Multidimensional Approaches to Enhance Access to Reproductive Health in Ethiopia

Over the last 15 years, Ethiopia has expanded access to family planning (FP) services, and the contraceptive prevalence rate (CPR) has quadrupled, from 8% in 2000 to 36% in 2016 (CSA & ORC Macro, 2001; CSA & ICF, 2016). (The CPR is the percentage of women of reproductive age who are using a contraceptive method at a particular point in time.) However, unmet need for FP in Ethiopia hovers around 22% (CSA & ICF, 2016), with contraceptive prevalence still relatively low. Ethiopia’s maternal mortality ratio (MMR) has fallen dramatically, from 676 per 100,000 live births in the period since the last Demographic and Health Survey (DHS) in 2011, to 412 deaths in the 2016 DHS, but it is still high (CSA & ICF, 2016). While the share of abortions performed within health facilities in Ethiopia (assumed to be the safest option) increased between 2008 and 2014, the number of women seeking treatment for abortion-related complications still almost doubled over the same time period (Ipas & Guttmacher Institute, 2017), indicating a need for high-quality safe abortion services and postabortion care. EngenderHealth’s Access to Reproductive Health Initiative (ABRI) seeks to reduce maternal mortality and morbidity in Ethiopia by expanding access to and use of quality comprehensive contraception and abortion care services. (Maternal morbidity is any medical complication caused by pregnancy, labor, or delivery that has a negative impact on the woman’s well-being.) Generously funded by an anonymous donor, ABRI has been operating in Ethiopia in successive phases since mid-2008.^[1]

During ABRI’s eight years of implementation, FP service utilization dramatically increased across ABRI-supported sites through enhanced services which include additional method options for clients—namely, the most effective long-acting and reversible contraceptives (LARCs) and permanent methods (PMs), and broader FP service availability (both in terms of number of health units offering FP services and extended hours). Eight years ago, only 58 project-supported facilities offered FP services, and 21 offered comprehensive abortion care (CAC) services; today both FP and CAC services are available in 424 sites. ABRI has also integrated FP with maternal health, child health, HIV care, and other services. The project attributes its success in expanding access to quality, voluntary FP and CAC in part to “holistic, multidimensional, and interrelated interventions” across various levels of the health system. At the national level, ABRI and the Federal Ministry of Health have worked together closely on a number of key guidelines, training and strategy documents designed to improve services, such as an update to the National Reproductive Health Strategy to include integration of RMNCH services, the development of a postpartum family planning training package, and training of trainers.

ABRI developed a structured on-the-job training package based on the national FP training package for comprehensive in-service FP training. The project provided individualized provider follow-up and support to trained providers to explore and address challenges in institutionalizing quality service delivery. Beyond training and ongoing mentorship, the project equipped facilities with needed supplies, instruments, equipment, and commodities, improved infrastructure through renovations to ensure service readiness and secure client privacy, and strengthened systems for effective internal referral. ABRI is also doing important work at the community level in support of the Ethiopian government’s health extension program. The project has designed and implemented community engagement strategies that include conducting focused community dialogues and household sessions, often involving couples, supported by confirmed community-facility referral linkages.

By the close of ABRI III, the project was supporting services in 220 districts across five regions and two city administrations. Since the start of ABRI, up to 5 million women received FP services at project-supported sites, with 1.4 million opting for a LARC or PM, and the percentage of postabortion clients adopting a FP method increased from 33% to 86%. FP service options and availability were  expanded as capacity was built to deliver—and maintain—high-quality services. High quality is defined by readiness to provide a wider range of contraceptive options, (particularly for underserved groups, such as postpartum and postabortion women)  to make methods available within a range of service units, as well as adhering to up-to-date processes of care, including sound counseling and infection prevention practices. Project strategies were geared toward reliably meeting needs for effective, quality contraception and CAC services and thereby contributing to the ultimate goal of reduced maternal mortality and morbidity in Ethiopia.

Indicators Report. Addis Ababa, Ethiopia, and Rockville, Maryland, USA. CSA and ICF.[1]ABRI Phase I: April 2008–May 2011; ABRI Phase II: June 2011–May 2013; ABRI Phase III: June 2013–May 2016 (with a no-cost extension through Sept. 2016)