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Introduction: Unsafe abortion is a major contributor to the continued high global maternal mortality and morbidity rates. Legal abortion frameworks and access to sexuality education and contraception have been pointed out as vital to reduce unsafe abortion rates. This paper explores the relationship between abortion law, policy and women’s access to safe abortion services within the different legal and political contexts of Ethiopia, Tanzania and Zambia. The research is inspired by recent calls for contextualized policy research. Methods: The research was based in Addis Ababa (Ethiopa), Dar es Salaam (Tanzania) and Lusaka (Zambia) and had a qualitative exploratory research design. The project involved studying the three countries’ abortion laws and policies. It moreover targeted formal organizations as implementers of policy as well as stakeholders in support of, or in opposition to the existing abortion laws. Semi-structured interviews were carried out with study participants (79) differently situated vis-à-vis abortion, exploring their views on abortion-related legal- and policy frames and their perceived implications for access. Results: The abortion laws have been classified as ‘liberal’ in Zambia, ‘semi-liberal’ in Ethiopia and ‘restrictive’ in Tanzania, but what we encountered in the three study contexts was a seeming paradoxical relationship between national abortion laws, abortion policy and women’s actual access to safe abortion services. The study findings moreover reveal that the texts that make up the three national abortion laws are highly ambiguous. The on-paper liberal Zambian and semi-liberal Ethiopian laws in no way ensure access, while the strict Tanzanian law is hardly sufficient to prevent young women from seeking and obtaining abortion. In line with Walt and Gilson’s call to move beyond a narrow focus on the content of policy, our study demonstrates that the connection between law, health policy and access to health services is complex and critically dependent on the socio-economic and political context of implementation. Conclusions: Legal frameworks are vital instruments for securing the right to health, but broad contextualized studies rather than classifications of law along a liberal-restrictive continuum are demanded in order to enhance existing knowledge on access to safe abortion services in a given context.
Our research was based on qualitative exploratory research and had a cross-country comparative design. It involved studying 1) the historically and contextually embedded content of abortion law and policy, and 2) abortion-related policy processes through the exploration of ideas, positions and practical engagement in abortion-related work by actors within the field. A review of central law and policy documents from the three countries was carried out in 2016–18. In addition, qualitative interviews were carried out with actors differently positioned within the field of abortion. This approach is well aligned with the classical call for ‘studying up’ in anthropology [39, 40], i.e. studying the views of powerful actors located in bureaucratic positions, in our case actors within ministries, NGOs and religious organizations. Six out of seven co-authors (AB, KMM, HH, GT, RS, MH) took part in at least one of four interview rounds with key stakeholders in Ethiopia, Tanzania and Zambia in 2016 and 2017. The article also draws upon abortion-related material generated in SAFEZT sub-studies by two of the co-authors (RS and MH). Through discussions in the research team key policy institutions, organisations and actors within the field of abortion were identified within each of the three study contexts. Recognizing the important part played by actors beyond the government structure in policy making and implementation, we recruited actors from a broad spectrum of organizations and institutions. These included ministries, non-governmental organizations, UN agencies, professional associations and religious organizations representing diverse positions in the abortion debates. The list was expanded during the course of the research. By and large parallel organizations were recruited in the three countries (cf table table22 below). However, as it was deemed vital to represent different positions and prominent voices in the abortion debates in the individual countries, there is also a certain variation. We interviewed a total of of 79 individuals within the following categories: ministries (MIN), religious organisations (RO), non-governmental organisations (NGO), international non-governmental organisations (INGO), UN agencies (UN), professional organisations (PO), health workers (HW), journalists (J) and others (O). See table below (Table (Table2).2). In the manuscript we refer to the various actors using these abbreviation with Z for Zambia, E for Ethiopia and T for Tanzania. Overview of categories of actors included in the study A formal invitation letter was sent to the selected institutions/organisations. Nearly all individuals or organizations that were contacted agreed to take part in an interview, and some were re-interviewed after a year. The study participants were informed about the project in writing by email prior to the fieldwork and at the onset of the interview. Information was also provided about key research ethical principles. Written or oral informed consent was secured from all study participants. The study received ethical clearance from Regional Ethical Committee Western Norway, Norway (2017/1191) and data management clearance from Norwegian Centre for Research Data (57089/3/00SIRH); ethical clearance from the University of Zambia Biomedical Research Ethics Committee (009-07-17) and National Health Research Authority in Zambia (MH/101/23/10/1 and research clearance and registration from the University of Dar es Salaam (CoSS- SO18011). In Ethiopia the research was carried out following social science research procedures at Addis Ababa University. The interviews were carried out in English and were guided by semi-structured and flexibly monitored interview guides. The informants were, by and large, articulate and actively engaged in the discussions. The topics raised included abortion policy, the role and activity of their organisation within the field of abortion, perceptions on their country’s abortion law and policy as well as on girls’ and women’s access to safe abortion services in their country. Most reflected critically on the topics raised. The interview material was audio recorded, transcribed and analyzed throughout the data collection phase and during shorter intervals following each phase, with a comparative analysis taking place at the end of the data collection. During the comparative phase a full review of the material took place to gain an overview and to identify major patterns, including cross-cutting, contrasting or contradictory themes emerging in the material. The review was followed by the manual coding of the entire data set. Central content was subsequently moved into a separate document under headings which reflected the various dimensions of the main emerging themes. This document formed the basis for further analysis and write up of the material. The team consisted of Ethiopian, Tanzanian, Zambian and Norwegian researchers, all employed at departments of social science or public health at national universities. All co-authors have substantial experience from long-term ethnographic research, primarily from research with a ‘reproductive health’ focus from eastern and southern Africa.
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