Personal Beliefs and Professional Responsibilities: Ethiopian Midwives' Attitudes toward Providing Abortion Services after Legal Reform.

Personal Beliefs and Professional Responsibilities: Ethiopian Midwives’ Attitudes toward Providing Abortion Services after Legal Reform Sarah Jane Holcombe, Aster Berhe, and Amsale Cherie

In 2005, Ethiopia liberalized its abortion law and subsequently authorized midwives to offer abortion services. Using a 2013 survey of 188 midwives and 12 interviews with third-year midwifery students, this cross-sectional research examines midwives’ attitudes toward abortion to understand their decisions about service provision. Most midwives were willing to provide abortion services. This willingness was positively and significantly related to clinical experience with abortion, but negatively and significantly related to religiosity, belief that providers have the right to refuse to provide services, and care of patients from periurban as opposed to rural areas. No significant relationship was found with perceptions of abortion stigma, years of work as a midwife, or knowledge of the law. Interview data suggest complex dynamics underlying midwives’ willingness to offer services, including conflicts between professional norms and religious beliefs. Findings can inform Ethiopia’s efforts to reduce maternal mortality through task-shifting to midwives and can aid other countries that are confronting provider shortages and high levels of maternal mortality and morbidity, particularly due to unsafe abortion. (Studies in Family Planning 2015; 46[1]: 73–95)

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n 2005, Ethiopia enacted a rare reform, liberalizing abortion law as part of the overhaul of its penal code and subsequently authorizing midwives to offer abortion services. In most political systems, the enactment of a law is no guarantee of its implementation (Patashnik 2003). This has been true for abortion laws in particular, because internationally legal liberalization has not reliably led to increased access to services, particularly in more traditional settings where abortion is prohibited on religious grounds (Benson, Andersen, and Samandari 2011; Norris and Inglehart 2011; Singh et al. 2012). This situation is likely the case in Ethiopia, which, like sub-Saharan Africa, has some of the world’s highest levels of maternal mortality, much of it a consequence of unsafe abortion. Maternal mortality resulting from unsafe abor-

Sarah Jane Holcombe is Bixby Associate Fellow, University of California, Berkeley, 17 University Hall, Berkeley, CA 94720. Email: [email protected]. Aster Berhe is Country Midwife Adviser, UNFPA, Ethiopia, and Amsale Cherie is Director, Department of Nursing and Midwifery, School of Allied Health Sciences, Addis Ababa University, Ethiopia. ©2015 The Population Council, Inc.

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Ethiopian Midwives’ Attitudes toward Providing Abortion Services after Legal Reform

tion is underreported and high (Adler et al. 2012) and could represent an increasing proportion of deaths given the country’s progress in reducing maternal mortality from other causes. Successful implementation of a policy reform can rest in large part on the shoulders of those on the frontlines of delivering services (Lipsky 1980). Medical professionals’ refusal to provide reproductive health services, including abortion, occurs globally and has created barriers to women’s access to abortion and other services (Chavkin, Leitman, and Polin 2013).1 Notably, medical professionals’ attitudes have hindered reform in South Africa by reducing access to services and quality of care (Harrison et al. 2000; Dickson et al. 2003). Our study adds to research on the factors associated with the willingness of mid-level providers to provide abortion services, particularly in sub-Saharan Africa and after legal reform.2 Further, by operationalizing measures of stigma and religiosity, we seek to understand how these factors relate to willingness to provide abortion services in low-income countries. The empirical literature has largely focused on physicians in affluent countries. Here, we draw on a sample of midwives who attended a national professional meeting to explore how their attitudes could influence implementation of Ethiopia’s reformed law by examining their willingness to provide abortion services. Using survey data and interviews, we test hypotheses that willingness to provide services is related to length of tenure as a midwife, attitudes toward abortion, past clinical experience with abortion, knowledge of the law, and views on whether abortion service provision is stigmatized by peers.

BACKGROUND Even more than in all other areas of Africa, maternal mortality remains persistently high in Ethiopia (676 deaths/100,000 live births, or 30 percent of all deaths to women aged 15–49), and unsafe abortion continues to be one of its top three causes (CSA and ICF 2012).3 Internationally, safe abortion services are recognized as reducing maternal mortality, and liberalized abortion laws are associated with reduced mortality resulting from unsafe abortion procedures (Singh et al. 2012; WHO 2012). Partly in response, a few countries in sub-Saharan Africa have liberalized their abortion laws—a still unusual phenomenon, although the global trend has been one of liberalization (Boland and Katzive 2008).4 Ethiopia faces multiple challenges in 1 Although health system structure and regulation can also affect the degree of stigma associated with abortion and individual providers’ ability to refuse to offer services (Weisman et al. 1986; Kumar, Hessini, and Mitchell 2009), these issues are not explored here. 2 Ethiopia’s 2006 regulations developed for the 2005 law refer to mid-level providers, thus we do the same here. We acknowledge the continuing discussion about appropriate terminology. Mid-level medical providers are defined as midwives, nurse practitioners, clinical officers, and physician assistants, among others (WHO et al. 2014). There is now international consensus on the medical appropriateness of mid-level providers offering first-trimester abortion services. World Health Organization 2003 guidelines indicate that both aspiration and medical abortion can be safely offered by mid-level providers at the primary-care level in the first trimester (WHO 2003). 3 We use maternal mortality statistics from the 2011 Ethiopia Demographic and Health Survey. The WHO 2013 estimate of an adjusted maternal mortality ratio for Ethiopia is lower: 420/100,000, down from 740/100,000 in 2005 (WHO 2014). WHO defines 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 1995). 4 In sub-Saharan Africa, through either legal or regulatory reform, Zambia (1972), South Africa (1996), Ghana (2006–12), and Mozambique (2014) have liberalized access to services beyond the indications of threat to life or health, rape, incest, or fetal impairment. In practice, access in Zambia remains limited because of the requirement of obtaining approval from three doctors. Cape Verde, South Africa, and Tunisia stand out for allowing abortion without restriction as to reason, but with gestational limits (Singh et al. 2009; Sedgh et al. 2012; Center for Reproductive Rights 2014).

