In sub-Saharan Africa, deaths from unsafe abortions have been steadily increasing since the 1990s [6], and the proportion of unsafe abortions in maternal deaths is estimated at 30% [7]. Young women from low-income countries, and especially young people living in rural areas, are disproportionately represented in the statistics [4], making unsafe abortions a huge problem of inequality. Despite the scale and severity of the challenge, the controversial nature of the issue has pushed abortion to the margins of the global health agenda, making it one of the most neglected sexual and reproductive health issues in the world today [8]. Surrounded by stigma and neglect, the high rate of unsafe abortions has been called a “silent pandemic” [9]. Lack of access to safe and legal abortion is a major cause of unsafe abortion in many countries [8], but moral and religious issues hinder political commitment and legal reforms needed to address the problem. But one of the main reasons women don`t get abortions safely is that most Ethiopians live in even less accessible places than Mosebo, which sits on a bumpy gravel road that stretches 43 km to the northern city of Bahir Dar. It is extremely difficult to get to a health facility that offers abortion care. The Ethiopian government, public health experts and civil society know that legal and safe abortion care is essential to saving lives. But the Trump-Pence administration`s expanded Global Gag Order (GGR) rule has undermined Ethiopia`s progress in reducing maternal mortality from unsafe abortions by excluding essential providers from U.S. global health funding. In 2005, Ethiopia`s abortion law was liberalized, which legalizes induced abortion after rape or incest when the woman`s life or physical health is in danger, when she is physically or mentally disabled, or when she is a minor (under 18 years of age).
In addition, abortion with fetal impairment is legal [6, 7]. Women of reproductive age in three selected lower districts of Bahir Dar, in northwestern Ethiopia, were included. Simple multi-level random sampling and simple sampling were used to select districts and respondents, respectively. The data were collected using a structured questionnaire that included questions on knowledge and attitudes regarding the legal status of abortions and cases where abortion is currently legally permitted in Ethiopia. Descriptive statistics were used to summarize the data and multivariate logistic regression, which was calculated to assess the extent and importance of associations. In addition to the practical challenge of obtaining signatures, it was pointed out that the process of obtaining signatures for INGOs involved in the practice of abortions was extremely expensive. It was taken into account that this requirement severely restricts access to safe abortion services; Access is very difficult, especially for poor and rural girls (INGO Z). Ministry informants stressed that the serious challenge of access to abortion services was valid beyond rural areas, one of them explained; In fact, it`s not just (difficult in) rural areas. I mean, the facilities closest to women are clinics and health centers, and they barely have a doctor to support the facility (MIN Z). The new law ended the legalization of abortion and decriminalized it. It also allows women to terminate a pregnancy resulting from rape or incest if the fetus has a serious abnormality or if a girl is under 18 years of age and cannot take care of the baby herself. Before 2005, a woman could only have an abortion when it came to life or death.
What we have seen is a relationship between abortion policy and access scenarios that has proven paradoxical, where an inherent aspect of ambiguity and disorder has opened up to a significant degree of political pragmatism. We found that even the most conservative and restrictive contexts, to some extent, ultimately allowed or operated pathways to abortion services. We have met with governments that tacitly accept that secret abortion services are being exploited; Governments that do not systematically persecute illegal abortion seekers, abortion providers or sellers of illegal abortion drugs, and religious leaders who have refrained from fighting the liberalization of the law. These paradoxical scenarios all point to a pragmatic approach to the implementation and enforcement of abortion policies. The momentum at work shows that policymakers, religious leaders and other key actors in the field are pragmatically maneuvering between ways to relate to a highly stigmatized public health challenge that causes suffering and death to large numbers of girls and women in their communities, and their own desire to remain morally clean. The conflict between the strong public condemnation of abortion, which can be found at all levels in the three countries, and the pragmatic attitude towards the flaws in the system is mainly pronounced by the rapid increase in the availability and accessibility of medicines for medical abortions [49]. Tanzania`s abortion law has remained very restrictive, as the Penal Code stipulates that abortion is legally permitted if it is performed to save a woman`s life [35]. However, unlike complicated procedures in Zambia, which require the signature of three doctors, including a specialist, Tanzania`s abortion law does not specify the amount of the provider who can decide on eligibility. In practice, an intermediate-level health worker, such as a midwife, can perform an abortion without consulting others [42].
Efforts to liberalize the law met with strong opposition and the last attempt in 2012 failed. As in Lusaka and Addis Ababa, a number of NGOs and UN organizations are working to expand safe abortion and post-abortion care (PAC) services to women and girls in a political and cultural context against abortion. The NGO representatives we interviewed said that the law should be changed because of the impact of the large number of unsafe abortions; I think the law should be revised, we have seen the negative side (of the law) for too long. They should both review sex education in schools and consider legalizing safe abortion. Mmmh, – this does not mean that abortions would be encouraged, but we will have to face the reality; People have abortions, it happens on a large scale. (INGO T). Another informant explained the same thing; We need to change the law, I think, because. You know that within the health services, you often interact with clients who have ordered an abortion, and they have come to you to provide services, so I think the law needs to be changed (INGO T). As noted at the beginning of this article, Wedel et al. [16] and Shore et al. [18] criticize the way political studies have often portrayed politics as orderly, omitting clutter, unpredictability, and disorderly elements of political processes. Our material addresses the messy and rather confusing articulation between law, politics and practice, a chaotic scenario with implications for access.
In the case of abortion policy and practice, the key dynamic behind the disorder is related to the fundamental dilemma of recognizing that induced abortions are performed, regardless of the law, and thus allowing for the existence of arenas where abortions can take place invisibly and relatively safely without having to take a morally impossible position to publicly fight for the right to legal abortion. While Tanzanian law and political discourse signal a very conservative and restrictive abortion scenario, our informants simultaneously communicated what turned out to be very real pathways to relatively safe abortion services, particularly in Dar es Salaam and other major cities. Lawsuits against girls or abortion providers could be encountered, but in terms of abortion rates, prosecutions proved to be extremely rare. In fact, informants from the NGO sector generally felt that abortions in the country would not be prosecuted; There are no convictions, no one persecutes and no one reports it. If people do not report, the law becomes inactive (T INGO). Under the guideline`s concept of “women-centred care,” eligible women have the right to access abortion services within three days of contact with health services. Most importantly, the additional clauses that the woman`s statement about rape or minors is sufficient to provide safe abortion services have fostered the understanding among many of our informants that abortion is almost allowed or legal; At this point, we are not thinking about the restriction [in the law that restricts safe abortion services]. This is indeed allowed (NGO E). Despite the fact that abortion is legal in the United States and an internationally recognized right, U.S. policies such as the global gag rule threaten the availability of safe abortion care for women and girls around the world. Through our advocacy and research, PAI advocates for the permanent repeal of the policy by arming our allies in Congress with direct evidence of its devastating effects.
We also help our global partners navigate this complex policy and support fellows who work with their own governments to make their health systems less dependent on foreign aid and the resulting harmful policies. A pragmatic approach to reporting abortions within the health care system has been communicated in the same way, one source said; In hospitals, when they come, even if you find out that this person has had an abortion, they will usually not report it anywhere. They will only treat the patient and that person will go home. (UN T). Another informant also said that girls should be helped and not prosecuted; Because it`s almost unfair to unilaterally target customers. You have broken the law, yes, but at this point you have to provide services.