A decade of progress providing safe abortion services in Ethiopia: results of national assessments in 2008 and 2014

Can mid-level providers manage medical abortion after 12 weeks' gestation as safely and effectively as physicians? A non-inferiority, randomized controlled trial in Addis Ababa, Ethiopia

OBJECTIVE

To determine whether clinical outcomes among clients undergoing medical abortion after 12 weeks' gestation differ by provider cadre.

METHODS

Randomized controlled trial conducted among eligible clients seeking abortion between 13 and 20 weeks' gestation. Participants seeking in-facility abortion were randomized to receive care from a mid-level provider (nurse/midwife) or physician. The primary outcome was median time to expulsion with non-inferiority margin of -1.5 h between provider groups. Quantile median regression models assessed non-inferiority. Secondary outcomes included retained placenta, complications, and patient acceptability.

RESULTS

After randomization and eligibility assessment by the provider, 171 women participated in the study: 81 in the physician group and 90 in the mid-level provider group. Their average age was 24 years, the mean gestational age was 16 weeks, and 65% were nulliparous in both groups. The median time to expulsion did not differ significantly, being 8.1 h for the mid-level group and 6.6 h for the physician group. The adjusted median difference was 0.8 h (95% confidence interval [CI] -1.15 to 2.66), within the non-inferiority margin. Retained placenta occurred similarly: 30.0% (n = 24) of the physician group and 20.5% (n = 18) of the mid-level provider group (adjusted risk difference [ARD] 7.6%, 95% CI -2.81 to 18.06). Complications occurred in 7% of cases, including 5.0% (n = 4) of patients in the physician group and 8.9% (n = 8) in the mid-level provider group (ARD -4.7%, 95% CI -12.43 to 3.12). Patient acceptability did not differ by group.

CONCLUSIONS

Training mid-level providers to provide abortion services after 12 weeks' gestation independently of physicians is feasible and may result in comparable clinical outcomes.

Health facilities readiness to provide comprehensive abortion care and factors associated with client satisfaction in Central Oromia Region, Ethiopia: a multilevel modeling approach

BACKGROUND

In Ethiopia only 53% of induced abortions were performed in a health facility. Even though efforts have been made to improve comprehensive abortion care (CAC), still several health facilities fail to provide the services. Even in facilities where such care is provided, significant numbers of clients report their dissatisfaction with the service. Hence, this study sought to assess availability and readiness to meet the need for CAC, client satisfaction with the service and associated factors in public health facilities of East Shawa Zone, from March 1 to July 31, 2020.

METHOD

Cross-sectional study was conducted taking a random sample of 30 health facilities and 900 women who received CAC and providers who delivered the services. Data were collected using interviewer-administered questionnaire and observational checklist. The analysis was performed using Stata-13. Descriptive summaries were used to characterize study participants, to determine service availability and readiness of facilities. The levels of satisfaction were estimated using proportion with a 95% confidence interval (CI). Multilevel ordinal logistic regression analysis was performed to identify factors associated with service satisfaction. The magnitude of association was estimated by adjusted odds ratios (AOR) with a 95% CI, and a p-value < 0.05 was used to declare statistical significance.

RESULTS

The study found that all health facilities fulfilled at least three-fourth (75%) of the requirements that ensure CAC services availability. However, the percentage of facilities that fulfilled at least three-fourth of equipment was 60%; medicines, 56.7%; and basic amenities, 46.7%. Overall, 19.3% of women (95% CI 16.9%, 22.0%) reported very high level of satisfaction with CAC services. The levels of Satisfaction with the services were associated with being treated with second trimester abortion (AOR) = 2.07; 95% CI 1.03, 4.15) and having good procedure outcome (AOR = 2.09; 95% CI 1.09, 4.15), being treated by younger service provider, less than 35 year old (AOR = 8.58; 95% CI 3.66, 20.12), by a nurse (AOR = 2.96; 95% CI 1.49, 5.87), provider with three to five years of experience (AOR = 0.46; 95% CI 0.23, 0.92) and with the availability of essential medicines (AOR = 4.34; 95% CI 1.06, 18.20).

CONCLUSIONS

The availability of essential medicines was below the standards set by World Health Organization. The levels of satisfaction with CAC is comparably lower than other studies findings and affected by the availability of essential medicines, procedure outcome, and gestational age of terminated pregnancy, the health care provider's age, profession and years of experience.

Impact of the global gag rule on women's contraceptive use and reproductive health outcomes in Ethiopia: a pre-post and difference-in-difference analysis

OBJECTIVE

To assess the impacts of the Protecting Life through Global Health Assistance policy (otherwise known as the expanded global gag rule (GGR)) on women's sexual and reproductive health (SRH) in Ethiopia. The GGR prohibits all non-US non-governmental organisations (NGOs) receiving US Government global health funding from providing, referring or advocating for abortion.

DESIGN

Pre-post analysis and difference-in-difference analysis.