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reducing maternal mortality, including mortality resulting from unsafe abortion. Even more than in most other African countries, Ethiopia has acute per capita shortages of trained medical professionals (Kinfu et al. 2009), as well as a conservative cultural context—67 percent of the population regard abortion as “never justifiable” (WVS 2007). Globally, cultural or religious objections to abortion have often led to refusal by some medical professionals to provide abortion services (Chavkin, Leitman, and Polin 2013), despite the position of international standard-setting institutions such as the World Medical Association and the International Federation of Gynecology and Obstetrics. These groups identify providers’ first duty as patient well-being, even when providers object to providing the services in question (World Medical Association 1964; Serour 2006). The midwifery profession has also grappled with defining midwives’ responsibilities for offering controversial reproductive health services, including abortion (Beal and Cappiello 2008).

Ethiopia’s Legal Reform and Expansion of the Midwifery Profession Ethiopia has taken notable policy and programmatic steps toward reducing maternal mortality, including liberalizing its abortion law and expanding service delivery by “task-shifting” to mid-level providers. Prior to the 2005 reform, abortion in Ethiopia was permitted only to “save the pregnant woman from grave and permanent danger to life or health” and required the approval of two doctors. The reformed law includes exceptions that permit legal abortion in cases of rape, incest, or fetal impairment; if pregnancy continuation or birth would endanger the health or life of the woman or fetus; if the woman has physical or mental disabilities; or if the woman is a minor (under age 18) who is physically or mentally unprepared for childbirth. The reduced evidence requirements for eligibility for legal abortion in case of rape (“mere statement from the woman”) (FDRE 2005) have provided the primary way in which women now access services. The law’s 2006 regulations further broaden access by authorizing mid-level providers, including midwives, to provide abortion services (FDRE 2006). However, full implementation of the law remains incomplete, because much of the public and even medical providers are unaware of or misinformed about it, and there remain cases of unsafe abortion. A 2013 community-based sample in one region revealed that fewer than half of the women surveyed were aware of the reform (Bitew et al. 2013). Even in the capital of Addis Ababa, a 2008 facility-based sample of medical professionals indicated that fewer than two-thirds correctly understood the law (Abdi 2008). A 2008 national estimate indicated that only 27 percent of induced abortions were performed in health facilities, and that more than half of all women in Ethiopia who have induced abortions were estimated to have serious complications (Singh et al. 2010). Nonetheless, abortion services are increasingly being provided through the public health system (FDRE 2011b). Through its four Health Sector Development Programs, Ethiopia has made a national commitment to expand access to health services and to reduce maternal mortality in particular (FDRE 2010 and 2012). Notably, it has significantly expanded the number of mid-level providers in the national health workforce, identifying midwives as the health professionals key to achieving its commitment of reducing maternal mortality. In Ethiopia and elsewhere, mid-level providers such as midwives outnumber physicians, can be more rapidly and less expensively trained, work in facilities closer to where women live, and offer more affordable care (WHO 2008). March 2015


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Modern midwifery in Ethiopia began in the 1950s, but the number of midwives increased little until the last decade; the country has less than one-third of the per capita number recommended by WHO (EMA 2012). While only 980 midwives were trained nationally between 1980 and 2005 (Gaym et al. 2008), their numbers almost quadrupled between 2008 and 2012, and the government is on track to have trained 8,635 midwives by 2015 (FDRE 2011a). In 2012, 4,725 midwives served Ethiopia’s 85 million people. To support this growth, the number of midwifery training institutions increased from 5 to 46 between 2000 and 2012. Ethiopia now has three chief categories of midwives. In addition to ten years of primary and secondary education, “bachelor’s degree midwives” have four years of post-secondary training, “diploma midwives” have three years of specialized midwifery training, and the new category of “accelerated midwives” have three years of nursing training and one year of midwifery training. The first group of accelerated midwives graduated in 2012. A distinctive feature of the midwifery profession in Ethiopia is the large and growing proportion of male midwives (22 percent) as a consequence of new exam-based selection criteria (EMA 2012). Given Ethiopian males’ historically preferential access to formal education, to date they have typically achieved higher scores than women on university entrance exams. The professional mission of Ethiopian midwives centers squarely on women, reproduction, and saving lives, and midwives are often the most highly trained medical professionals in the facility where they are based, particularly in rural areas. The expansion of the size and scope of practice of midwives in Ethiopia has enabled policymakers and leaders in the health professions to instill a clear mission and norms for midwives. These norms emphasize midwives’ core mission as one of maternal mortality prevention, including maternal mortality due to unsafe abortion. From 2005 to the present, the government and the Ethiopian Midwives Association (EMA) have conducted nationwide media campaigns targeting both the public and medical professionals that stress the central role of midwives and other birth attendants in reducing maternal mortality.

Theoretical and Empirical Underpinnings Our understanding of midwives’ views on abortion provision in this study is shaped by theories about the professions and of stigma and by empirical research. The two theoretical literatures point to diametrically opposed influences on midwives’ decisionmaking regarding maternal mortality, unsafe abortion, and provision of abortion services. The first suggests we look to the collective (as opposed to the self-interested) mission of medical professions, in our case midwifery, as influencing the decisionmaking of individual providers. This orientation manifests as a professional commitment to prioritize patient well-being over personal gain (Parsons 1951) and entails the creation of a professional culture and mission (Becker et al. 1961; Cohen 1981; Toit 1995; Brennan and McSherry 2007; Ware 2008). The second points to stigma as a countervailing influence on midwives’ willingness to provide abortion services. It operates within the individual and through organizational and societal interactions and structures. A particular condition or behavior is identified and characterized as abnormal and immoral and is applied to individuals, leaving them with diminished social standing in relationships and potentially limited life opportunities (Goffman 1963; Link and Phelan 2006; Yang et al. 2007). Medical providers and others performing work that is considered socially unacceptable can Studies in Family Planning 46(1)

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suffer from loss of status, discrimination, and psychological distress (Goffman 1963; Major and Gramzow 1999). Abortion has been identified as a stigmatized medical service, both in low-income and more affluent countries and across categories of medical providers (Kumar, Hessini, and Mitchell 2009; Chavkin, Leitman, and Polin 2013). In many settings, the technical competency of medical professionals who provide abortion services is questioned, as are their personal or financial motivations (Grimes 1992). These negative abortion-related attitudes can discourage even well-trained medical providers from offering life-saving care (Lithur 2004; Martin et al. 2011 and 2014; Aniteye and Mayhew 2013). Whether medical professionals refuse to provide stigmatized abortion services on religious or philosophical grounds or from concern about the reactions of others, the result is the same: decreased and/or more difficult access to safe abortion services for women.

