Nelima was a young woman from Migori with good grades, ambitions, loved ones, and a future she was working toward. Then she faced an unintended pregnancy. She wanted to stay in school, and to protect that future, she went to an unqualified provider who gave her a concoction. Soon after, she developed complications and sought care at a health facility in Awendo. She had done what we so often ask women and girls to do: reach the health system. But the care she needed did not reach her in time. Her referral to a higher-level facility was delayed, and by the time she could access the treatment she urgently needed, it was too late.
Nelima’s death cannot be understood only through the lens of unsafe abortion. It also tells us what happened next: she sought help, reached a health facility, and still did not receive the care she needed in time. This forces us to ask a harder question: when women and girls turn to the health system in a moment of crisis, is that system actually ready for them? A service may exist in policy, but if a woman cannot get it when she needs it, that is not meaningful access. The World Health Organization defines comprehensive abortion care broadly: it includes information, abortion management, and care related to pregnancy loss and post-abortion complications. But none of these can work in isolation. They depend on a health system that is ready to respond with trained providers, essential medicines and supplies, appropriate equipment, working referral pathways, and services that women and girls can reach without unnecessary delay.
Health-system gaps
The evidence suggests that the central challenge is not simply whether post-abortion care is nominally available, but whether the health system is sufficiently organised and resourced to deliver it consistently when women and girls need it. A 2023 national health facility survey found that 18.3% of primary-level facilities met the definition for basic post-abortion care, while 24.1% of referral-level facilities met the definition for comprehensive post-abortion care. When readiness was assessed based on conditions on the day of the survey, rather than whether services had been provided at some point during the preceding six months, those proportions fell to 3.3% and 7.2% respectively. This distinction matters because it highlights the gap between nominal service availability and functional readiness. Post-abortion care is one component of comprehensive abortion care. Still, the findings provide an important window into a broader systems problem: a service can exist in policy, be included within a facility’s mandate, or even have been delivered previously, while remaining unavailable to the woman who needs it at a particular moment.
Understanding this gap requires looking across the core functions of the health system rather than treating abortion care as a stand-alone clinical service. Service delivery determines whether appropriate care is available at the right level and whether women can move through the system without unnecessary delay. The health workforce determines whether providers have sufficient competencies, confidence, and institutional support to provide care. Medicines, commodities, and health technologies determine whether providers have the drugs, supplies, equipment, and other inputs needed to translate their training into treatment. Health information systems should enable governments and facility managers to know where services are available, where commodities are missing, where referrals break down, and where women are being lost along the care pathway. Health financing determines whether facilities can maintain these capacities and whether the costs of accessing care are shifted onto women and their families. Finally, leadership and governance determine whether standards are implemented, responsibilities are clear, services are supervised, and system failures trigger corrective action.
These functions are interdependent. Training a provider achieves little if essential medicines are unavailable; stocking a facility is insufficient if no appropriately trained provider is present; and identifying complications at primary level does not protect a woman if referral arrangements cannot connect her quickly to a facility capable of managing them. The same is true of information. Women and girls may know care is available. Still, that knowledge has limited value if the facility they reach cannot provide the service or if neither the patient nor the referring provider knows where to obtain appropriate care. Comprehensive abortion care therefore depends on the functioning of a pathway, not simply the presence of individual interventions within separate parts of the health system.
These weaknesses also have unequal consequences. When a referral fails, a woman who can afford private transport or private care may still be able to navigate around the failure. In contrast, an adolescent, a woman living in a rural area, or someone with limited income may have far fewer alternatives. Delays may require additional transport costs, time away from paid or unpaid work, childcare arrangements, or repeated travel between facilities. In this sense, failures in service delivery, financing, and referral systems are not only technical shortcomings; they reproduce existing inequalities in those who can obtain timely care. Health-system readiness is therefore inseparable from reproductive justice because the ability to exercise reproductive choice depends not only on what the law or policy provides, but also on whether women have equitable access to a system that can deliver that care.
Strengthening comprehensive abortion care must therefore focus on the whole care pathway. Women and girls need accurate information they can understand and act on; providers need the skills, support and working conditions necessary to deliver respectful, evidence-based care; facilities need reliable medicines, commodities and equipment; financing arrangements must protect women from costs that become barriers to access; health information systems must identify gaps in availability and readiness; and referral systems must reliably connect patients to higher levels of care when necessary. The measure of a functioning system is therefore not simply whether comprehensive abortion care appears in policy or whether a facility reports offering it, but whether all of these elements come together sufficiently for a woman to receive appropriate care when she needs it.
