Chapter 20
Women and Reproductive Health in Contemporary Ethiopia
p. 259-274
Texte intégral
“If there is one message that echoes forth from this conference, let it be that human rights are women’s rights and women’s rights are human rights, once and for all!”
Hillary Rodham Clinton, “Video Recording of First Lady Hillary Rodham Clinton Speaking at the United Nations Fourth Womens’ Conference in Beijing, China,” September 5, 1995, from Clinton Digital Library, Collection WJC-FL, Series Melanne Verveer’s Subject Files, video.
1No systematic study has been undertaken on the history of women and reproductive health in Ethiopia. Richard Pankhurst dedicated some articles to the history of diseases and traditional medicines. The introduction of some European traditions of medicine and medical practices in Ethiopia dates to the reign of Emperor Lǝbnä Dǝngǝl (1508–1540), and they were introduced by missionaries, travellers, and members of diplomatic missions. Mǝnilǝk II (1889–1913) and Ḫaylä Sǝllase (1930–1974) facilitated the promotion of some European traditions of medicine (Pankhurst, 1965).
2On the contrary, many studies emerged on the topic in the last two decades, mainly focusing on women’s challenges to access affordable, quality, and equitable reproductive health services and the government’s efforts to address the problem. This chapter provides an account of the evolution of national health policies and strategies in contemporary Ethiopia, followed by descriptions of the situations of maternal health, abortion, syphilis, HIV/AIDS, child marriage, and family planning and their implications on the lived experiences of women.
1. The evolution of national health policies and strategies
3The first national policy and strategy for health was formulated in 1963, aiming to reach rural areas by expanding a decentralised basic health services network and integrating preventive and curative services (Kloos 1998). Since its founding in 1948, the Ministry of Public Health trained primary healthcare personnel in various aspects of healthcare services during the 1950s. The Ethiopian Red Cross Society established the first national nursing school in 1949 (Stommes and Sisaye 1980). However, this and subsequent plans failed to bring health equity between rural and urban areas. To address this gap, the Mengistu Ḫayle Mariam (Därg) regime (1974–1991), rooted in the 1978 Alma Ata declaration, emphasised the importance of primary healthcare.
4The 10 years Perspective Health Plan from 1984/1985 to 1993/1994 focused on expanding and strengthening maternal and child health services, with community health agents and traditional birth attendants running community health services and advocating for essential health services at affordable cost. Although the Därg regime implemented various community programs and expanded the rural health service, it failed to revolutionise health services. Out of the slightly more than 5,000 trained community health agents and traditional birth attendants who were trained by 1984, only 30% continued their services in 1984 due to lack of remuneration, refresher courses, and supervision (Kloos 1998).
5Following the Därg regime, Ethiopia enacted a series of Health Sector Development Programs (HSDP I, II, III and IV) from 1997 to 2015 and Heath Sector Transformation Plans from 2015 to 2025. The government of Ethiopia launched “the Health Extension Program (HEP)” in 2003 under HSDP II with a philosophy that “if the right health knowledge and skill is transferred, households can take responsibility for producing and maintaining their own health” (MOH 2010, 14). At the heart of HEP have been health extension workers who had been trained by local government and deployed in pairs at health posts in local communities. There has been improvement during this period in terms of family planning services, for example, contraceptive coverage increased from the 1996/97 level of 4% to 25% in 2004/05. Building upon the successes and challenges of the successive Health Sector Development Programs (HSDPs) implemented over the last years, the government launched the five years Health Sector Transformation Plan (HSTP), which is part of the country’s GTP-II and the first phase of a 20-year health sector strategy titled ‘Envisioning Ethiopia’s Path to Universal Health Care through Strengthening of Primary Health Care.’
6Ethiopia implemented the first Health Sector Transformation Plan (HSTP-I) from 2015/16 to 2019/20, which improved access to and utilisation of health services, reduced maternal mortality, and increased skilled birth delivery. However, there are significant challenges in addressing the unmet need for contraception, reducing maternal mortality, and disparities in service utilisation among people with different socioeconomic statuses. The second Health Sector Transformation Plan (HSTP II) covers the period from 2020/21—24/25 with a focus on top priority areas, including quality and equity of health services, development of health workforce, information revolution, and health financing and leadership (MOH 2021).