Evidence on Medical Professionals’ Willingness to Provide Abortion Services The empirical literature has largely focused on ob-gyns and other physicians in more affluent countries and is typically based on small convenience samples. However, there is a growing body of research in sub-Saharan African countries that have liberalized or are contemplating liberalizing their laws (Ghana and South Africa, among others). This research reveals significant associations between medical professionals’ willingness to provide abortion services and their personal attitudes, attributes, and experience. Not unexpectedly, in both affluent and low-income countries, general attitudes toward abortion are often significantly associated with willingness to provide services (Stewart 1978; Fischer 1979; Weisman et al. 1986; Faúndes et al. 2004; Fischer, Schaeffer, and Hunter 2005; Abdi 2008; Wheeler et al. 2012). Many of the characteristics significantly and positively associated with greater willingness to provide abortion services are not easily changed. These include being in a professional category requiring more training (e.g., an ob-gyn versus a nurse) (Hammarstedt et al. 2005; Abdi 2008), having practiced longer (Faúndes et al. 2004), or having completed medical training (as opposed to still being a student) (Wheeler et al. 2012). A multivariate analysis of South African medical students intent on providing abortion services found a significant association with religious affiliation (Wheeler et al. 2012), although this association was not found among private medical providers in Nigeria (Okonofua et al. 2005). Most studies, however, do not control for religiosity, which has also been associated with decreased willingness to provide abortion services (Faúndes et al. 2004). Sex of the provider has been significantly related to willingness to provide abortion services, although the relationship may differ in more versus less traditional cultural contexts. Female physicians are found to be more willing to provide abortion in the United States (Weisman et al. 1986; Miller, Miller, and Koenigs 1998; Harris et al. 2011). In low-income countries, according to limited evidence, the findings have been mixed, with female providers more willing to provide abortion in two Indian states (Creanga, Roy, and Tsui 2008) and less willing in a six-city sample of physicians and medical students in Mexico (Lisker, Carnevale, and Villa 2006). Not surprisingly, some evidence indicates that the legal status of abortion is associated with medical professionals’ willingness to offer care, with increased willingness to provide services after legal liberalization (Potts, Diggory, and Peel 1977; Miller 1979; Dayananda et al. 2012). March 2015


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Modifiable characteristics of providers are those most relevant to health systems that are seeking to expand access. Characteristics closely linked with medical professionals’ willingness to provide abortion services include clinical abortion training (Steinauer et al. 2008; Wheeler et al. 2012), previous experience providing abortion (Hammarstedt, Lalos, and Wulff 2006), and knowledge of the law in low-resource settings (Abdi 2008). Research in many low- income countries (Brazil, Ethiopia, Ghana, Nigeria, and South Africa) indicates that providers’ knowledge of national laws on abortion is limited (Masho 1997; Goldman et al. 2005; Morhe, Morhe, and Danso 2007; Kamanga 2012). However, reverse causation may be present, since those more willing to provide services may also be more motivated to undergo training or to learn about the law. Little research is available concerning Ethiopian medical professionals’ willingness to provide abortion services. A 2011 survey at Debre Markos University found that 49 percent of nursing students were willing to provide services (Asmamaw 2011). A stratified survey representative of public hospitals and health centers and private hospitals and clinics in Addis Ababa shortly after the legal reform showed low willingness (37 percent) to provide abortion services among all providers, as well as low levels of support for legal abortion among midwives and nurses (41 percent) (Abdi 2008). Furthermore, while providers had a clear sense that the availability of safe legal abortion could reduce maternal mortality caused by unsafe abortion (76 percent agreeing), the majority (61 percent) reported feeling that abortion was a sinful act, and a minority (27 percent) felt comfortable in a facility where abortion was being provided. If such ambivalent or hostile attitudes toward abortion and abortion services among midwives result in reluctance to provide care, there can be adverse consequences for availability and quality of services. Thus, learning midwives’ views can provide a perspective on implementation challenges for Ethiopia’s strategy of maternal mortality prevention through liberalization of the law on abortion and deployment of midwives.

METHODS This cross-sectional study uses both survey and interview data. We adapted surveys conducted in Cambodia and Zambia to the Ethiopian context and pretested the revised version with third-year midwifery students at Addis Ababa University. The final survey contained questions on demographics, knowledge of the law, attitudes toward abortion and abortion service provision, training and clinical experience related to abortion, willingness to provide services, and respondents’ views of midwives’ responsibilities regarding maternal mortality and abortion. We fielded a self-administered paper survey in English at the May 2013 meeting of the Ethiopian Midwives Association (EMA) in Addis Ababa and collected completed surveys from 188 of the 218 midwives attending the meeting (86 percent response rate). Midwives attending EMA’s annual meeting come from each region of the country and are selected in consultation with the Regional Health Bureaus and EMA’s regional branch offices on the basis of EMA membership and volunteer activities. Attendees are thus likely to be more proactive and involved with EMA and the future of their profession. Survey data were prepared and analyzed using EpiInfo7 and Stata 13 software, with descriptive statistics on midwives’ characteristics and a multivariate logistic regression model using marginal effects to identify Studies in Family Planning 46(1)