What must change
Strengthening comprehensive abortion care requires us to think beyond individual services and focus on the conditions that allow women and girls to make informed decisions and receive appropriate care when they need it. That means connecting three commitments that are too often treated separately: bodily autonomy, comprehensive sexuality education, and universal health access.
1. Protect bodily autonomy
Bodily autonomy begins with recognising women and girls as decision-makers in their own lives. It means ensuring that they can make informed decisions about sexuality, contraception, pregnancy, and reproductive healthcare without coercion, discrimination, or unnecessary interference. Autonomy cannot be reduced to whether a legal provision or clinical guideline exists. It must also be reflected in whether a woman can obtain accurate information about her options, seek care without stigma or fear, be treated with dignity, and receive the care she is legally entitled to access. Where abortion is permitted within the law, the health system must be able to give practical effect to those provisions. A right that cannot be exercised because services are unavailable, providers are unsupported, referrals fail, or women fear mistreatment remains incomplete in practice. Protecting bodily autonomy therefore requires both safeguarding reproductive freedoms and ensuring that health institutions, providers, and systems are capable of respecting and supporting the decisions women and girls make about their own bodies and lives.
2. Make comprehensive sexuality education part of the care pathway
A functioning reproductive health system begins long before a woman or girl arrives at a health facility. Young people need access to accurate, age-appropriate and evidence-based information that enables them to understand their bodies, prevent unintended pregnancies, recognise health risks, understand their reproductive health options and know where to seek care. Comprehensive sexuality education is therefore not separate from health-system strengthening. It is part of the information pathway that allows people to make informed decisions and navigate the health system effectively.
But information alone is not enough. A young person may understand her options and know where to seek care. Still, that knowledge has limited value if the facility she reaches cannot provide the service, if she encounters stigma, or if the referral system fails. Comprehensive sexuality education must therefore be connected to health services that are accessible, responsive, and capable of meeting the needs that education helps young people identify. Governments, education systems, health institutions, communities, and civil society all have a role in ensuring that young people have access to reliable sexuality education and clear pathways into appropriate health services.
3. Build universal health access around the whole care pathway
Universal health access means that women and girls can obtain the health services they need without their income, age, geography or social circumstances determining whether they receive timely and appropriate care. This includes access to modern contraception, maternal healthcare, comprehensive abortion care within the applicable legal framework, post-abortion care and other essential sexual and reproductive health services. Achieving this requires more than increasing the number of facilities that report offering a service. The whole care pathway must work.
Health systems depend on interconnected functions: service delivery, the health workforce, health information systems, essential medicines and technologies, financing, and leadership and governance. Weakness in any one of these areas can undermine the entire pathway. Training providers achieve little if medicines or equipment are unavailable. A well-equipped primary facility cannot manage a complication requiring specialist care if the referral system fails. A referral pathway is ineffective if the receiving facility is itself unprepared.
National and county governments must therefore plan and finance readiness, ensuring facilities have adequate staff, essential medicines and supplies, appropriate equipment, and functioning referral systems. Facility managers need to know routinely whether the services they oversee are ready to respond and to address gaps before patients encounter them. Training institutions, including the Kenya Medical Training College, universities and other accredited institutions, must ensure that pre-service curricula prepare health workers to manage reproductive health needs and abortion-related complications competently and without stigma. Professional regulators also play an important role in maintaining standards of practice and ensuring that continuing professional development reflects the realities providers encounter in clinical settings.
Communities must also be connected to this pathway. Community Health Promoters and other trusted community structures can help women and girls recognise danger signs, understand where appropriate services are available and seek care without unnecessary delay. Civil society, researchers and funders should, in turn, strengthen accountability by asking not only whether policies, facilities or trained providers exist, but whether the system works in practice. Was a trained provider available when the woman arrived? Were essential medicines, supplies and equipment in place? Could the facility provide the care she needed? If not, did the referral system connect her to a facility that could? How long did she wait? Could she receive care without stigma, judgement or an unaffordable financial burden? These three commitments are inseparable. A woman cannot exercise bodily autonomy without access to information. Information has limited value if no functioning service exists at the other end. And health services cannot be described as universally accessible if only women with enough money, mobility, or social power can navigate their failures.
On this International Safe Abortion Day, the challenge is therefore not only whether abortion care is discussed in policy or permitted within particular legal frameworks. It is whether women and girls have the autonomy to make decisions, the information required to make those decisions meaningfully, and a health system capable of responding when they seek care. Strengthening the whole care pathway means bringing these elements together so that comprehensive abortion care is not simply available in principle, but accessible, equitable, respectful and safe in practice.
