Playing it Safe: Legal and Clandestine Abortions Among Adolescents in Ethiopia.

PURPOSE: The 2005 expansion of the Ethiopian abortion law provided minors access to legal abortions, yet little is known about abortion among adolescents. This paper estimates the incidence of legal and clandestine abortions and the severity of abortion-related complications among adolescent and nonadolescent women in Ethiopia in 2014. METHODS: This paper uses data from three surveys: a Health Facility Survey (n = 822) to collect data on legal abortions and postabortion complications, a Health Professionals Survey (n = 82) to estimate the share of clandestine abortions that resulted in treated complications, and a Prospective Data Survey (n = 5,604) to collect data on abortion care clients. An age-specific variant of the Abortion Incidence Complications Method was used to estimate abortions by age-group. RESULTS: Adolescents have the lowest abortion rate among all women below age 35 (19.6 per 1,000 women). After adjusting for lower levels of sexual activity among adolescents however, we find that adolescents have the highest abortion rate among all age-groups. Adolescents also have the highest proportion (64%) of legal abortions compared with other age-groups. We find no differences in the severity of abortion-related complications between adolescent and nonadolescent women. CONCLUSIONS: We find no evidence that adolescents are more likely than older women to have clandestine abortions. However, the higher abortion and pregnancy rates among sexually active adolescents suggest that they face barriers in access to and use of contraceptive services. Further work is needed to address the persistence of clandestine abortions among adolescents in a context where safe and legal abortion is available.

A decade of progress providing safe abortion services in Ethiopia: results of national assessments in 2008 and 2014.

BACKGROUND: Ethiopia has one of the highest maternal mortality ratios in the world (420 per 100,000 live births in 2013), and unsafe abortion continues to be one of the major causes. To reduce deaths and disabilities from unsafe abortion, Ethiopia liberalized its abortion law in 2005 to allow safe abortion under certain conditions. This study aimed to measure how availability and utilization of safe abortion services has changed in the last decade in Ethiopia. METHODS: This paper draws on results from nationally representative health facility studies conducted in Ethiopia in 2008 and 2014. The data come from three sources at two points in time: 1) interviews with 335 health providers in 2008 and 822 health care providers in 2014, 2) review of facility logbooks, and 3) prospective data on 3092 women in 2008 and 5604 women in 2014 seeking treatment for abortion complications or induced abortion over a one month period. The Safe Abortion Care Model was used as a framework of analysis. RESULTS: There has been a rapid expansion of health facilities eligible to provide legal abortion services in Ethiopia since 2008. Between 2008 and 2014, the number of facilities reporting basic and comprehensive signal functions for abortion care increased. In 2014, access to basic abortion care services exceeded the recommended level of available facilities providing the service, increasing from 25 to 117%, with more than half of regions meeting the recommended level. Comprehensive abortion services increased from 20% of the recommended level in 2008 to 38% in 2014. Smaller regions and city administrations achieved or exceeded the recommended level of comprehensive service facilities, yet larger regions fall short. Between 2008 and 2014, the use of appropriate technology for conducting first and second trimester abortion and the provision of post abortion family planning has increased at the same time that abortion-related obstetric complications have decreased. CONCLUSION: Ten years after the change in abortion law, service availability and quality has increased, but access to lifesaving comprehensive care still falls short of recommended levels.

Changes in Morbidity and Abortion Care in Ethiopia After Legal Reform: National Results from 2008 and 2014.

CONTEXT: In Ethiopia, liberalization of the abortion law in 2005 led to changes in abortion services. It is important to examine how levels and types of abortion care-i.e., legal abortion and treatment of abortion complications-changed over time. METHODS: Between December 2013 and May 2014, data were collected on symptoms, procedures and treatment from 5,604 women who sought abortion care at a sample of 439 public and private health facilities; the sample did not include lower-level private facilities-some of which provide abortion care-to maintain comparability with the sample from a 2008 study. These data were combined with monitoring data from 105,806 women treated in 74 nongovernmental organization facilities in 2013. Descriptive analyses were conducted and annual estimates were calculated to compare the numbers and types of abortion care services provided in 2008 and 2014. RESULTS: The estimated annual number of women seeking a legal abortion in the types of facilities sampled increased from 158,000 in 2008 to 220,000 in 2014, and the estimated number presenting for postabortion care increased from 58,000 to 125,000. The proportion of abortion care provided in the public sector increased from 36% to 56% nationally. The proportion of women presenting for postabortion care who had severe complications rose from 7% to 11%, the share of all abortion procedures accounted for by medical abortion increased from 0% to 36%, and the proportion of abortion care provided by midlevel health workers increased from 48% to 83%. Most women received postabortion contraception. CONCLUSIONS: Ethiopia has made substantial progress in expanding comprehensive abortion care; however, eradication of morbidity from unsafe abortion has not yet been achieved.