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factors associated with midwives’ willingness to provide abortion services. Marginal effects produce a single number that expresses the effect of a given independent variable on the probability of the outcome shifting from 0 to 1 (i.e., between the two outcome categories—from “Unwilling” to “Willing or possibly willing”). To better understand the impact of statistically significant variables, we calculated their marginal effects at representative values of the other independent variables: all categorical variables are held at their reference value, and years of work as a midwife was set at the mean of 6.8 years. To clarify the thinking behind midwives’ survey responses, we conducted in-depth interviews with 12 third-year bachelor’s degree midwifery students from Addis Ababa University, or 14 percent of the third-year class. We chose to interview third-year midwifery students for several reasons. First, given the dramatic expansion of the country’s midwifery profession, students are now an unprecedentedly large proportion of it. In 2012, a total of 7,767 midwives were in school—almost double the number of practicing midwives (4,725) nationwide (EMA 2012). Furthermore, at the close of their third year of training, midwifery students have almost completed the most important stage of professional acculturation. Midwifery school is the prime juncture at which midwives’ professional culture and norms are transmitted through both didactic and practical training (Toit 1995; Ware 2008). In addition, bachelor’s degree midwives from the country’s premier university (Addis Ababa University) are likely to have significant future influence within the profession. Finally, third-year midwifery students are a relatively more accessible population. Specific third-year students were selected on the basis of their availability on the day of the interview. The interviews were conducted using a structured guide containing six questions on students’ views of the midwifery profession, of maternal mortality in Ethiopia, and of their willingness to provide abortion services. All 12 interviews were digitally recorded, 8 were transcribed verbatim, and 4 were written up from notes post-interview and from recordings because of poor recording quality. Interviews and the open-ended survey question on midwives’ responsibilities regarding abortion service provision were coded using the HyperResearch qualitative data (textual) analysis tool. Codes were based on the hypotheses as well as on themes emerging from the data. All survey and interview participants provided written informed consent, and data were kept confidential and anonymous. Ethical approval was obtained from the Institutional Review Board of Addis Ababa University and from the Committee to Protect Human Subjects of the University of California, Berkeley (Protocol ID: 2011-03010). The Ethiopian Midwives Association and the Addis Ababa University Centralized School of Nursing facilitated data collection.

Hypotheses We tested six hypotheses concerning midwives’ willingness to provide abortion services. The first five hypotheses are that midwives having more years of work experience, less frequent religious-service attendance, the view that medical professionals are obligated to provide abortion services, more clinical experience with abortion, and better knowledge of the law will be more likely to be willing to provide services. The sixth is that those midwives who view provision of abortion services as a stigmatizing activity will be less willing to provide services. Variables in the estimation and survey samples and the logistic regression models are found in Tables 1 and 4. March 2015


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TABLE 1 Comparison of estimation and survey samples, Ethiopia Percent or mean Estimation sample Full sample Characteristic (n = 148) (n = 165–188) Willing or possibly willing to provide abortion services Not willing 28 30 Possibly willing 16 17 Willing 56 53 Sex (r = female) 66 65 Age (19–58) 29 29.1 Years in current job (0–36) 5.5 5.1 Years as a midwife (0–29) 6.8 6.6 Marital status (r = “never married”) 50 49 Religious affiliation Ethiopian Orthodox Christian 68 68 Muslim 15 14 Evangelical Christian/Protestant 17 18 Frequency of attendance at religious services (r = “more than once a week”) 50 49 Type of midwife Diploma 57 52 Bachelor’s 43 48 Origin of patients served Rural 41 40 Urban 45 46 Periurban 14 14 Believe providers have the right to refuse to provide services on religious grounds (r = “agree”) 66 65 Knowledge of eligibility conditions for legal abortion Less (less than 3 criteria) 65 63 More (all 3 criteria) 35 37 Whether ever having recommended medical abortion (r = “never”) 37 41 Perception that colleagues will not respect midwives who offer abortion services (r = “agree”) 37 37 Timing of midwifery training (r = pre-reform) 36 38 Facility type where respondent works Health center 40 38 Hospital, clinic, or other 60 62 r = Reference category. NOTE: There were no statistically significant differences between the two samples (at p < 0.05). Chi square goodness-of-fit test used for categorical variables, paired t-tests used for continuous variables.

Outcome We selected the fourth of four questions on willingness to provide abortion services as the dependent variable. It posed a higher hurdle for respondents’ willingness to provide abortion services because it specified provision in their own workplace (“Would you be willing to provide abortion services in the facility where you work?”), and its placement near the end of the survey could allow a more considered response. This dummy variable resulted from combining the four categories into two. “Not willing” and “Am not allowed” were included in “Not willing,” making the conservative assumption that those saying they were “not allowed” were more likely to be unwilling to provide services. “Willing” and “Possibly willing” were combined as “Willing or possibly willing,” because these responses showed openness to provision of services. Sparseness in the sex and attitudes toward abortion provision variables prevented use of a three-category outcome variable (“Not willing,” “Possibly willing,” and “Willing”). Using the dichotomous outcome variStudies in Family Planning 46(1)

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able makes it more likely that we will not detect an effect, since a three-category outcome variable would probably reveal a bigger difference between the “Willing” and “Not willing” categories.

Independent Variables The first principal independent variable indicates how many years the respondent has worked as a midwife. Two dichotomous variables represent attitudes toward abortion (“Health care providers should be able to refuse to provide any procedure with which they have a moral or religious disagreement”) and clinical experience with abortion (“Ever having provided medical abortion”), with the reference categories “agree” and “never,” respectively. We then constructed an index measure of respondents’ knowledge of the law from three questions on legal evidence requirements for abortion in case of rape that indicates whether respondents knew the correct response to none, one, two, or three of the questions. Cronbach’s alpha (.83) indicated that the questions were relatively internally consistent, and exploratory factor analysis revealed only one dimension/factor. Because of sparseness, we then collapsed this variable into a low and a high category, with the first three values in the low (less knowledgeable) category and the last value in the high (more knowledgeable) category. To explore stigma related to abortion services, we used a question asking whether respondents believe that they will be judged negatively by their colleagues if they provide abortion services, with “agree” as the reference category. We controlled for five demographic characteristics previously shown to be related to willingness to provide services. We include sex, a three-category variable for religious affiliation (Ethiopian Orthodox Christian, the reference category; Muslim; Evangelical Christian/Protestant); a dummy variable for religiosity (attendance at religious services more than once a week versus once a week or less); type of midwife (diploma versus bachelor’s degree); and a threecategory variable to represent the geographic origin of the patient population served by the respondent (rural, urban, and periurban areas). The rationale for including this last variable is that because midwives serving more patients from rural areas might be the only providers serving them, they might have a clear sense of the likely effects of not providing services and be more willing to provide services. We used complete case analysis with 148 of the 188 cases. The only significant difference between variables in the estimation and survey samples (using t-tests and Chi-square goodness-of-fit tests for the categorical variables) was in a variable not used in our analyses. Midwives in the estimation sample have spent four months more in their current job. Twoway cross tabulations for each categorical independent variable and the dichotomous outcome variable revealed in all but one instance that there were at least ten observations per cell, meaning that there should not be a sparseness limitation when estimating logistic regression models. Religious affiliation was the only variable for which this was not true: out of the 22 Muslim midwives, only two were unwilling to provide services.

