Regional and residential disparities in knowledge of abortion legality and availability of facility-based abortion services in Ethiopia

  • Contraception: X, Volume 3, Year 2021

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Study Justification:
The study aims to provide regional, residential, and nationally representative estimates of knowledge of abortion legality and availability among women of reproductive age in Ethiopia. This is important because understanding the level of knowledge in these areas can help identify disparities and inform efforts to improve access to safe abortion care. By examining how knowledge varies across regions and urban/rural residence, the study can shed light on potential geographic inequities in access to and use of safe abortion care.
Highlights:
– The study found significant regional and urban/rural disparities in knowledge of abortion legality and availability in Ethiopia.
– Nationally, only 27% of women are aware of the abortion law, and just 5% have comprehensive knowledge of the law.
– Knowledge of facility-based abortion service availability is even lower, with only 30% of women knowing where to access these services.
– Regionally, there is a wide range of estimates, with general awareness of the law ranging from 2% in Somali to 45% in Addis Ababa, comprehensive knowledge of the law ranging from 0% in Afar to 27% in Harare, and knowledge of abortion availability ranging from 8% in Afar to 57% in Tigray.
– Knowledge of all measures is higher in urban areas compared to rural areas.
Recommendations:
– Efforts to expand knowledge of abortion legality and availability are needed in Ethiopia.
– These efforts should be tailored to regional contexts, taking into account the specific knowledge gaps and disparities identified in the study.
– Improving knowledge of abortion legality and availability is crucial for protecting and expanding access to safe abortion care, especially in a context like Ethiopia where abortion is available for multiple indications.
Key Role Players:
– Ministry of Health: Responsible for implementing and coordinating efforts to improve knowledge of abortion legality and availability.
– Regional Health Bureaus: Play a key role in tailoring interventions to address regional disparities and ensure effective implementation at the local level.
– Non-governmental Organizations (NGOs): Can provide support and resources for awareness campaigns, education programs, and community outreach initiatives.
– Health Workers: Act as key intermediaries in disseminating accurate information and providing counseling on abortion legality and availability.
– Community Leaders and Advocacy Groups: Can help raise awareness, reduce stigma, and promote accurate information about abortion.
Cost Items for Planning Recommendations:
– Development and printing of educational materials: Including brochures, posters, and pamphlets to disseminate information about abortion legality and availability.
– Training programs for health workers: To ensure they have accurate and up-to-date knowledge to provide counseling and support to women seeking abortion services.
– Awareness campaigns: Including media advertisements, community events, and outreach activities to raise awareness and reduce stigma surrounding abortion.
– Monitoring and evaluation: To assess the effectiveness of interventions and make necessary adjustments.
– Collaboration and coordination: Budget items to support collaboration between different stakeholders, such as workshops, meetings, and coordination activities.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a nationally representative, cross-sectional survey with a large sample size. The study design and survey administration are described in detail, and the data collection process is well-explained. The study received ethics approval from reputable institutions. The authors used appropriate statistical analyses to generate nationally and regionally representative estimates. However, to improve the evidence, it would be helpful to provide more information on the survey questions used to measure knowledge of abortion legality and availability, as well as the specific statistical tests used to assess regional and urban/rural differences. Additionally, including information on the response rate and any potential limitations of the study would further strengthen the evidence.

Objectives: To generate regional, residential, and nationally representative estimates of knowledge of abortion legality and availability among women of reproductive age in Ethiopia, and examine how knowledge varies across regions and by urban/rural residence. Study Design: Our study draws on data from a nationally representative, cross-sectional survey implemented in 2019 in each of Ethiopia’s regional and administrative states, yielding a sample of 8,837 women aged 15 to 49. We compare weighted estimates and regional distributions of 3 outcomes: (1) general awareness and (2) correct knowledge of the abortion law, and (3) knowledge of facility-based abortion service availability. Results: Significant regional and urban/rural disparities in knowledge of abortion legality and availability exist. Nationally, 27% of women are aware of the abortion law and just 5% of women have comprehensive knowledge of the law, while 30% know where to access facility-based abortion services. Regionally, estimates range significantly, from 2% in Somali to 45% in Addis Ababa for general awareness of the law, 0% in Afar to 27% in Harare for comprehensive knowledge of the law, and 8% in Afar to 57% in Tigray for knowledge of abortion availability. Knowledge of all measures is higher in urban than in rural areas. Conclusions: Regional disparities in abortion knowledge may contribute to geographic inequities in access to and use of safe abortion care. Efforts to expand knowledge of abortion legality and availability are needed and should be tailored to regional contexts. Implications: Knowledge of abortion legality and availability is imperative to protecting and expanding access to safe abortion care, especially in contexts like Ethiopia where abortion is available for multiple indications. Efforts to improve knowledge of abortion legality and availability are needed, and should be locally tailored to address regional inequities.

