Implementation of the Maputo Protocol in the Bunia Health Zone, Ituri Province (Democratic Republic of the Congo): Experiences and Expectations of Midwives

Abstract

Abortion laws remain restrictive in most sub-Saharan African countries. Yet, member states of the African Union, including the Democratic Republic of Congo, have ratified the Maputo Protocol, which recognizes medical abortion as a right in reproductive health. However, its implementation remains limited, contributing to persistently high maternal mortality rates, particularly in the Bunia health zone (Ituri). This study seeks to analyze the experiences and expectations of midwives regarding the implementation of the Maputo Protocol in this region. It is an exploratory, descriptive, and multicenter study, based on a phenomenological approach. Fourteen midwives from the urban-rural health zone of Bunia were interviewed through semi-structured interviews. Findings reveal ambivalent perceptions: hope for progress in reproductive rights, yet frustration with the slow and partial operationalization. Several obstacles hinder implementation: resistance from healthcare providers, strong social stigma, and a gap between the legal framework and its practical application. Nonetheless, some enabling factors were identified: continuous training of midwives, community awareness campaigns, and mobilization of financial, human, and material resources. Participants expressed strong expectations, highlighting the urgent need for structured engagement from health and legal authorities. The study, approved by the institutional ethics committee (n°055/ESU/ISTM/DG/2022 of 06/10/2022), with free and informed consent obtained from all participants, provides concrete insights for strengthening the operationalization of the Protocol in post-conflict areas. It emphasizes the need for synergy between political commitment, capacity building, and sociocultural transformation to ensure effective and equitable access to reproductive health rights