“Without this program, women can lose their lives”: migrant women’s experiences with the Safe Abortion Referral Programme in Chiang Mai, Thailand

Abstract For displaced and migrant women in northern Thailand, access to health care is often limited, unwanted pregnancy is common, and unsafe abortion is a major contributor to maternal death and disability. Based on a pilot project and situational analysis research, in 2015 a multinational team introduced the Safe Abortion Referral Programme (SARP) in Chiang Mai, Thailand, to reduce the socio-linguistic, economic, documentation, and transportation barriers women from Burma face in accessing safe and legal abortion care in Thailand. Our qualitative study documented the experiences of women with unwanted pregnancies who accessed the SARP in order to inform programme improvement and expansion. We conducted 22 in-depth, in-person interviews and analysed them for content and themes using deductive and inductive techniques. Women were overwhelmingly positive about their experiences using the SARP. They reported lack of costs, friendly programme staff, accompaniment to and interpretation at the providing facility, and safety of services as key features. Financial and legal circumstances shaped access to the programme and women learned about the SARP through word-of-mouth and community workshops. After accessing the SARP and receiving support, women became community advocates for reproductive health. Efforts to expand the programme and raise awareness in migrant communities appear warranted. Our findings suggest that referral programmes for safe and legal abortion can be successful in settings with large displaced and migrant populations. Identifying ways to work within legal constraints to expand access to safe services has the potential to reduce harm from unsafe abortion even in humanitarian settings.


Introduction
The overarching political and economic environment in Burma* has led to the displacement of millions of people. Some 230,000 people are displaced internally 1 and over 100,000 live in nine refugee camps along the Thailand-Burma border. 2 Additionally, northern Thailand hosts hundreds of thousands of documented and undocumented migrants from Burma. 3 The unmet reproductive health needs of displaced and migrant women from Burma are well documented. [4][5][6][7][8][9][10] Estimates place the maternal mortality ratio (MMR) in conflict-affected Eastern Burma at around 1000 deaths per 100,000 live births. 11 This is about five times higher than the MMR for Burma as a whole 12 and higher still than the MMR of 20 in Thailand. 13 Notwithstanding the efforts of a multitude of international and local non-governmental organisations, 4,5,14 displaced women from Burma are at risk of sexual violence, and unintended pregnancy and unsafe abortion remain common. 4,10,[15][16][17] In Burma, abortion is illegal unless performed to save the life of the woman, an exception that is narrowly interpreted. 18 Unauthorised abortion puts both the woman and the provider at risk of jail time, fines, or both. 17 In Thailand, abortion is legally permitted for a broader range of circumstances, including when the pregnancy endangers the life, physical health, or mental health of the woman, is the result of rape or incest, occurs before the woman is 16 years of age, or involves a foetal anomaly. 19 However, it remains difficult for women from Burma to obtain abortion care in Thailand, even if their pregnancy falls into one of the legally permissible categories. Barriers to access arise from a lack of facilities and providers, misunderstanding or misinterpretation of Thai law, linguistic differences between care providers and patients, costs, restrictions on travel, and social and cultural taboos. 4,10,16,[19][20][21][22] Given this overarching context, in 2012 a multidisciplinary, multi-national team launched a safe abortion referral pilot project in Mae Sot, Thailand. 21 Building on years of collaboration and with funding from both an anonymous donor and a women's collective in New Zealand, researchers, law and policy experts, and clinicians at Ibis Reproductive Health (USA), the University of Ottawa (Canada), and the Mae Tao Clinic (Thailand) designed and implemented the project. Based on 18 months of situational analysis research and stakeholder engagement, the pilot project aimed to refer women from Burma who met the eligibility criteria for a legal abortion to a qualified, public sector Thai provider. Over the first year of the programme, Burmese community-based organisations (CBOs) operating in the Thailand-Burma border region successfully referred 24 women to Mae Sot Hospital for safe and legal abortion care. 21 Subsequent research with women who had utilised the referral system showed that the culturally resonant programme met a significant need and highlighted areas for improvement. 23 The success of the pilot project suggested that navigating complex legal parameters to increase access to safe and legal abortion for displaced women in a conflict-affected setting was possible and justified scaling-up the initiative. 21 In the fall of 2014, a multi-national team from Cambridge Reproductive Health Consultants (USA), the University of Ottawa, the Mae Tao Clinic, and the Adolescent Reproductive Health Zone (Thailand) carried out situational analysis research to assess the feasibility of introducing a Safe Abortion Referral Programme (SARP) in Chiang Mai, Thailand. 22 The research included reviews of institutional documents and interviews with relevant healthcare professionals and representatives of CBOs. Discussions with displaced and migrant women also helped the team understand public perceptions of abortion and gauge interest in a referral initiative. The results suggested that creation of the SARP had the potential to meet a significant need among women residing in Northern Thailand and both Burmese CBOs and local Thai providers were willing to participate in the programme.