Timing of first antenatal care attendance and associated factors among pregnant women in Arba Minch Town and Arba Minch District, Gamo Gofa Zone, south Ethiopia.

OBJECTIVE: To assess the timing of first antenatal care attendance and associated factors among pregnant women in Arba Minch Town and Arba Minch District, south Ethiopia. METHOD: Facility based cross-sectional study employing both quantitative and qualitative methods was conducted from February to March, 2014, in Arba Minch Town and Arba Minch District. Data were collected from 409 pregnant women attending antenatal care clinics in nine public health facilities using systematic random sampling. Analysis was done using SPSS version 20. Descriptive statistics and binary and multiple logistic regression analysis were done. RESULTS: The mean (SD±) age of the respondents was 26 ± 5.5 years. The mean gestational age at first antenatal care attendance was 5 ± 1.5 months. This study indicated that pregnant women with low monthly income (AOR = 4.9, CI: 1.71, 14.08), women who did not receive advise on when to start ANC (AOR = 3, CI: 1.48, 6.24), women with household food insecurity (AOR = 4.66, CI: 1.007, 21.59) and women with unplanned pregnancy (AOR = 4.49, CI: 2.16, 9.35) had higher odds of late antenatal care attendance compared with their counterparts. CONCLUSIONS: The study showed that majority of the pregnant women attended late for first antenatal care. Hence, providing health education on the timing of antenatal care is important.

The effects of pregnancy intention on the use of antenatal care services: systematic review and meta-analysis.

BACKGROUND: There has been considerable debate in the reproductive health literature as to whether unintended pregnancy influences use of maternal health services, particularly antenatal care. Despite the wealth of studies examining the association between pregnancy intention and antenatal care, findings remain mixed and inconclusive. The objective of this study is to systematically review and meta-analyse studies on the association between pregnancy intention and antenatal care. METHODS: We reviewed studies reporting on pregnancy intention and antenatal care from PubMed, Popline, CINHAL and Jstor search engines by developing search strategies. Study quality was assessed for biases in selection, definition of exposure and outcome variables, confounder adjustment, and type of analyses. Adjusted odds ratios, standard errors and sample size were extracted from the included studies and meta-analyzed using STATA version 11. Heterogeneity among studies was assessed using Q test statistic. Effect-size was measured by Odds ratio. Pooled odds ratio for the effects of unintended pregnancy on the use of antenatal care services were calculated using the random effects model. RESULTS: Our results indicate increased odds of delayed antenatal care use among women with unintended pregnancies (OR 1.42 with 95% CI, 1.27, 1.59) as compared to women with intended pregnancies. Sub-group analysis for developed (1.50 with 95% CI, 1.34, 1.68) and developing (1. 36 with 95% CI, 1.13, 1.65) countries showed significant associations. Moreover, there is an increased odds of inadequate antenatal care use among women with unintended pregnancies as compared to women with intended pregnancies (OR 1.64, 95% CI: 1.47, 1.82). Subgroup analysis for developed (OR, 1.86; 95% CI: 1.62, 2.14) and developing (OR, 1.54; 95% CI: 1.33, 1.77) countries also showed a statistically significant association. However, there were heterogeneities in the studies included in this analysis. CONCLUSION: Unintended pregnancy is associated with late initiation and inadequate use of antenatal care services. Hence, women who report an unintended pregnancy should be targeted for antenatal care counseling and services to prevent adverse maternal and perinatal outcomes. Moreover, providing information on the importance of planning and healthy timing of pregnancies, and the means to do so, to all women of reproductive ages is essential.

Determinants of maternal health care utilization in Holeta town, central Ethiopia.

BACKGROUND: In developing countries a large number of women are dying due to factors related to pregnancy and child birth. Implementing and assuring utilization of maternal health care services is potentially one of the most effective health interventions for preventing maternal morbidity and mortality. However, in Ethiopia the utilization of maternal health care is low. METHODS: A cross-sectional study was conducted from January 20 to February 20, 2012 in Holeta town, central Ethiopia, to assess the determinants of maternal health care utilization among women who had given birth in the past three years prior to the survey. Structured questionnaire and focus group discussion guides were used for data collection. Data were collected from a sample of 422 women in the town. Descriptive, bivariate and multivariate logistic regression analyses were conducted. Statistical tests were done at a level of significance of p<0.05. RESULTS: The study revealed that 87% of the women had at least one antenatal visit during their last pregnancy. Among the antenatal service users, 33.7% had less than four antenatal visits. More than half of the antenatal care (ANC) attendants made their first visit during their second and third trimester of pregnancy although WHO recommended ANC should be started at the first trimester of the pregnancy. There was a significant association (P<0.05) between ANC attendance and some demographic, socio-economic and health related factors (age at last birth, literacy status of women, average monthly family income, media exposure, attitude towards pregnancy, knowledge on danger signs of pregnancy and presence of husband approval on ANC). The study also revealed that about 61.6% of the women had given birth in the health institutions. Parity, literacy status of women, average monthly family income, media exposure, decision where to give birth, perception of distance to health institutions (HI) and ANC attendance were found to be significantly associated (P<0.05) with delivery care (DC) attendance. CONCLUSIONS: The utilization of ANC and DC service is inadequate in the town. The utilization of ANC and DC were influenced by demographic, socio-economic and health related factors. Improving the status of women by expanding educational opportunities, strengthening promotion of antenatal and delivery care by enhancing community awareness about the importance of ANC and DC are recommended.

