"We need to confirm at least from two or three": Healthcare workers' discretion as gatekeepers in the context of the Ethiopian abortion law.

INTRODUCTION: Women's access to legal and safe abortion is a vital means to reduce unsafe abortion, which in turn is known to reduce maternal morbidity and mortality. In 2005, Ethiopia enacted a relatively permissive abortion legislation. However, there is evidence that access to abortion care services may be challenging and controversial even if progressive abortion laws are in place. This article examines women's access to abortion services from the perspective of healthcare workers in a rural setting in Ethiopia. Drawing on Lipsky's theory of street-level bureaucrats, the article discusses healthcare workers' discretion and the substantial authority they hold as gatekeepers to safe abortion services. METHODS: The study draws upon a qualitative, interpretative methodological approach, with in-depth semi-structured interviews with healthcare workers as the key method of data generation. The data was analyzed and interpreted thematically. Healthcare workers' perspectives were examined with reference to the national abortion legislation and guidelines. RESULTS: The findings reveal that healthcare workers make decisions on behalf of the women who seek abortion, and they involve parents and partners in abortion-related decision-making processes. Moreover, they assess the social context of the pregnancy such as the marital and economic statuses of the abortion-seeking women in ways that restrict women's access to legally-endorsed abortion services. CONCLUSIONS: Healthcare workers' practices in this rural area were found to challenge the basic provisions laid out in Ethiopia's abortion legislation. Their negative discretion of the legislation contributes to the substantial barriers Ethiopian abortion-seeking women face in gaining access to legal abortion services, despite the presence of a progressive legal framework and guidelines.

Between 'block course relationships' and abstinence: cultures of sexuality among students at Addis Ababa University.

Inspired by African and other feminist scholarship on gender, sexuality and agency, this article studies narrations of norms and practices in sexual relationships between university students. A main aim of the article is to move beyond the problem focus in earlier scholarship on women, sexuality and reproduction, and to identify potential spaces of freedom and expansion of female agency. The article is based on qualitative research conducted with students at Addis Ababa University. The findings a vivid space for male-female relationships. Study participants report being sexually engaged as "the new normal" and claim that many female students are active both in seeking relationships and in discontinuing them. These ideas and practices indicate increasing female agency and emerge in stark contrast to dominant social norms for sexual conduct, which demand chastity before marriage, particularly for women. Students are conscious of this discrepancy and bring it up in their narratives. Findings also show that some students prefer to stay abstinent and make an effort to avoid sexual relations. We argue that expressions of female agency are evident not only in norm-transgressive sexual conduct, but also in norm-conforming strategies of sexual abstinence.

"I came to escort someone": Men's experiences of antenatal care services in urban Ghana-a qualitative study.

BACKGROUND: Male involvement in maternal healthcare has been widely recognized as essential for positive health outcomes for expectant mothers and their unborn babies. However, few studies have explored men's experiences of maternal health services. The purpose of this paper is to explore men's involvement in antenatal care in urban Ghana and to discuss how men navigate their roles in a space that has been constructed as feminine. The study draws upon theories of space, place, and gender. METHODS: A qualitative exploratory study using semistructured interviews, focus group discussion, and observation was conducted in Accra, Ghana. Expectant fathers and health workers were interviewed, and observation was conducted at a selected public hospital in Accra. RESULTS: The findings suggest that the few men who attend antenatal care with their expecting partners become involved to a limited extent in the clinic's activities. Beyond a few who take an active role, most men stay on the outskirts of the hospital grounds and rarely participate in consultations with their partner and midwife. Men still view their presence as necessary to acquire knowledge and as sources of emotional, financial, and physical support for their partners. On the health workers' side, the study found no clear agenda for engaging men at the clinic, and nurses/midwives felt there was a lack of staff who could engage more directly with the men. CONCLUSION: The study indicates that most expecting fathers feel too shy and uncomfortable to locate themselves in the female space that makes up antenatal care/maternity wards. Health workers do not feel they have the necessary resources to involve men fruitfully. Thus, men do not engage in the activity as hoped but rather remain on the outskirts of the maternity clinic. However, if men continue to negotiate their involvement at the clinic and become more assertive in their roles, the maternity clinic as a female space could, with time, be transformed into a space in which both expecting mothers and fathers can actively participate and be engaged to the benefit of all.