RESULTS Survey Findings Two-thirds of the midwives in the estimation sample were female, the average age was 29, and half were married. They had worked for an average of 6.8 years as midwives, and 60 perMarch 2015


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cent worked in hospital settings. Most were Ethiopian Orthodox Christians (68 percent), and smaller and relatively equal proportions were Muslim and Evangelical Christian/ Protestant. Midwives revealed high levels of religious identification and practice: half attended a religious service more than once a week, and more than half agreed that “health care providers should carry their religious values into their professional life and behavior” (57 percent) (not shown) and that midwives had the right to refuse to provide services on religious or moral grounds (66 percent) (Table 1). Table 2 presents the percent of midwives willing to provide abortion services by demographic characteristics and factors related to experience as midwives. Figure 1 shows how religiosity relates to willingness to provide services, taking into account religious affiliation. Comparison with Ethiopia’s 2012 National Census of Midwives shows that our estimation sample differs significantly from the national population of midwives, having greater proporTABLE 2 Percent of midwives willing to provide abortion services by demographic and experience characteristics, Ethiopia (n = 148) Willing to provide services Characteristic No Yes P-value Sex * Female 34 66 Male 18 82 Marital status Never married 25 75 Ever married 30 70 Religious affiliation * Ethiopian Orthodox Christian 28 72 Muslima 9 91 Evangelical Christian/Protestant a 48 52 Frequency of religious service attendance * More than once a week 36 64 Once a week or less 20 80 Type of midwife Diploma 26 74 Bachelor’s 32 68 Number of years as a midwife * Origin of patients served * Rural 20 80 Urban 28 72 Periurbana 52 48 Believe health care providers have the right to refuse to provide services on religious grounds * Agree 33 67 Disagree 20 80 Knowledge of eligibility conditions for legal abortion Less (less than 3 criteria) 32 68 More (all 3 criteria) 21 79 Whether ever having recommended medical abortion * Never 38 62 Ever 23 77 Perception that colleagues will not respect midwives who offer abortion services Agree 36 64 Disagree 24 76 a Cell size less than 5.

NOTE: Differences in demographic characteristics (Chi square or Fischer’s exact test where cell size is below 5; ANOVA where continuous and categorical variables compared): *significant at p < 0.05; **p < 0.01; ***p < 0.001.


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FIGURE 1 Midwives’ possible willingness to provide abortion services (percent), according to religious affiliation and religiosity, Ethiopia (n = 148) 100 80

Percent

80

85

79

69 61

60

47 40 20 0

Ethiopian Orthodox Christian

Muslim

Evangelical Christian/Protestant

More frequent religious service attendance (more than once a week) Less frequent religious service attendance (once a week or less)

tions of men (34 percent vs. 22 percent), more highly educated bachelor’s degree midwives (43 percent vs. 9 percent), more midwives working in hospitals rather than health centers (60 percent vs. 45 percent), and more urban-based midwives (40 percent vs. 8 percent). These differences on balance would tend to bias our findings toward greater willingness to provide abortion services. Midwives had near-complete consensus about the seriousness of the problem of unsafe abortion: 95 percent agreed that “unsafe abortion was a serious problem in Ethiopia,” and 86 percent agreed that “without legal abortion, too many women would die from unsafe abortions.” They also had high levels of clinical exposure to abortion and abortion-related mortality and morbidity: 72 percent have had a patient who asked them for information about terminating a pregnancy, 91 percent have encountered a patient with an incomplete abortion, and 46 percent have had a patient who has died from an unsafe abortion. In addition, a majority of midwives had previously provided abortion care, particularly medical abortion: 63 percent had recommended medical abortion to legally terminate a pregnancy, substantially more than the percentage indicating that they had received the relevant training (49 percent). Respondents were also interested in receiving further training (78 percent). Table 3 and Figures 2 and 3 depict midwives’ attitudes toward and clinical experience with abortion. The publicly articulated rationale for reform of Ethiopia’s law on abortion was to prevent maternal mortality, particularly that of young girls; the debate was not couched in terms of women’s rights. Perhaps reflecting this, Ethiopian midwives were not particularly supportive of a woman’s right to have an abortion: less than half agreed that there was a right (49 percent) (see Table 3). Nonetheless, midwives largely supported girls’ or women’s autonomy to decide about abortion vis-à-vis the authority of others. Approximately two-thirds of respondents March 2015


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TABLE 3 Ethiopian medical providers’ attitudes and experiences related to abortion, pre- and post-legal reform, 2000, 2008, 2013 Abortion-related mortality and morbidity are significant public health problems Access to safe abortion would reduce maternal death/ If abortion is illegal, women will die of unsafe abortions Abortion should be legally permitted for economic reasons Ob-gyns Nurses (including midwives) Abortion should be legally permitted in cases of contraceptive failure Ob-gyns Nurses (including midwives) A woman has the right to terminate her pregnancy if she wishes Views on who should provide abortion services Only MDs should provide abortions/Mid-level providers are able to provide surgical abortions/ Midwives should be allowed to provide surgical abortion services in the first trimester Ever encountered a patient with an incomplete abortion Ever had anyone request an abortion Ever had abortion training/Ever had training in first-trimester abortion Ever terminated a pregnancy/Ever recommended medical abortion Willing to provide MVA abortion/Definitely willing to provide abortion View self as (very or somewhat) familiar with the law Correctly understand that only the woman’s statement that she was raped is required Feel comfortable working at a site where abortion is performed Consider termination of unwanted pregnancy to be a sinful act

ESOG (2000)

Percent agreeing Abdi (2008)

EMA (2013)

98

97

95

na

82

86

78 na na 51 na 56 82 na na 58 na 52 na 41 49

75 97 72 na 35 (private) 15 (public) na na

30 na na 29 30

84 91 72 49 63

37 68

55 80

na 67 64 na 27 na na 61 na

MVA = Manual vacuum aspiration. na = Not available. NOTE: The 2000 data are drawn from a nationally representative survey conducted by the Ethiopian Society of Obstetrician-Gynecologists (ESOG 2002). The 2008 data are drawn from a survey of medical professionals at four health facilities in Addis Ababa. The 2013 data are drawn from the research presented here—the survey of midwives at the Ethiopian Midwives Association (EMA) annual meeting. Unless otherwise noted, ESOG’s and Abdi’s respondents are of all provider types; EMA respondents are midwives.