SETTING

Six regions of Ethiopia (Tigray, Afar, Amhara, Oromiya, SNNPR and Addis Ababa).

PARTICIPANTS

Panel of 4909 reproductive-age women recruited from the Performance Monitoring for Accountability 2018 survey, administered face-to-face surveys in 2018 and 2020.

MEASURES

We assessed impacts of the GGR on contraceptive use, pregnancies, births and abortions. Due to the 2019 'Pompeo Expansion' and widespread application of the GGR, we use a pre-post analysis to investigate changes in women's reproductive outcomes. We then use a difference-in-differences design to measure the additional effect of NGOs refusal to comply with the policy and the resulting loss in funding; districts are classified as more exposed if organisations impacted by lost funding were providing services there and women are classified based on their district.

RESULTS

At baseline, 27% (n=1365) of women were using a modern contraceptive (7% using long-acting reversible contraceptive methods (LARCs) and 20% using short-acting methods. The pre-post analysis revealed statistically significant declines from 2018 to 2020 in the use of LARCs (-0.9, 95% CI: -1.6 to -0.2) and short-acting methods (-1.0, 95% CI: -1.8 to -0.2). These changes were deviations from prior trends. In our difference-in-differences analysis, women exposed to non-compliant organisations experienced greater declines in LARC use (-1.5, 95% CI: -2.9 to -0.1) and short-acting method use (-1.7, 95% CI: -3.2 to -0.1) as compared with less-exposed women.

CONCLUSIONS

The GGR resulted in a stagnation in the previous growth in contraceptive use in Ethiopia. Longer-term strategies are needed to ensure that SRH progress globally is protected from changes in US political administrations.

Postabortion and safe abortion care coverage, capacity, and caseloads during the global gag rule policy period in Ethiopia and Uganda

BACKGROUND

Abortion-related complications contribute to preventable maternal mortality, accounting for 9.8% of maternal deaths globally, and 15.6% in sub-Saharan Africa. High-quality postabortion care (PAC) can mitigate the negative health outcomes associated with unsafe abortion. While the expanded Global Gag Rule policy did not prohibit the provision of PAC, other research has suggested that over-implementation of the policy has resulted in impacts on these services. The purpose of this study was to assess health facilities' capacity to provide PAC services in Uganda and PAC and safe abortion care (SAC) in Ethiopia during the time in which the policy was in effect.

METHODS

We collected abortion care data between 2018 and 2020 from public health facilities in Ethiopia (N = 282) and Uganda (N = 223). We adapted a signal functions approach to create composite indicators of health facilities' capacity to provide basic and comprehensive PAC and SAC and present descriptive statistics documenting the state of service provision both before and after the GGR went into effect. We also investigate trends in caseloads over the time-period.

RESULTS

In both countries, service coverage was high and improved over time, but facilities' capacity to provide basic PAC services was low in Uganda (17.8% in 2019) and Ethiopia (15.0% in 2020). The number of PAC cases increased by 15.5% over time in Uganda and decreased by 7% in Ethiopia. Basic SAC capacity increased substantially in Ethiopia from 66.7 to 82.8% overall, due in part to an increase in the provision of medication abortion, and the number of safe abortions increased in Ethiopia by 9.7%.

CONCLUSIONS

The findings from this analysis suggest that public health systems in both Ethiopia and Uganda were able to maintain essential PAC/SAC services during the GGR period. In Ethiopia, there were improvements in the availability of safe abortion services and an overall improvement in the safety of abortion during this time-period. Despite loss of partnerships and potential disruptions in referral chains, lower-level facilities were able to expand their capacity to provide PAC services. However, PAC caseloads increased in Uganda which could indicate that, as hypothesized, abortion became more stigmatized, less accessible and less safe.

Community-based intervention improves abortion knowledge and reduces abortion stigma among women in Oromia, Ethiopia: a quasi-experimental mixed methods evaluation

BACKGROUND

Since liberalization of the Ethiopian abortion law, there have been significant improvements in the availability and utilization of facility-based abortion services in the country. However, nearly half of abortions still take place outside of health facilities, where the quality of procedures remains unknown. Abortion stigma is one reason that unsafe abortion persists. This study aims to evaluate the effect of community interventions conducted from 2016 to 2019 on the level and manifestation of abortion stigma and knowledge in a community in Oromia region, Ethiopia.

METHODS

The study is a quasi-experimental mixed methods evaluation including intervention and comparison communities. Two cross-sectional structured household surveys with independent samples, participatory evaluation wheels, and participatory impact diagrams were conducted with women of reproductive age (15-49) living in the communities. The baseline was conducted in 2016 and the endline in 2019. Difference-in-differences analysis was used to estimate the effect of the intervention on abortion knowledge and Stigmatizing Attitudes, Beliefs, and Actions Scale (SABAS) scores in the intervention community.

