Ethiopia has among the highest fertility, infant mortality, and maternal death rates in the world.

But while reproductive health and family planning services are in demand in Ethiopia, less than half the population has access to modern health care services. The recent war between Ethiopia and Eritrea has thrown the contrast between supply and demand into even higher relief.

A critical need

The need for family planning in Ethiopia has reached critical levels. On average, an Ethiopian woman gives birth to seven children during her lifetime. Statistics show that for every 1,000 live births, 14 Ethiopian women die in childbirth.

Although an estimated 50% of Ethiopian women of reproductive age would like to prevent or delay pregnancy, only 4% of the overall population use contraception.

Without access to family planning services, many poor women must obtain unsafe-and illegal-abortions. The lack of postabortion care compounds the problem even further.

An investigation

To help remedy this crisis, the Population Program of the David and Lucile Packard Foundation, a longtime supporter of family planning options in Ethiopia, asked AVSC to assess the state of long-term and permanent contraceptive services in selected areas of the country.

Last January, the assessment team-comprising representatives from regional and federal governments and nongovernmental organizations-visited health care sites to observe counseling sessions, surgical procedures, and the state of facilities, equipment, and supplies.

The team found far too few providers trained in delivering long-term and permanent contraception. This shortage of skilled staff results from a lack of training, high staff attrition in public health care facilities, and an emphasis on curative rather than preventive care.

"Family planning is not a priority," says Feddis Mumba, AVSC program manager and member of the assessment team.

"Condoms remain within family planning clinics. They're still kept in drawers," she continued. "A client has to make a request for the drawer to be opened."

The team also found that public facilities, in particular, lack sterilization kits, educational materials for clients, and other supplies.

Three recommendations

As a result of the assessment, the team called for a coordinated effort to ensure an adequate number of trained providers in both public and private facilities. To meet this goal, the team advocated more on-site and on-the-job training.

In addition, the team recommended that minilaparotomy and no-scalpel vasectomy kits-generally unavailable in Ethiopia-be provided to public and private facilities that demonstrate serious commitment to providing these services.

Given dwindling resources and increased demand in Ethiopia, the team also stressed that the public, private, and nongovernmental sectors must collaborate to plan and develop family planning services that ensure informed consent, quality improvement, clinical training, and infection prevention.

AVSC pledges to continue this important work in Ethiopia to ensure that these recommendations become reality.

David Adriance is Senior Director of AVSC's program in Kenya.