MINORS’ AWARENESS ABOUT THE NEW ABORTION LAW AND ACCESS TO SAFE ABORTION SERVICES IN ETHIOPIA: The Case of Marie Stopes International Ethiopia Centers in Addis Ababa BY: FASIKA FEREDE ALEMU UNIVERSITY OF AMSTERDAM AMSTERDAM MASTER’S IN MEDICAL ANTHROPOLOGY Thesis Supervisor: DR. WINNY KOSTER Co-reader: ERICA VAN DER SIJPT AUGUST 2010, AMSTERDAM Table of Contents Abstract ............................................................................................................................................ 4 ACKNOWLEDGMENTS ................................................................................................................. 5 INTRODUCTION ....................................................................................................................... 7 1.1. Introduction and Background ......................................................................................... 7 1.2. Statement of the Problem ............................................................................................... 8 1.3. Study Objective and Questions ..................................................................................... 11 1.4. Research Question and Sub-questions .......................................................................... 11 1.5. Organization of the Thesis ............................................................................................ 11 CHAPTER TWO ............................................................................................................................ 13 LITERATURE REVIEW AND THEORETICAL FRAMEWORK ....................................... 13 2.1. Overview of Abortion Laws and Practices .................................................................... 13 2.2. Ethiopian New Abortion Law ....................................................................................... 14 2.3. Socio- Cultural Context of Abortion ............................................................................. 15 2.4. Theoretical framework ................................................................................................. 16 CHAPTER THREE ......................................................................................................................... 19 RESEARCH METHODOLOGY .............................................................................................. 19 3.1. The Study Location ...................................................................................................... 19 3.2. Study Design................................................................................................................ 20 3.3. The Study Population ................................................................................................... 20 3.4. Access to the Field ....................................................................................................... 20 3.5. Data Collection Methods .............................................................................................. 21 3.6. Secondary Data Collection ........................................................................................... 24 3.7. Data Processing and Analysis ....................................................................................... 24 3.8. Reflections ................................................................................................................... 25 3.9. Ethical consideration .................................................................................................... 26 3.10. Limitations ............................................................................................................... 26 CHAPTER FOUR ........................................................................................................................... 28 AWARENESS ON THE NEW ETHIOPIAN LIBERALIZED ABORTION LAW AND MSIE ................................................................................................................................................... 28 4.1. Awareness on the New Liberalized Abortion Law ........................................................ 28 4.2. MSIE and the New Liberalized Abortion Law .............................................................. 29 4.3. Provision of Abortion Services at MSIE Centers .......................................................... 31 1 4.4. Minors Experience at MSIE Centers ............................................................................. 34 CHAPTER FIVE ............................................................................................................................ 36 COMMUNITY AND HEALTH PROFESSIONALS PERCEPTION AND RELIGIOUS INSTITUTIONS OPINION ON MINORS’ CONTRACEPTIVES USE, PREGNANCY AND ABORTION ............................................................................................................................... 36 5.1. Magnitude of Unintended Pregnancy and Abortion ...................................................... 36 5.2. Consequences of Unwanted Pregnancy on Boys ........................................................... 38 5.3. Community Perception on Minors Pregnancy and Contraceptives Use .......................... 39 5.4. Community Perception on Minors Abortion ................................................................. 42 5.5. Health Professionals Opinion and Experience on Contraceptives Use ........................... 43 5.6. Health Professionals Opinion and Experience on Abortion ........................................... 44 5.7. Opinion and Stand of Religious Institutions on Contraceptives Use and Abortion ......... 46 CHAPTER SIX ............................................................................................................................... 52 MINORS’ PERCEPTION AND EXPERIENCE WITH CONTRACEPTIVES AND ABORTION ............................................................................................................................... 52 6.1. Perception and Use of Contraceptives........................................................................... 52 6.2. Causes for unwanted pregnancy ................................................................................... 53 6.3. Minors Opinion and Perception about Abortion ............................................................ 55 6.4. Reasons for Abortion ................................................................................................... 55 6.5. Reasons for the Delay of Abortion ............................................................................... 56 6.6. Abortion Experience .................................................................................................... 57 6.7. Consequences of Abortion ........................................................................................... 