disagreed with requiring parents’ or a male partner’s consent for an abortion (63 percent and 67 percent, respectively). There were also smaller majorities for permitting abortion on socioeconomic grounds (56 percent) and in cases of contraceptive failure (52 percent) (not shown). We found relatively little evidence of stigma attached to the provision of abortion services. Most midwives felt that health professionals deserved respect for providing such services (81 percent) and did not fear loss of respect from colleagues if they did so (63 percent). Strong support was also shown for permitting midwives to provide abortion services and for participation in relevant training (83 percent and 89 percent, respectively). A smaller majority (52 percent) reported feeling that health professionals should be required to provide abortion services, even if this contravened their religious beliefs. At the same time, however, more than half of midwives (66 percent) expressed the contradictory view that providers should have a right to refuse to provide services. Furthermore, fewer than half of respondents (42 percent) thought that there would be administrative repercussions for refusing to provide abortion services. F inally, respondents had significant deficiencies in their knowledge of the law, with only 28 percent correctly identifying the legal eligibility criteria for abortion in case of rape (not shown). Fifty-six percent of midwives reported that they were willing, and 16 percent possibly willing, to provide abortion services in the facility where they worked (Table 1). In the multiStudies in Family Planning 46(1)

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FIGURE 2 Midwives’ attitudes toward providing abortion services (percent agreeing, n = 148), Ethiopia

Midwives should be allowed to provide surgical abortion services

84

Health professionals who provide abortion services deserve respect for the work that they do

81

My health care provider colleagues would not respect me if I provided abortion services

37

Midwives and doctors should be required to provide abortion services to women even if it goes against their personal beliefs

52

Health care providers should be able to refuse to provide any procedure with which they have religious or moral objections

66

There are serious consequences for those who do not provide abortion services as required by regulation

42 0

20

40

Percent

60

80

100

FIGURE 3 Midwives’ clinical experience with abortion, Ethiopia (n = 148)

Have been asked by patient about abortion services

72

Have had a patient with an unsafe abortion

91

Had a patient who has died because of an unsafe abortion

46

Have had training on first-trimester abortion

49

Have recommended medication to legally terminate an unwanted pregnancy

63 0

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40

Percent

60

80

100


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variate logistic regression model (Table 4, last column), four marginal effects coefficients are significantly associated with willingness to provide abortion services: frequency of religious attendance, origin of patients served, view on whether midwives have the right to refuse to provide abortion, and experience recommending medical abortion. We thus found support for three of our six hypotheses. Midwives who had less frequent religious service attendance, who believe that midwives do not have the right to refuse to provide services, and who have more clinical experience with abortion indicated significantly greater willingness to provide services. However, in contrast to our expectations and to the literature on medical professionals’ willingness to provide services in low-income countries, we did not find support for the hypothesis that midwives with more years of experience would be more willing to provide services. To the contrary, the effect, although just shy of significance, was in the opposite direction. We also found no significant support for the hypothesis that abortion-related stigma is linked with willingness to provide abortion services. Although we made no related predictions, we found that midwives caring primarily for patients from periurban rather than rural areas were significantly less likely to be willing to offer abortion services. The marginal effects statistics help clarify these results. For midwives who have worked the average number of years (6.8), all other factors held constant, willingness to provide abortion services increases by 14 percent if they attend religious services less frequently (once a week or less). Believing that midwives do not have the right to refuse to provide abortion services is associated with a 15 percent increase in willingness to provide services. Serving patients from periurban areas is associated with a 25 percent decrease in willingness to provide services.

TABLE 4 Logistic regression models with odds ratios and marginal effects of Ethiopian midwives’ willingness to provide abortion services by demographic, attitudinal, and clinical experience characteristics, 2013 Odds ratios Marginal effects Model 1 Model 2 Full model coefficient Sex (r = female) 2.19 2.25 1.80 0.09 Years as midwife 0.95 0.97 0.93 –0.01 Religion (r = Ethiopian Orthodox Christian) Muslim 1.30 3.50 5.45* 0.21** Evangelical Christian/ Protestant 0.54 0.52 0.63 –0.08 Religious service attendance (dummy, r = more than once a week) 2.42* 2.17* 2.40 0.14* Type of midwife (r = Diploma midwife) 0.68 0.94 1.05 0.01 Patient origin (r = rural) Urban 0.81 1.02 0.003 Periurban 0.30 0.24* –0.25* View whether medical professionals have right to refuse to provide services to which they have religious objections (dummy, r = agree) 2.60 0.15* Knowledge of law on abortion (dummy, r = less) 2.42 0.14 Ever having recommended medical abortion (r = never) 2.85* 0.16* Perception that colleagues will not respect one if one offers abortion services (dummy, r = agree) 1.21 0.03 Constant 2.25 2.37 0.75 Observations 168 149 148 148 *Significant at p < 0.05; **p < 0.01; ***p < 0.001. r = Reference category. NOTE: Marginal effects coefficients are expressed as average marginal effects calculated from logit models.


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Finally, and not surprisingly, midwives who have ever recommended medical abortion to a patient (a proxy for clinical experience) have a 16 percent increase in willingness to provide abortion services (Table 4).