Informed by the results of the pilot project in Mae Sot and the results of the situation analysis research in Chiang Mai, the Adolescent Reproductive Health Zone (ARHZ), a network of five CBOs serving refugee and migrant women from Burma, launched the SARP in April 2015. Prior to the launch, ARHZ counsellors participated in a three-day training focused on the legal and medical frameworks around abortion in Thailand and Burma, pregnancy options counselling skill-building exercises, and the logistics of the SARP. The training also provided an opportunity for the ARHZ counsellors to meet colleagues who were involved in the pilot project in Mae Sot, Thai abortion providers, and North American researchers who provided technical assistance and monitoring and evaluation support. In addition to providing women with referrals for care, the SARP offers women financial support, including coverage of both the procedure and travel costs, interpreting services, and accompaniment, as needed and desired.
Between 1 April 2015 and 31 March 2017, 81 women from Burmese communities in Northern Thailand accessed the SARP. These women averaged 23 years of age (range: 15-39) and included both migrants and refugees. Women hailed from a variety of communities in Burma and identified with a range of ethnicities, linguistic groups, and religions. Fifty-two women (64%) were successfully referred for care and received safe and legal abortions in either a Thai public hospital or a Thai private clinic. Seventeen women (21%) accessed the SARP but were denied either a referral or an abortion because they did not meet the eligibility criteria in Thailand. Most of these denials occurred in the months after the launch of the programme and were tied to an individual clinician's narrow interpretation of the mental health exception; SARP counsellors learned from these early experiences and prioritised referring women to other providers. In addition, eight women (10%) were unable to obtain a desired abortion because of a funding gap in 2016; once additional funding was secured the programme resumed. Finally, four women (5%) accessed the SARP and over the course of pregnancy options counselling decided to continue their pregnancies; these women were not referred for abortion care. In this article, we present the findings from a qualitative study with women who accessed the SARP in order to understand better their experiences and identify avenues for improving the programme.

Methods
From December 2016 through March 2017, we conducted 22 in-depth, semi-structured, openended interviews with women who sought abortion care through the SARP since its inception in April 2015. Using contact information provided by women who accessed the programme, RKL, a Burmese national fluent in both Burmese and English, reached out to women and invited them to meet with the research team at a mutually convenient time and location. We purposively recruited both women who were successfully referred for abortion care and those who did not receive an abortion; we did not recruit women who decided to carry the pregnancy to term. We also purposively recruited women of different ages and from different ethnic and religious communities in order to obtain a range of perspectives. We used thematic saturation 24 as our endpoint; we suspected we had reached thematic saturation after 16 interviews and did 6 additional interviews for confirmation after which we stopped recruiting participants.
We based our interview guides for this evaluation on the results of the pilot project in Mae Sot, Thailand and the situational analysis research in Chiang Mai. [21][22][23] ET, a Canadian national, conducted all interviews with the help of RKL, after receiving training from AMF, an American medical anthropologist and medical doctor with extensive experience in the border region. After obtaining oral consent from participants, we began each interview by collecting general demographic information. We then asked participants about their sexual, contraceptive, and pregnancy histories and further explored each significant reproductive health event. Next, we asked about the circumstances surrounding the unwanted pregnancy and the participant's experience obtaining options counselling through the SARP. From there, the two interview guides differed: we asked women who received referrals about their experience receiving abortion care and we asked women who did not receive an abortion about the outcome of their pregnancy and the impact of being unable to receive a funded abortion. We concluded all interviews with a discussion of how reproductive health services, in general, and the SARP, in particular, could better meet the needs of migrant and refugee women in northern Thailand.
Interviews lasted an average of one hour. To thank women for participating, we gave them THB300 (USD9), covered all travel expenses associated with participating in the interview, and provided drinks and snacks. Almost all participants declined to have the interviews audio-recorded. ET took extensive field notes during and after interviews, immediately debriefed with RKL after each interview, and formally memoed shortly thereafter. The memoing process allowed for reflections on the participant-researcher-interpreter interaction as well as the establishment of thematic saturation.
Our analytic plan involved an iterative process that began with data collection. We analysed the extensive notes and memos, as well as the transcripts from the small number of recorded interviews, for content and themes, using both pre-determined and emergent codes and categories; 25 ET developed the codebook with guidance from AMF. Regular team meetings guided our interpretation and we resolved disagreements through discussion.
