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Introduction: At the turn of the century, when the Millennium Development Goals placed maternal mortality reduction high on the global agenda, Ethiopia relaxed its restrictive abortion law to expand grounds on which a woman could legally obtain an abortion. This radical policy shift took place within a context of predominant anti-abortion public opinion shaped by strong religious convictions. Drawing upon Walt and Gilson’s policy analysis framework, this paper explores the tension between public policy and religious dogma for the strategies chosen by the Ethiopian Ministry of Health and its partners implementing the new policy, and for access to safe abortion services. Methods: The study employed a qualitative research methodology. It targeted organizations that are key stakeholders in the field of reproductive health. These included policy makers and policy implementers like ministries, UN agencies and international and national NGOs as well as religious organizations as key opinion leaders. The data collection took place in Addis Ababa between 2016 and 2018. A total of 26 interviews were conducted, transcribed, and analyzed using the principles of qualitative content analysis. Results: Our analysis showed that the implementing organizations adopted a strategy of silence not to provoke anti-abortion sentiments and politicization of the abortion issue which was seen as a threat to the revised law and policy. This strategy has facilitated a rollout of services and has improved access to safe abortion care. Nevertheless informants were concerned that the silence strategy has prevented dissemination of knowledge about the revised law to the general public, to health workers and to the police. In turn this has caused confusion about eligibility to legal and safe abortion procedures. Conclusions: While silence as a strategy works to protect the law enhancing the health and survival of young women, it may at the same time prevent the law from being fully effective. As a long term strategy, silence fails to expand awareness and access to safe abortion services, and may not sufficiently serve to fulfill the potential of the law to prevent abortion related maternal deaths.
This article reports on one of three country cases in the project entitled ‘Competing discourses impacting girls’ and women’s rights: The case of fertility control and safe abortion in Ethiopia, Tanzania and Zambia’. The Ethiopian case study analyzed here targeted organizations and institutions that are key stakeholders in the field of reproductive health acting as policy makers/advocates for policy change and implementers including ministries, international and national NGOs and UN agencies. Importantly, the study also included religious organizations as key opinion leaders in the field of reproductive health. We used a qualitative interview design to explore experiences and perceptions related to the law and its implementation. A total of 23 organizations were included in the study. Twenty six interviews (including three repeat interviews) were carried out by the four co-authors (22 interviews) and an MA student from the Department of Sociology, Addis Ababa University (AAU) (four interviews) in three rounds in Addis Ababa in November 2016, March 2017 and March–April 2018. We made a list of eligible ministries, UN agencies, international and local NGOs, professional associations and religious organizations that we wished to interview, and produced an interview guide and an information letter to explain the purpose of the study. A local gender specialist research assistant, who is centrally located in the field of reproductive health in Ethiopia, helped the authors in accessing the organizations and arranging appointments. She contacted the organizations first by phone and later by e-mail with the information letter and interview guide attached. Based on their responses, she developed an interview schedule for the team. Apart from a few that did not respond, the study participants were enthusiastic about sharing their experiences and perceptions of the law and its implementation. Altogether 23 organizations were included in the sample. The organizations interviewed include: Five ministries (Ministry of Health, Ministry of Education, Ministry of Justice, Ministry of Youth and Sports Affair, Ministry of Women and Children); three United Nations (UN) agencies (United Nations Population Fund (UNFPA), World Health Organization (WHO), UN Women); two professionals associations (Midwives Association and Ethiopian Society of Obstetricians and Gynecologists); one professor from School of Public Health, Addis Ababa University; four International NGOs (Engender Health, Pathfinder, IPAS, Marie Stopes International), four local NGOs (Family Guidance Association of Ethiopia (FGAE), Ethiopian Women’s Lawyers Association (EWLA), Organization for the Development of Women and Children in Ethiopia (ODWACE), Women Health Association of Ethiopia); five religious organizations (Ethiopian Inter-faith Forum for Development Dialogue and Action (EIFDA), Ethiopian Islamic Affairs Council, Ethiopian Evangelical Church, (EEC), Ethiopian Orthodox Tewahdo Church and Ethiopian Orthodox Tewahdo Church Development Commission- EOTCDC). Informants from FGAE, Pathfinder, and IPAS were interviewed twice (in 2016 and 2017) to follow-up emerging issues from the first round of interviews. The organizations had appointed one to three individuals to take part in the interviews. Twenty two of the interviews were conducted by pairs of researchers in English and usually took between 60 and 90 min. Four interviews were conducted in Amharic by a MA student supervised by first author G.T. All interviewees had read the information letter that was sent to the organization beforehand and consented to participate in the study. Among the 22 interviews conducted by the authors of this paper, 20 were audio