Sarah Jane Holcombe

Background Midwives are a large proportion of Ethiopia’s health care workforce, and their attitudes and practices shape the quality of reproductive health care, including safe abortion care (SAC) services. This study examines how midwives’ conceptions of their professional roles and views on women who have abortions relate to their willingness to provide respectful SAC. Methods This study uses a cross-sectional, mixed methods design to conduct a regionally representative survey of midwives in Ethiopia’s five largest regions (Oromia; Amhara; Southern Nations, Nationalities, and Peoples [SNNP]; Tigray; and Addis Ababa) with a multistage, cluster sampling design (n = 944). The study reports survey-weighted population estimates and the results of multivariate logistic regression analyzing factors associated with midwives’ willingness to provide SAC. Survey data were triangulated with results from seven focus group discussions (FGDs) held with midwives in the five study regions. Deductiv...

Background In 2005, Ethiopia took a bold step in reforming its abortion law as part of the overhaul of its Penal Code. Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have liberalized their laws to permit safer, legal abortion. Methods This retrospective case study describes the actors and processes involved in Ethiopia’s reform and assesses the applicability of theories of agenda setting focused on internal versus external explanations. It draws on 54 interviews conducted in 2007 and 2012 with informants from civil society organizations, health professionals, government, international nongovernmental organizations and donors, and others familiar with the reproductive health policy context in Ethiopia as well as on government data, national policies, and media reports. The analytic methodology is within-case analysis through process tracing: using causal process observations (pieces of data that provide informa...

Background Cervical cancer is the second most commonly diagnosed cancer among Ethiopian women, killing an estimated 4700 women each year. As the government rolls out the country’s first national cancer control strategy, information on patient and provider experiences in receiving and providing cervical cancer screening, diagnosis, and treatment is critical. Methods This qualitative study aimed to assess the availability of cervical cancer care; explore care barriers and sources of delay; and describe women’s and providers’ perceptions and experiences of care. We analyzed data from 45 informants collected at 16 health centers, district hospitals and referral hospitals in East Gojjam Zone and a support center in Addis Ababa. Thirty providers and ten women receiving care were interviewed, and five women in treatment or post-treatment participated in a focus group discussion. Deductive and inductive codes were used to thematically analyze data. Results Providers lacked equipment and spa...

VERSION JANUARY 20, 2015 A Review of Behavioral Economics in Reproductive Health Prepared for the Center for Effective Global Action (CEGA) by Lydia Ashton, Nisha Giridhar, Sarah Jane Holcombe, Temina Madon, and Ellie Turner www.cega.org |www.beri-research.org

Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have reformed their laws to permit safer, legal abortion, and professional medical associations have not tended to spearhead this type of reform. Support from a professional association typically carries more weight than does that from an individual medical professional. However, theory predicts and the empirical record largely reveals that medical associations shy from engagement in conflictual policymaking such as on abortion, except when professional autonomy or income is at stake. Using interviews with 10 obstetrician-gynaecologists and 44 other leaders familiar with Ethiopia's reproductive health policy context, as well as other primary and secondary sources, this research examines why, counter to theoretical expectations from the sociology of medical professions literature and experience elsewhere, the Ethiopian Society of Obstetricians & Gynecologists (...

This study assessed the applicability to medical professionals in Ethiopia of an abortion stigma assessment tool developed for community members, and examined the relationship between stigma and willingness to provide safe abortion care (SAC). The Stigmatizing Attitudes, Beliefs and Actions Scale (SABAS) was fielded to a convenience sample of 397 Ethiopian midwives. Scale reliability and validity were assessed, and associations were examined using multivariate linear and logistic regression. Levels of stigma were low compared to those reported elsewhere, and 49% of midwives were willing to provide SAC. The revised SABAS was reliable (alpha = 0.82), but items did not group into SABAS' conceptual categories, and some had limited face validity. SABAS scores had a small but significant negative association with willingness to provide SAC (OR=0.95, p < 0.05), with negative stereotyping subscale items most predictive. SABAS' limitations found here suggest the need for an adapte...

ABSTRACT Liberalization of abortion law has been linked with greater access to safe abortion and a concomitant reduction in maternal mortality. However, for such liberalization to take place in democratic societies, voter support is a prerequisite and political parties are the primary mechanism by which legal and policy change takes place. This paper uses data from the 2007 Latinobarmetro survey of Mexican public opinion and employs logistic regression models to decompose vote choice nationally and within the Federal District, where in 2007 abortion was decriminalized in the first 12 weeks of pregnancy. The analyses examine the elements predicting voter support for two of the three main political parties (the Partido de la Revolucin Democratica (PRD) on the left and the Partido de Accin Nacional (PAN) on the right) with the most clearly delineated positions on abortion. Results support the hypothesis that opinion on abortion access does predict individuals' support for political parties - but only in the Federal District and only for the center-left PRD. As Mexico's experience with legal and accessible abortion in the Federal District continues, and as the PAN and the PRI carry out abortion-related political strategies in the states, further research with more current opinion data will be critical to revealing whether abortion opinion has a growing influence on party vote choice. More finely tuned understanding of the role that abortion opinion plays on vote choice will aid advocates seeking to expand abortion access and reduce maternal mortality.