Our study draws on data collected by Performance Monitoring for Action (PMA) Ethiopia. PMA Ethiopia is a 5-year project implemented collaboratively by Addis Ababa University (AAU) and Johns Hopkins University (JHU). PMA Ethiopia conducts nationally representative surveys measuring a range of key reproductive, maternal, and newborn health indicators. The study design and survey administration have been described in detail elsewhere [19]. Data come from a cross-sectional survey of women aged 15 to 49, collected from October through December 2019. A 2-stage cluster sampling design was used, and data were collected in each of 9 regional states and 2 administrative states. A total of 265 geographic enumeration areas (EAs) were selected by the Central Statistical Agency, and a cross-section of 35 households were selected randomly within each EA. Women were eligible to complete the survey if they were aged 15 to 49 years, lived within the selected EA boundaries, and slept in the selected household the night prior to the survey. Participants provided oral informed consent. Altogether, 8890 women from 9202 households participated in the female survey, with a response rate of 98.4%; our final analytic sample included 8837 women from whom we had complete data on the outcomes of interest (knowledge of abortion legality and availability), as well as current contraceptive use. The study received ethics approval from the JHU and AAU Institutional Review Boards. Our 3 dependent variables comprised (1) general awareness of abortion legality, (2) comprehensive knowledge of the national abortion law, and (3) knowledge of facility-based abortion service availability. We assessed awareness and knowledge of the abortion law using responses to 2 survey questions. First, we asked participants if they knew about a law regulating abortion in Ethiopia. Per the definition used by Assifi et al. in their systematic review on women’s knowledge of abortion laws, we consider this question to measure women’s general awareness of abortion legality [2]. Women who replied affirmatively were then asked to indicate under which circumstances it is legal to have an abortion in Ethiopia. The response options were read aloud to participants and included: (1) rape, when the (2) pregnancy poses a risk to the life of the woman and/or fetus (risk to the woman), (3) fetus has been diagnosed with an incurable disease or serious deformity (fetal impairment), (4) pregnant woman is incapacitated, or physically/mentally unfit to be a mother (maternal disability), and (5) under no circumstances. We used women’s responses to these items to measure comprehensive knowledge of the abortion law. We examined binary measures of knowledge of each specific legal ground, knowledge of any legal ground, and whether the respondent had comprehensive knowledge of the law (i.e., correctly identified that abortion is legal under the 4 circumstances indicated).1 Women who reported that abortion is not legal under any circumstances are not included as having comprehensive knowledge. Finally, a binary measure of knowledge of facility-based abortion service availability was assessed by asking women, “Do you know where a woman can access facility-based abortion services in the community where you live?” (Yes/No). These questions were asked to all women who completed the survey, regardless of age, marital status, or reproductive history. Our primary independent variables were region, comprising Ethiopia’s 11 regional and administrative states: Addis Ababa, Afar, Amhara, Benishangul-Gumuz (BG), Dire Dawa, Gambella, Harare, Oromiya, Southern Nations, Nationalities, and People’s Region (SNNP),2 Somali, and Tigray, and urban and/or rural residence. We first explored sample characteristics and calculated prevalence estimates by region and urban and/or rural residence, assessing differences in women’s awareness and knowledge of abortion legality and facility-based abortion availability. We then examined bivariate distributions of regional and urban/rural residence by women’s general awareness of the abortion law, knowledge of specific legal grounds, comprehensive knowledge of the abortion law and knowledge of facility-based service availability; statistical differences between regions and residence were assessed via one-way ANOVA tests and design-based F statistics, respectively. Finally, we examined the relationship between knowledge of legality and availability by assessing knowledge of facility-based abortion service availability among women who correctly reported at least 1 legal ground for abortion, and vice versa. We used design-based analyses to account for the complex sampling design, including accounting for clustering of women within EAs and applying survey weights to account for differential probability of selection, in order to generate nationally and regionally representative estimates. We did not further account for clustering of responses within households as all women in the household share the same probability of selection. As there was slightly fewer than 1 woman (0.98) per household among all sampled households, there was not significant evidence of clustering within households. We analyzed data using Stata 16.1 (Statcorp LP, College Station, TX).

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Based on the information provided, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services that provide accurate and up-to-date information on abortion legality and availability, as well as facility-based abortion services. These tools can be easily accessible to women in both urban and rural areas, helping to bridge the knowledge gap.