recorded with the consent of the interviewees while two preferred not to be recorded and the interviewers wrote detailed notes. The recorded interviews were later transcribed verbatim by an experienced assistant. The four interviews conducted by the MA student were audio-recorded, transcribed and translated into English in a summarized form. The transcripts, the English summaries and the notes from the two interviews not transcribed were analyzed by the first authors assisted by the co-authors using the principles of content analysis. This process involved reading and re-reading the transcripts to become familiar with the data, coding the data material, identifying categories and defining themes drawing upon the perspectives of Shore and Wright [14] and the policy analysis frameworks of Walt and Gilson [15]. In order to protect the identity of the interviewees, individual statements have been anonymized, and the organization to which the person belonged is indicated only in categories. Exceptions to this rule are made when the name of the organisation is needed to make sense of the quote. The categories are ministries (MIN), UN agencies (UN), international NGOs (INGO), local NGOs (NGO), professional associations (PA) and religious organizations (RO). The project was approved by the Department of Sociology, Addis Ababa University, by each of the organizations included in the study, and by Norwegian Centre for Research Data (NSD project number 57089/3/00SIRH). Our analysis showed how different actors positioned themselves in the abortion landscape after the revision of the law, how they perceived the development after the law was passed, and how they developed strategies to protect their interest in the field. Silence was identified as a strategy used by actors on several levels, and below we describe how this was enacted and expressed, and what kinds of challenges this strategy implied for access to safe abortion services. Firstly, we look into the various improvements the law has spurred, as narrated by actors centrally situated in the field. Not surprisingly, the law was praised by many of our informants from the government and non-government sectors for being progressive and opening up different pathways to access safe abortion: The law is one of the progressive abortion laws in Africa. Although it is not on demand, more or less every woman who requests safe abortion can access the service. As much as possible barriers to services are reduced. (INGO) Not the least, the positive implications of the law for victims of rape were emphasized: Yes, that law has significantly changed the way clients are getting safe abortion services, said an informant from an International NGO. Prior to the revision of the law, the rape victim had to go through a long probation process in court and only if the court supported her case, would she be able to return to the clinic to terminate the pregnancy. In the meantime, the pregnancy advanced, making it more difficult and more risky to get an abortion. The clause in the present abortion law about the woman’s statement of rape or incest to qualify for abortion services was seen as critical for provision of timely services: ‘But now [that] the word of the client is enough, she doesn’t need to go to the court, to the police and so on, that makes it [the process] very rapid. (INGO) Likewise, stated age as qualification for age-based abortion was considered a vital tool to address unwanted pregnancy among young girls. The law and the guidelines also served to instruct and justify actions taken by health workers and were referred to as ‘our bible’ telling the health workers ‘on what level and on what criteria to provide the service’. (NGO) Access was also said to have improved because of the efforts of the government and non-government actors to enhance infrastructure, through expanding the number of health centres and midwives particularly in rural areas, and by task-shifting abortion care to mid-level professionals. Previously, it was a board of three physicians who had to approve the service, now one mid-level provider is enough and he/she does not have to be a doctor. The guideline has also eased requirements about who could provide safe abortion. In the past, it was the doctor’s job to carry out abortions (clandestine abortions not taken into consideration), but the guideline stipulates that mid-level providers (nurses, mid-wives, clinical officers) could provide both medical and surgical abortion. (INGO) One informant from the INGO sector described the developments in the following way: For a long time, abortion services revolved around the Marie Stopes clinics, the pioneer in providing safe abortion. But now it is provided in almost all health care institutions. I felt the difference between the time when I started my career ten years ago and now. Now, if you randomly go to a health centre, you can find that the service is being provided and, relatively speaking, the service providers are not being stigmatized as they were before. Therefore, abortion is becoming more acceptable. (INGO) A major impact of the liberalization of the law as experienced by the Ministry of Health and service-providing institutions was that septic abortions were almost done away with. ‘Previously we used to encounter highly complicated cases with severe infections, with injured organs and so on due to unsafe abortion’. (INGO). This change was demonstrated by the fact that hospitals around the country had closed their ‘septic rooms’ which had previously been used frequently for severe abortion complications. Echoing the above assertion, an official from the Ministry of Health also noted that maternal mortality due to abortion had gone down dramatically. These improvements in access to safe abortion care and health outcomes could not have been achieved without the revised law, but as one of our informants put it, ‘changing the law is not enough, changing the guideline