Four years after the abortion law was liberalized, only a quarter of all abortions in Ethiopia occur in safe and legal settings. According to recent research, efforts to provide safe abortion care have been most successful in urban areas; services remain especially limited in rural areas, where the majority of Ethiopian women live.

These findings come from a study released today by Ipas Ethiopia and the Guttmacher Institute. The study was conducted in collaboration with the Ethiopian Society of Obstetricians and Gynecologists and the Ethiopian Public Health Association, in conjunction with Ethiopia’s Regional Health Bureaus. The Federal Ministry of Health endorsed the study and advised the research team.

Only 14% of Ethiopian women of reproductive age use contraceptives. The low level of contraceptive use leads to high levels of unintended pregnancy, the root cause of abortion: Some 42% of all pregnancies are unintended. The study also found that the majority of women seeking treatment for complications of unsafe abortion—81%—were married. By contrast, only 46% of women seeking induced abortions were married. The vast majority of both groups—92% of women seeking postabortion care and 79% of women who had abortions—were mothers. The average age among both groups was 28.

Until Ethiopia expanded abortion access in 2005, abortion was permitted only to save the life of a woman or to protect her physical health. Abortion is now legal in Ethiopia in cases of rape, incest or fetal impairment. In addition, a woman can legally terminate a pregnancy if her life or her child’s life is in danger or if continuing the pregnancy or giving birth endangers her life. A woman may also terminate a pregnancy if she is unable to bring up the child, owing to her status as a minor or to a physical or mental infirmity.

The study estimates that, in 2008, 382,500 abortions were performed in Ethiopia, for an annual rate of 23 per 1,000 women aged 15–44. Despite women’s expanded legal access to abortion, only 27% of these—103,000—were legal and safe procedures performed in health facilities.

The study also found that, in 2008, 58,600 women were treated for abortion-related complications, primarily resulting from unsafe procedures. Among these, 100 women died from their complications, and many more suffered from related injuries or illnesses. Four out of 10 women showed signs of infection or invasive injuries when they arrived at health facilities for postabortion care. Many women with complications never reach health care facilities, because they live too far from services, they avoid seeking help because of fear and stigma, or they die before reaching a facility.

“A number of factors may explain why access to safe abortion services is not yet a reality in many parts of the country,” said Hailemichael Gebreselassie of Ipas, a coauthor of the study. “These include the fact that many women and health care providers alike are unaware of the expanded criteria under which abortion is legal and that too few health care facilities outside of urban areas are equipped to offer the services.”

The authors recommend that the Ethiopian government increase the availability of safe abortion services and postabortion care in government hospitals and health centers, educate providers and women about the new law, and provide additional resources to improve access to safe abortion services. They also note that the introduction of medical abortion could greatly expand access to abortion care in a cost-efficient manner.

In addition, the authors call for expanded access to modern contraceptive methods and counseling as an effective way to reduce unintended pregnancy and unsafe abortion.

Global data show that expanding legal abortion access reduces death and illness from unsafe abortion. For example, South Africa saw abortion-related maternal mortality decline by more than 50% after expanding access in 1997. Many stakeholders throughout the region are looking to Ethiopia as a model for addressing a crisis in maternal mortality. The current study will serve as a baseline for assessing the country’s progress in reducing maternal deaths as the government continues to expand services.

The complete results of the study will be released in two articles published in the March issue of International Perspectives on Sexual and Reproductive Health :

A short fact sheet synthesizing the findings can also be found here.