7Ethiopia’s health policy is influenced by global health conventions, declarations, and global reproductive health discourses. Ethiopia is a signatory to international conventions/charters and declarations, including those arising from the 1987 Safe Motherhood Conference in Nairobi; the 1990 World Summit for Children; the 1994 ICPD; the Fourth World Conference on Women in Beijing and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) (MOH 2011, 17).
2. The burden on women in reproductive health
2.1 Maternal mortality
8Though few studies have been undertaken in the past, scrutinising Ethiopian hagiographies, Steven Kaplan (1986) noticed that medieval women faced health issues related to pregnancy, miscarriage, and death at delivery or soon after delivery. He emphasised the importance given to the problem of women’s barrenness; a topic as well studied with more detail by Mersha Alehegne (2015) while uncovering the childhood of the saints.
9Maternal mortality as a global health issue has only gained increased recognition over the past two decades and become part of international discourse on reproductive health and human right (see for example, the 1990 World Summit for Children, the 1994 ICPD; the 1995 World Conference on Women; the Fifth United Nations (UN) Millennium Development Goal (MDG); Tessama et al. (2017) study on trends and causes of maternal mortality in Ethiopia during 1990–2013).
10There are many factors that affect the outcome of pregnancy, but it is most adversely affected by delays that occur in seeking, reaching, and receiving health care. Delays can occur when seeking care due to socioeconomic factors, individual and community perceptions of accessibility and quality of care, and cultural/traditional practices that restrict women from seeking healthcare. Delays in reaching care can occur due to the distance to reach healthcare facilities and the inability to afford transport costs, and delays in receiving care can happen due to inadequate facilities and poorly skilled staff and management (Thaddeus and Maine 1994).
11The causes of maternal deaths vary with time. The proportion of maternal deaths due to unsafe abortion and infection have declined in the last decades due to improvement in laws, access to safe abortion and post-abortion care, and an increase in awareness about safe abortion. However, obstructed labour continues to be the major cause of maternal deaths, while hypertensive disorders and haemorrhages showed an increasing trend (Yifru and Asres 2014). Central Statistical Agency & ICF (2016) indicates that maternal mortality (MM) is decreasing. However, the current maternal mortality ratio is still high, with an estimated 412 maternal deaths per 100,000 live births for the 7 years before the 2016 EDHS survey. The EDHS 2000–2011 conducted by the United Nations Population Fund (UNFPA 2012) showed differences in terms of maternal mortality rate between regions and between rural and urban women, and among women with different socioeconomic statuses. Somali, Afar, SNNP, Amhara, and Oromia are estimated to have a higher maternal mortality burden than the national average.
12One of the most devastating events for women who survived maternal death is the occurrence of obstetric fistula, which occurs when the baby’s head cannot pass through the birth canal after prolonged and obstructed labour. Fistula is an opening between the mother’s vagina and bladder (vesico-vaginal) or vagina and rectum (rectovaginal), or both (Donnay and Weil 2004, 71). Obstructed labour is the major cause of obstetric fistula, which can also be caused by other socioeconomic factors, including poverty, malnutrition, women’s low status, early marriage, lack of health facilities, and female genital mutilation/cutting. However, fistula can be prevented if adequate care is available and effective prevention measures are undertaken (See for example, Rahwa 2014 & UNFPA & Engender Health 2003). Obstetric fistula can result in negative social, psychological, and physical consequences. The late Dr Catherine Hamlin (1924–2020) and her late husband were the first to discover women with fistula in Ethiopia and to officially open the Addis Ababa Fistula Hospital in 1974.
2.2 Abortion
13Unsafe abortion is one of the major causes of maternal deaths, although the proportion of maternal deaths occurring due to unsafe abortion has declined in Ethiopia. Unsafe abortion can also cause other complications, including haemorrhage, sepsis, and trauma to the cervix, vagina, uterus, and abdominal organs.
