Ethiopia has one of the highest maternal mortality rates (MMR) in the world (676 per 100 000) , to which unsafe abortion contributes significantly . To decrease the MMR, the Ethiopian abortion law was liberalized in 2005 and the Ministry of Health (FMOH) issued guidelines including the legal indications for abortion in the second trimester. Women may terminate pregnancies through 28 weeks of pregnancy for reasons of rape/incest, fetal anomaly, maternal physical or mental deficiency including being a minor, or endangerment of the life/health of the mother.
After these legal reforms, Ipas—a global nongovernmental organization working to end deaths and disabilities from unsafe abortion—in partnership with the FMOH, successfully introduced first trimester abortion services into the public sector. A 2009 survey on abortion in Ethiopia highlighted that one-third of women needed second trimester services and that providers were not offering services owing to lack of technical training and support .
In response, Ipas and the FMOH implemented a systematic approach for second trimester abortion that included meetings with key stakeholders, needs assessments, minor infrastructure and supply updates, identification of potential sites and trainees, sensitization workshops, technical training, adverse events tracking, and supportive supervision visits . Initial activities started in January 2010. Site assessments at four key centers demonstrated that over 50% of women presenting in the second trimester were suffering from incomplete abortions. Dilation and evacuation (D&E) requires specialized equipment that was not initially available. Thus, the program focused on the introduction of medical abortion using the World Health Organization recommended regimen of mifepristone and misoprostol .
Intervention sites were strategically chosen so that each region in Ethiopia would have a second trimester referral center. Between October 2010 and May 2014, eight clinical trainings were conducted with health professionals from 23 hospitals. All sites are currently providing services. Institutional Review Board exemption to review and report logbook data was received. A total of 7484 women accessed services from October 2010 to December 2013. The rate of serious adverse events was within or lower (b1%) than rates reported in the literature [5–7].
The comprehensive structured program design, the collaboration between the MOH and Ipas, and provider dedication enabled a successful introduction of second trimester abortion services in major regions/ states of Ethiopia. A focus on second trimester medical abortion allows for rapid service introduction without extensive changes to facilities, equipment, or staffing as the needs are similar to obstetric care. Availability of services comes with challenges including ensuring medication availability, providing postabortion contraception (typically provided in a different unit), and limited hospital bed capacity. Ongoing work is focused on determining the impact of these programs on MMR, continuing to expand service provision, and D&E introduction at higher volume sites.