RESULTS

One thousand five hundred fifty-five women participated in the household survey and 28 women participated in participatory evaluation meetings. Over one-third (37%) of women surveyed in the intervention community were exposed to the intervention activities. Knowledge of one or more indications of legal abortion increased from 21 to 85% in the intervention community, compared to an increase from 30 to 57% in the comparison. Mean SABAS scores decreased by 9.3 points in the intervention community and increased by 5.3 points in the comparison community. Differences-in-differences models indicate that exposure to the intervention resulted in decreased stigma scores (coefficient = - 9.33, p < 0.001) and increased knowledge (coefficient = 0.26, p < 0.001).

CONCLUSIONS

This is one of the first studies to measure changes in community-level abortion stigma and knowledge over time in Ethiopia using a mixed method, quasi-experimental design. The results indicate that the community-based intervention improved abortion knowledge and reduced abortion stigma.

The U.S. Global Gag Rule in Ethiopia: a foreign policy challenging domestic sexual and reproductive health and rights gains

BACKGROUND

Ethiopia's government and civil society have driven crosscutting initiatives in the last 15 years to improve sexual and reproductive health outcomes, including passing a 2005 abortion law that facilitated reduced rates of maternal death due to unsafe abortion. However, both the government and nongovernmental organizations have relied on external funding for sexual and reproductive health and rights, particularly from the U.S. government, which has been Ethiopia's largest global health donor. This article explores how the implementation and expansion of the 2017-2021 U.S. foreign policy "Protecting Life in Global Health Assistance," also known as the Global Gag Rule-which attached itself to a nongovernmental organization's funding-impacted sexual and reproductive health and rights, including safe abortion care, in Ethiopia.

METHODS

This article is based on research conducted by PAI staff in Ethiopia in 2018 with follow-up in 2019. PAI held in-depth semistructured interviews with representatives of 30 organizations in Ethiopia's capital, Addis Ababa. Among these groups were U.S.-based and non-U.S. nongovernmental organizations, including community-based organizations, non-U.S. government donors, and Ethiopian government officials.

RESULTS

Nongovernmental organizations have been essential to sexual and reproductive health service provision and advocacy in Ethiopia. Because of the sector's reliance on U.S. global health assistance, these organizations; their activities; and, consequently, the wider health system were negatively impacted by the Global Gag Rule. Certain vulnerable groups, particularly adolescents and youth, have traditionally relied on the private sector for sexual and reproductive health services. PAI's research demonstrates that U.S. policy disrupted activities and service delivery, threatened the closure of private clinics, stalled mobile outreach, and impacted safe abortion training of health personnel. Additionally, the Global Gag Rule dismantled partnerships, affected non-U.S. government donors' investments, and caused confusion that limited activities permissible under the policy.

CONCLUSIONS

The Trump administration's Global Gag Rule forced non-U.S. organizations to choose between providing comprehensive care or losing U.S. global health assistance, ultimately impacting populations in need of services. Ethiopia provides a clear example of how the Global Gag Rule can threaten a country's domestic health agenda by targeting nongovernmental organizations that are vital to health service delivery and safe abortion care.

Availability and Utilization of Postabortion Care Services in Burkina Faso, Côte d'Ivoire, and Guinea: A Secondary Analysis of Emergency Obstetric and Neonatal Care Needs Assessments (EmONC)

SYNOPSIS: Generally, there are disparities in the availability and utilization of postabortion care services within the different regions at the national level in Burkina Faso, Cote d’Ivoire, and Guinea and between the 3 countries. Access to postabortion care at the primary level must be improved and the adoption of family planning when providing postabortion care.

Unsafe abortion remains one of the leading causes of maternal mortality in sub-Sahara Africa, with relatively poor access to quality postabortion care (PAC) services. This study evaluated the quantity and distribution as well as the utilization of PAC services in Burkina Faso, Cote d’Ivoire, and Guinea. We conducted a secondary data analysis using the most recent EmONC surveys in the 3 countries between 2016 and 2017. We used PAC signal functions approach to assess facilities’ capacity to provide basic PAC at both primary and referral level of care and comprehensive PAC at the referral level. We illustrated population coverage of PAC services based on the WHO benchmark, and then assessed the utilization of PAC services. Basic PAC capacity at primary level was low (36.6%), ranging from 16.2% in Burkina Faso to 36% in Cote d’Ivoire. About 82.0% of hospitals could provide comprehensive PAC. There were disparities in the geographical distribution of PAC services at both national and subnational levels. Abortion complications represented 16.2% of all obstetric emergencies, and uptake of PAC modern contraceptive was low (37.1%) in all countries. There is a need to focus on access to PAC at the primary level of care in the 3 countries.

