How Ethiopia solved its abortion problem

ADDIS ABABA, Ethiopia — Zebiba, 28, sits in her purple headscarf in the small clinic room, the cramping already beginning. She took the tablets early this morning. She is three months pregnant.

By 2 p.m., her abortion should be complete. She will return to her two children, now at school. She is divorcing their father, who has taken a second wife.

Thus far, she has refused pain medications. Her relief at the ease of this termination is palpable. “She was nervous coming here,” says the nurse.

A generation ago, botched abortions were the single biggest contributor to Ethiopia’s sky-high maternal mortality rate. Doctors in the largest public hospital in Addis Ababa, where Zebiba lives, still remember the time when three-quarters of the beds in the maternal ward were reserved purely for complications from such procedures.

Then, in 2005, the country liberalized its abortion law.

Today, it’s hard to find a health provider who’s seen more than one abortion-related death in the past five years. Although access to safe procedures and high quality care could still be expanded, doctors say that, increasingly, those who need an abortion can get one safely.

But this success story has a catch: abortion is still illegal. Only under very limited circumstances is it allowed, and Zebiba's case does not fall into one of the specified categories.

Many of the women whose lives doctors and NGOs have saved in the past few years have been ushered through a legal loophole — and it’s possible that’s what the government intended all along.

Abortion in a highly religious population

Fasika Menge and Tirigno Alamerw are health extension workers in rural Mosebo village. They are both Orthodox Christian, and say the traditional methods of abortion were very dangerous.

Asked whether Muslim religious leaders would approve of what she is doing, Zebiba gasps in horrified laughter, shaking her head. “No.” On a busy weekday morning at this clinic, only one woman in the waiting area admits to knowing a woman who has had an abortion. That’s in the city. In rural Mosebo village some 500 miles north, Mekdes Mulugeta, an Orthodox Christian woman Zebiba's age, gasps at the notion of even discussing it.

Over 95 percent of Ethiopia’s population is either Orthodox Christian, Muslim, or Protestant. All three religions forbid abortion.

But religious belief has historically proven little or no barrier to the women seeking the procedures. In the years before 2005, when abortion was only legal if two doctors agreed it was necessary to save a mother’s life, and when trained health providers were therefore wary of offering such services, Ethiopian women turned to dangerous home methods instead.

“Some take the roots of trees and they chop and pound it then they mix it with water and drink it. Some boil chaff of teff,” says Fasika Menge, a health extension worker in Mosebo village, who recalls seeing botched abortions in her home district. “The baby will die, definitely.” As for the mother, “it’s kind of 50-50.”

“The metal was in her when they brought her,” says Fetlework Taye, a nurse in Hawassa, recalling a woman who had attempted a physical method of termination and died of sepsis.

Sepsis, pelvic abcesses, bowel perforations, incomplete abortions — city gynecologists say they used to see them all on a daily basis. “It was not uncommon,” says Dr. Eskinder, an obstetrician in Addis Ababa’s largest public hospital, “to see a patient undergoing two or three operations and having hysterectomies for the complications.”

Squaring a circle

The Ethiopian government's Health Extension Program puts pairs of young women in rural "health posts." The walls of the post in Mosebo village are covered in tallies for services provided, including safe abortions. Heather Horn/GlobalPost

In pursuit of the UN’s Millennium Development goals, aimed at fighting poverty and associated problems, the Ethiopian government has remodeled its entire health system. For example, in 2003 it rolled out the ambitious Health Extension Program, training young women in basic services and preventative care, and placing them in rural villages. In 2011 the government launched a “Women’s Development Army” whose community volunteers, if the Ministry of Health’s numbers are to be believed, now dwarf Ethiopia’s real army by a ratio of 16 to 1.

But one Millennium Development Goal in particular presented Ethiopia with an unusual challenge: slashing 1990 maternal mortality figures 75 percent by 2015.

To meet that goal, Ethiopia had to solve its abortion problem — because in the 1990s, 54 percent of maternal mortality could be traced to abortion complications. Even in 2004 and 2005, after a massive contraception push and, it is rumored, some health care providers started quietly offering safe abortions on the sly, unsafe abortion’s contribution to maternal mortality was still at 32 percent.