14Ethiopia’s laws on abortion have been changing over time from being too restrictive to semi-liberal. Part of the Fǝtḥä Nägäśt content (Chapter XLVIII, Corporal and Spiritual Punishment for Fornication; VII–72) that dealt with abortion, as cited in Wada (2008: 20), states, “if a woman conceives and wants to abort the unborn child in her womb, she shall be beaten and exiled.” The 1930 Penal Code allowed no exceptions to abortion, and abortion was punishable by imprisonment. The 1957 Penal Code departed from the Fǝtḥä Nägäśt and the 1930 Penal Code and recognised grounds on which abortion is performed, such as to save the life of the women and to preserve the physical and mental health of women. The enactment of the new criminal code in 2004 overturned previous restrictive laws or positions on abortion. The revised criminal code of 2004 introduced major changes and allowed a woman to abort in cases of rape/incest, fetal impairment, to save the life of the woman and to preserve the physical and mental health of the woman (Wada 2008, 20). Although the abortion law in Ethiopia has been classified as ‘semi-liberal,’ it does not ensure access. There is need to focus attention from the content of policy to socioeconomic and political contexts that affect the relationship between abortion laws, policies, and access to health services (Blystad et al. 2019).
15Abortion decision-making is an intra-subjective process that involves moral and/or religious dilemmas and considerations of health and safety. Though there is widespread condemnation of female premarital sex and moral sanction against induced abortion, young Ethiopian women still seek induced abortions, which could result in grave physical harm and social stigmatisation (Meselu et al. 2012). A study by Moore et al. (2016) further indicated that an estimated 620,300 induced abortions were performed in Ethiopia in 2014, and the annual abortion rate increased from 22 per 1,000 in 2008 to 28 per 1,000 among women aged 15-49 years in 2014. The proportion of abortions occurring in facilities increased from 27% to 53% between 2008 and 2014, and treatment for complications from induced abortion nearly doubled between 2008 and 2014, from 52,600 to 103,600. The proportion of women accessing post-abortion care (PAC) has also increased. The expansion of comprehensive abortion care, improved access to health care services, greater availability of free services, and increase in contraceptive use accounted for the improvement. Nevertheless, significant numbers of abortions continue to occur outside of health facilities under unsafe conditions: one-third of adolescent abortions are clandestine and thus potentially unsafe. Complications from unsafe abortions account for 19.6% of all maternal deaths (Tessema et al. 2017).
2.3 A historical account of syphilis and HIV/AIDS
16Pankhurst (1975) dedicated one of his articles to the old-time treatment for syphilis (17th-20th centuries). In the course of his research, he mentioned epidemics and venereal diseases that were cured with hot water during the 1930s. He also mentioned that soldiers and merchants were the biggest spreaders of venereal diseases. Cases of syphilis were known at the end of the 1890s. Richard Pankhurst quoted a Shoan couplet recorded by Marcel Cohen: “ቂጥኝም፡ቢይዘኝ፡ለውሃ፡እወርዳለሁ፡ (“if I catch syphilis, I will go down to the hot water”). In 1949, Thorstein Guthe (1949) wrote a report for the World Health Organization (WHO) on venereal diseases in Ethiopia. In the 1960s, people used to believe that the best cure for syphilis was to have as many sexual encounters as possible to weaken the disease. From 1974 to 2000, some medical studies and reports were found on venereal diseases, especially on syphilis and some reproductive health issues.
17The prevalence of syphilis had declined globally over the last three decades. No nationwide studies in Ethiopia show the prevalence and the epidemiology of syphilis among all and specific groups of the population. However, both available antenatal care-based sentinel HIV surveillance and individual studies on syphilis show inconsistencies in the prevalence of syphilis, with antenatal care-based sentinel HIV surveillance showing a decline of syphilis from 2.7% in 2007 to 2.3% in 2009; in 2012 and 2014 showing a slight increment of syphilis prevalence from 1.0% in 2012 to 1.2% in 2014 (Kebede et al. 2019).
18HIV infection and syphilis are interlinked as the higher prevalence of one worsens the other. HIV/AIDS has been studied since the end of the 1990s along with other venereal disease studies, especially syphilis. HIV infections were first found in Ethiopia in 1984, and the relatively virulent HIV-1 is the major strain of the virus in Ethiopia. During the 1980s and 1990s, HIV/AIDS was mainly spread by commercial sex workers and truck drivers. Children, adolescents, and the general population were increasingly infected (Kloos 2001).