The association of unwanted pregnancy and social support with depressive symptoms in pregnancy: evidence from rural Southwestern Ethiopia.

BACKGROUND: Depression in pregnancy has adverse health outcomes for mothers and children. The magnitude and risk factors of maternal depression during pregnancy is less known in developing countries. This study examines the association between pregnancy intention, social support and depressive symptoms in pregnancy in Ethiopia. METHODS: Data for this study comes from a baseline survey conducted as part of a community- based cohort study that involved 627 pregnant women from a Demographic Surveillance Site (DSS) in Southwestern Ethiopia. The Edinburgh Postnatal Depression Scale (EPDS) was used to measure depressive symptoms during pregnancy. Data on depressive symptoms, pregnancy intention, social support and other explanatory variables were gathered using an interviewer-administered structured questionnaire. The association between independent variables and depressive symptom during pregnancy was assessed using multivariable logistic regression. RESULTS: The prevalence of depressive symptoms during pregnancy was 19.9% (95% CI, 16.8-23.1), using EPDS cut off point of 13 and above. The mean score on the EPDS was 8, ranging from 0 to 25 (SD ±5.4). Women reporting that the pregnancy was unwanted were almost twice as likely to experience depressive symptoms compared with women with a wanted pregnancy. (Adjusted Odds Ratio (AOR) = 1.96, 95% Confidence Interval (CI) 1.04-3.69) Women who reported moderate (AOR = 0.27; 95% CI 0.14-0.53) and high (AOR = 0.23, 95% CI 0.11-0.47) social support during pregnancy were significantly less likely to report depressive symptoms. Women who experienced household food insecurity and intimate partner physical violence during pregnancy were also more likely to report depressive symptoms. CONCLUSION: About one in five pregnant women in the study area reported symptoms of depression. While unwanted pregnancy increases women's risk of depression, increased social support plays a buffering role from depression. Thus, identifying women's pregnancy intention and the extent of social support they receive during antenatal care visits is needed to provide appropriate counseling and improve women's mental health during pregnancy.

Child spacing and fertility planning behavior among women in mana district, jimma zone, South west ethiopia.

BACKGROUND: Short birth intervals and unintended pregnancies pose serious health risks to mothers and their infants by causing unnecessary high risk of pregnancy related complications and self induced abortions. The objective of the study was to assess the child spacing and fertility planning behavior of women in Mana district, Jimma zone. METHODS: A cross-sectional survey was conducted from July 18 - August 17, 2008 on 645 women who had a live birth in the three years prior to the survey. A simple random sampling technique was used to identify eligible women. A pre-tested structured questionnaire was used for data collection. Data were analyzed using SPSS for windows version 15. Frequency distributions, cross-tabulation, and logistic regression analysis were performed. RESULTS: Analysis of birth intervals for women with non first births showed that 27% of births occurred within less than 24 months after a previous birth, showing that a considerable proportion of births were not adequately spaced to promote maternal and child health. About 39% of women reported that their recent pregnancy was unintended. Women with unintended pregnancy are more likely to be illiterate (OR=1.85,95%CI,1.23-2.79), have four or more living children(OR=2.77,95% CI,1.77-4.33), had a previous birth interval of less than 24 months(OR=1.78,95% CI(1.19-2.69), have never used contraception (OR=4.53, 95% CI, 3.05-6.75) and did not desire any more children (OR=1.84, 95% CI, 1.23-2.76). CONCLUSION: The study showed that an inadequate child spacing and high level of unintended pregnancy among considerable proportion of the study population. Unintended pregnancy and short birth intervals can pose serious health risks to mothers and their infants by causing unnecessary high risk of pregnancy related complications. Thus, improving access to safe and voluntary family planning counseling and services is essential to reduce the high level of unintended pregnancy and short birth intervals.

Prevalence and correlates of intimate partner physical violence against women in Kofale District, Ethiopia.

Using a community-based cross-sectional survey, this study attempted to determine the prevalence and correlates of intimate partner physical violence against women in Kofale District, Ethiopia. The study showed that 52.6% of the respondents had experienced intimate partner physical violence in their lifetime and 30.2% in the 12 months before the survey. Witnessing family violence as a child, education, place of residence, parity, duration of the marriage, a tradition of marriage arrangement and the partners' use of alcohol were associated with intimate partner physical violence.