In 2005, Ethiopia liberalized its abortion law and subsequently authorized midwives to offer abortion services. Using a 2013 survey of 188 midwives and 12 interviews with third-year midwifery students, this cross-sectional research examines midwives' attitudes toward abortion to understand their decisions about service provision. Most midwives were willing to provide abortion services. This willingness was positively and significantly related to clinical experience with abortion, but negatively and significantly related to religiosity, belief that providers have the right to refuse to provide services, and care of patients from periurban as opposed to rural areas. No significant relationship was found with perceptions of abortion stigma, years of work as a midwife, or knowledge of the law. Interview data suggest complex dynamics underlying midwives' willingness to offer services, including conflicts between professional norms and religious beliefs. Findings can inform Ethiop...

Population and Community Development Association (PDA) in Chieng Rai province in northern Thailand implemented its Environmental Sanitation for the Hill Tribes Project in March 1988 to reduce parasite infection and generate interest in self help development projects. As of early 1990, the hill tribes population growth rate stood at 4.5% compared to 1.5% in lowland Thailand. Other problems included villagers defecating around dwellings, not drinking safe water (since none was available), and not wearing shoes all of which contributed to a high rate of parasite infection. In fact, an analysis of stool samples revealed that parasites infected a mean of almost 70% of the villagers. PDA staff informed villagers about basic environmental health information which influenced them to improve sanitation conditions. They also demonstrated how to build the 1st model latrine. After that, each villager designed and constructed his own latrine. Each villager took out a Baht 150 (US$6) loan to pay for the construction materials (squat casings and cement) provided by PDA. Over the following 10 months, the staff returned to the villages to collect payments and to provide technical assistance. Those villagers that constructed a latrine persuaded others to also construct a latrine. In fact, villagers, not always PDA staff, have even transferred the knowledge to other villages. As of early 1990, villagers and staff have built 1000 squats and 993 latrines. With the health education and latrine use, PDA hoped to see a subsequent reduction in parasite infections. With the help of volunteer contraceptive distributors, PDA has also been able to expand its family planning program to 250 villages. It has also initiated a parasite control pilot project in the area in which infection rates have steadily decreased.

Liberalization of abortion law has been linked with greater access to safe abortion and a concomitant reduction in maternal mortality. However, for such liberalization to take place in democratic societies, voter support is a prerequisite and political parties are the primary mechanism by which legal and policy change takes place. This paper uses data from the 2007 Latinobarmetro survey of Mexican public opinion and employs logistic regression models to decompose vote choice nationally and within the Federal District, where in 2007 abortion was decriminalized in the first 12 weeks of pregnancy. The analyses examine the elements predicting voter support for two of the three main political parties (the Partido de la Revolucin Democratica (PRD) on the left and the Partido de Accin Nacional (PAN) on the right) with the most clearly delineated positions on abortion. Results support the hypothesis that opinion on abortion access does predict individuals' support for political parties ...

Liberalization of abortion law has the potential to reduce maternal mortality through expansion of access to safe and legal abortion care. Countries liberalizing their abortion law have increased in number in recent decades; however, the phenomenon is still relatively rare. Providers, particularly those with high status such as obstetrician-gynecologists, can play important roles in furthering health policy reform, especially related to reproductive health. Ethiopia has one of the highest maternal mortality rates in the world, a significant proportion of which is due to unsafe abortion, particularly in urban areas. In 2005, Ethiopia greatly expanded legal access to abortion through liberalization of its stringent 1957 law. The medical profession, particularly the Ethiopian Society of Obstetricians & Gynecologists (ESOG), was a central actor in legal reform efforts. This qualitative research explores the nature of ob-gyn attitudes and engagement in the legal reform process through 25...

In 2005, Ethiopia liberalized its abortion law and subsequently authorized midwives to offer abortion services. Using a 2013 survey of 188 midwives and 12 interviews with third-year midwifery students, this cross-sectional research examines midwives' attitudes toward abortion to understand their decisions about service provision. Most midwives were willing to provide abortion services. This willingness was positively and significantly related to clinical experience with abortion, but negatively and significantly related to religiosity, belief that providers have the right to refuse to provide services, and care of patients from periurban as opposed to rural areas. No significant relationship was found with perceptions of abortion stigma, years of work as a midwife, or knowledge of the law. Interview data suggest complex dynamics underlying midwives' willingness to offer services, including conflicts between professional norms and religious beliefs. Findings can inform Ethiopia's efforts to reduce maternal mortality through task-shifting to midwives and can aid other countries that are confronting provider shortages and high levels of maternal mortality and morbidity, particularly due to unsafe abortion. (Studies in Family Planning 2015; 46[1]: 73–95)