Contemplating abortion: a qualitative study of men and women’s reactions to unplanned pregnancy in Sierra Leone

Globally, millions of unintended pregnancies result in unsafe abortions each year. In Sierra Leone, abortion-related complications are a major driver of maternal mortality. Despite these costs, women continue to seek unsafe abortions, yet how individuals understand the risks and benefits of pregnancy termination remains under-researched. This study seeks to understand perceptions of abortion by women and men experiencing unplanned pregnancy and to highlight factors that inform their abortion trajectories. Findings indicate that abortion was contemplated in response to anxieties regarding caring for a child, interruptions to schooling, and stigma associated with extra-marital pregnancy. While many women and men preferred not to abort-due to cultural values tied to parenthood-others faced obstacles stemming from lack of knowledge of and access to services. Findings can be used to inform interventions to support women and men in realising their fertility preferences in the face of unplanned pregnancy.

Navigating abortion law dilemmas: experiences and attitudes among Ethiopian health care professionals

BACKGROUND

Ethiopia's 2005 abortion law improved access to legal abortion. In this study we examine the experiences of abortion providers with the revised abortion law, including how they view and resolve perceived moral challenges.

METHODS

Thirty healthcare professionals involved in abortion provisions in Addis Ababa were interviewed. Transcripts were analyzed using systematic text condensation, a qualitative analysis framework.

RESULTS

Most participants considered the 2005 abortion law a clear improvement-yet it does not solve all problems and has led to new dilemmas. As a main finding, the law appears to have opened a large space for professionals' individual interpretation and discretion concerning whether criteria for abortion are met or not. Regarding abortion for fetal abnormalities, participants support the woman's authority in deciding whether to choose abortion or not, although several saw these decisions as moral dilemmas. All thought that abortion was a justified choice when a diagnosis of fetal abnormality had been made.

CONCLUSION

Ethiopian practitioners experience moral dilemmas in connection with abortion. The law places significant authority, burden and responsibility on each practitioner.

Necessary but not sufficient: a scoping review of legal accountability for sexual and reproductive health in low-income and middle-income countries

Background

This paper is a scoping review of the impact of legal accountability efforts for sexual and reproductive health and rights (SRHR), exploring the links between legal accountability strategies and changes in the desired SRHR outcomes.

Methods

We defined legal accountability as use of the judicial system following state failure to respect, protect or fulfil SRHR as enshrined in national law, as well as individuals’ or the state’s use of criminal law mechanisms to prevent unwanted behaviour and to provide remedy. We undertook a keyword search in PubMed, Scopus and LexisNexis and then consulted a group of experts to provide guidance regarding further peer-reviewed and grey literature, yielding a total of 191 articles.

Results

The majority of the empirical, peer-reviewed articles identified were regarding abortion law and abortion care availability, followed by violence against women. Most of these articles explore the gaps between law and practice. We identified seven key factors that shape the efficacy of legal accountability efforts, including the ways a law or court decision is formulated, access to courts, the (dis)advantages of criminal law in the given context, cultural norms, politics, state capacity and resources and the potential for further litigation. Many articles explained that use of the judiciary may be necessary to effect change and that the act of claiming rights can empower, but that legal avenues for change can be imperfect tools for justice.

Conclusions

Legal accountability can be effective as part of a broader, long-term strategy, with due attention to context.

Regional and residential disparities in knowledge of abortion legality and availability of facility-based abortion services in Ethiopia

Objectives

To generate regional, residential, and nationally representative estimates of knowledge of abortion legality and availability among women of reproductive age in Ethiopia, and examine how knowledge varies across regions and by urban/rural residence.

Study Design

Our study draws on data from a nationally representative, cross-sectional survey implemented in 2019 in each of Ethiopia's regional and administrative states, yielding a sample of 8,837 women aged 15 to 49. We compare weighted estimates and regional distributions of 3 outcomes: (1) general awareness and (2) correct knowledge of the abortion law, and (3) knowledge of facility-based abortion service availability.

Results

Significant regional and urban/rural disparities in knowledge of abortion legality and availability exist. Nationally, 27% of women are aware of the abortion law and just 5% of women have comprehensive knowledge of the law, while 30% know where to access facility-based abortion services. Regionally, estimates range significantly, from 2% in Somali to 45% in Addis Ababa for general awareness of the law, 0% in Afar to 27% in Harare for comprehensive knowledge of the law, and 8% in Afar to 57% in Tigray for knowledge of abortion availability. Knowledge of all measures is higher in urban than in rural areas.

Conclusions

Regional disparities in abortion knowledge may contribute to geographic inequities in access to and use of safe abortion care. Efforts to expand knowledge of abortion legality and availability are needed and should be tailored to regional contexts.

Implications

Knowledge of abortion legality and availability is imperative to protecting and expanding access to safe abortion care, especially in contexts like Ethiopia where abortion is available for multiple indications. Efforts to improve knowledge of abortion legality and availability are needed, and should be locally tailored to address regional inequities.

Regional and residential disparities in knowledge of abortion legality and availability of facility-based abortion services in Ethiopia

OBJECTIVES

To generate regional, residential, and nationally representative estimates of knowledge of abortion legality and availability among women of reproductive age in Ethiopia, and examine how knowledge varies across regions and by urban/rural residence.

