A decade of change in safe abortion services in Ethiopia: Results from national assessments in 2008 & 2014 Sally Dijkerman, Yohannes Dibaba, Tam Fetters, Hailemichael Gebreselassie, Yirgu Gebrehiwot, Ann Moore, Janie Benson, Yonas Getachew, Mengistu Hailemariam Presented by: Sally Dijkerman, MPH Research and Evaluation Advisor Ipas

Partners and Funding

• Ministry of Health • Ethiopian Public Health Association • Ethiopian Society of OBGYNs •  Ipas • Guttmacher Institute

•  Funding provided by Dfid (UK Aid) and Ipas

Background •  In 2005, Ethiopia liberalized its abortion law

•  Abortion can be performed legally in cases of:

•  Rape/incest •  Woman has physical or mental disabilities •  To preserve the life or physical health of the woman •  Woman is a minor who is physically or mentally unprepared for

childbirth

•  Since then, comprehensive safe abortion services have scaled up in the health care system rapidly

•  Despite this, service availability is still variable across the large and expansive country of over 90 million people

Objectives & Significance •  First study in 2008 with aim to estimate

national baseline levels of abortion-related incidence and morbidity

•  Repeated in 2014 to assess changes in national incidence, magnitude of abortion-related morbidity, and availability of safe abortion services

•  Implications in Ethiopia and beyond •  One of very few studies to… o explore incidence of unsafe abortion

morbidity over time o assess the impact of abortion policy

reform and practice over time in a low-resource setting

Methodology

Study Design •  Cross-sectional descriptive survey of health facilities and the Prospective

Morbidity Methodology (PMM) developed by WHO

•  2 sources of data were collected: 1. Survey of national sample of facilities (344 in 2008; 821 in 2014)

•  Including public hospitals & health centers, NGO reproductive health clinics, private & NGO hospitals, & higher private clinics

•  Interviewed most senior abortion care provider or someone knowledgeable about abortion services at facilities on facility infrastructure, capacity to provide abortion services, performance and caseload, attitudes, and more

2. Prospective abortion morbidity survey of all post-abortion patients treated at those facilities (3,092 in 2008; 5,604 in 2014)

•  1 provider from each facility was selected to participate in training to learn to extract case information on the care and case management of all women who sought care for abortion services over a 30 day period

•  Service statistics were collected from MSI and FGAE

Analysis methodology: Measuring SAC delivery in 2008 & 2014

Limited analysis to public sector facilities, stratifying by year and facility type (health centers and hospitals) SAC model developed by Healy, Otsea, & Benson (2006) was used as analysis framework

v  Adapted from UN/WHO Emergency Obstetric Care (EmOC) model •  Life-saving “signal functions” and Safe Abortion Care (SAC) indicators to

monitor: •  Service availability and geographic distribution: recommends 5 SAC

facilities for every 500,000 residents, 4 basic and 1 comprehensive •  Service utilization and quality

•  3 essential elements of SAC: •  Induced abortion (TOP) •  Treatment of abortion complications (PAC) •  Post-abortion contraception (PAFP)

Sample distribution

•  Health centers are eligible and expected to provide basic SAC and hospitals comprehensive SAC, respectively. Being expected to provide this care does not necessarily mean that they do.

•  Since legal reform went into effect in 2006, there has been a rapid expansion of public sector health facilities eligible to provide legal abortion services, especially basic SAC

•  The number of facilities eligible to provide basic SAC increased by over 300%

•  The number of health facilities eligible to provide comprehensive SAC similarly increased by 28%

Results

61%  

80%   84%  

50%  

34%  

76%  82%  

97%  92%  

76%  

39%  

77%  

Gives  essen3al  an3bio3cs  

Gives  IV  replacement  

fluids  

Administers  oxytocics  

Performs  first  trimester  PAC  

Performs  first  trimester  TOP  

Providers  PAFP  

Percent  &  Frequency  of  Public  Health  Centers  Performing  6  Signal  Func3ons  for  Basic  Safe  Abor3on  Care  Service  Delivery,  2008  &  2014  

2008  (N=152)   2014  (N=368)  

Performance of 6 signal functions for basic SAC service delivery at public health centers improved greatly between 2008 and 2014.