The Steering Committee of ARHZ convened a community ethics panel to review and approve the study protocol and ensure that the project met both international and local research standards. In our results section, we present key themes that emerged in our interviews. We present illustrative quotes that ET and RKL wrote verbatim at the time of the interview. We have redacted or masked all personally identifying information and use pseudonyms throughout. In order to provide a thick description 26 of women's lived experiences, we also present several narrative vignettes (Figures 1 and 2).

Participant characteristics
We interviewed 22 women who accessed the SARP for unwanted pregnancies. Seventeen participants obtained a safe and legal abortion through the referral system and five did not obtain a funded abortion. At the time of the interview, our participants' ages ranged from 17 to 41 with an average age of 29. All of our participants were currently living in northern Thailand (see map 27 ) as documented (n = 10) or undocumented migrants (n = 12) † ; they had lived in Thailand for an average of 7 years. Our participants identified with a range of ethnicities, educational backgrounds, and work experiences. At the time of the interview, our 22 participants had a total of 24 lifetime abortions and 17 had at least one child.
Fifteen of our participants had used at least one method of modern contraception at some point in their lives; four were using a modern contraception method during the month they became pregnant. At the time of the first contact with the SARP, participants' pregnancies were between four and 8 weeks' gestation, with an average gestational age of approximately 5 weeks, per the self-reported date of the last menstrual period. Of the 17 women who were successfully referred for abortion care through the programme, four obtained care from a government hospital and 13 from a private medical clinic in Chiang Mai. Four received medication abortions with misoprostol-alone and 13 received aspiration abortions. Of the five women who were unable to obtain a funded abortion through the programme, two carried their pregnancies to term and three terminated their pregnancies using other methods; these methods included abdominal/pummel massage, traditional Burmese medicines (e.g. kay thi pan), and alcohol. † Although all of our interviewees identified as migrants at the time of the interview, these categories are somewhat fluid. Indeed, several of our participants had lived in refugee camps in Thailand at some point.
Women's experiences with the SARP were overwhelmingly positive "The program is good, I had a good experience … This project is good for people who have no documents or who cannot cover the cost of going to the clinic. I hope in the future the program will continue … For other migrant women who have [insecure or exploitative] jobs or no documents, they cannot go by themselves for unwanted pregnancies … Without this program, women can lose their lives." (Ra Mi La, age 31) All of our participants, both those who received an abortion and those who did not, spoke very highly of their overall experience with the SARP. As reflected in Soi Win's story (Figure 1), women who successfully received an abortion focused specifically on how obtaining the termination allowed them to avoid the negative consequences that having an unsafe abortion or carrying an unwanted pregnancy to term and parenting a (or another) child would have had on themselves and their families. Participants described the SARP counsellors as understanding, open, and friendly and appreciated the counselling that they received. Obtaining information and nonjudgmental support from someone within the community who understands women's daily struggles was also comforting. As succinctly stated by Phyu Phyu, age 27: "I was very happy with the counselling. She [the SARP counsellor] is very warm and I felt like I was talking to a parent." Most women discussed entrenched poverty, job insecurity, unstable and abusive relationships, and/or the needs of existing children as reasons for seeking the abortion. Given the economic insecurity within this setting, women were especially grateful that the SARP covered the costs of both the procedure and transportation. As Chaw Su Da, age 31, reflected: "At that time I had no money at all for transportation, not even 10 baht [US$0.30]. I am surprised … that everything is paid for. I am happy because I really have no money to pay for anything. I am working but cannot collect money because I have a lot of debt … So this project is very effective to help migrant women. They are very poor so this program can help them [get the abortions they need]." Undocumented migrant women, in particular, stated that without the SARP they would not have been able to access a safe abortion because of both the financial and legal implications of seeking and obtaining care. As Ra Mi La, explained, "I came to Thailand to get money to send to my parents but [after arriving] I faced many problems. I have to move around and I feel hopeless … My boss is not so good and sometimes I do not have money, so I have to change jobs. I have no documents so I worry if I am pregnant, how can I go in the clinic? In every hospital they ask for documents and I don't have them. That's why I didn't want a baby … I never know when my boss will end my job. I worry a lot. If I had a baby I know I couldn't care for it." For many women from Burma, the Thai medical system is confusing and non-intuitive, dynamics that are compounded by cultural and linguistic differences. That SARP counsellors accompanied women during the process and helped them navigate the system was critical. As explained by Su Su Aung, age 33: "Before I thought this would be impossible, that all the costs would be covered and that I would have translation. I couldn't believe that I got support for everything." Most women also reported having positive experiences with the providing hospital or clinic and none of the participants reported being scolded when obtaining care. However, three women described the abortion-providing physicians as rushed and brusque, which made them feel uneasy. Finally, one woman explained that one of the SARP partner hospitals initially denied her an abortion. She reported that enduring numerous hospital visits and completing extensive paperwork only to be told she was ineligible was discouraging and inconvenient. However, a qualified doctor at another hospital deemed her eligible for a safe and legal abortion; she was ultimately very satisfied with the care she received.
