This article is based on a report jointly authored by Ipas and the Guttmacher Institute. 

If you live in Addis Ababa or in another Ethiopian city and seek a safe abortion, you’re likely to find it. But if you’re like the majority of Ethiopian women and live in a rural area, safe abortion services are hard to find. Four years after the abortion law was liberalized and the health system set to work to implement the new guidelines, only a quarter of all abortions in the country are induced in safe and legal settings.

This week, Ipas and the Guttmacher Institute, in collaboration with Ethiopian Society of Obstetricians and Gynecologists, the Ethiopian Public Health Association and Ethiopia’s Federal Ministry of Health, released the results of the first-ever nationwide assessment of abortion in Ethiopia  — showing that while the country has made significant inroads in making safe abortion services available, increased access to high-quality contraception and safe abortion services is needed, as well as treatment of complications of unsafe abortion.

The demand for abortion in this poor and predominantly rural country is rooted in low contraceptive use and high levels of unintended pregnancy. Indeed, only 14 percent of Ethiopian women of reproductive age use contraception and more than 40 percent of pregnancies are unintended. It is no wonder then that hundreds of thousands of women seek abortions every year, often with tragic consequences. It is with this in mind that the government moved to make legal safe abortion more accessible. But training providers and educating communities in such a large country takes time.

As in many countries (including the United States), the majority of women who seek abortions are mothers. But when safe abortion services are limited or nonexistent, women will turn to unsafe procedures to end an unwanted pregnancy. Any complications that may arise will affect not only these women but their children as well. Their families pay a tremendous price—one that could be prevented through expansion of comprehensive reproductive health care, including high quality contraceptive services and safe abortion care, throughout the country.

Our study found that in 2008, more than 50,000 women were treated for complications from unsafe abortion procedures. Forty percent of these women showed signs of infection or invasive injuries when they arrived at health facilities for treatment.  Many other women never reach a facility because they live too far from services, because fear and stigma prevent them from seeking help or because they die before reaching the facility.

And sadly, many women just don’t know they can seek safe abortion under the new law. While the Ethiopian Ministry of Health and organizations like Ipas are working with women’s groups around the country to educate communities, it takes time to reach women in such a vast rural country. Similarly, health-care facilities outside of urban areas are less likely to be equipped to offer services.

Though it is clear more work must be done to expand services, major findings from this national study do point to positive trends. Substantial progress has been made in providing legal, safe abortion services in the short time since legal reform. Forty-three percent of all health facilities provided safe abortion services in 2008, with higher proportions in public hospitals and private or nongovernmental facilities than public health clinics, accounting for just over a quarter of the roughly 383,000 abortions in Ethiopia in 2008.  The remaining procedures were unsafe—that is, performed outside of authorized facilities by untrained or unskilled providers in an unhygienic environment.

The reformed law and new guidelines have certainly resulted in more doctors and midwives being trained to provide abortion care, which has facilitated expansion of safe abortion services throughout the country. To build on this progress, the Ethiopian government must increase the availability of abortion and postabortion care in government hospitals and health centers. Providers and women alike must be educated about the new law. The introduction of medication abortion could also greatly expand access, particularly in rural areas, because it requires less health system resources and provider training. Finally, expansion of contraceptive services is crucial if unintended pregnancy and abortion-related mortality and morbidity are to be reduced. When used effectively, modern contraception can prevent nearly all unintended pregnancies. But for it to work, women must have access to quality services and to methods that suit their lives and they must be able to consistently get these methods.