
Tunisia is a small country of 11 million inhabitants in north Africa.
It is the only country in the Middle East and North Africa region where abortion is legal during the first 3 months of pregnancy at a woman's request. 1 The law that legalized abortion was instituted as part of a political strategy to modernize Tunisian society. Just a few months after Tunisian independence from France in 1956, a Personal Status Code was promulgated, granting women more rights in several areas-particularly marriage (e.g. divorce, age of marriage) and in relation to male family members (e.g. parental authority, certain inheritance rights)-by expanding the existing laws that were strictly based on Islamic Law, particularly the Maliki and Hanafi schools of law. These developments were followed shortly after by the implementation of policies that guaranteed compulsory education for boys and girls. In the 1990s, coinciding with the program of the International Conference on Population and Development (ICPD), national family planning shifted from population planning to a rights-based approach, including providing access to family planning and abortion as part of women's reproductive rights.
During the 2000s there were decreases in total fertility rate and maternal and infant mortality, as well as an increase in life expectancy; increased access to education for girls and greater opportunities for employment for women were also evident. 6   With the introduction of medical abortion using mifepristone and misoprostol in 2001, midwives played a central, double role as advocates and providers. 12 Medical abortion is now used in 80% of abortion procedures performed in the public sector in Tunisia 13 and its availability has not caused an increase in the total number of abortions performed each year (Fig. 1).
The country's new constitution-adopted after the Arab Spring in 2014-recognizes the principles of human rights, including the right to health, reproductive rights, freedom of conscience and religion, respect for privacy, physical and moral integrity, dignity, education, and access to information. However, laws, policies, and practices do not always reflect the new constitution. Furthermore, after the Arab Spring, with growing conservatism and Islamist influence on society in general and on service providers, particularly midwives, we are witnessing the increased stigmatization of abortion, creating barriers that drastically reduce access to legal abortion.
The present study was undertaken as part of a multicountry case study, in collaboration with the WHO, on the inclusion of broader groups of healthcare workers in the delivery of safe abortion care. The aim of the present study was to review the relevant literature on abortion and summarize interviews with key stakeholders to assess the role of midwives in the evolution of abortion-related care in Tunisia. Interviewees' answers were transcribed, and the written reports were compiled and grouped by themes according to the six specific sections. The answers provided by each interviewee were compiled and a global analysis of the responses was conducted.

| RESULTS
Although the historical context of abortion in Tunisia is well known, interesting information and details were highlighted and developed by the testimonies of those interviewed.

| Sharing of abortion-related tasks
Since its creation, the ONFP, more than any other department in the Ministry of Public Health, has encouraged task-sharing of several tasks-including medical abortion-with nonphysician health workers.

| Services and policies developed for task-sharing and delegation
The creation of the ONFP in 1973, followed by its training center, MVA is rarely used in Tunisia, but it has been introduced in the main gynecology service in Tunis and delegated to midwives for two indications: incomplete abortion after medical abortion and surgical abortion in early pregnancies that can be performed outside operating theaters when using MVA with local anesthetic.
Misoprostol administration for cervical dilatation after 12 weeks of pregnancy is delegated to midwives in tertiary hospitals where second-trimester abortions are performed with a combination of mifepristone and misoprostol or misoprostol alone.
Task-sharing has also helped reduce regional disparities in human resource allocation due to limited numbers of specialists, gynecologists, and obstetricians in central and southern Tunisia.
In practice, nurses and midwives manage first-trimester medical abortions in these areas, providing administration of misoprostol and follow-up.

| Self-administered medical abortion
Women's ability to manage and successfully control their own abortion process has been well demonstrated by research and field practice in Tunisia. [15][16][17] According to these studies, use of misoprostol at home after mifepristone administration at the clinic was accepted and well managed by women; 80% chose this procedure in the sites where it was proposed. 16 Furthermore, 40% of the women who benefitted from medical abortion considered that it was necessary to return for the planned follow-up visit, and the medical records did not indicate any complications. 16 Through on-site counseling, women were well informed about the medical abortion process and its potential complications. Additional studies developed in Tunisia showed that women were able to use the semiquantitative urine test to confirm that medical abortion had been successful. 17