Interview Findings In-depth interviews (IDIs) and responses to the open-ended survey questions help clarify the survey results, in particular the values, beliefs, and views that underlie the readiness (or lack thereof) of midwives to implement a new and socially contentious policy. Midwives expressed strong professional and personal commitment to saving individual women’s lives. All of the interviews and many of the open-ended responses on the survey mentioned preventing maternal deaths as midwives’ primary mission. Midwives also believed that their efforts advanced the country’s well-being. It is clear … so many mothers and babies are dying every day in this country due to pregnancyrelated causes. As a man, I consider myself very lucky to be able to help my country reduce the mortality rate in general, and to save as many mothers’ lives as I can in particular. This profession is more than just a career, and to be a midwife is a great opportunity for me. (Male midwifery student)

Midwives’ emphasis on advancing national development through their work is in keeping with the ruling party’s emphasis on Ethiopia as a “developmental state” that prioritizes national, social, and economic development (Zenawi 2006). While focusing on the prevention of maternal mortality, the midwifery students also expressed a sense of the injustice of pregnant women dying as a result of child-bearing. Reducing the rate of maternal mortality must be the most important issue to be considered. Mothers should be helped in delivering a baby and should not die while delivering a baby. The mother’s life should come first…. Safe abortion for the sake of the mother’s life is fair. In this regard, midwives should play a significant role since we are aware of this bitter fact. (Female midwifery student)

Midwifery students unanimously identified preventing maternal mortality as their highest priority and were able to articulate it clearly, which is understandable both because of the focus of their training and because of the broader national focus on maternal mortality prevention. National advertising campaigns and the goal of the midwives’ professional association (“To contribute towards the reduction of maternal and child mortality and morbidity in Ethiopia”) have emphasized the central role of midwives in preventing maternal mortality. When midwifery students discussed whether they would be willing to provide abortion services, they exhibited a range of reactions. They all understood that abortion was legally available and that midwives were authorized to provide abortion. They recognized that government policy mandates the service and that it can reduce maternal mortality. Several were readily willing to offer services: Definitely, I am ready to offer abortion services whenever they are needed. (Male midwifery student) I will provide. If I refuse, then she will use her cultural beliefs [to induce an abortion]. (Male midwifery student) March 2015


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Other midwives described the specific conditions under which they would be willing to provide abortion services, often mentioning indications such as rape or incest, even while acknowledging the clear prohibitions of their religious faith. Several mentioned the likelihood that a woman seeking an abortion would obtain services from an unsafe provider if she could not get formal health services. They described providing abortion as a necessary choice of the lesser of two evils for midwives: Personally, I don’t want to do abortion, but if a woman came to me to have an abortion, according to the legal exceptions that make abortion legal, I would do it. Even if it is killing the baby, but she came being pregnant from her father or brother, it is hard to live with that. Even having a baby from a father or brother is not legal. So, this is a sin, and performing an abortion is also a sin. I think that when I weigh it, performing an abortion for her is much better than letting her live with that baby. Even if I say I will not perform an abortion, I know that this will not stop this lady from aborting. She will go to other places that are not safe. (Female midwifery student)

Several midwifery students voiced even more divided feelings and internal conflicts concerning what they would prefer to do about a service they viewed as religiously proscribed and what their professional training and the rules of the public health system recommend or require. They grappled with whether they would provide abortion services and what they would do if they do not provide such services. I don’t think I can, even if it is legal. I am not sure … I don’t know what to do. If the situation forced me … maybe I will do it to save the mother’s life. Anyway, it is very hard for me. If I have the right to say “No, I don’t do it,” I would prefer not to do it. If I must do it, I will. (Female midwifery student)

Even as she spoke, this student was contemplating whether she should provide services and under what conditions, all while considering facility and/or national health system expectations about abortion-service provision. A few midwifery students stated clearly that they would not provide abortion services. However, most were pragmatic, not ideological, recognizing that women would seek abortions elsewhere if they were turned away from the facility. Even in the cases where they indicated they would not provide services, most said that they would refer patients to colleagues who would. No way … I am not going to provide abortion services in any case. But I may look for other solutions … like, for example, if I have a patient who needs abortion services, contacting my midwife friends who are willing to offer the service. (Male midwifery student)

Midwives who indicated they would not provide services usually went on to explain why and also to offer alternative ways to help patients. They did not just say “no.” The unease midwifery students expressed about providing abortion services most often stemmed from their religious beliefs. Several were very clear about their religious faith, its prohibition of abortion, and their decision not to provide abortion services. A Protestant student emphasized her church’s opposition to abortion, her personal belief that abortion is killing, and her desire to focus on other aspects of midwifery. Studies in Family Planning 46(1)

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Deep down in my soul there is something telling me that abortion is killing … do you understand me? Abortion means nothing but stopping someone’s growth by killing. In my religion, the unborn baby is considered as a person starting from conception … it has a life since the fertilization of the egg. So it is a sin to take the life of the embryo. I know my religion never allows me to offer abortion services. We have been teaching in the church every Sunday that abortion is a great sin; it is horrible to see a picture of women who committed abortion. As a midwife, I just want to do activities other than abortion. (Female midwifery student)

In the interviews and in the open-ended survey responses, midwives conveyed their conviction that offering abortion services should not be the first line of effort. Rather, they emphasized the need for prevention education and more extensive provision of family planning services. They were not enthusiastic about providing abortion services and saw abortion as a last resort. We should work more on preventing unwanted pregnancy as opposed to focusing on offering abortion services. We have to teach women to take contraceptives and about reproductive health and other preventive methods. We can use abortion service as a safety valve…. I mean, if the situation is beyond our capacity to prevent, such as in the case of rape, we can offer abortion services. There is no better way than prevention to reduce maternal mortality. (Male midwifery student)

The in-depth interviews reveal the struggles underlying the expressed willingness of the majority of midwifery students (and midwives) to provide abortion services. These struggles are between their self-described sense of professional duty and their knowledge of maternal mortality related to unsafe abortion, on the one hand, and their personal religious beliefs proscribing and stigmatizing abortion, on the other. They did not articulate a rights-based rationale for providing abortion services.

Study Design Limitations Limitations to this research include recall and social acceptability bias, as is generally the case for nonrandomized research relying on self-report.5 Such bias may be less likely, however, because survey administration was not face-to-face, increasing confidentiality; because clinical events related to abortion are less easily ignored; and because findings elsewhere suggest that people tend to have opinions on abortion and that these opinions tend not to be easily altered (Jelen and Wilcox 2003). Furthermore, over-reporting of religious-service attendance is less likely in traditional cultural settings (Inglehart and Baker 2000). As with any survey data, measurement bias is also possible. Although our survey and interview data are not nationally representative, we argue that they enable us to get a broad, as well as an in-depth, view of midwives’ values and attitudes that reflects the perspectives of midwives who are likely to be influential in communicating the mission of the midwifery profession in Ethiopia. The interviews were conducted with third-year midwifery students at Addis Ababa University, rather 5 Midwifery student interviewees may well be subject to social desirability bias. They likely know that the norms of their profession and the perspective of their interviewer support midwives’ provision of abortion services. If this bias does exist, however, it can be interpreted as a sign of the strength of the awareness and/or adoption of these norms—although it is not possible here to determine whether they themselves have internalized these perspectives or are merely asserting what they are aware of as the expectation for their profession (Tajfel 1979; Abrams 1992; Abrams 1996). Several descriptive studies of socialization in nursing find a phenomenon of “fitting in” (Melia 1984; Howkins and Ewens 1999), although others refer to personal transformation (Toit 1995).