is not enough’. (PO) The actors involved in implementing the law and the strategies they developed to extend services without attracting public attention in a predominantly anti-abortion environment seemed to be vital in this process. Although the resistance that arose in the law revision process was no longer loud, many of the proponents of a liberal abortion law and safe abortion services acknowledged the risk of backlash. In order to circumvent upheavals, they kept a low profile and avoided confrontation with groups that were displeased with the change in the law. Many of our informants noted that there is no public strategy on creating demand or advocating for safe abortion services since, as they told us, ‘public opinion is dominantly against abortion’. We don’t speak publicly about abortion, we don’t have any media intervention. If you go to the Ministry of Health, they don’t want to talk much about abortion, but do it silently. (INGO) For the same reason, most of the actors involved in reproductive health in the country also seem to have chosen not to frame abortion as a rights or gender issue, fearing that this would be counter-productive to their cause. Even though the guideline was, as mentioned above, framed in the language of gender and rights, the discourse chosen by government and non-government actors was that of public health and they packaged their messages very carefully: We don’t directly talk about abortion law, we don’t confront religious groups. Even when they have negative speeches, we don’t want to respond directly. We seek opportunity to speak about the magnitude of unsafe abortion packaging the message. We talk about reproductive health, we talk about maternal mortality and we go in detail about the causes of maternal mortality, then people start to talk about unwanted pregnancy and then they talk about unsafe abortion, these are our approaches at the community level. (INGO) Hence the entry point to conversations in the community was reproductive health and the terms used by the actors to discuss unwanted pregnancy and abortion with the community were carefully chosen in an attempt to make the messages culturally sensitive and encourage people to talk about sexuality and reproduction. We don’t promote abortion because the nation is a very conservative society, people don’t talk openly about sexuality. We don’t use the word abortion in Amharic, rather pregnancy termination (Tsense Maquaret). The word abortion itself is stigmatizing, the Amharic equivalent is Wurja, literally meaning abortion, but we don’t use this term. (INGO) Because of the sensitive nature of the topic, awareness creation about the guideline was very limited. As one informant commented: We cannot gather people and tell them this is the new guideline; it is difficult to share the guideline with the media. We focus on practical ways of addressing demand, if we openly talked about it, it may backfire. (INGO) Our informant from the Ministry of Health also endorsed this argument and said that they don’t talk about the law. For example, if you are looking at South Africa it is legal but the service is very limited. Here in Ethiopia, the providers are doing it quietly.… keeping silent made the resistance less. They don’t say anything in public…. The commitment of the ministry is to do that silent work. We are very supportive, silently. (MIN) An informant from a UN organization reiterated the importance of working quietly. She said that they don’t carry out promotion or activism at the community level or through media about where abortion is available and how it is provided. If we do a promotion activity or activism, the resistance will come especially from the conservative part of the population, religious people will rise. As it is, we are getting the results we want, so I don’t see the need for any more promotion or activism. (UN) The organizations working to increase access to safe abortion services, based on the provisions of the law, expressed very clearly that the aim of the silent approach they had chosen was to protect the law. As argued by one of these organizations’ representatives: We work to protect the law. Unless we protect the law, there might be some opposition groups from abroad or from inside the country. We scan the environment; we have regional abortion technical groups in four major regions, five or six persons from different fields. So we scan the media, events and we also scan different speeches and document that. We analyze it and if it has continuity, we see it together with our partners and plan for a strategy on how to respond. (INGO) At present, there seems to be little opposition to the law. Anti-abortion, or pro-life groups as they commonly call themselves, though registered with a home-page on the internet, show very little activity. This was confirmed by our informants: ‘We have not that much strong opposition like other African countries such as Kenya, Nigeria and Tanzania where funds from abroad create strong opposition’ (INGO) and as summed up by one of our informants: ‘The silence is the secret behind the success’. (INGO). A major concern for organizations working to extend safe abortion services to eligible girls and women, as defined by the law, was not to provoke anti-abortion sentiments and public reactions, including reactions from religious leaders. An important question was how this strategy was met by religious leaders. Our informants from religious organizations did not speak directly about the process of revising the law, but they did demonstrate their resistance to the law in very specific ways. When asked about his knowledge of the law, one religious leader from EOTC admitted that he did not know the law very well, but he nevertheless rejected it: I do not have awareness of the abortion law. The government can pass whatever law and it can also do whatsoever possible to enforce the law, but it cannot force the church to change its