65 6.8. Men‟s Role in Abortion Decision ................................................................................. 65 6.9. Barriers on Minors‟ Access to Safe Abortion Services .................................................. 66 CHAPTER SEVEN ......................................................................................................................... 69 DISCUSSIONS, CONCLUSION AND RECOMMENDATIONS ........................................... 69 7.1. Discussion and Conclusion ........................................................................................... 69 7.2. Recommendations ........................................................................................................ 78 References ...................................................................................................................................... 80 Annexes .......................................................................................................................................... 84 Annex 1. Research Instruments ....................................................................................................... 84 Annex 2. Introduction and Consent.................................................................................................. 87 Annex 3. Profile of IDI Participant Girls......................................................................................... 88 2 Annex 4. MSIE Centers Consent form for Abortion Service ............................................................ 89 Annex 5. EOTC Declaration on Abortion ........................................................................................ 90 3 Abstract Women‟s abortion perception and experience is a little studied reproductive health component in social sciences in Ethiopia. This thesis is about minors‟ abortion opinion and experience, awareness on the new abortion law and their access to safe abortion services in Addis Ababa. Thus, it aims to add to the scanty information on the subject. This study is qualitative in which the researcher used various data collection methods. The research outcomes indicate that the study participant girls and women awareness on the new liberalized abortion law is almost inexistent. Their access to safe abortion services is also very limited due to lack of awareness on legal status of abortion and where to go for the service. The major hindrances for the minors for low use of contraceptives are socio-cultural and religious factors. Minor who use contraceptives may be considered as promiscuous, when she gets pregnant it is out of the social norm and if she terminates the pregnancy again it stigmatized her. If she gives birth also; she will be stigmatized and dishonor her family and the baby is also dishonored as „diqalla‟. This study also reveals that educational status of minors increases the awareness on contraceptives but not its use and there is no significant difference between educated and uneducated women on perception and opinion towards modern contraceptives. Most minors used self induced abortion mechanisms before visiting abortion service providers. They also went to illegal and unsafe abortion service providers because of lack of information on the legal status of abortion, inaffordability of the fee, lengthy process and to keep their secret. Sex before marriage and abortion is taboo but the study indicates it is becoming common for minors and unmarried women. Most minors‟ unwanted pregnancies are ended in abortion and are undertaken self-induced or traditional and in illegal places. Most girls who undertook abortion feel ashamed; guilty of committed sin and crime hence they have no internal peace. Minors who are from relatively lower income family mostly go to traditional abortionists. The major religious institutions in Ethiopia have no official stand on contraceptives use to married women and leave the choice for individual‟s decision. However, the institutions highly condemn sex before marriage and abortion. Most of the study participants have no awareness on the legality of MSIE services and consider MSIE as clinic that provide only secret abortion service. 4 ACKNOWLEDGMENTS I would like to extend my sincere thanks and gratitude to my thesis supervisor Dr. Winny Koster, who encouraged me in every step and devoted her time in reading the essay in draft form and gave me valuable suggestion and constructive criticism for the improvement of the paper. The completion of this thesis would not have been possible without the generous assistance and encouragement of my beloved wife Sinkinesh Beyene. She has always been my strength and motivation to work hard throughout my study. I could not complete my study without the understanding and patience of my beloved son Kaleb Fasika while I was abroad. I would like to express my gratitude, to all my family members, for their priceless assistance in taking responsibility and taking care of my son as well as their endless moral support in my study. I also heartily thank my informants for their co-operation and willingness in giving all private and secret information for the fulfillment of the study. My special thanks go to Abrina Demissie and Abeba Mohammed for facilitating FGDs and IDIs. My heartfelt gratitude goes to Meron, Ermisha, Dr. Abeba, Daniel, Tsedey, Ejigayehu, Heran, Girma, Dn. Neway and Kebede for their kind assistance in my field work. My special thanks go to my friends Yidne and Mathiew for their comments and editing of the draft which enables me to complete my work successful. I am obliged to my class fellow students for their love, respect, friendship and memorable moments. Last but not least I am highly indebted to The Netherlands Fellowship Programs (Nuffic) for granting the fellowship and AMMA for making all this possible. Errors, misinterpretations and weaknesses that might appear in this thesis are all mine. 5 Acronyms AIG- Alan Guttmacher Institute CAC- Comprehensive Abortion Care CHAD-ET- Children Aid Ethiopia CPR- Contraceptive Prevalence Rate EDHS- Ethiopian Demographic and Health survey EOTC- Ethiopian Orthodox Tewahdo Church ETB- Ethiopian Birr FDRE- Federal Democratic Republic of Ethiopia FGD- Focus Group Discussion FP- Family Planning HDI- Human Development Index HPI- Human Poverty Index IDI- In depth Interview KAP- Knowledge Attitude and Practice MMR- Maternal Mortality Rate MOH- Ministry of Health MPS-Making Pregnancy Safer MSIE- Marie Stopes International Ethiopia MSP- Marie Stopes Procedure MSMP- Marie Stopes Medical Procedure MVA- Manual Vacuum Aspiration NCTPE- National Committee for Traditional Practices Eradication PRB- Population Reference Bureau RH- Reproductive Health STD- Sexually Transmitted Diseases