A disruption in programme funding occurred in 2016. As a result, eight women who sought abortion care through the SARP were not able to obtain a funded abortion. In speaking with five of these women, it became apparent that even though they were unable to get safe and legal care, they were grateful for the counselling and encouragement they received through the programme. As Su Khin Kyaw, age 26, explained: "The ARHZ counselling is good.
[The] organisation gives options [and] new hope to women who don't have any hope." Women learned about the SARP through wordof-mouth and community workshops "Other women in Hang Dong told me there is another woman who can help migrant women." (Soi Win, age 30) Our participants rely primarily on their social networks for information and advice. Over half of our interviewees learned about the SARP through word-of-mouth either from a friend or relative who had heard of or used the programme or from one of the SARP counsellors in the context of religious or other community activities. As Chaw Su Da explained: "At first I didn't know where to get help. But I explained my feelings to [a staff member of a CBO] who told me about the referral program.
[She] is very close to migrant women. At first, I was not friends with her but I knew her from the community, through my friends. Now I am very close with [her]." During the interviews, a number of participants also shared friends' and fellow migrant and displaced women's experiences with unwanted pregnancies or unsafe abortions. These stories not only provide context for the role that the SARP is playing in these communities but also emphasise the ease by which word spreads among women. Na Bo, age 39, stated: "I heard a lot of things happening to migrant women. They use unsafe methods like traditional medicine … I heard of one girl only 14 or 15. She got pregnant and didn't tell other people. She died by herself, suicide. I don't want to hear about this in the future. I worry about this a lot." Awareness-raising efforts by the SARP counsellors have also been effective in educating women from Burma about the programme. Staff regularly travel to migrant and refugee communities to give workshops on reproductive health, safe abortion, and the referral programme. In 2016, for instance, counsellors gave trainings in six different areas. Eight of the 22 women we spoke to learned about the SARP through one such workshop.
Women receive support from the SARP for a range of reproductive health and social issues "Women here are unhappy all the time, they are crying because a woman's life is very difficult here. So thank you, there is no other organisation helping us like that." (Na Na May, age 30) For women from Burma living along the border, an unintended pregnancy is often just one of many challenges and hardships. In addition to the contextual factors that led to their displacement or migration, our participants also referenced the lack of documentation, language difficulties, employment insecurity, low salaries, unstable relationships, rape, domestic abuse, and discrimination as challenges. As evinced by Lu Shi Ya's story (Figure 2), the SARP counsellors often helped women address a range of issues that intersected with the unintended pregnancy. As Myar Neh, age 32, reported: "When I got pregnant I contacted [the SARP counsellor] because I knew she could solve my problem. I also had an STD at this time so she helped me with my two problems!" As trusted members of the community, the SARP counsellors are familiar with the complexities of migrant and refugee women's lives and offer comprehensive and non-judgmental support. The SARP counsellors, often working through their CBOs, have helped participants find jobs, advised them on their relationships, and guided women in their contraceptive and sexual health decisions. Furthermore, after contacting the SARP because of an unwanted pregnancy several women temporarily lived at CBO facilities for both financial and familial reasons. Thus, for some women, the SARP served as an entry point to a broader array of support services. As Ra Mi La reported: After accessing counselling and care through the SARP, almost all participants in our study selfidentified as community advocates for reproductive health and safe abortion. Their personal experiences with the programme, and the knowledge they gained through the process, motivated and empowered them to share their stories with others in the community. As Myar Neh explained: "I have experience with the referral program so I am not afraid to explain to others … Now I can explain so much, many types of things, and everything is good, so I can recommend them." Women that we interviewed expressed concern that community awareness of sexual and reproductive health, in general, and safe abortion, in particular, was minimal. As Na Bo explained: "The counselling [through the SARP] is good but in the future to improve we have to give trainings in other places. I heard about many young migrant women who live together far from Chiang Mai. It is important to give [them] trainings. Many young migrant women get pregnant and do abortion by themselves. We need to tell those in the far away villages about this service. They don't know how to protect themselves." Every woman we spoke with stressed the need for improved knowledge of reproductive health and safe abortion among migrants and refugees from Burma. The overwhelming majority of participants indicated that awareness of the SARP, specifically, could be improved. Participants suggested regular, ongoing reproductive health and safe abortion trainings, as new women are continuously arriving in migrant communities. Several mentioned the need for awareness-raising campaigns directed specifically at youth so that young women with unwanted pregnancies can receive safe abortion care and stay in school. Numerous participants also wanted to see workshops and trainings in remote, harder-to-reach communities in northern Thailand, where women have difficulty accessing reproductive information and health care. Finally, women were hopeful that programmes similar to the SARP could be available in Burma in the future. As summed up by Su Su Aung: "The project is good, but we need to spread this to other places, especially in Burma. In Burma, there is very little knowledge about reproductive health. No one has that kind of organisation in Burma."

