Thirty (30) healthcare professionals agreed to be interviewed. Of these, most (22) provided abortions directly, while eight participants provided contraceptives and post-abortion care and/or worked with abortion in an administrative capacity. Participants had experience with abortion provision ranging from two months up to 14 years. The genders were equally represented with 15 being female and 15 being male. Twenty-one participants identified as Ethiopian Orthodox, five as Protestant/Evangelical, and two as Muslim. One was religiously unaffiliated and one did not want to disclose.
A general finding was that there was a range of viewpoints both on the abortion law and on potential moral challenges. Informants’ viewpoints clearly correlated with their moral views on abortion. For instance, informants who regarded abortion as a moral problem typically also were critical or ambivalent of aspects of the new abortion law thought to be too liberal/open, whereas informants who did not see abortion as a moral problem typically welcomed liberal interpretations of the law and sometimes found it to be too restrictive.
Views on the abortion law
A majority of informants, especially from private/NGO clinics, stated that they were content with the law, even though they pointed to shortcomings. The most important consequence of the law was that it reduces the incidence of unsafe abortion, and thus saves women’s lives and reduces the number of complications significantly.
Those days abortion was done by nonskilled individuals. … Even if it was by professionals, it was not by skilled professionals. Many of our sisters, mothers have lost their lives. There are some who [have had to] remove their uterus and lost their chance to ever have children. Whose marriage became unstable, who faced psychological problems. (#17, female nurse, public hospital)
The good side [of the new law] is that it has helped her to receive a complete treatment by bringing the service to health institutions. It saves many mothers from death. (#18, male resident, public hospital)
Other positive effects highlighted were that the law provides freedom of choice to pregnant women, protects patient confidentiality, and reduces delay. It was pointed out as a problem for freedom of choice that many citizens are insufficiently familiar with the law. For several, an important argument in favor of legal access to abortion was that many women with unwanted pregnancies would choose abortion whether it is legal or not, as illustrated in the quote below:
If women have once made up their minds, nothing stops them. Their reason must be respected. That is her right. I have no problem [with that]. Therefore, it is better that we terminate it in a safe way. (#20, male resident, public hospital)
Some respondents, while content that the law gives many women access to abortion, would like further liberalization with extra criteria. Some stated that it was good that they did not have to ask for evidence or witnesses beyond the woman’s statement in relation to the rape criterion.
However, some informants thought that the law went too far, in not requiring this evidence, or in being too liberal, as abortion was still in their view a moral dilemma. Some feared that the threshold for seeking abortion had become too low and saw women returning for multiple abortions as a sign of this. They thought that abortion had become de facto accessible on request.
Because we have made it loose, any woman can abort without any check. … What it looks like now is that abortion is legal. It is open. It is not what was intended [when] the law [was passed]. ... Any woman can receive abortion... Even when [it is promoted] the message is that people should not go to private institutions, go to the governmental ones and say that you have been raped. (#22, female GYN/OBS resident, public hospital)
The law’s criteria were considered open to interpretation. This could be seen as an advantage for those who supported liberal access to abortion. For instance, one female health officer from a private/NGO clinic stated:
It can be said that [the health criterion] indirectly has allowed everything. … [Abortion] is not permitted completely, but it is permitted indirectly. For example, if you say mentally, it means that it is allowed if it involves stress. The majority of pregnancies are stressful. They come because they are stressed. When you think like that, [abortion] is allowed. (#6, female health officer, private clinic)
Health care practitioners’ experienced dilemmas
Informants were asked about which moral challenges, if any, they encountered in their work with abortion. Although there were many who pointed to different moral issues, others claimed that they experienced no significant moral challenges. Some pointed out that the decision whether to choose and perform abortion by its nature is a moral issue: “Abortion is an ethical dilemma both [for the patient] and the one who performs it.” (#21, male GYN/OBS, public hospital)
The major moral dilemmas typically involved the interpretation and application of the law’s criteria for abortion. Some admitted that they interpreted the criteria widely. Others appeared to feel burdened by expectations and pressure from patients in cases where criteria were not met, or where there was uncertainty with whether criteria were met. Sometimes this led to discussions and disagreement among colleagues. In general, informants from public hospitals appeared somewhat less liberal and less comfortable with wide interpretations of the law’s criteria than did informants from the private/NGO sector.
