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 Abortion

Texas Pro-Choice Advocates Push Back Against State’s Anti-Choice Pamphlet

Teddy Wilson

The “A Woman’s Right to Know” pamphlet, published by the state, has not been updated since 2003. The pamphlet includes the medically dubious link between abortion care and breast cancer, among other medical inaccuracies common in anti-choice literature.

Reproductive rights advocates are calling for changes to information forced on pregnant people seeking abortion services, thanks to a Texas mandate.

Texas lawmakers passed the Texas Woman’s Right to Know Act in 2003, which requires abortion providers to inform pregnant people of the medical risks associated with abortion care, as well as the probable gestational age of the fetus and the medical risks of carrying a pregnancy to term.

The “A Woman’s Right to Know” pamphlet, published by the state, has not been updated or revised since it was first made public in 2003. The pamphlet includes the medically dubious link between abortion care and breast cancer, among other medical inaccuracies common in anti-choice literature. 

The Texas Department of State Health Services (DSHS) in June published a revised draft version of the pamphlet. The draft version of “A Woman’s Right to Know” was published online, and proposed revisions are available for public comment until Friday.

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John Seago, spokesperson for the anti-choice Texas Right to Life, told KUT that the pamphlet was created so pregnant people have accurate information before they consent to receiving abortion care.

“This is a booklet that’s not going to be put in the hands of experts, it’s not going to be put in the hands of OB-GYNs or scientists–it’s going to be put in the hands of women who will range in education, will range in background, and we want this booklet to be user-friendly enough that anyone can read this booklet and be informed,” he said.

Reproductive rights advocates charge that the information in the pamphlet presented an anti-abortion bias and includes factually incorrect information.

More than 34 percent of the information found in the previous version of the state’s “A Woman’s Right to Know” pamphlet was medically inaccurate, according to a study by a Rutgers University research team.

State lawmakers and activists held a press conference Wednesday outside the DSHS offices in Austin and delivered nearly 5,000 Texans’ comments to the agency.  

Kryston Skinner, an organizer with the Texas Equal Access Fund, spoke during the press conference about her experience having an abortion in Texas, and how the state-mandated pamphlet made her feel stigmatized.

Skinner told Rewire that the pamphlet “causes fear” in pregnant people who are unaware that the pamphlet is rife with misinformation. “It’s obviously a deterrent,” Skinner said. “There is no other reason for the state to force a medical professional to provide misinformation to their patients.”

State Rep. Donna Howard (D-Austin) said in a statement that the pamphlet is the “latest shameful example” of Texas lawmakers playing politics with reproductive health care. “As a former registered nurse, I find it outrageous that the state requires health professionals to provide misleading and coercive information to patients,” Howard said.

Howard, vice chair of the Texas House Women’s Health Caucus, vowed to propose legislation that would rid the booklet of its many inaccuracies if DSHS fails to take the thousands of comments into account, according to the Austin Chronicle

Lawmakers in several states have passed laws mandating that states provide written materials to pregnant people seeking abortion services. These so-called informed consent laws often require that the material include inaccurate or misleading information pushed by legislators and organizations that oppose legal abortion care. 

The American Congress of Obstetricians and Gynecologists (ACOG) sent a letter to DSHS that said the organization has “significant concerns with some of the material and how it is presented.”

Among the most controversial statements made in the pamphlet is the claim that “doctors and scientists are actively studying the complex biology of breast cancer to understand whether abortion may affect the risk of breast cancer.”

Texas Right to Life said in a statement that the organization wants the DSHS include “stronger language” about the supposed correlation between abortion and breast cancer. The organization wants the pamphlet to explicitly cite “the numerous studies that indicate undergoing an elective abortion contributes to the incidence of breast cancer in women.”

Rep. Sarah Davis (R-West University Place) said in a statement that the state should provide the “most accurate science available” to pregnant people seeking an abortion. “As a breast cancer survivor, I am disappointed that DSHS has published revisions to the ‘A Woman’s Right to Know’ booklet that remain scientifically and medically inaccurate,” Davis said.

The link between abortion and cancer has been repeatedly debunked by scientific research.

“Scientific research studies have not found a cause-and-effect relationship between abortion and breast cancer,” according to the American Cancer Society.

A report by the National Cancer Institute explains, “having an abortion or miscarriage does not increase a woman’s subsequent risk of developing breast cancer.”

