A central issue on the global public health and human rights agenda is abortion services. In many countries where the abortion law has been liberalized, abortion still gives rise to controversy both among health professionals and among the general public, not the least in countries where faith traditions and practices are prevalent, as is the case in sub-Saharan Africa.
The path to liberalization of the abortion law in Ethiopia
The 1994 International Conference on Population and Development highlighted the need to prevent unsafe abortions and provide safe abortion services where lawful . In the aftermath of the conference the liberalization of abortion laws in Africa has been promoted. African leaders agreed to address the problems constituted by unsafe abortion and lack of access to safe abortion through reforming national laws and policies, preparing service delivery guidelines and regulations, strengthening training programs, and expanding community outreach programs .
Throughout the 1990s, the abortion issue was put on the political agenda in Ethiopia. Advocates of liberalization wanted to reduce the incidence of unwanted pregnancies and save lives. Yet, they were met with opposition, often rooted in religious faith traditions and religious practices. In Ethiopia, the majority of the population regard themselves as religious: 44% are Orthodox Christians, 34% are Muslims and 19% are Protestants . A 2007 study of the Ethiopian population showed that a majority (67%) regarded induced abortion as ‘never justifiable’ .
Relatedly, the Ethiopian population policy goal set in 1993 was to harmonize the rate of population growth with that of the economy. Among its many objectives were reduction of the high fertility rate from 7.7 to 4, and increasing the prevalence of modern contraceptive use among married women of reproductive age from less than 5% to at least 44% . The principle that every pregnancy should be planned and wanted was incorporated into Ethiopia’s population policy.
In 2005, the Ethiopian abortion law was liberalized, making induced abortion legal after rape or incest, if the woman’s life or physical health is endangered, if she is physically or mentally disabled, or if she is a minor (less than 18). In addition, abortion is legal in the case of fetal impairment [6, 7].
Abortion in Ethiopia
In Ethiopia, abortions are performed by several different healthcare professionals: nurses, midwives, health extension workers (community health workers with one and a half year of training), health officers, integrated emergency surgical officers, and doctors who are general practitioners or specialists or in training as gynecologists-obstetricians (GYN-OBS). The 2014 guidelines authorize integrated emergency surgical officers to give comprehensive abortion care for second trimester abortions . From 2008 to 2014, the proportion of abortion-related services provided by non-physicians increased from 48% in to 83% . Not much research exists about health professionals’ attitudes towards abortion; in one study, most practicing midwives were positive to provide abortion services and their attitude was positively associated with clinical experience .
Studies in 2008 and 2014 show that abortion services in Ethiopia have undergone rapid expansion and improvement since the introduction of the law in 2005, as assessed by the standards of the well-established ‘safe abortion care’ and ‘emergency obstetric care’ frameworks [11, 12]. An estimated 620,000 abortions were performed in 2014, corresponding to an annual rate of 28 per 1000 women aged 15–49. The proportion of abortions performed in health care facilities rose from 27% in 2008 to 53% in 2014. Two-thirds of abortions are performed in private/non-governmental organisation (NGO) centers (henceforth termed ‘private’, for ease of expression) .
Ethiopians’ knowledge of the abortion law is moderate. For instance, a survey of women aged 15–49 from Bahir Dar in North-Eastern Ethiopia revealed that two-thirds were aware of the existence of the new law, yet 57% had little knowledge of it .
Research on abortion providers
Research on Ethiopian abortion practices has been sparse. In particular, the political, medical and ethical struggles over abortion among health professionals tasked with performing and assisting with abortion themselves have not been given much attention. A recent study from Addis Ababa, which parallels ours in involving interviews with abortion providers, describes health professionals’ struggle to balance religiously- and morally-based opposition to abortion against their professional duty to provide abortions and their concern for the women . A key finding in this study was that religious anguish and the stigma associated with the job appeared to lead to burnout for some. Seeing as how the health care workers’ own attitudes towards the law and abortion practices varied, the researchers hypothesized that such attitudes would be likely to influence which patients would get access to abortion.
A national survey of physicians working in Ethiopian public hospitals showed that the respondents often experienced dilemmas related to reproductive health issues . Respondents pointed to moral doubt and regrets in cases of abortion, as well as obligations to mitigate harm to women who might otherwise seek out unsafe abortions. Some respondents thought the abortion law was too strict, and that they were put in a dilemma when they found the abortion to be justified yet the woman did not fulfill the law’s criteria.
In a review of studies on Sub-Saharan and Southeast Asian healthcare professionals’ perceptions of and attitudes towards abortion, Loi and colleagues found that religion, among other factors, influenced attitudes towards abortion, and that professionals’ attitudes subsequently affected the relationship to the patient seeking abortion . They noted that a majority of professionals support abortion after rape or incest to save the woman’s life, or when severe fetal abnormalities were discovered .
Study setting and aims
Ethiopia’s total population is 105 million, of which about 3.4 million live in the capital Addis Ababa where the study took place. The capital is the most well-developed region in the country. Ethiopia spends on average $7.6 per capita on all dimensions of health care yearly. The fertility rate at 1.5 is half the national average . The abortion rate is the highest in the country’s capital, estimated at 92 per 1000 women age 14 to 49. The 2014 national abortion rate 2014 was 17.6 per 100 live births .
As described above, in Ethiopia in the preceding three decades the international normative framework of reproductive human rights has clashed with traditional and religious opposition to abortion. In this study, we wanted to explore how health professionals experience and negotiate presumably conflicting allegiances. Thus, the aim was to shed light on health professionals’ moral reasoning and experience with regard to moral dilemmas surrounding abortion. In this article we report on the professionals’ views on the fetus and fetal moral status and how this is balanced with the right of the woman, and on the role and place of religion in professionals’ moral deliberations.