Sometimes informants were expected to perform abortions beyond the law’s gestational limit of 28 weeks:
We come across problems quite often, especially, a woman admitted late in the pregnancy in the name of safe abortion. … This is not legal. … I cannot assist in a delivery of [a] 1 kg [child] and call it an abortion. We have had a lot of conflicts over this issue. We know it. Things that are not acceptable for your conscience are done. (#22, female GYN/OBS resident, public hospital)
In some cases, the law’s criteria for abortion were not clearly met. Some of the informants would then reject performing abortion, whereas others would sometimes accept it.
If she comes for abortion with no reason, I do not do it because I do not accept it … but I transfer it to one who does it. Because I do not believe that is her right. Many of us do not do it. (#22, female GYN/OBS resident, public hospital)
There are [criteria] stated in the law. There are also some who approach us because of other factors. Many times, we do not base our service on the law. We base it on the case which the woman who approaches us tell us. We do not assess whether Ethiopian law allows that or not. (#4, female nurse, private clinic)
To be honest, if she says that she does not want to give birth, … we do not [turn her away]. We perform the abortion. (#1, female nurse, private clinic)
As noted above, some informants remarked that in the case of rape the law does not require further evidence than the woman’s own word that the pregnancy was due to rape. Informants expressed that this could potentially give women seeking abortion incentives to lie in order to fulfill the law’s criterion. Similarly, some informants claimed that patients sometimes lied about their age, claiming to be minors when they clearly were not, in order to comply with the law’s age criterion. This led to dilemmas for practitioners.
The bad side [of the law] is that it makes it liberal. If a woman lies intentionally because the law is on her side, she is given the service. That affects us a bit. I have seen some who attempt suicide when they are told it is too late. If she is 40 but claims to be 13, I am obliged to carry it out, even if I know that she is not telling the truth. It opens up for things. Which means any woman as long as she knows where the service is offered, she can get it. I think that makes [the law] a bit liberal. It affects us. Other than that, the good side [i.e., the positive aspects of the law] weighs more. (#18, female GYN-OBS resident, public hospital)
Whereas most moral dilemmas experienced were directly related to interpretation and application of the abortion law, some further dilemmas were not. Specifically, dilemmas arose when professionals became involved in a patient’s quarrels with partner or family members. Some patients were pressured to abort or to continue the pregnancy against their preference. Furthermore, many pointed to the low level of awareness of family planning and contraception in the population as an moral problem.
Abortion for fetal abnormalities
When asked about termination of pregnancy in cases of fetal abnormalities, the majority said that they believed termination should be performed/offered. Informants highlighted serious negative consequences of having children with abnormalities on the woman, her family, and also society. Some explicitly pointed to the economic burdens for society, and some cited the shortcomings of the Ethiopian healthcare system which would make it difficult to give the child proper care.
If there is disability, it has to be terminated. If it is early, the mother can also be affected psychologically. It would be difficult. [If] it is early, it is better to terminate quickly. Even [some] mothers who deliver a baby with cleft lip do not want to have another child. (#10, female nurse, public hospital)
Had the health system of our country been good, [the child] could grow up if delivered. But we do not have [a good health system]. If they are delivered the problem comes to the family, to the society, to the country. (#11, male public health specialist, private clinic)
Only a few expressed ambivalence to this view, such as this informant:
I want the decision to be taken based on the family situation and economic ability. However, this collides with the rights of the disabled. When you see it from a different angle there needs to be a balance. It needs to be approached from the human right aspect. It is very problematic. (#6, female nurse, private clinic)
Informants were unanimous in wanting to leave the decision whether to terminate a fetus with abnormalities to the woman herself:
It is the mother who takes care of [the child] at the end of the day. ... It means that a decision is made on her. Therefore, in my view, she should have a say. (#21, male GYN/OBS, public hospital)
Many were clear that one should distinguish between lethal malformations and milder abnormalities. Termination was considered the right choice for the former, whereas views differed on the latter. Informants were invited to reflect on Down syndrome as a specific case. Most favored termination, whereas some did not or were ambivalent.
I believe that Down syndrome has to be aborted. It is [costly] for the country. … I think it is reasonable to abort that child. (#15, male, public health specialist, private clinic)
The degree [of being affected by Down syndrome] determines it. If it is severe, it is better that it is not born. But those who are mild or moderate, it is preferred that they live [and receive] training and support. They [can be], to a degree, independent. (#9, female nurse, public hospital)