DSHS spokesperson Carrie Williams told the Texas Tribune that the original booklet was written by a group of agency officials, legislators and public health and medical professionals.

“We carefully considered medical and scientific information when updating the draft booklet,” Williams said.

News Law and Policy

Three Crisis Pregnancy Centers Served for Breaking California Law

Nicole Knight Shine

The notices of violation issued this month mark the first time authorities anywhere in the state are enforcing the seven-month-old Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act.

The Los Angeles City Attorney is warning three area fake clinics, commonly known as crisis pregnancy centers (CPCs), that they’re breaking a new state reproductive disclosure law and could face fines of $500 if they don’t comply.

The notices of violation issued this month mark the first time authorities anywhere in the state are enforcing the seven-month-old Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act, advocates and the state Attorney General’s office indicate.

The office of City Attorney Mike Feuer served the notices on July 15 and July 18 to two unlicensed and one licensed clinic, a representative from the office told Rewire. The Los Angeles area facilities are Harbor Pregnancy Help Center, Los Angeles Pregnancy Services, and Pregnancy Counseling Center.

The law requires the state’s licensed pregnancy-related centers to display a brief statement with a number to call for access to free and low-cost birth control and abortion care, and for unlicensed centers to disclose that they are not medical facilities.

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“Our investigation revealed,” one of the letters from the city attorney warns, “that your facility failed to post the required onsite notice anywhere at your facility and that your facility failed to distribute the required notice either through a printed document or digitally.”

The centers have 30 days from the date of the letter to comply or face a $500 fine for an initial offense and $1,000 for subsequent violations.

“I think this is the first instance of a city attorney or any other authority enforcing the FACT Act, and we really admire City Attorney Mike Feuer for taking the lead,” Amy Everitt, state director of NARAL Pro-Choice California, told Rewire on Wednesday.

Feuer in May unveiled a campaign to crack down on violators, announcing that his office was “not going to wait” amid reports that some jurisdictions had chosen not to enforce the law while five separate court challenges brought by multiple fake clinics are pending.

Federal and state courts have denied requests to temporarily block the law, although appeals are pending before U.S. Court of Appeals for the Ninth Circuit.

In April, Rebecca Plevin of the local NPR affiliate KPCC found that six of eight area fake clinics were defying the FACT Act.

Although firm numbers are hard to come by, around 25 fake clinics, or CPCs, operate in Los Angeles County, according to estimates from a representative of NARAL Pro-Choice California. There are upwards of 1,200 CPCs across the country, according to their own accounting.

Last week, Rewire paid visits to the three violators: Harbor Pregnancy Help Center, Los Angeles Pregnancy Services, and Pregnancy Counseling Center.

Christie Kwan, a nurse manager at Pregnancy Counseling Center, declined to discuss the clinic’s noncompliance, but described their opposition to the state law as a “First Amendment concern.”

All three centers referred questions to their legal counsel, Alliance Defending Freedom (ADF), an Arizona-based nonprofit and frequent defender of discriminatory “religious liberty” laws.

Matt Bowman, senior counsel with ADF, said in an email to Rewire that forcing faith-based clinics to “communicate messages or promote ideas they disagree with, especially on life-and-death issues like abortion,” violates their “core beliefs” and threatens their free speech rights.

“The First Amendment protects all Americans, including pro-life people, from being targeted by a government conspiring with pro-abortion activists,” Bowman said.

Rewire found that some clinics are following the law. Claris Health, which was contacted as part of Feuer’s enforcement campaign in May, includes the public notice with patient intake forms, where it’s translated into more than a dozen languages, CEO Talitha Phillips said in an email to Rewire.

Open Arms Pregnancy Center in the San Fernando Valley has posted the public notice in the waiting room.

“To us, it’s a non-issue,” Debi Harvey, the center’s executive director, told Rewire. “We don’t provide abortion, we’re an abortion-alternative organization, we’re very clear on that. But we educate on all options.”

Even so, reports of deceit by 91 percent of fake clinics surveyed by NARAL Pro-Choice California helped spur the passage of the FACT Act last October. Until recently, a person who Googled “abortion clinic” might be directed to a fake clinic, or CPC.

Oakland last week became the second U.S. city to ban false advertising by facilities that city leaders described as “fronts for anti-abortion activists.” San Francisco passed a similar ordinance in 2011.