This article discusses men's roles and involvement in health workers' activities when they accompany their pregnant partners to the maternity clinic. Health workers organize antenatal care services (ANCs) for expectant mothers to receive regular check-ups during pregnancy. Since pregnancy and childbirth are generally viewed as women's domains, men have not traditionally been expected to attend antenatal care with their partners. However, recent national and global agendas have recognized men's inclusion in maternal healthcare as central to improving mothers' and unborn babies' health. Men are being encouraged to play an active role in supporting their partners during pregnancy, and as part of this role, they are encouraged to attend antenatal care services. In the health facility where this study was conducted, we found that the few men who attended antenatal care most of the time stayed outside the maternity clinic under trees or in other empty spaces around the clinic. They opted to remain in the outside areas because they felt shy sitting among women who were a substantial majority at the clinic. We also found that health workers rarely involved men in ANC activities because of a lack of staff to engage men in separate sessions. Although the fathers attending antenatal care were disappointed that they were not engaged in activities, they still found it necessary to attend to give their partners emotional, physical, and financial support. Without the consideration of how ANC activities are structured and the appropriate resources for health workers, men's active participation in ANCs will remain minimal.

Reproductive health and the politics of abortion.

This editorial provides an overview of a thematic series that brings attention to the persistently deficient and unequal access to sexual and reproductive health services for young women in sub-Saharan Africa. It represents an effort to analyze the multifaceted relationship between laws, policies and access to services in Ethiopia, Zambia and Tanzania. Using a comparative perspective and qualitative research methodology, the papers presented in this issue explore legal, political and social factors and circumstances that condition access to sexual and reproductive health services within and across the three countries. Through these examples we show the often inconsistent and even paradoxical relationship between the formal law and practices on the ground. Particular emphasis is placed on safe abortion services as an intensely politicized issue in global sexual and reproductive health. In addition to the presentation of the individual papers, this editorial comments on the global politics of abortion which represents a critical context for the regional and local developments in sexual and reproductive health policy and care provision in general, and for the contentious issue of abortion in particular.

When abortion is not within reach: Ethiopian university students struggling with unintended pregnancies.

BACKGROUND: In spite of increasing international commitment to young people's sexual and reproductive health, unintended pregnancies remain a major problem for young women worldwide. This article explores the issue of unintended pregnancies among Ethiopian university students and investigates narratives of students who carried their pregnancy to term. Ethiopia's relatively permissive abortion law forms part of the backdrop for the exploration. We also consider how socio-cultural and religious norms surrounding female premarital sex/pregnancy, and gendered and urban-rural inequities, play a role in how students handle the challenge. METHODS: The article is based on research conducted among students at Addis Ababa, Jimma and Mekelle Universities in Ethiopia between September 2016 and June 2017. Drawing on an interpretative, phenomenological approach to science and employing a qualitative methodology, the authors conducted in-depth interviews with 53 students and 24 selected staff at the three universities, and held two focus group discussions with students at Addis Ababa University. RESULTS: The study findings show three possible scenarios for how students can deal with an unwanted pregnancy. The first is to have the pregnancy terminated secretly, and thereby avoid the stigma linked to premarital pregnancy. The second is to make a deliberate decision to keep the pregnancy and face the consequences to come. The third scenario is found in cases where the student seems paralyzed by feelings of shame, and where she ends up keeping the pregnancy due to her inability to act. Students who end up carrying their pregnancy to term face many problems. Few support structures at the university are in place to cater for their needs. Moreover, family support is endangered by pregnancy, as it puts the student at risk of being ostracized from her family due to the shame she has imposed on them. Shame and silence are thus important social forces in these students' lives, underpinned by gendered inequities and patriarchal norms. CONCLUSIONS: Along with rural-urban and gendered inequities, the article demonstrates how a shame-silence nexus forcefully operates in the lives of female students struggling with reproductive challenges, and the serious consequences a pregnancy may have for those who carry it to term.

Health, life and rights: a discourse analysis of a hybrid abortion regime in Tanzania.