STUDY DESIGN

Our study draws on data from a nationally representative, cross-sectional survey implemented in 2019 in each of Ethiopia's regional and administrative states, yielding a sample of 8,837 women aged 15-49. We compare weighted estimates and regional distributions of three outcomes: 1) general awareness and 2) correct knowledge of the abortion law, and 3) knowledge of facility-based abortion service availability.

RESULTS

Significant regional and urban/rural disparities in knowledge of abortion legality and availability exist. Nationally, 27% of women are aware of the abortion law and just 5% of women have comprehensive knowledge of the law, while 30% know where to access facility-based abortion services. Regionally, estimates range significantly, from 2% in Somali to 45% in Addis Ababa for general awareness of the law, 0% in Afar to 27% in Harare for comprehensive knowledge of the law, and 8% in Afar to 57% in Tigray for knowledge of abortion availability. Knowledge of all measures is higher in urban than in rural areas.

CONCLUSIONS

Regional disparities in abortion knowledge may contribute to geographic inequities in access to and use of safe abortion care. Efforts to expand knowledge of abortion legality and availability are needed and should be tailored to regional contexts.

IMPLICATIONS

Knowledge of abortion legality and availability is imperative to protecting and expanding access to safe abortion care, especially in contexts like Ethiopia where abortion is available for multiple indications. Efforts to improve knowledge of abortion legality and availability are needed, and should be locally tailored to address regional inequities.

Determinants of Second-Trimester Safe Termination of Pregnancy in Public Health Facilities of Amhara Region, Northwest Ethiopia: An Unmatched Case-Control Study

Background. Second-trimester medical abortion is the termination of pregnancy between 13 and 28 weeks of gestational age. Although the majority of abortions are performed in the first trimester, 10–15% of terminations of pregnancies have taken place in the second trimester globally. Objective. To identify the determinant factors of second-trimester safe termination of pregnancy in public health facilities of the Amhara region, northwest Ethiopia. Methods. An institution-based unmatched retrospective case-control study conducted from 01/10/2019–30/02/2020. A systematic random sampling technique was used to select 119 cases and 238 controls. An interviewer-administered questionnaire was used to collect the data. A binary logistic regression model was fitted to identify determinant factors. The odds ratio with 95% CI was computed to assess the strength and significance of the association between dependent and independent variables. Result. Rural resident (adjusted odds ratio (AOR) = 1.9; 95% CI 1.07–3.25), irregular menses (AOR = 1.8; 1.06–3.13), had no known symptoms of pregnancy (AOR = 1.9; (95% CI 1.06–3.46)), not knowing the abortion law (AOR = 3.0; (95% CI 1.63–5.60)), low level of education (1st–8th grade) (AOR = 2.7; (95% CI 1.06–6.60), opposition against abortion care (AOR = 2.6; (1.22–5.42)), delayed referral (AOR = 10.1 (95% CI 4.02–29.18)), and not undertaking pregnancy test (AOR = 2.2; (95% CI (1.21–4.04)) were determinants of second-trimester safe termination of pregnancy. Conclusion. Women being rural residents, irregular menses, not undertaking pregnancy test, not knowing the abortion law, low-level educational status, delayed referral, no knowledge about signs and symptoms of pregnancy, and opposition of safe abortion were determinants of second-trimester safe termination. The Regional Health Bureau and Health Facilities should give emphasis to women living in rural areas, and they should increase awareness towards abortion law and sign and symptoms of pregnancy and encourage female education.

An examination of the characteristics and contraceptive acceptance of post-abortion clients in Ethiopia

This national study examined the socio-demographic, health facility, and provider characteristics associated with the use of postabortion contraception in Ethiopia in 2014. We used data from a Prospective Morbidity Survey (PMS) conducted in Ethiopia in 2014 to measure abortion incidence and morbidity nationally. Data were collected on the presentation, care and treatment of 5,604 women who sought abortion services in 365 health facilities over 30 days. Descriptive and multivariate logistic regression analysis were used to examine postabortion contraceptive uptake. Nearly 75% of abortion clients received postabortion contraception. The majority received short-acting methods, around one-third chose a long-acting or permanent method. Most women sought abortion services at public health centers (61.8%) and were cared for by midlevel providers (82.5%). Multivariate regression results showed that women who sought services during the first trimester (odds ratio/OR = 1.44; 95% confidence interval/CI 1.06, 1.95), for induced abortions (OR = 3.55; 95% CI 2.52, 4.99), from public sector facilities, and those served by midlevel providers, had greater odds of receiving postabortion contraception. We conclude that providing strong contraceptive services postabortion in government facilities, including long-acting methods in the method mix, and providing this care by midlevel providers could further reduce unmet need for contraception and repeat abortions.

Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia

Universal Health Coverage (UHC) forces governments to consider not only how services will be provided – but which services – and to whom, when, where, how and at what cost. This paper considers the implications for achieving UHC through the lens of abortion-related care for adolescents. Our comparative study design includes three countries purposively selected to represent varying levels of restriction on access to abortion: Ethiopia (abortion is legal and services implemented); Zambia (legal, complex services with numerous barriers to implementations and provision of information); Malawi (legally highly restricted). Our policy and legal analyses are supplemented by comparative vignettes based on interviews (n = 330) in 2018/2019 with adolescents aged 10–19 who have sought abortion-related care in each country. We focus on an under-considered but critical legal framing for adolescents – the age of consent. We compare legal and political commitments to advancing adolescent sexual and reproductive health and rights, including abortion-related care. Ethiopia appears to approach UHC for safe abortion care, and the legal provision for under 18-year-olds appears to be critical. In Malawi, the most restrictive legal environment for abortion, little progress appears to have been made towards UHC for adolescents. In Zambia, despite longstanding legal provision for safe abortion on a wide range of grounds, the limited services combined with low levels of knowledge of the law mean that the combined rights and technical agendas of UHC have not yet been realised. Our comparative analyses showing how policies and laws are framed have critical implications for equity and justice.

Knowledge and attitude of reproductive age group (15-49) women towards Ethiopian current abortion law and associated factors in Bahir Dar city, Ethiopia

BACKGROUND

Unsafe abortion accounts for nearly 60% of all gynecologic admissions and almost 30% of all obstetric and gynecologic admissions. Studies on abortion in Ethiopia have given less attention to women's perceptions and experiences of abortion laws. Although the 2005 revised abortion law allows women to access safe abortion services, still unsafe abortion is one of the leading causes of pregnancy-related deaths. Therefore, the current study aimed to assess women's knowledge and attitude towards the Ethiopian current abortion law in Bahir Dar City Administration.

METHODS

A community-based cross-sectional study using a systematic random sampling technique was carried out among 403 randomly selected reproductive age women using a pre-tested structured questionnaire in Bahir Dar City Administration from May to June /2017. Data were entered into Epi data version 3.1 and analyzed using SPSS version 21.0 software. Logistic regression was done to identify the possible factors associated with women's knowledge and attitude towards the Ethiopian current abortion law.

RESULTS

Three hundred eighty-six respondents partook with a response rate of 95.7%. The study showed that 43% had good knowledge and 38% had a favorable attitude towards the Ethiopian current abortion law. Women's in the age group of 25-29 years (AOR = 2.7, 95% CI: 1.02, 6.9), partner's educational status of primary (AOR = 2.9, 95% CI: 1.19, 7.08), secondary (AOR = 5.5, 95% CI: 2.09, 14.4) and college and above (AOR = 8.2, 95% CI: 2.3, 28.6) were significantly associated with good knowledge of the Ethiopian current abortion law. While partner's educational status; college and above (AOR = 6.15, 95% CI: 1.87, 20.22) was significantly associated with the favorable attitude towards the Ethiopian current abortion law.

CONCLUSIONS

43% of respondents had good knowledge and 38% had a favorable attitude towards the Ethiopian current abortion law. Forty-nine respondents had a history of abortion of which, 8 occurred through induction. Woman's age and partner's education determine the status of knowledge while merely; the partner's educational status of college and above was significantly associated with the attitude towards Ethiopian current abortion law, respectively.

Evaluating the quality and coverage of post-abortion care in Zimbabwe: a cross-sectional study with a census of health facilities

Background

An estimated 65,000 abortions occurred in Zimbabwe in 2016, and 40 % resulted in complications that required treatment. Quality post-abortion care (PAC) services are essential to treat abortion complications and prevent future unintended pregnancies, and there have been recent national efforts to improve PAC provision. This study evaluates two components of quality of care: structural quality, using PAC signal functions, a monitoring framework of key life-saving interventions that treat abortion complications; and process quality, which examines the standards of care provided to PAC patients.

Methods

We utilized a 2016 national census of health facilities in Zimbabwe with PAC capacity (n = 227) and a prospective, facility-based 28-day survey of women seeking PAC in a nationally representative sample of those facilities (n = 1002 PAC patients at 127 facilities). PAC signal functions, which are the critical services in the management of abortion complications, were used to classify facilities as having the capability to provide basic or comprehensive care. All facilities were expected to provide basic care, and referral-level facilities were designed to provide comprehensive care. We also assessed population coverage of PAC services based on the WHO recommendation for obstetric services of 5 facilities per 500,000 residents.

Results

We found critical gaps in the availability of PAC services; only 21% of facilities had basic PAC capability and 10% of referral facilities had comprehensive capability. For process quality, only one-fourth (25%) of PAC patients were treated with the appropriate medical procedure. The health system had only 41% of the basic PAC facilities recommended for the needs of Zimbabwe’s population, and 55% of the recommended comprehensive PAC facilities.