firm position against abortion. According to the EOTC, abortion is completely prohibited and it should not be allowed. No one can force the church to change this firm stand, because the church has long been autonomous and respected. The church is governed by the resolutions of the synod, not by the law of the government. My knowledge of the law, therefore, does not change anything. (RO) An Islamic religious leader made a similar statement: ….I think abortion is allowed by the law. No matter what the law says, we do not ask why it is allowed. The government makes laws and as a religious organization we have our own perspectives about it, and our perspectives about abortion are as mentioned thus far [it is a sin and should not be permitted]. … Abortion should not be regarded as a matter of women’s rights, as the life of the mother and that of the child both belong to Allah….. The Ethiopian Islamic Affairs Council has not rejected the law, but gives recognition to only one ground on which abortion can be provided- to save the life of the mother. (RO) Interestingly, this Islamic leader admitted that his organization has not rejected the law officially. In the same vein, the Ethiopian Evangelical Church (EEC) did not officially reject the law. As one of the leaders stated: I have awareness of the newly revised abortion law. There is no official stand by the EEC concerning abortion. No official stand means we have not objected to the law, and it may also imply that the church has reservations about it. The law should not be regarded as an opportunity for women to practice their rights to terminating an unwanted pregnancy. The life of the fetus has a divinity connotation. God created humans and the life of human being is honorable. Terminating this life is only the sole right and power of God. Abortion is a breach of the relationships between God and his creatures and the power interplay between man and God. Breaching these relationships by man is a sinful act. Therefore, a woman should not simply jump into making decision to terminate pregnancy, she should think time and again before making this decision. (RO) Even though all the religious organizations included in our sample had a very clear stand against abortion, they had not voiced their opposition to the law officially after its enactment, and did not seem to foster a political debate to restrict the law. Their strong stand against abortion as a violation of God/Allah’s commandments was communicated through priests and sheiks down to the community level but did not seem to result in a confrontational strategy vis a vis the federal law. The limited public debate and limited voiced opposition against the law indicated above, were seen as closely linked to the silent approach adopted by the actors working to secure access to safe abortion services within the law. While this strategy seems to have worked effectively in terms of preventing confrontation, its limitations are clear. The silence has also hindered the law and its guidelines from becoming known. Women, especially in rural areas or in regional towns, therefore lack knowledge about the law and have little access to information that safe abortion services are available through the health system. In a situation where abortion is surrounded by societal silence, religious actors can, within their own domain, pursue a discourse on abortion as a sin and as a moral transgression, meeting very little opposition. According to our informants, women tend to believe that ‘abortion is illegal on all grounds’ and do not know where to seek help if they experience an unwanted pregnancy. Hence, as emphasized by some informants, safe abortion services offered through public health services at primary care level still tend to be under-used because of lack of knowledge, especially in rural areas. One of our informants from an INGO told us: There are recently conducted studies on abortion stigma and we were trying to investigate community-level barriers to women’s access to safe abortion services. We asked the women if they knew about the abortion law of the country and only 48% knew about the law. However, when we go deep down and ask them some of the broad indications of the abortion law, only very few of them knew about the provision. Therefore, information about the abortion law is not widely disseminated to the women though it has progressed over the past ten years. (INGO) Lack of information about the law was voiced as a problem not only for potential service users but also for health care professionals including midwives, physicians and nurses. Among the health professionals themselves, there is misunderstanding about the law, a representative from a professional organization told us. That is why the nurse said to a girl [a victim of rape] who appeared for safe abortion and related service, “I will take you to the police”[to report the case]. (PA) Our informant from a local NGO also noted: We still are witnessing the fact that some service providers do not know the conditions and the entitlements of young people for the services. The challenge now is that many young people are not getting enough information on policy and technical procedural guidelines. We should not be very much deceived by what we see in Addis. A good number of young people are lacking information about this in the country. (NGO) The same lack of knowledge about the law was seen among other civil servants. According to informants in the NGO sector, even the police and others in the criminal justice system lack knowledge about the law and the procedural guidelines. We experienced this knowledge gap ourselves, when interviewing a high-level official from the Ministry of Justice who demonstrated lack of awareness about the amendment in the law and said that a woman’s word that she was raped is not sufficient to qualify for abortion. He said: If a woman is raped, she should report to the police station to get