BACKGROUND: Unsafe abortion continues to be a major hazard for maternal health in Sub-Saharan Africa, where abortion remains highly controversial and access to safe abortion services is unequally distributed. Although national abortion laws are central in indicating women's potential for accessing safe abortion services, the character of an abortion law may alone say little about national discursive abortion landscapes and access scenarios. The article calls for the study and problematization of the relationship between legal abortion frameworks on the one hand, and discourses surrounding abortion on the other, in an attempt to move closer to an understanding of the complexity of factors that influence knowledge about and access to safer abortion services. With the restrictive abortion law in Tanzania as a starting point, the paper explores the ways in which the major global abortion discourses manifest themselves in the country and indicate potential implications of a hybrid abortion regime. METHODS: The study combined a review of major legal and policy documents on abortion, a review of publications on abortion in Tanzanian newspapers between 2000 and 2015 (300 articles), and 23 semi-structured qualitative interviews with representatives from central institutions and organizations engaged in policy- or practical work related to reproductive health. RESULTS: Tanzania's abortion law is highly restrictive, but the discursive abortion landscape is diverse and is made manifest through legal- and policy documents and legal- and policy related disputes. The discourses were characterized by diverse frames of reference based in religion, public health and in human rights-based values, and as such reflect the major global discourses. Fairclough's concepts interdiscursivity and recontextualization were drawn upon to develop an understanding of how the concepts health, rights and life emerge across the discourses, but are employed in contrasting lines of argumentation in struggles for hegemony and legitimacy. DISCUSSION AND CONCLUSIONS: The paper demonstrates that a hybrid discursive regime relating to abortion characterizes the legally restrictive abortion context of Tanzania. We argue that such a complex discursive landscape, which cuts across the restrictive - liberal divide, generates an environment that seems to open avenues for enhanced access to abortion related knowledge and services.

'An uneasy compromise': strategies and dilemmas in realizing a permissive abortion law in Ethiopia.

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.

The access paradox: abortion law, policy and practice in Ethiopia, Tanzania and Zambia.

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.

Why teach sexuality education in school? Teacher discretion in implementing comprehensive sexuality education in rural Zambia.

BACKGROUND: Reproductive health problems such as HIV, unwanted pregnancy and unsafe abortion among adolescents are closely linked to insufficient knowledge about sexuality and reproduction and lack of access to contraceptives. Supported by international agencies, Zambia has introduced an ambitious nation-wide program for comprehensive sexuality education (CSE) to be implemented into ordinary school activities by teachers. The curriculum is firmly based in a discourse of sexual and reproductive rights, not commonly found in the public debate on sexuality in Zambia. This paper explores how teachers perceive the curriculum and practice discretion when implementing the CSE in mid-level schools in Nyimba district in Zambia. METHODS: Using a case study design, data were collected through in-depth interviews with 18 teachers and analyzed thematically drawing upon theories of discretion and policy implementation. RESULTS: Individual teachers make decisions on their own regarding what and when to teach CSE. This discretion implies holding back information from the learners, teaching abstinence as the only way of preventing pregnancy or cancelling sexuality education sessions altogether. Teachers' choices about the CSE program were linked to lack of guidance on teaching of the curriculum, especially with regards to how to integrate sexuality education into existing subjects. Limited prioritization of CSE in the educational sector was observed. The incompatibility of CSE with local norms and understandings about adolescent sexuality combined with teacher-parent role dilemmas emerged as problematic in implementing the policy. Limited ownership of the new curriculum further undermined teachers' motivation to actively include CSE in daily teaching activities. Use of discretion has resulted in arbitrary teaching thus affecting the acquisition of comprehensive sexual and reproductive health knowledge among learners. CONCLUSION: The CSE had limited legitimacy in the community and was met with resistance from teachers tasked with its' implementation. In order to enhance ownership to the CSE program, local concerns about the contents of the curriculum and the parent-teacher role dilemma must be taken into consideration. Not addressing these challenges may undermine the policy's intention of increasing knowledge about sexuality and reproduction and empowering adolescents to access contraceptive services and avoid unwanted pregnancies.

Shaping the abortion policy - competing discourses on the Zambian termination of pregnancy act.

