Step By Step, Ethiopia Pushes Back Unsafe Abortion

Susheela Singh and Tamara Fetters

Ethiopia is leading the way in reducing maternal deaths from unsafe abortion through liberalized abortion laws and changes in the health care system. Still,  only one-fourth of all abortions in the country are safe and legal.

This article is based on a report jointly authored by Ipas and the Guttmacher Institute

If you live in Addis Ababa or in another Ethiopian city and seek a safe abortion, you’re likely to find it. But if you’re like the majority of Ethiopian women and live in a rural area, safe abortion services are hard to find. Four years after the abortion law was liberalized and the health system set to work to implement the new guidelines, only a quarter of all abortions in the country are induced in safe and legal settings.

This week, Ipas and the Guttmacher Institute, in collaboration with Ethiopian Society of Obstetricians and Gynecologists, the Ethiopian Public Health Association and Ethiopia’s Federal Ministry of Health, released the results of the first-ever nationwide assessment of abortion in Ethiopia  — showing that while the country has made significant inroads in making safe abortion services available, increased access to high-quality contraception and safe abortion services is needed, as well as treatment of complications of unsafe abortion.

The demand for abortion in this poor and predominantly rural country is rooted in low contraceptive use and high levels of unintended pregnancy. Indeed, only 14 percent of Ethiopian women of reproductive age use contraception and more than 40 percent of pregnancies are unintended. It is no wonder then that hundreds of thousands of women seek abortions every year, often with tragic consequences. It is with this in mind that the government moved to make legal safe abortion more accessible. But training providers and educating communities in such a large country takes time.

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As in many countries (including the United States), the majority of women who seek abortions are mothers. But when safe abortion services are limited or nonexistent, women will turn to unsafe procedures to end an unwanted pregnancy. Any complications that may arise will affect not only these women but their children as well. Their families pay a tremendous price—one that could be prevented through expansion of comprehensive reproductive health care, including high quality contraceptive services and safe abortion care, throughout the country.

Our study found that in 2008, more than 50,000 women were treated for complications from unsafe abortion procedures. Forty percent of these women showed signs of infection or invasive injuries when they arrived at health facilities for treatment.  Many other women never reach a facility because they live too far from services, because fear and stigma prevent them from seeking help or because they die before reaching the facility.

And sadly, many women just don’t know they can seek safe abortion under the new law. While the Ethiopian Ministry of Health and organizations like Ipas are working with women’s groups around the country to educate communities, it takes time to reach women in such a vast rural country. Similarly, health-care facilities outside of urban areas are less likely to be equipped to offer services.

Though it is clear more work must be done to expand services, major findings from this national study do point to positive trends. Substantial progress has been made in providing legal, safe abortion services in the short time since legal reform. Forty-three percent of all health facilities provided safe abortion services in 2008, with higher proportions in public hospitals and private or nongovernmental facilities than public health clinics, accounting for just over a quarter of the roughly 383,000 abortions in Ethiopia in 2008.  The remaining procedures were unsafe—that is, performed outside of authorized facilities by untrained or unskilled providers in an unhygienic environment.

The reformed law and new guidelines have certainly resulted in more doctors and midwives being trained to provide abortion care, which has facilitated expansion of safe abortion services throughout the country. To build on this progress, the Ethiopian government must increase the availability of abortion and postabortion care in government hospitals and health centers. Providers and women alike must be educated about the new law. The introduction of medication abortion could also greatly expand access, particularly in rural areas, because it requires less health system resources and provider training. Finally, expansion of contraceptive services is crucial if unintended pregnancy and abortion-related mortality and morbidity are to be reduced. When used effectively, modern contraception can prevent nearly all unintended pregnancies. But for it to work, women must have access to quality services and to methods that suit their lives and they must be able to consistently get these methods.

News Health Systems

Complaint: Citing Catholic Rules, Doctor Turns Away Bleeding Woman With Dislodged IUD

Amy Littlefield

“It felt heartbreaking,” said Melanie Jones. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

Melanie Jones arrived for her doctor’s appointment bleeding and in pain. Jones, 28, who lives in the Chicago area, had slipped in her bathroom, and suspected the fall had dislodged her copper intrauterine device (IUD).

Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“I think my first feeling was shock,” Jones told Rewire in an interview. “I thought that eventually they were going to recognize that my health was the top priority.”

The doctor left Jones to confer with colleagues, before returning to confirm that her “hands [were] tied,” according to two complaints filed by the ACLU of Illinois. Not only could she not help her, the doctor said, but no one in Jones’ health insurance network could remove the IUD, because all of them followed similar restrictions. Mercy, like many Catholic providers, follows directives issued by the U.S. Conference of Catholic Bishops that restrict access to an array of services, including abortion care, tubal ligations, and contraception.

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Some Catholic providers may get around the rules by purporting to prescribe hormonal contraception for acne or heavy periods, rather than for birth control, but in the case of copper IUDs, there is no such pretext available.

“She told Ms. Jones that that process [of switching networks] would take her a month, and that she should feel fortunate because sometimes switching networks takes up to six months or even a year,” the ACLU of Illinois wrote in a pair of complaints filed in late June.

Jones hadn’t even realized her health-care network was Catholic.