The simplest solution, particularly given that Ethiopia in the early 2000s was in the midst of sweeping penal code reform, would have been to legalize abortion, so women could go to trained physicians instead of relying on dangerous home procedures. Some say the government considered that, though the Ministry of Health won’t confirm whether that’s true. In particular, two Ethiopian experts on maternal health who knew doctors involved in the drafting process, and who asked not to be named, say an early draft legalized pregnancy termination outright, within certain limits.

But there was intense opposition from religious groups to modifying the law at all. Even in this country where protests are frequently suppressed, "some Protestant doctors were on the streets [demonstrating],” says one OB/GYN working in Addis. A Protestant group called Christian Workers Union for Health Care in Ethiopia was particularly vocal and circulated pamphlets suggesting safe abortions were a myth, according to one NGO worker.

“There were suspicions but no proof,” read a 2008 report by reproductive rights group Ipas, that the Protestant group “received financial support from an external, perhaps US, anti-choice organization.” GlobalPost was not able to reach Christian Workers Union representatives for comment.

But if the group had indeed been funded by a US organization, they of course wouldn’t have been the only ones receiving external funding. The same could be said for all the NGOs on the other side of the reproductive rights debate, including Ipas and Marie Stopes.

One Ethiopian maternal health expert said resistance from “donors” to changing the law was also an issue: “Your [US] Congress has been active on anti-abortion.” An estimated 50 to 60 percent of Ethiopia’s national budget comes from foreign aid, with the US the largest single-state donor. During the years Ethiopia’s abortion law was under debate, when President George W. Bush was in office with a Republican Congress, the US was publicly criticized for having used aid stipulations to pressure Uganda into emphasizing abstinence, not condoms, in its HIV prevention program.

Did the same thing happen in Ethiopia? “Since 1973, the Helms Amendment has prohibited the use of US foreign assistance funds to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortions,” responded a USAID press officer. But the officer denied that USAID would have pulled funding from Ethiopia’s health system if parts of that health system were involved in offering abortions. “USAID would only have ensured that none of our NGO partners were using US funds to perform abortions.”

Regardless of what communications the Ethiopian government did or did not receive from donor countries, officials remain convinced to this day that outright legalization is not an option. “If you say that abortion is legalized in this country, the consequence will be huge on the government, the ministry, and so on,” says Dr. Addis Woldemariam, chief of staff at the Ministry of Health.

It was into this atmosphere that the 2005 abortion liberalization was dropped.

Everything in the details

A nurse at a Family Guidance clinic specializing in adolescents in Bahir Dar holds a copy of the 2005 law. Heather Horn/GlobalPost

The seven sections of Proclamation 414 of Ethiopia’s Criminal Code dealing with abortion — now referred to as the liberalization law — did not look all that permissive at first glance. They declared intentional pregnancy terminations punishable by imprisonment for both patient and provider. Only pregnancies caused by rape or incest, pregnancies of minors or severely handicapped individuals, pregnancies endangering the life of the mother, and pregnancies featuring “incurable and serious” fetal problems or other “grave and imminent danger” would be exempt.

Yet the final of the seven articles contained an intriguing postscript: The Ministry of Health would “shortly issue a directive” with further instructions for implementation. It also included an important stipulation regarding the exceptions: “the mere statement by the woman is adequate to prove that her pregnancy is the result of rape or incest.”

The guidelines that followed a year later offered a gloss in an entirely different tone from the original document: The introduction emphasized the gender equality principle enshrined in Ethiopia’s constitution, and “woman-centered abortion care.” Crucial among the components of woman-centered abortion, the document states, is “choice…. The right to determine if and when to become pregnant, [or] to continue or terminate a pregnancy.”

The document expanded on Proclamation 414’s use of a woman’s word as sufficient evidence of rape or incest: In addition, “the stated age on the medical record” is all that is needed to authorize an age-based abortion.

A layman might miss the implications of such a rule. “If you, yourself, you come to our center and when you come to reception you tell her that your age is 17,” explains Dr. Eskinder, “while your age is 60, or 40, then the health personnel have no right to confirm that your age is not 18 [or older].”

Nor is there any mention, in the guidelines, of the Western world’s ubiquitous mandatory "waiting period." On the contrary, they hint at a deadline being imposed on the doctor: “A woman who is eligible for pregnancy termination should obtain the service within three working days” of having showed up to the clinic. The document also notes the importance of making information available to “eligible women” about their termination options.