358  2,111  

469  2,519  

494  2,382  

295  1,962  

199  1,011  

447  1,986  

Provides PAFP

99%   100%   99%   96%  

75%  

93%  100%   100%   100%   99%  

91%  97%  

Gives  essen3al  an3bio3cs  

Gives  IV  replacement  

fluids  

Administers  oxytocics  

Performs  first  trimester  PAC  

Performs  first  trimester  TOP  

Providers  PAFP  

Percent  &  Frequency  of  Public  Hospitals  Performing  6  Signal  Func3ons  for  Basic  Safe  Abor3on  Care,  2008  &  2014  

2008  (N=90)   2014  (N=117)  

93   118   94   118   93   118   90   117   70   107   87   115  

Since 2008, public hospitals have increased performance of all 10 signal functions for basic and comprehensive SAC service delivery.

Provides PAFP

89%  

60%   59%  50%  

93%  86%  

91%  

65%  

Performs  second  trimester  PAC  

Performs  blood  transfusion  

Performs  laparotomy   Performs  second  trimester  TOP  

Percent  &  Frequency  of  Public  Hospitals  Performing  4  Signal  Func3ons  for  Comprehensive  Safe  Abor3on  Care,  2008  &  2014  

2008  (N=90)   2014  (N=117)  

84   107  101  110   56   55   47   77  

Since 2008, public hospitals have increased performance of all 10 signal functions for basic and comprehensive SAC service delivery.

  Basic SAC Service Delivery     2008   2014    

Recommended   Actual  %

Achieved   Recommended   Actual  %

Achieved  National4   591   149   25   704   889   126                

Harari   1   3   300   2   3   150  Dire Dawa   3   1   33   3   5   167  Gambella   2   4   200   3   9   300  

Addis Ababa   22   1   5   26   28   108  Tigray   35   14   40   40   78   195  

Oromia   217   58   27   263   265   101  Amhara   138   38   28   160   240   150  SNNPR   120   26   22   143   226   158  

Benshangul-Gumuz   5   1   20   8   11   138  

Afar   11   1   9   13   13   100  Somali   36   3   8   42   12   29  

Recommended and achieved levels of basic SAC in public facilities nationally and by region, 2008 & 2014

Recommended and achieved levels of comprehensive SAC in public hospitals nationally and by region, 2008 & 2014

    Comprehensive SAC Service Delivery       2008   2014      

Recommended Actual %

Achieved Recommended Actual %

Achieved Na/onal   148   29   20   176   66   38                  

Harari   1   0   0   1   2   200  Dire  Dawa   1   1   100   1   1   100  Gambella   1   0   0   1   1   100  

Addis  Ababa   5   6   120   6   7   117  Tigray   9   5   56   10   10   100  

Oromia   54   6   11   66   23   35  Amhara   34   5   15   40   9   23  SNNPR   30   6   20   36   8   22  

Benshangul-­‐Gumuz   1   0   0   2   0   0  

Afar   3   0   0   3   1   33  Somali   9   0   0   11   3   27  

% of women treated for obstetric complications that are abortion

related

(95% CI: 46, 48) (95% CI: 24, 42)

(95% CI: 27, 31) (95% CI: 29, 34)

% of women treated for abortion complications that are serious

Fewer obstetric complications are abortion-related, but there was no change in severe complications.

% of women who received abortion services that were induced

procedures

% of women who received abortion services that obtained contraception

There was a shift towards safe and legal abortion and greater contraceptive acceptance.

(95% CI: 27, 36) (95% CI: 47, 55)

(95% CI: 50, 56) (95% CI: 75, 79)

% of uterine evacuations performed with appropriate technology, regardless of trimester

1st trimester

2nd trimester

Greater use of appropriate technology, but 2nd trimester

technology lags behind.

29%

(95% CI: 45, 54) (95% CI: 83, 86)

What have we learned?

Discussion •  Shows tremendous progress overall in Ethiopia.

•  Basic SAC availability increased six-fold & comprehensive SAC more than doubled.

•  Expansion of health centers has outpaced the training of health workers to provide first trimester induced abortion.

•  Access to lifesaving comprehensive SAC falls short of recommended levels almost entirely due to low provision of second trimester induced abortion.

Discussion •  Increased use of appropriate technology and PAFP; however still poor use of appropriate technology for second trimester procedures.

• Higher proportion of safe and legal abortion procedures compared to complications.

•  Limitations • Availability and capability is not equivalent to utilization,

accessibility • Meeting recommended level does not necessarily translate to

access, particularly for widely dispersed and remote regions

Recommendations •  Need a stronger focus on basic SAC

in health centers, particularly first trimester abortion.

•  Needs to be a stronger focus on second trimester safe and legal abortion.

•  The severe complications indicate that there is still a lot of unsafe abortion in the country that has not been eradicated by working in health facilities only.

Ø Further research is needed to discover what methods women are using to induce outside of facilities.

Thank you!