Conclusion

This is the first national assessment of the Zimbabwean health system’s coverage and quality of PAC services. These findings highlight the large gaps in the availability and distribution of facilities with basic and comprehensive PAC capability. These structural gaps are a contributing barrier to the provision of evidence-based care. This study shows the need for increased focus and investment in expanding the provision of and improving the quality of these essential, life-saving PAC services.

Still a moral dilemma: how Ethiopian professionals providing abortion come to terms with conflicting norms and demands

Background

The Ethiopian law on abortion was liberalized in 2005. However, as a strongly religious country, the new law has remained controversial from the outset. Many abortion providers have religious allegiances, which begs the question how to negotiate the conflicting demands of their jobs and their commitment to their patients on the one hand, and their religious convictions and moral values on the other.

Method

A qualitative study based on in-depth interviews with 30 healthcare professionals involved in abortion services in either private/non-governmental clinics or in public hospitals in Addis Ababa, Ethiopia. Transcripts were analyzed using systematic text condensation, a qualitative analysis framework.

Results

For the participants, religious norms and the view that the early fetus has a moral right to life count against providing abortion; while the interests and needs of the pregnant woman supports providing abortion services. The professionals weighed these value considerations differently and reached different conclusions. One group appears to have experienced genuine conflicts of conscience, while another group attempted to reconcile religious norms and values with their work, especially through framing provision of abortion as helping and preventing harm and suffering. The professionals handle this moral balancing act on their own. In general, participants working in the private sector reported less moral dilemma with abortion than did their colleagues from public hospitals.

Conclusions

This study highlights the difficulties in reconciling tensions between religious convictions and moral norms and values, and professional duties. Such insights might inform guidelines and healthcare ethics education.

Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review

At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.

Determinants of reproductive health services utilization among rural female adolescents in Asgede-Tsimbla district Northern Ethiopia: a community based cross-sectional study

BACKGROUND

Adolescents especially females in rural area are vulnerable to a wide range of reproductive health problems including sexually transmitted infections, unwanted pregnancies, and unsafe abortion. They have limited access to reproductive health services that focus on the special needs of female adolescents. This study was aimed to assess the determinants of reproductive health service utilization among rural female adolescents of Asgede-Tsimbla district.

METHODS

A community-based cross-sectional study was carried out from February to April 2018, in eight randomly selected sub-districts of Asgede-Tsimbla. A total of 844 female adolescents aged 15-19 were interviewed using a pre-tested structured questionnaire. Data were entered into Epi-info Version 3.5.3 and then exported to SPSS Version 21 for analysis. Bivariate and multivariate logistic regression analysis was carried out to assess the association. Statistical significance was declared by 95% confidence interval of the odds ratio.

RESULT

From 844 participants, 95.5% of female adolescents heard about reproductive services from different sources and 69.7% of them utilized the reproductive health services within the last 12 months. Factors like, age of 16-20 years (AOR = 1.85, 95%CI: 1.17-2.92), mother's educational status (being illiterate (AOR = .33, 95%CI:.14-.77)), discussion about reproductive health services with their family (AOR = 8.02, 9%CI:5.52-11.66), being Merchant (AOR = 2.7995%CI:1.11-6.96), unemployed (AOR = 2.90, 95%CI:1.19-7.06) or student (AOR:2.38, 95%CI:1.04-5.42) in occupation, high perceived severity (AOR = 4.05, 95%CI:2.68-6.11), high perceived barriers (AOR = .44, 95%CI:.30-64) were independent predictors of reproductive health services utilization among female adolescents the study area.

CONCLUSION

About 69.7% of the adolescent females were utilizing reproductive health services in the study area though it was very low as compared with the national plan. Introducing messages that increase the perceived threat and decreasing perceived barriers to utilize reproductive health services as well as increasing self-efficacy of adolescent females would help further increase reproductive health services utilization by adolescent females.

Health systems' capacity to provide post-abortion care: a multicountry analysis using signal functions

Background

Abortion-related mortality is one of the main causes of maternal mortality worldwide. Laws often restrict the provision of safe abortion care, yet post-abortion care is a service that all countries have committed to provide to manage abortion complications. There is minimal evidence on the capacity of national health systems to provide post-abortion care.

Methods

We did a multicountry analysis of data from nationally representative Service Provision Assessment surveys done between 2007 to 2017 in ten countries across three regions (Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda). Data were available for all ten countries from 2007 to 2015. We included facilities offering childbirth delivery services and classified facilities as primary or referral level. We measured signal functions for post-abortion care (the availability of key equipment and ability to perform services) to assess the proportion of primary-level and referral-level facilities in each country with the capacity to provide basic and comprehensive post-abortion care, respectively. We calculated the proportion of facilities providing each post-abortion care signal function to examine specific gaps in service provision.