INTRODUCTION: The Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds, but access to safe abortion services is limited and this constitutes a considerable problem for rights to sexual and reproductive health. The case of Zambia provides an opportunity to explore the relationship between a legal framework that permits abortion on diverse grounds, the moral and political disputes around abortion and access to sexual and reproductive health services. METHODS: This paper draws upon eleven months of ethnographic fieldwork in Zambia. The fieldwork included 28 open-ended interviews with key stakeholders as well as the collection of archival material related to the origins of Zambia's legal framework for abortion. The archival material and the interview data were analyzed thematically, using theoretical perspectives on discourse and the anthropology of policies. RESULTS: The study findings show that the Zambian case is not easily placed into standard categories of liberal or restrictive abortion laws. The archival material reveals that restrictive elements were in focus when the Zambian Termination of Pregnancy Act was passed (1972). The restrictive aspects of the law were emphasized further when Zambia was later declared as a Christian nation. Some of these restrictive elements are still readily recognized in today's abortion debate. Currently there are multiple opinions on whether Zambian abortion policy is liberal, restrictive or neither. The law emerges as ambiguous, and this ambiguity is actively used by both those working to increase access to safe and legal abortion services, and those who work to limit such access. Coupled with a lack of knowledge about the law, its ambiguity may work to reduce access to safe abortion services on the grounds permitted by the law. CONCLUSIONS: We argue that the Zambian Termination of Pregnancy Act is ambiguous and leaves much room for interpretation. This paper challenges the notion that the Zambian abortion law is liberal and opens up for further discussion on the relationship between how a law is described and perceived by the public, and the rights to health and services ensured by it.

When abortion becomes public - Everyday politics of reproduction in rural Zambia.

This article takes the public reaction to the discovery of an aborted foetus in a rural Zambian community as the empirical starting point for exploring the everyday politics of reproduction. It builds on eleven months of ethnographic fieldwork on abortion and abortion policy in Zambia in 2017 and 2018, including participant observation in the community where the episode took place and interviews with clinic staff and neighbours. The article explores local dynamics of abortion opposition in a country where abortion is legally permitted on broad grounds. By analysing this case as an anthropological event, it discusses how opposition to abortion is dynamic and changes depending on the situation at hand. While abortions that avoid public attention may be silently tolerated, abortions that become openly known are harshly condemned. Through scrutiny of a specific case of collective moral judgement of abortion, the article examines how values like responsible motherhood, sexual virtue and protection of life emerge and are shared, allowing participants to protect and accumulate their own integrity in a moral economy that forges stronger social ties within the community. The article argues that even the harshest expressions of opposition to abortion may not be as categorical as they first appear. It calls for increased attention to dynamics of moral and political opposition to abortion to understand what is socially at stake for those who engage in it.

Silent politics and unknown numbers: Rural health bureaucrats and Zambian abortion policy.

This article addresses the gaps between knowledge, policy and practice in reproductive health by exploring the processes involved in translating Zambian abortion policy from paperwork to practice in a predominantly rural province. Central to these processes are rural health bureaucrats, who are tasked with administering and monitoring a myriad of reproductive health policies and programmes. The articles is based on eleven months of ethnographic fieldwork in Zambia from September 2017 to August 2018, including in-depth interviews with rural health bureaucrats and participant observation in health management and policy meetings. It examines how health bureaucrats deal with the abortion-related challenges they face. Our findings reveal a complex landscape of reproductive health politics and moral double-binds and give insight into the gap between Zambia's seemingly liberal abortion policy and the lack of access to abortion services in rural areas. Despite the bureaucrats' knowledge about abortion policy, none of the hospitals in the study province offer legal abortion services. While many bureaucrats consider abortion to be a public health issue and see the need to offer legal services to abortion-seeking women, they often bypass abortion-related issues and treat them with silence in policy meetings and public settings. The silence corresponds with the lack of data on abortion and post-abortion care in district and provincial health offices and should be understood in relation to both the dominant moral regime of the Zambian state and global pressure towards specific reproductive health targets. This article calls for increased focus on politics and power dynamics in the state apparatus in order to understand the gaps between knowledge, policy and practice in sexual and reproductive health.