ADDIS ABABA, Ethiopia — Khadija, 29, was a domestic worker in Bahrain when she was raped in circumstances she preferred not to replay. She became pregnant, and by June it began to show. She knew then she had to go. Desperate, Khadija (who declined to have her real name used) called a friend back home in Addis Ababa, Ethiopia’s capital, who told her about a clinic that could help.
At the clinic in late June, Khadija wrung her hands in pain as the pill moved through her system, inducing abortion and causing cramps and abdominal pain. She had not told her husband about the rape or the abortion. She was making this move on her own.
Khadija kept saying how lucky she felt. And statistically, she was. A decade ago, she couldn’t have had the procedure, at least not legally. Ethiopia legalized abortion in certain cases in 2005. That year, botched abortion contributed to about one-third of maternal deaths in Ethiopia — and that’s according to government figures, which are likely to be conservative. Today, the reported rate is closer to a quarter, though many more are likely never even spoken about.
The Ethiopian government attributes the decline in part to its much-publicized push to expand family planning programs and health facilities. The push was about more than unsafe abortion: In 2000, 1 in 24 women died from pregnancy-related causes, and the country’s rising population (90 million and growing) put pressure on jobs and land.
The government’s effort to make contraception affordable is significant for a country where one-third of the population lives on less than $1 a day, and most of the population remains in rural areas still dominated by traditional ties and religious teachings that don’t favor modern family planning. In 2000, 8% of married women used contraceptives. That shot up to 30% in 2011, according to the latest Demographic and Health Survey (DHS).
In public clinics, most services are free. In private clinics, where conditions are often nicer, costs vary. Contraceptives like the popular Depo-Provera injection, which lasts three months, costs around $1, while an abortion costs about $15. The government promotes a female-centered contraception conversation; male condom use remains far less common. Health services in the capital are generally better than in the rest of the country. But even in Addis hospitals, water still randomly stops and power cuts are a daily disruption.
Behind the statistics lurks politics. In 2009, Ethiopia passed a draconian NGO law forbidding groups from advocating for human rights and policy change. This means that reproductive health groups cannot speak publicly about the right of citizens to abortion, contraception, and other forms of reproductive care.
Instead, they speak of the economic benefit that contraception and family planning offer Ethiopia. It’s a subtle language difference that appeals to many of the country’s conservative mores — while staying within the dicey political line of accepted speech. “Better not ask about government policy,” said 34-year-old Abebe (pictured above), an experienced midwife, clearly agitated when asked what improvements she’d like to see.
The Ethiopian government also clamps down on dissent through a tight surveillance network that reaches from the most local level up to the government-run phone and internet services. Internet access is only about 1% (compared to 47% in nearby Kenya), creating more hurdles for women seeking health information.
Medical professionals are often loathe to discuss the gritty details of abortion and contraception use. Dr. Addis Tamire Woldemariam, the chief of staff at the Ministry of Health, said that the government accurately knows exactly how many newborns die in the most remote corners of Ethiopia, and can recall the number of hospitals and clinics that have been built. But when it comes to abortion and contraception figures, he said he’s “not good with numbers,” and the subject becomes a black hole.
Saba Kidanemariamm, country leader for the international reproductive group IPAS, said the ministry’s language illustrates a change from 2004, when reproductive health groups like IPAS lobbied Ethiopia’s parliament to pass one of Africa’s most liberal abortion laws, which legalized abortion in cases of rape, incest, underage (under 18) pregnancy, and physical or psychological harm to the woman or fetus.
A year later, the Health Ministry further clarified that a patient didn’t have to give health providers proof of the reason for her abortion. Of course, Kidanemariamm noted, abortion remains highly sensitive and forbidden by many tribal and religious codes. But now, she said, political opportunities for pushing for further abortion liberalization have diminished. Kidanemariamm said she’s optimistic that another opening will come, but she has little control over the trajectory of reform in Ethiopia’s precarious political space.
These days, the government proudly notes that most religious leaders, from state-affiliated preachers down to the local level, will not publicly speak out against the state’s contraceptive-heavy national family planning agenda.
Mebrate Tenagne’s (pictured above) husband is one of those small-time preachers, with just a handful of followers in his village of Mosebo, in the rural north. The preacher was curt when asked about his wife’s own use of a contraceptive shot; it was a fast day for Orthodox Christians like him, and prayer time was approaching. In theory, he said, he disagreed with the use of contraception — but he had to be realistic: He was poor and did not own land, which meant it would be difficult for him to support many children. He also said that he found the government’s local health workers convincing, who, unlike for most Ethiopians, worked just steps away from his mud-based home.
Fetlework Taye, 32 (pictured above), finds cases of rape the hardest to handle. Taye is the abortion provider at a hospital in Hawassa, in southern Ethiopia. She smiles frequently but grew solemn as she described the latest traumatic case she saw: a 14-year-old girl who was raped by her father. The girl ran away to her aunts, who brought her in for an abortion. Taye dodged questions about unsafe abortions, which she said happen more often in the villages.
But in Addis, at the crumbling Black Lion Hospital, one 26-year-old medical resident, Kiflome Testate, did not sugarcoat the situation. Kiflome believes the figures that say unsafe abortions are down, but he’s seen and heard all kinds of cases: the women in shock who come in with metal or wooden rods stuck in them, or women who bleed profusely from deadly homemade concoctions, or women who self-medicate with abortion pills available virtually on the street.
Even after they are admitted, most women deny that they tried to do what the doctors plainly see. He thinks that many of the women turn to unsafe services because they still don’t know what their legal rights are, or they may not feel confident about accessing them. Others may feel pressure from family and friends to fall back on past practices and, nervous about their conditions, can be easily misguided.
When Yordis, 20, called the Marie Stopes reproductive health clinic in Addis, the nurse on the phone told her to be wary of brokers — men who are paid by other clinics to loiter near the international NGO’s clinic and confuse women into following them to their facilities, where they charge higher prices and sometimes perform unsafe abortions. The brokers prey on women who are alone or seem insecure.
No one warned Zebiba, 28, about the brokers, but she made to a Marie Stopes clinic in Addis Ababa on her own anyway. It was around 11 a.m. and Zebiba’s black eyes were weary as she cringed from the cramps. She had taken her first dose nearly six hours earlier. By the early afternoon, her abortion would be complete.
Zebiba was three months pregnant and angry. After 10 years of marriage, her husband had taken a second wife without her consent. Now she wanted a divorce, and another pregnancy only made the situation worse. Zebiba had heard about the Marie Stopes clinic from TV advertisements. She told only her sister where she was going that morning.
Zebiba laughed when asked whether her religious and community leaders sanctioned her decision. No, Zebiba said, it was not OK. But she was here anyway.
Miriam Berger was reporting from Ethiopia as a fellow with the International Reporting Project (IRP).