Mercy has about nine off-site locations in the Chicago area, including the Dearborn Station office Jones visited, said Eric Rhodes, senior vice president of administrative and professional services. It is part of Trinity Health, one of the largest Catholic health systems in the country.

The ACLU and ACLU of Michigan sued Trinity last year for its “repeated and systematic failure to provide women suffering pregnancy complications with appropriate emergency abortions as required by federal law.” The lawsuit was dismissed but the ACLU has asked for reconsideration.

In a written statement to Rewire, Mercy said, “Generally, our protocol in caring for a woman with a dislodged or troublesome IUD is to offer to remove it.”

Rhodes said Mercy was reviewing its education process on Catholic directives for physicians and residents.

“That act [of removing an IUD] in itself does not violate the directives,” Marty Folan, Mercy’s director of mission integration, told Rewire.

The number of acute care hospitals that are Catholic owned or affiliated has grown by 22 percent over the past 15 years, according to MergerWatch, with one in every six acute care hospital beds now in a Catholic owned or affiliated facility. Women in such hospitals have been turned away while miscarrying and denied tubal ligations.

“We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions,” said Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU of Illinois, in a phone interview with Rewire. “It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves.”

Jones left her doctor’s office, still in pain and bleeding. Her options were limited. She couldn’t afford a $1,000 trip to the emergency room, and an urgent care facility was out of the question since her Blue Cross Blue Shield of Illinois insurance policy would only cover treatment within her network—and she had just been told that her entire network followed Catholic restrictions.

Jones, on the advice of a friend, contacted the ACLU of Illinois. Attorneys there advised Jones to call her insurance company and demand they expedite her network change. After five hours of phone calls, Jones was able to see a doctor who removed her IUD, five days after her initial appointment and almost two weeks after she fell in the bathroom.

Before the IUD was removed, Jones suffered from cramps she compared to those she felt after the IUD was first placed, severe enough that she medicated herself to cope with the pain.

She experienced another feeling after being turned away: stigma.

“It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

The ACLU of Illinois has filed two complaints in Jones’ case: one before the Illinois Department of Human Rights and another with the U.S. Department of Health and Human Services Office for Civil Rights under the anti-discrimination provision of the Affordable Care Act. Chaiten said it’s clear Jones was discriminated against because of her gender.

“We don’t know what Mercy’s policies are, but I would find it hard to believe that if there were a man who was suffering complications from a vasectomy and came to the emergency room, that they would turn him away,” Chaiten said. “This the equivalent of that, right, this is a woman who had an IUD, and because they couldn’t pretend the purpose of the IUD was something other than pregnancy prevention, they told her, ‘We can’t help you.’”

News Law and Policy

Anti-Choice Group: End Clinic ‘Bubble Zones’ for Chicago Abortion Patients

Michelle D. Anderson

Chicago officials in October 2009 passed the "bubble zone" ordinance with nearly two-thirds of the city aldermen in support.

An anti-choice group has announced plans to file a lawsuit and launch a public protest over Chicago’s nearly seven-year-old “bubble zone” ordinance for patients seeking care at local abortion clinics.

The Pro-Life Action League, an anti-choice group based in Chicago, announced on its website that its lawyers at the Thomas More Society would file the lawsuit this week.

City officials in October 2009 passed the ordinance with nearly two-thirds of the city aldermen in support. The law makes it illegal to come within eight feet of someone walking toward an abortion clinic once that person is within 50 feet of the entrance, if the person did not give their consent.

Those found violating the ordinance could be fined up to $500.

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Harassment of people seeking abortion care has been well documented. A 2013 survey from the National Abortion Federation found that 92 percent of providers had a patient entering their facility express personal safety concerns.

The ordinance targets people seeking to pass a leaflet or handbill or engaging in “oral protest, education, or counseling with such other person in the public way.” The regulation bans the use of force, threat of force and physical obstruction to intentionally injure, intimidate or interfere any person entering or leaving any hospital, medical clinic or health-care facility.

The Pro-Life Action League lamented on its website that the law makes it difficult for anti-choice sidewalk counselors “to reach abortion-bound mothers.” The group suggested that lawmakers created the ordinance to create confusion and that police have repeatedly violated counselors’ First Amendment rights.

“Chicago police have been misapplying it from Day One, and it’s caused endless problems for our faithful sidewalk counselors,” the group said.

The League said it would protest and hold a press conference outside of the Planned Parenthood clinic in the city’s Old Town neighborhood.

Julie Lynn, a Planned Parenthood of Illinois spokesperson, told Rewire in an email that the health-care provider is preparing for the protest.

“We plan to have volunteer escorts at the health center to make sure all patients have safe access to the entrance,” Lynn said.

The anti-choice group has suggested that its lawsuit would be successful because of a 2014 U.S. Supreme Court decision that ruled a similar law in Massachusetts unconstitutional.

Pam Sutherland, vice president of public policy and education for Planned Parenthood of Illinois, told the Chicago Tribune back then that the health-care provider expected the city’s bubble zone to be challenged following the 2014 decision.

But in an effort to avoid legal challenges, Chicago city officials had based its bubble zone law on a Colorado law that created an eight-foot no-approach zone within 100 feet of all health-care facilities, according to the Tribune. Sidewalk counselor Leila Hill and others challenged that Colorado law, but the U.S. Supreme Court upheld it in 2000.

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