19HIV prevalence varies based on age, sex, and geographical location. According to EDHS (2011), HIV prevalence among men aged 15-49 years is 1.0 percent, while among women aged 15–49 is 1.9 percent, and HIV prevalence is highest among women aged 30–34 years and men aged 35–39 years. According to a recent estimate by EPHI (2017), the adult prevalence of HIV in Ethiopia is estimated to be 1.13% in 2019, which falls under the category of an outbreak. The epidemic has been a threat to the social and economic fabric of the country, including voluntary social institutions such as Ǝddǝr (a form of community-based funeral association) (Pankhurst and Mariam 2000).
20Biological, social, and cultural factors put women and adolescent girls at greater risk of HIV infection when compared with men. Women’s vulnerability to HIV/AIDS is increased through a culture of silence surrounding sex, women’s economic dependency on marriage, violence against women, and power imbalance in gender. While men’s vulnerability to HIV/AIDS is increased through traditional notions of masculinity that expect men to engage in a wide range of risk-taking behaviour, to be well-informed and experienced about sex, to have a variety of sexual partners, to be self-contained and not to express their emotions and seek assistance when needed (Gupta 2000).
3. The issues of child marriage and family planning
3.1 Child marriage
21There is lack of a universally accepted definition for the age of marriage, as it can be defined socially and in terms of age. According to international human rights documents, childhood is regarded as lasting until an individual reaches the age of eighteen. The practice of child marriage violates a range of human rights, including those contained in the Convention on the Rights of the Child (CRC) and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). The previous Ethiopian family law, which was adopted in 1960, set the legal age for marriage at 15 years for girls and 18 for boys. The newly revised family law adopted in 2000 set 18 years as the minimum age of marriage for both girls and boys. The new law also states that marriage should be entered into with the full consent of the intending spouses (Federal Negarit Gazetta of the Federal Democratic Republic of Ethiopia 2000). The practice of child marriage has shown a decline in recent years in Ethiopia. EDHS 2016 shows that the median age at marriage increased from 16.5 years in 2011 to 17.1 years in 2016, and the percentage of women who married before age 18 decreased from 63% in 2011 to 58% in 2016. There are not only differences in terms of the practice of child marriage between regions, but variation also exists in different localities within a region (Jones et al. 2016). However, COVID-19 seriously threatened the progress that has been made in the last decade, with 10 million additional girls at risk of child marriage globally (UNICEF 2021).
22The main types of child marriage can be categorised as: arranged, abduction, and free choice. Arranged marriage can be performed at any time during childhood, and it includes promissory marriage, where a marriage is arranged while the foetus is in the uterus. Abduction is widely practised in the southern part of Ethiopia, where a high bride price is offered in the form of cattle or money to the family of the bride. Free-will marriage is becoming common in contexts where marriage occurs in late adolescence or early adulthood, mainly in urbanised areas (UNICEF 2016, 11).
23Early marriage arrangement patterns change in line with the changing historical, political, and socioeconomic conditions. Early marriage was arranged for political alliance through dynastic intermarriage before 1941, and it was practised for economic reasons from 1941 to 1975, mainly to gain access to land. From the late 1980s to the present, it is practised for cultural and religious or sociocultural reasons such as societal desire to control girls’ sexuality and maintain their purity, girls’ wish to avoid the stigma directed at unmarried girls, families desire to form social and economic alliances with other families and to secure care and protection for their daughters (Alemante 2004).
24Child marriage has negative social, psychological, and economic consequences for girls. It violates girls’ basic human rights and results in unequal partnerships in marriage, which often end in divorce or separation. It also restricts girls’ decision-making power and can increase the risks of maternal health problems and sexually transmitted diseases (UNICEF 2016).
25Building upon previous measures to eliminate harmful traditional practices in Ethiopia, the Ministry of Women, Children, and Youth developed the National Costed Roadmap to End Child Marriage and FGM/C by 2025. The roadmap stipulated a comprehensive set of strategies, such as empowering girls and families; enhancing engagement of communities; strengthening systems; ensuring an enabling environment and disseminating data and evidence for informed policy and programmatic engagement. Despite these policies and strategies and laws against child marriage, communities continue to use different social tactics to perpetuate the practice. Combined initiatives that target to transform social and gender norms through continuous dialogue and interventions that aim to increase girls’ education and use them as change agents remain pertinent.
3.2 Family planning
26Family planning is vital in saving and safeguarding women’s lives and meeting their practical and strategic needs. It is not only a matter of human rights but is also critical to empowering women, reducing poverty, and achieving sustainable development.