2. Community-Based Education Programs: Implement community-based education programs that focus on raising awareness and knowledge of abortion legality and availability. These programs can be tailored to specific regional contexts, taking into account cultural and social factors that may influence perceptions and understanding of abortion.

3. Telemedicine Services: Establish telemedicine services that allow women to consult with healthcare providers remotely, particularly in areas where access to healthcare facilities is limited. This can provide women with information, counseling, and support regarding abortion services, ensuring they have the necessary knowledge to make informed decisions.

4. Training and Capacity Building: Invest in training and capacity building programs for healthcare providers in regions with low knowledge of abortion legality and availability. This can help ensure that healthcare providers are knowledgeable about the law and can provide accurate information and services to women seeking abortions.

5. Partnerships and Collaboration: Foster partnerships and collaboration between government agencies, non-governmental organizations, and community-based organizations to collectively address the regional disparities in knowledge of abortion legality and availability. By working together, these stakeholders can develop comprehensive strategies and interventions to improve access to maternal health services.

It is important to note that the implementation of these innovations should be context-specific and take into account the unique needs and challenges of each region in Ethiopia.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health would be to develop targeted interventions to expand knowledge of abortion legality and availability, specifically tailored to regional contexts in Ethiopia.

These interventions should focus on increasing general awareness of the abortion law, comprehensive knowledge of the law (including knowledge of specific legal grounds), and knowledge of facility-based abortion service availability.

Efforts should be made to address the significant regional and urban/rural disparities in knowledge that currently exist. This could involve implementing educational campaigns, community outreach programs, and training for healthcare providers to ensure accurate and up-to-date information is disseminated.

Additionally, collaboration between organizations such as Performance Monitoring for Action (PMA) Ethiopia, Addis Ababa University (AAU), and Johns Hopkins University (JHU) can be strengthened to support the development and implementation of these interventions.

By improving knowledge of abortion legality and availability, access to safe abortion care can be protected and expanded, ultimately reducing geographic inequities in maternal health outcomes.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase awareness campaigns: Develop and implement targeted awareness campaigns to educate women of reproductive age about the legality of abortion and the availability of facility-based abortion services. These campaigns should be tailored to regional contexts and address the specific knowledge gaps identified in the study.

2. Strengthen regional healthcare systems: Invest in strengthening healthcare systems at the regional level to ensure that facility-based abortion services are accessible and available. This may involve improving infrastructure, training healthcare providers, and ensuring the availability of necessary equipment and supplies.

3. Enhance community engagement: Engage local communities and community leaders in promoting knowledge and awareness of abortion legality and availability. This can be done through community meetings, workshops, and partnerships with local organizations to address cultural and social barriers that may hinder access to maternal health services.

4. Improve data collection and monitoring: Enhance data collection and monitoring systems to track knowledge levels and access to maternal health services over time. This will help identify areas of improvement and measure the impact of interventions.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline assessment: Conduct a comprehensive assessment of the current knowledge levels and access to maternal health services in different regions and urban/rural areas. This can be done through surveys, interviews, and data analysis.

2. Intervention design: Develop interventions based on the identified recommendations, taking into account regional contexts and specific knowledge gaps. These interventions should be evidence-based and tailored to the needs of the target population.

3. Implementation: Implement the interventions in selected regions or communities, ensuring proper coordination and collaboration with relevant stakeholders, including healthcare providers, community leaders, and local organizations.

4. Data collection: Collect data on the impact of the interventions, including changes in knowledge levels, utilization of maternal health services, and any other relevant indicators. This can be done through surveys, interviews, and monitoring systems.

5. Analysis: Analyze the collected data to assess the impact of the interventions on improving access to maternal health. This may involve comparing pre- and post-intervention data, conducting statistical analysis, and evaluating the effectiveness of the interventions.

6. Evaluation and adjustment: Evaluate the results of the analysis and make any necessary adjustments to the interventions. This may involve refining the interventions, scaling up successful approaches, or addressing any challenges or barriers that were identified during the implementation phase.

7. Continuous monitoring and improvement: Establish a system for continuous monitoring and improvement to ensure sustained progress in improving access to maternal health. This may involve regular data collection, ongoing evaluation of interventions, and adapting strategies based on emerging needs and challenges.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions for future interventions and policies.


Identifiers:
DOI: 10.1016/j.conx.2021.100066
Research Areas:
Community Interventions, Disability, Disparities, Health System and Policy, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Violence and Injury
Study Countries:
Ethiopia
Study Design:
Cross Sectional Study
Study Approach:
Mixed-methods, Quantitative, Systematic Review
Participants Gender:
Female
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