In 2005, Ethiopia's parliament liberalized the country's penal code, which had allowed women to obtain an abortion only if the pregnancy placed her in "grave or imminent danger." The amended law permits legal pregnancy termination if the woman became pregnant through rape or incest, has a physical or mental disability, would be putting her life or health at risk by continuing the pregnancy or is younger than 18 and is physically or mentally unprepared for childbirth. Yet, despite rapid scaling-up of abortion services after legalization, an estimated 73% of induced abortions in 2008 were likely performed by someone lacking the necessary skills or knowledge or occurred in an environment that did not meet minimal medical standards, or both. Two articles in this issue of IPSRH—based on differing data and methods—examine changes between 2008 and 2014 in the incidence of induced abortion and in the provision of services related to abortion and postabortion care.
Ann Moore and colleagues estimate that the number of induced abortions in Ethiopia increased from 382,300 in 2008 to 620,300 in 2014, and that the annual abortion rate rose from 22 to 28 per 1,000 women of reproductive age. The proportion of procedures provided in a health facility doubled (from 27% to 53%). Nevertheless, the treatment rate for complications of abortion rose from 3.0 per 1,000 women of reproductive age in 2008 to 4.7 per 1,000 in 2014. The authors note that despite the improvements in access to health care, a substantial number of abortions still occur under unsafe conditions.
Following liberalization of Ethiopia's abortion law, the government greatly expanded access to care by constructing new health centers and by, training midlevel health workers to perform abortions and treat abortion complications. Yirgu Gebrehiwot and colleagues examine how levels and types of abortion care—legal abortion and treatment of abortion complications—have changed since the amendment of the law. The proportion of abortion care provided in public-sector facilities rose by more than 50% between 2008 and 2014, from 36% to 56%, and the share of such care provided by midlevel health workers increased from 48% to 83%. Medication abortion accounted for 36% of pregnancy terminations in 2014, compared with none in 2008. Meanwhile, among women seeking treatment for abortion complications, the proportion with severe morbidity rose from 7% to 11%. The authors conclude that despite Ethiopia's substantial progress in expanding access to comprehensive abortion care, morbidity from unsafe abortion remains a challenge.
The Method Information Index, calculated from Demographic and Health Survey data on three aspects of the information received by clients during contraceptive visits, yields one measure of how well family planning programs are serving their clients. Using MII values (the percentages of women who had received all three types of information on their method) for 25 developing countries with two surveys at least five years apart, Anrudh Jain found that, on average, the index increased from 34% at the earlier survey to 39% at the later survey; index values for individual countries ranged from 19% to 64% at the first survey and from 13% to 65% at the second survey. The MII increased between surveys in 15 countries and decreased in 10. In analyses by contraceptive method, the MII tended to be highest among implant users and lowest among women relying on sterilization. It was generally higher among women living in urban areas than among those in rural areas, and tended to rise with women's education and household wealth.
Contraceptive stockouts are a common problem at health care facilities in developing countries. More than 60% of public and private facilities in Africa, Asia and Latin America and the Caribbean were out of at least one modern method on the day they were surveyed in 2014; in Uganda, that proportion was 79%. Using focus groups with contraceptive clients and in-depth interviews with service providers, policymakers and decision makers in two districts of Uganda, Kate Grindlay found that stockouts of long-term methods and oral contraceptives were particularly common. For contraceptive clients, the consequences included stress, increased costs, domestic conflict and unwanted pregnancies. Service providers reported emotional distress, blame from clients, deterioration of technical skills, and feelings of helplessness to address the issue. Despite the prevalence of stockouts, policymakers reported being unaware of problems. According to the authors, supply chain issues must be addressed if stockouts are to be reduced.
Also in This Issue
In a Special Report, Angel Foster and colleagues describe a pilot program designed to determine the feasibility of a referral system to help displaced Burmese women on the Thailand-Burma border obtain safe abortion services. Although they had faced severely limited access to abortion under Burmese law, 26 of the 27 women referred by the system met the less-restrictive Thai legal criteria and 24 obtained a safe procedure from a Thai provider. According to the authors, the results of the pilot program indicate that creation of a safe and legal referral program is feasible, even in a context characterized by protracted displacement and conflict.