| Current obstacles to accessing abortion
Despite the existence of a well-established task-sharing policy for health workers, research has identified several barriers to accessing abortion. 18,19 In the last decade, with new orientations after the Tunisian revolution and the election of a Conservative government in 2012-2014, healthcare providers (mainly midwives and nurses, and then physicians) have gradually developed a conservative attitude toward abortion and have begun to develop a stigmatizing discourse against women and girls who request an abortion. In many cases, women have been denied access to abortion procedures and/or access has been delayed by unnecessary examinations. 18,19 Regarding providers' attitudes, a lack of interest among gynecologists or even opposition from obstetrician-gynecologists has been reported. 19 The study also revealed ambivalence, if not opposition, from some ONFP administrative or political staff. 20 These obstacles have never been solved, although the institution itself is the country's main agency in charge of the regulation and institutionalization of these policies.

| Factors influencing providers negative attitudes
Barriers to the provision of reproductive health services were widely discussed and commented upon in the interviews with providers and decision makers, and several recognized that these barriers existed and were influenced by numerous factors: • Abandonment or lack of political will among Ministry of Health staff members who have conservative opinions that do not support the ONFP program and oppose access to abortion.
• Lack of governance; for example, Medabon (a combination of misoprostol and mifepristone) is legally registered but not available for bureaucratic reasons. Mifepristone is limited by the Central Pharmacy of Tunisia for use only in public services, although the law allows its use in the private sector also (hospitals and private clinics).
• The reluctance and opposition of midwives and physicians who use conscientious objection without respecting its conditions.
• The total disinterest or embarrassment and reluctance of the media and international agencies to deal with issues perceived as taboos.
We were able to draw several conclusions from the interviews: • The political will to delegate abortion-related medical tasks to providers other than physicians is essential.
• Sustainability is essential and must be guaranteed by legal texts and guidelines on standards and procedures, legitimizing/enforcing task delegation to value midwives and other providers and prevent exposing them to the risk of prosecution. Access should also be ensured by permanent availability of the products, quality of the services, and the availability of providers whose negative attitudes can be reversed by training in values clarification.
• Research as an evidence tool, and providers' assessment must accompany all stages of the process.
• Follow-up and assessment by researchers and practitioners should be put in place from the start of the process and must be maintained.

4.
Allow women to self-monitor their medical abortions, and thus have a single visit to the clinic. This would be easily achievable, given that 60% of women did not consider it necessary to return for follow-up control visits as there were no reported failures or complications. 17 The present study allowed us to develop a structured reflection based on interviews with personnel who had significant experience and solid knowledge of how sexual and reproductive health services were created in Tunisia. The information allowed us to consider proposals for a future strategy aimed at integrating task-sharing into abortion care and address the barriers to legal and safe abortion access for all women.
A current obstacle to access is the reluctance of providers (physicians and midwives) to provide abortion care. Their views are sometimes more conservative than the current laws. 18,19 The task-sharing debate can help decision-makers and key stakeholders reflect on what can be developed in the context of providers' professional activities.
It can also help politicians and stakeholders understand how to promote greater sharing of tasks to implement best practices within the existing legal framework. Assessment of behaviors and professional attitudes on a regular basis should be introduced as part of regular assessment of the performance of health professionals in public institutions in charge of managing reproductive health in the country.
In conclusion, the following strategies should be addressed as a priority in Tunisia and could be part of more global recommendations: 1. Advocate with the political authorities, decision-makers, stakeholders, and associations of health professionals and medical staff for task-sharing in sexual and reproductive health as an effective, safe, and valuable tool to expand access to contraception and risk-free abortion. It is imperative to establish strong links between them.
2. Improve, support, multiply, and sustain the training of health workers from a human rights perspective, integrating the values of humanism and compassion, highlighting the negative impact of taboos, using appropriate tools such as values clarification training to consolidate motivation and empowerment of midwives.
Promote women's empathy and autonomy in training programs.

3.
Develop collaboration with other civil society organizations to encourage the recognition of human rights.

4.
Include comprehensive contraceptive and abortion programs for health students (physicians, midwives, nurses), and include sex education in school curricula.

AUTHOR CONTRIBUTIONS
SH conducted the interviews and drafted the manuscript. HB participated in analysis of the interviews and manuscript writing.

CONFLICTS OF INTEREST
The authors have no conflicts of interest.