27The Family Guidance Association of Ethiopia (FGAE) was established in 1966 as a volunteer-based association, and it is the pioneer in meeting the needs of modern family planning and other reproductive health services by targeting poor, under-served, youth and marginalised segments of the population in the country. FGAE provided its first family planning service from a single-room clinic that was run by one nurse. FGAE has a network of 8 branch offices, 7 higher clinics, 15 Medium SRH clinics, 13 youth centres, 10 sex-worker friendly clinics (SWFCs), and 1 gynaecology and obstetrics speciality clinic. Until 1982, a husband’s signed consent was required by the Family Guidance Association of Ethiopia to provide contraceptives to his wife. As a result, 16% of the women who requested contraceptives were not provided with the service. After the requirement of spousal authorisation was removed, utilisation of family planning services increased by 26% within a few months (Cook et al. 1987).
28According to EDHS 2016, total fertility rate has continued to drop. Total fertility rate was 5.5 in 2000 and it dropped to 4.6 in 2016 (2.3 in urban areas and 5.2 in rural areas). Yet despite these impressive gains, modern contraceptive use is still low (35%). The survey further indicates that highly educated women and women living in Addis Ababa have lower fertility rates. Women mostly use injectables, followed by implants. Public sector (84%) followed by private medical sector (14%) were the most used sources for modern contraception. Facilities providing family planning services have expanded in terms of number and outreach in Ethiopia. Despite the improvements, over one-third of all contraceptive users (35%) discontinued the use of contraceptives within 12 months.
29The above progresses have been made over the last two decades due to government integration of family planning as a component of the 16 health packages of primary healthcare and development of health infrastructure, and human resources for health. The government has also integrated UHC as a main objective of Ethiopia’s five-year health sector transformation plan and has implemented community-based health insurance (CBHI) in several Woredas or districts for people who are not employed in Ethiopia’s formal economy. However, because family planning and maternal and child healthcare are currently free through funding from external donors, they are not covered under community-based health insurance (CBHI). Further, women encounter barriers to accessing their preferred methods of contraception due to lack of supply, poor spousal communication, and inequitable fertility decision-making. This is further aggravated by healthcare workers’ inequitable targeting of women for family planning promotion within the primary healthcare system. Despite prevailing and constraining gender and patriarchal order and resistance from husbands, women exercise their own agency by using silence as a strategy to use contraceptives without the knowledge of their husbands (Mjaaland 2014).
Conclusion
30Ethiopia implemented the Heath Sector Transformation Plan (HSTP-I) from July 2015–June 2020, which resulted in reduction in maternal mortality, improved utilisation of contraception by married women, increased antenatal coverage, and access to safe abortion services and post-abortion care. During this period, Ethiopia implemented financial risk protection to increase access to essential health services through the provision of high-impact interventions free of charge; subsidisation of more than 80% of the cost of care in public health facilities, and implementation of community-based health insurance (CBHI) scheme (MOH 2021, 10). Despite these improvements, the unmet need for contraception remains high (22%) and the maternal mortality rate was 401 per 100,000 live births in 2017 (MOH 2021) and family planning is not integrated into community-based health insurance (CBHI). Furthermore, the existing harmful traditional practices continue to violate women’s bodily autonomy and compromise their social and psychological integrity and constrain their choices and agencies. Therefore, given the importance of primary healthcare to achieve sustainable and equitable health services, investment in health care infrastructure and the development of a skilled, well compensated, and compassionate health workforce is critical. Moreover, government efforts should be backed by the involvement of civil society organisations to support domestic resource mobilisation efforts and ensure equity and quality in the delivery of health services. Civil society organisations also play a key role in holding the government accountable for its commitments/policies and their implementation. In addition, given that reproductive decisions are made within existing social and gender relations, it is essential to implement interventions that address social and gender norms and support women’s empowerment by creating and reinforcing positive social norms, engaging men and youth as active participants in health-seeking processes and promoting equitable couple’s decision-making.
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Auteur
Le texte seul est utilisable sous licence Creative Commons - Attribution - Partage dans les Mêmes Conditions 4.0 International - CC BY-SA 4.0. Les autres éléments (illustrations, fichiers annexes importés) sont « Tous droits réservés », sauf mention contraire.
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