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than with practicing midwives. However, given the dramatic expansion of the country’s midwife workforce, the opinions of these younger students are likely to be representative of the growing majority of Ethiopian midwives. Finally, our purposive sample makes it difficult to untangle the direction of relationships between variables. For example, midwives who are already inclined to provide abortion services might then be more motivated to learn the law’s requirements rather than the opposite relationship postulated in our model.

DISCUSSION A premise underpinning this research is that successful policymaking takes place not only at the adoption stage, but also during implementation through the behavior of frontline service providers: midwives. Midwives’ attitudes can contribute to expanding or restricting women’s access to abortion services. Findings here suggest the need for midwifery training to more fully cover key areas where we found shortcomings, for vigilance in identifying and addressing any refusal to provide abortion services or to refer women to willing providers, and the value of further exploring how professional norms related to willingness to provide abortion services can be created and maintained. Countries and national health systems seeking to replicate Ethiopia’s combination of task-shifting to midwives and increased access to legal and safe abortion to reduce maternal mortality should explicitly address the norms and perspectives of midwives. We found that substantial proportions of midwives have not received clinical training related to abortion (despite having provided medical abortion services) and lack knowledge of the current law. Thus a clear need for additional training exists. These findings can inform the efforts of Ethiopia’s health system to strengthen and fully implement midwifery education curricula. While the pre-service curriculum for midwives is already extensive, pre-service training is less expensive and logistically easier than in-service training and sets in place enduring patterns of practice. Fully implementing such training, with greater emphasis on facilitating women’s informed decisionmaking about their reproductive health, can also help midwives better adhere to their profession’s standards (International Confederation of Midwives 2008). While we found that almost three-fourths of midwives were either willing or possibly willing to provide abortion (a proportion higher than that found in many other countries) (Holcombe, Berhe, and Cherie 2014), more than 25 percent of midwives indicated that they would not provide services. This unwillingness exists despite their work in government health facilities where legal abortion provision is the clear policy. Thus women’s lack of access to abortion services should remain a concern. This is all the more true in rural health facilities, those serving the vast majority of Ethiopia’s population. Midwives in rural areas are often the only medical professionals present who are trained to provide abortion services, and the facilities’ remote locations make referrals difficult. If midwives refuse to provide or to refer, women’s access to services is obviously compromised. Clearer and more effective referral guidelines and practices should be established and implemented. The interview findings suggest that how the professional role of midwives is defined is closely related to willingness to provide abortion services. The findings highlighted how midwives’ keen sense of professional mission, identified as preventing maternal mortality and Studies in Family Planning 46(1)

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helping their country, appears to act as a counterbalance to personal religious beliefs that abortion is a sin. We find some support for theories describing medical professionals’ motivation as stemming from professional social commitment to the well-being of others, as well as from commitment to national development. It is worthwhile to further explore this relationship between the development of a professional mission and norms that prioritize saving women’s lives, on the one hand, and the numbers of medical professionals willing to offer abortion services, on the other. At the same time, the norm of preventing maternal mortality underpinning midwives’ rationale for providing legal abortion care could complicate any future efforts to maintain or expand abortion access, especially as maternal mortality declines. The lack of support for our hypothesis that midwives with more work experience would be more willing to provide abortion services was unexpected, especially as the direction of the effect is the reverse of our prediction. One possible explanation is that more than threefourths of Ethiopia’s midwives, as well as of the midwives in our sample, have worked solely in the more liberal legal environment resulting from the 2005 reform, and thus may be more likely to accept the law as a normal and expected part of their work environment. As new midwives start to establish their professional identity, they may be more receptive to the national campaigns and the public-sector focus on emphasizing midwives’ responsibilities for maternal mortality prevention. Finally, midwives who were working in the profession before the legal reform likely resented the additional workload it created for them (authors’ professional experience). Although we did not find support for the hypothesis that stigma attached to abortion provision affects midwives’ willingness to provide services, the effect was in the predicted direction. It is premature to rule out the influence of stigma given the strong predictions from theory, experience elsewhere with the effects of stigma on health professionals, and the negative religious views on abortion in Ethiopia. There are plausible explanations for the absence of a significant relationship here. Midwives may not want to acknowledge the possibility of their peers judging them negatively. In addition, national campaigns post-reform have emphasized maternal mortality prevention as the central duty of midwives, leading midwives to view abortion services as a difficult but necessary responsibility of their profession in order to prevent maternal mortality from unsafe abortion. This view may reduce the stigma associated with providing abortion services. This topic requires further study in Ethiopia, because stigma can be an important predictor not only of refusal to provide services but also of professional disillusionment among those who do provide abortion care (Martin et al. 2014). As implementation of Ethiopia’s law continues, future research should also examine the incidence of refusal to provide services or referrals. On the one hand, resistance to service provision could decrease over time, as new cohorts of midwives trained and acculturated in Ethiopia’s liberalized legal environment make up greater and greater proportions of the profession. However, as contraceptive use continues to increase and maternal morbidity and mortality related to unsafe abortion decrease, Ethiopian policymakers should also be alert to any repercussions on midwives’ continued willingness to provide abortion services, as interviews identified maternal mortality prevention, rather than women’s rights, as midwives’ central rationale for abortion service provision.

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ACKNOWLEDGMENTS We are grateful to the midwives who shared their time and insights, and to the Ethiopian Midwives Association’s generous collaboration and commitment to improving quality of care. Survey assistance from Tam Fetters and Lisa Martin was extremely helpful. We thank Ann Keller, Malcolm Potts, Ndola Prata, and Will Dow for their valuable comments on earlier drafts. Financial support from the Society of Family Planning Research Fund and the Center for African Studies, University of California, Berkeley, is appreciatively acknowledged. A previous version of this paper was presented at the Population Association of America Annual Meeting, Boston, Massachusetts, 1–5 May 2014. The findings and conclusions expressed are entirely those of the authors.

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