‘The anti-abortion were happy and the pro-abortion were happy’

It’s almost as if the government wanted to legalize abortion in fact while looking like it was affirming its prohibition on paper. Some say that’s exactly what happened.

Look at the age, rape, and incest exceptions that require no proof, says an OB/GYN at one of the public hospitals, who asks not to be named. “It was intended to give a loophole for the woman.” And it worked: “Everybody knows the trick … Either they will tell you that the pregnancy is from incest, or it is from rape, or the age is underage.”

The Ethiopian government, the doctor smiles, doodling on a pad of paper at his desk, knows how to do one thing with the right hand and another with the left: “They’re very good at it.” Backed into a corner by religious groups in 2005, he says, they deployed the skill.

“What they said is, you people, don’t worry, we are going to give you a law which prohibits abortion, but permits some allowances for those who are very in need, like if it is rape, it is incest, or congenital malformation or a very young woman and so on. So everybody was happy. The anti-abortion were happy and the pro-abortion were happy.”

The guidelines in particular made it clear, he argues: “When it comes to the ground, then the government is pushing that this service should be available to everybody.”

That’s an interpretation echoed by NGO workers focusing on reproductive rights, but one the government strongly rejects.

“Unplanned pregnancy is not an indicator for abortion in Ethiopia,” says chief of staff Woldemariam, in a conference room at the Ministry of Health across town.

Did the government, then, deliberately stop short of saying abortion was legalized? “I cannot say that this is true,” responds Woldemariam firmly. The exceptions, he says, were instituted for a very specific reason: “A lady coming to the health facility having been raped, and being requested to present a paper — it’s not human.”

An awful lot of “rapes”

Fetlework Taye says she knows some of her patients are lying to her. Heather Horn/GlobalPost

On the ground, however, there is no ambiguity about how the policy is playing out. Rape is a well-documented problem in Ethiopia, but clinic workers say the number of rapes being offered these days as reasons for pregnancy termination strain credulity.

“I know some of them may be telling me lies,” admits Fetlework Taye, 32, a nurse at Adare Hopital in Hawassa. “But the law says I have to accept their evidence, their information, so I do the service according to that.”

“Almost all of our clients, the reason is rape,” says Biadig Amsalu, a health officer and clinical nurse at a Family Guidance Association clinic in Bahir Dar. He says that the surrounding area is very conservative, very anti-abortion. Nevertheless, he admits when asked for numbers, the clinic has performed 454 safe abortions in the first three months of 2014 — this in a town with only around 93,000 women, and eight public health centers in the area offering safe abortion services, not to mention dozens of private clinics and several hospitals.

“Now everybody is willing to provide the service,” says one doctor at a Marie Stopes clinic in Addis. “Previously, if you provide abortion service for a woman out[side] of the law, then in one year or so you will be a jail.”

He echoes Eskinder’s assessment of the law’s practical implications.

“A woman can be 20, she can [say she is] 17 if the need arises, for the purpose of the service,” he says. “And even if they are over 17, if they don’t want to go with the pregnancy, they can mention any of the reasons.”

And then there are some clinics where the elaborate game appears to have been abandoned altogether: visitors would be hard-pressed to realize that abortion has any restrictions on it at all.

As the doctor speaks, a woman is sitting in a room behind him, waiting for an abortion. Rural in origin, poor, she does not speak either of the languages commonly spoken in Addis very well. “She has communicated that she is here for a job and now she is pregnant,” says a provider. “It is the first time she is pregnant. She wants an abortion.” Why? “It is unwanted.”

A week and a half later at this same clinic, Zebiba's abortion is underway. Having a husband who is taking a second wife is not a case that falls under any of the 2005 exceptions. What will the clinic write on the record? “We do not write the problem, for most of them,” says a nurse. “We just accept them.”

A country where an abortion is considered a saved life

Tikur Anbessa Hospital, the largest public hospital in Addis, where three-quarters of the beds on the obstetrics ward used to be used for post-abortion complications. Heather Horn/GlobalPost

NGOs must work closely with the Ethiopian government to continue being allowed to operate in the country. It’s unlikely the government is ignorant of what is going on at these clinics.

But it’s also unlikely that post-abortion deaths would have dropped as quickly as they have if safe abortions were truly being limited to the exceptions outlined in the 2005 law. Abebe Shibru, Deputy Country Director at Marie Stopes in Ethiopia, says that botched abortions’ contribution to the maternal mortality rate has plummeted from 35 percent to 6 or 7 percent.