Findings

There are critical gaps in the provision of post-abortion care at all facilities that offer delivery services. In seven (70%) of ten countries, less than 10% of primary-level facilities could provide basic post-abortion care, and in eight (80%) of ten countries less than 40% of referral-level facilities could provide comprehensive post-abortion care. In no country could all referral facilities provide all the essential services that need to be included in basic post-abortion care.

Interpretation

The capacity of primary-level and referral-level health facilities to provide basic and comprehensive post-abortion care, respectively, is low. The results highlight the gap between political commitments to address the consequences of unsafe abortion and the capacity of health systems to provide post-abortion care. Increasing the provision of good-quality post-abortion care is essential to reduce the level of abortion-related morbidity and mortality.

Legal but limited? Abortion service availability and readiness assessment in Nepal

The government of Nepal revised its law in 2002 to allow women to terminate a pregnancy up to 12 weeks gestation for any indication on request, and up to 18 weeks if certain conditions are met. We evaluated the readiness of facilities in Nepal to provide three abortion services, manual vacuum aspiration (MVA), medication abortion (MA) and post-abortion care (PAC), using the service availability and readiness assessment (SARA) framework. The framework consists broadly of three domains; service availability, general service readiness and service readiness specific to individual services (i.e. service-specific readiness). We applied the framework to data from the Nepal Health Facility Survey 2015, a nationally representative survey of 992 health facilities. Overall, we find that access to safe abortion remains limited in Nepal. Of the facilities that reported offering delivery services and were thus eligible to provide safe abortion services, 44.5, 36.0 and 25.6% had provided any MVA, MA or PAC services, respectively, in the 3 months prior to the survey, and <2% were 'ready' to provide any abortion service based on our application of the SARA criteria for service-specific readiness. Among only the facilities that reported providing an abortion service in the 3 months prior to the survey, 3.2% of facilities that provided MVA, 1.5% of facilities that provided MA and 1.1% of the facilities that provided PAC had all the components of care required. Although the private sector conducted approximately half of all abortion services provided in the 3 months prior to the survey, no private sector facilities had all the abortion service-specific readiness components. Results suggest that accessing safe abortion services remains a significant challenge for Nepalese women, despite a set of permissive laws.

Playing it Safe: Legal and Clandestine Abortions Among Adolescents in Ethiopia

PURPOSE

The 2005 expansion of the Ethiopian abortion law provided minors access to legal abortions, yet little is known about abortion among adolescents. This paper estimates the incidence of legal and clandestine abortions and the severity of abortion-related complications among adolescent and nonadolescent women in Ethiopia in 2014.

METHODS

This paper uses data from three surveys: a Health Facility Survey (n = 822) to collect data on legal abortions and postabortion complications, a Health Professionals Survey (n = 82) to estimate the share of clandestine abortions that resulted in treated complications, and a Prospective Data Survey (n = 5,604) to collect data on abortion care clients. An age-specific variant of the Abortion Incidence Complications Method was used to estimate abortions by age-group.

RESULTS

Adolescents have the lowest abortion rate among all women below age 35 (19.6 per 1,000 women). After adjusting for lower levels of sexual activity among adolescents however, we find that adolescents have the highest abortion rate among all age-groups. Adolescents also have the highest proportion (64%) of legal abortions compared with other age-groups. We find no differences in the severity of abortion-related complications between adolescent and nonadolescent women.

CONCLUSIONS

We find no evidence that adolescents are more likely than older women to have clandestine abortions. However, the higher abortion and pregnancy rates among sexually active adolescents suggest that they face barriers in access to and use of contraceptive services. Further work is needed to address the persistence of clandestine abortions among adolescents in a context where safe and legal abortion is available.

The status of provision of post abortion care services for women and girls in Eastern and Southern Africa: a systematic review

OBJECTIVE

To conduct a systematic review of the status of post-abortion care (PAC) provision in Eastern and Southern Africa with particular reference to reach, quality and costs of these services.

STUDY DESIGN

We searched Pubmed, EMBASE, Science Direct, POPLINE and Web of Science for articles published between 2000 and October 2017 presenting primary or secondary data from one or more countries in the region.

RESULTS

Seventy articles representing data from fourteen countries were abstracted and included in the review. Implementation of PAC services was found to be patchy across countries for which data was available. However, there is evidence of efforts to introduce PAC at lower level health facilities, to use mid-level providers and to employ less invasive medical techniques. Eleven countries from the region were not represented in this review, exposing a considerable knowledge gap over the state of PAC in the region. The disparate access for rural women and girls, the suboptimal service quality and the neglect of adolescent-specific needs were critical gaps in the current PAC provision.

CONCLUSION

PAC provision and research in this domain cannot be detached from the broader legal and societal context, as social stigma constitutes a major blockage to the advancement of the service. Adolescent girls are a particularly vulnerable and underserved group in the region.

IMPLICATIONS

The next generation research on PAC should favor multi-country and interdisciplinary study designs with a view to understanding inter-regional differences and supporting advancement towards universal access of PAC by 2030.