Discussion
Unsafe abortion remains a significant contributor to maternal mortality and morbidity worldwide 28 and up to 65% of all abortions in Southeast Asia are defined as unsafe. 29 A multitude of efforts have been undertaken in legally restrictive settings in this region to expand access to safe, or safer, services, including legal reform advocacy, telemedicine programmes, and harm reduction initiatives. 19,[30][31][32][33] However, far fewer efforts have been undertaken to increase access to safe abortion care in refugee, crisis, conflict, and emergency settings. 34 Although unsafe abortion is likely a major contributor to maternal death in humanitarian settings, a number of political, institutional, funding, and logistical barriers have hampered efforts to address this area of reproductive health. [34][35][36] Indeed, a 2015 study of 82 agencies providing services in humanitarian settings found that only 65% conducted activities related to referrals for induced or post-abortion services. 35 The findings from this project suggest that it is possible to establish a formal abortion referral programme in a legally restricted, protracted humanitarian setting. Although the program continues to grow, the initial results demonstrate that the SARP is effective at linking displaced and migrant women from Burma with safe and legal abortion services in northern Thailand. Indeed, the overwhelmingly positive response to the programme by women in the community indicates that the SARP is not only meeting a significant need but is doing so in ways that are contextually appropriate and culturally resonant.
Women's experiences with the SARP also highlight the fact that the programme is not only about referrals for abortion care. A confluence of social, community, relationship, and individual factors influence both the risk of unintended pregnancy and a woman's decision to have an abortion. SARP counsellors recognise these complex dynamics and, in addition to helping women navigate the Thai health system to obtain a legal abortion, they support women with a range of structural and familial issues that influence reproductive health. This speaks to the importance of integrating abortion care within larger reproductive health and social service programmes rather than siloing this component of women's health and lives. That engagement with the SARP motivated many of our interviewees to become visible and vocal advocates within their communities, not only for safe abortion care but also for reproductive health more broadly, is further testament to the importance of (re)integrating abortion within family planning, reproductive health, and reproductive rights programmes and frameworks.
The results from this programme also suggest areas for improvement. Women who accessed services through the SARP strongly support expanding the initiative to both additional populations and more geographic areas. Women repeatedly raised the importance of targeting information sessions and workshops at unmarried women in particular. Working formally with previous beneficiaries of the programme may be an effective way to expand the reach of the programme. However, to do so will require more resources. That eight women were unable to obtain abortion care during 2016 because of a funding gap, and that at least three of these women went on to have unsafe abortions, is a stark reminder that even small or temporary disruptions in donor support can have significant consequences in these settings.

Limitations
Our study has a number of limitations. Although we believe that our findings are transferable beyond the bounds of the immediate study population, this is a qualitative study and the results are neither representative nor generalisable. Furthermore, for reasons related to logistics and security, we interviewed women who continued to live in or who could travel to and within northern Thailand. As a result, the perspectives of women who returned to Eastern Burma after accessing the SARP and were not able to return to Thailand are not included in this study. Future research would benefit from the perspectives of women from both sides of the border. In addition, research that specifically explores the experiences of women denied a referral or an abortion because of eligibility issues could be valuable. Finally, as is true of qualitative research in general, the positionality of the members of our study team undoubtedly influenced the interviewer-intervieweeinterpreter interactions. We believe that through memoing and regular debriefings, we were able to understand these influences, thereby enhancing the credibility and trustworthiness of the study.

Conclusion
In all but six countries in the world, abortion is legally permissible for at least some indications. 37 The SARP in Chiang Mai, Thailand, reinforces the notion that it is possible to work within legal constraints to expand access to safe services, even in a humanitarian context. Working with humanitarian stakeholders to identify ways to provide abortion care to the full extent of the law and establish referral systems such that eligible women can obtain safe and legal services appears warranted. The lessons learned from this project in terms of design, implementation, outcomes, and evaluation may facilitate these efforts.