Official numbers in Ethiopia are sometimes suspect, but in this case, the anecdotal testimony from individual providers backs them up, at least in populous areas.

Dr. Eskinder works at a hospital which used to reserve 12 of the 16 OB/GYN beds for post-abortion complications. “Now we have changed the beds to be used for common gynaecological disorders or oncology, chemotherapy, and so on. We very, very rarely see complications of abortion nowadays. Maybe two or three cases a year.”

“I haven’t come across anybody who has come as a result of unsafe abortion complications,” says Fetlework Taye, who has been working as a nurse for 13 years, and at Adare Hospital in Hawassa for the last three years. “Never.” Before the law, “there were many.”

Health workers serving further afield report similarly. And while they say it’s the law, not increased contraceptive use, that’s behind the change, they also say those who come for an abortion generally receive contraception counseling at the same time, and rarely return for termination services.

In part because of these results, if health workers are aware of the doublespeak in the 2005 law, they do not seem troubled by it. On the contrary: the praise heaped on the law by providers is so enthusiastic as to stand out even in a country where individuals generally praise the government merely out of caution.

“I know that no religion in our country encourages abortion,” says Fetlework Taye, the nurse who recalls a woman coming in with a metal rod in her uterus. But “we are saving lives.”

“I personally think this to be a great change in this country,” says health extension worker Fasika Menge, recalling the number of people who used to die. Her work partner, Tirigno Alamerw, who like Menge describes herself as “very, very religious,” says she agrees.

It’s difficult to tell what the population at large thinks. Unlike in the US, it is rare for abortion providers to face harassment, although the centers that provide the service are widely known. One Marie Stopes nurse acknowledges that occasionally an angry husband comes in, but that’s it.

“There is no social safety net in Ethiopia,” notes one Addis-based political science and security studies researcher, musing on these more mild responses. An unplanned pregnancy can thus present an unmanageable crisis, even an existential threat, where family food consumption is concerned. If Ethiopians are “more practical” than Americans on abortion ethics, he suggests, it’s because they have to be.

Or perhaps it’s because they’re just not clear about what’s going on — it’s difficult to tell in Ethiopia where transparent policy slides into “gentlemen’s agreement,” or gentlemen’s agreement slides into mass deception. Despite an elaborate reporting system for both public hospitals and clinics run by NGOs, the government does not appear to be collecting data on the reasons given for abortions performed. As a result, the only evidence available on how the law is playing out is either anecdotal, or a matter of gut reaction to the sharp drop in abortion-related deaths.

The level of public awareness is also difficult to gauge. While reproductive rights advocates and doctors talk openly about the law, the responses from individuals outside the profession are all over the map. “But abortion is illegal in Ethiopia!” a villager, or a driver for an NGO, may insist. “Marie Stopes? A lot of abortions there,” a cabbie in Addis comments, knowingly. One reproductive rights advocate is worried: “There will be people who will say it is high time we revisited this abortion law,” he says, if the media discusses its real implications. He doesn't think the wider population is aware of what the law did for abortion access. But then there’s the example of women like Zebiba, who have known they could go to clinics and receive services, regardless of reason: How could so many women find their ways to the clinic doors if knowledge were not widespread? 

Muddying the waters further, Dr. Seyoum Antonios, currently heading the Christian Workers Union that lead the opposition to the law, has given interviews in which he seemed aware of the law's effects, telling one reporter for Public Radio International that "the interpretation [of the new law] opened the floodgate for people to exploit the new penal code."

Dealing with abortion in Ethiopia means dealing with contradiction. But in a land of many paradoxes, such contradictions can persist far longer than they might in a more open society. For now, at least, the uneasy compromise remains in place.

Even after her husband took a second wife without her consent, it took Zebiba 15 days to make the decision to get this abortion. She doesn't know any other woman who has had one. But after coming to the clinic to discuss, she made an appointment for the following day, her sister accompanying her in the early hours of the morning.

Asked whether she is aware of abortion's tricky legal status in Ethiopia, she responds through a nurse, who translates. "She knows this about this government, that it would be difficult."

Next on the agenda are the court procedures for the divorce. Technically, polygamy is illegal in Ethiopia, too.

Heather Horn was in Ethiopia on a fellowship with the International Reporting Project.