safe abortion service. If she goes directly to the health facility for abortion purpose without reporting to the police, she can’t get the service…. She should report to the Ministry of Justice or police to make an investigation. Then, the abortion process will start after the prosecutors prove that she is raped. If health care facilities provide an abortion based on the word of a woman, it is not the proper way. (MIN) The limited information of the law seemed to reinforce an anti-abortion sentiment among health workers and the public alike, and was seen to sustain the stigma associated with abortion and abortion providers. The silent strategy was not considered helpful in addressing this problem since ‘it is difficult to fight stigma without talking about it’. Health workers trained in safe abortion care and deployed in their rural home area commonly experienced stigma and found it difficult to provide the services. As an informant from the INGO sector explained to us: People can easily identify them as abortion care providers and they say a lot of things about them like ‘you are the baby killer’. Some even go to their husband and wife and they might hear it. They sometimes come on [confront] them by their religion by claiming it is against religion. (INGO) The role of health workers as gate keepers to safe abortion services was an issue that was raised by several actors. According to our informants from the service-providing organizations, some providers and facilities resist giving safe abortion services since it goes against their religion and their professional ethos of saving lives. Hence they use their discretionary power to deny services. They make their own judgment and when they feel that she [the woman seeking abortion services] might not be telling them the truth, they may say ‘you don’t qualify for the service and we will not give you’ [the service]. (INGO) Rather than denying the abortion seeker services altogether, some health workers would, according to the same informant, avoid providing abortion services by suggesting an alternative procedure: Some advise the client to go and buy medication abortion and return [for post abortion care] if they see bleeding. (INGO) In this way the health worker would assist the woman and provide post abortion care to ensure health and survival without playing an active part in inducing the abortion. This strategy would be easier to defend before God as well as the community. The service-providing organizations that we talked to were troubled by the problems of disseminating knowledge and creating awareness of the guideline: ‘Because of its sensitive nature, advocacy is not being done. We cannot gather people and tell them this is the new guideline; it is difficult to share the guideline with the media’. (INGO) Accordingly, dissemination mainly takes place through training of health workers who receive a copy of the guideline and take it home to share with their colleagues. According to one of our informants in the INGO sector a major problem is that the law is included in the criminal code: The law becomes a hindrance in itself. We have asked for safe abortion rooms in the region where we are working, but they refused because the law didn’t allow it since it has some prohibitions. If you open up a safe abortion room or publicly announce about it, people assume that you are encouraging it. (INGO) The ambiguity of the law and the lack of knowledge and public debate about it was also said to hinder documentation of abortion services: The hidden nature and restrictions make it difficult to have national data. I have seen a receipt of an acquaintance who accessed abortion services in a private hospital and it reads medical check-up. I do not know about government hospitals, but in the private ones it is hidden – they don’t write explicitly. (UN) The commitment of the government to take responsibility for the roll-out of services into rural areas was also questioned. Some informants were concerned that in this highly conservative religious and cultural context ‘the government is reluctant to promote safe abortion and decentralize the agenda’. It was observed that the abortion issue was commonly avoided in the regional health system review and planning meetings and hence ‘they will not be able to allocate budget for abortion care service’. (INGO) Availability of the service out of urban centres was seen as a continued problem: ‘the services should be available at the health centre level but only a few of them are providing the services. The law is here, but it is up to the NGOs to expand the services’. (INGO) From our informants in the NGO sector we learned that international NGOs and UN agencies supported implementation of the law and the roll-out of services in a variety of ways. The assistance ranged from providing material support for abortion and post-abortion care services, training public sector health workers in clinical abortion and post-abortion care skills, operating private clinics to supplement public services (in the case of FGEA and Marie Stopes) or supporting local governmental and non-governmental organizations working on safe abortion. The lack of information reaching potential service users has been acknowledged by the Ministry of Health, and the revised guidelines of 2014 took a new step in strengthening awareness of the law and access to services into the rural areas through the health extension programme. According to one of our UN informants, health extension workers now give information not only about access to safe abortion services but also ‘on legal issues like if she [the woman] goes to the health centres she needs to present reasons for abortion’. (UN) This was regarded as an important step in strengthening access because presenting a reason that is outside the provisions of the law would exclude the woman from obtaining safe abortion services.
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