TFR- Total Fertility Rate USAID- United States Agency for International Development WHO- World Health Organization 6 CHAPTER ONE INTRODUCTION 1.1. Introduction and Background According to MoH definition induced abortion is “the termination of pregnancy before fetal viability, which is conventionally taken to be less than twenty eight weeks from the last normal menstrual period. If the last normal menstrual period is not known, a birth weight of less than 1000g is considered as abortion” (MoH 2006:3). Unplanned pregnancy most of the time results in induced abortion which causes severe health problems like infertility and death mainly in developing countries (MoH 2006). WHO estimates that about 600,000 annual pregnancy-related maternal deaths occur worldwide, of this estimate an average of thirteen percent is due to unsafe abortion. Every year over 70,000 women die and millions more suffer injuries as a result of unsafe abortion (WHO 2007). WHO defined unsafe abortion as “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both” (WHO 1993). According to Ethiopian the Ministry of Health (2006), in Ethiopia about 32% of all maternal deaths are the result of complications related to unsafe abortion. Abortion is the second leading cause of death for women, after tuberculosis (MoH 2006). It is estimated that annually 2 million to 4.4 million abortions among adolescents occur in developing countries (PRB 1997). According to hospital records of many developing countries between 38% and 68% of women treated for complications of abortion are under twenty years of age (WHO 2004). The 2004 Ethiopian revised criminal code allows abortion under certain circumstances. In the previous code abortion was only allowed to save the woman‟s life. While in the new liberalized law abortion is permitted when; the pregnancy is resulted from rape or incest, the woman‟s or fetus‟ lives are threatened, the fetus has severe abnormalities, the woman has physical or mental disabilities and when a minor is physically or psychologically unprepared to raise a child. According to the new law there is no need of proof for age or whether the pregnancy is resulted from rape or incest. 7 In Ethiopia induced abortion is one of the uncovered issues in social science researches in general and in anthropology in particular. Researches conducted on the issue so far are focused on the incidence rate, prevalence and biomedical aspect of the problem rather than on the social and cultural aspects, and women‟s perceptions and experiences (Singh et.al 2010, Senbeto et.al 2005). Therefore, in this research I will address the issue by using anthropological research tools and emphasizing on minors. My work experience in the field of reproductive health and family planning (RH/FP) at Marie Stopes International Ethiopia enabled me to observe different barriers faced by clients seeking safe abortion and some gaps in the implementation of the service delivery. The socio-cultural factors that hindered women, especially minors from accessing safe abortion services is the main area that motivated me to conduct this study. According to the 2000 revised family code of Ethiopia and the technical and procedural guidelines for safe abortion services in Ethiopia, 2006: minors are young boys and girls who are below the age of eighteen. This study thus, reviews the influence of the new Ethiopian abortion law of 2005 on minors exercising their reproductive health rights in Addis Ababa. The technical and procedural guide line for safe abortion service 2006 clarified that the new abortion law allows legal abortion service for minors and the provider will use the stated age to determine whether the person is under eighteen year ages or not without any proof of age. I believe that this study will contribute to reveal the gap between the existing laws and practices in exercising the reproductive health rights both by the service providers and the beneficiaries in Ethiopia. The second contribution of the study would be the use of the results by various stakeholders at different levels to promote minors‟ reproductive health rights to access information about and safe abortion services. In addition, it would also awake social scientists to conduct further studies on abortion and reproductive health rights. 1.2. Statement of the Problem As in most of developing countries, in Ethiopia access to safe abortion continues to depend on women‟s awareness of the law. Goodman et al. stated that “although the new 2005 Ethiopian abortion law is relatively liberal, due to lack of knowledge of legal rights among 8 most women, shortage of safe abortion services provision and significant amount of socio- cultural pressures women still go to unsafe abortion service” (Goodman et al. 2008). As Senbeto et al. on their study of prevalence and associated risk factors of induced abortion in northwest Ethiopia indicated that traditional healers and health professionals prescribe plastic tube and various oral medicines as common methods used for unsafe abortion (Senbeto et.al 2005). In Ethiopia the current use of any method of contraceptive (CPR) for people in reproductive health group is 14.7% while the estimated current use rate of modern methods of contraception in Addis Ababa city administration is about 45.2% and for any method is 56.9% (EDHS, 2005). According to the Ethiopian Ministry of Health report unsafe abortions is one of the top ten causes of hospital admissions among women in Ethiopia. Unsafe abortion accounts for nearly 60% of all gynecologic admissions and almost 30% of all obstetric and gynecologic admissions. A research conducted in a hospital in Addis Ababa indicated that 54% of maternal deaths resulted from unsafe abortion (MoH 2006). Since unsafe abortion services are secret in nature these figures represent only the smaller scale because not all complications come to the hospital. Koster‟s study in Nigeria found that the highest abortion prevalence and the biggest problems with unsafe abortion and abortion complications occurred among single young women (2003). Olukoya and Koster study in Nigeria showed that due to different reasons adolescents mostly choose to go to untrained abortion service providers and delay in getting help when complications happen resulted in higher threat of morbidity and mortality. In addition, Adolescents are more likely to experience complications (Olukoya et.al. 2001, Koster 2003). In Ethiopian society as premarital sex is taboo, unmarried adolescents in general and minors in particular are discouraged from using any kind of contraceptives. From my work exposure, I observed that limited attention is given to address the reproductive needs of minors and inaccessibility of services coupled with socio-cultural barriers to use 9