In a small rural hospital in Ethiopia more than two decades ago, a teenage girl arrived at Dr Abebe Shibru’s clinic, alone, frightened and pregnant. She was just 14 and had been raped. But with one of the world’s most restrictive abortion laws then in place, she was turned away without help. Later, Dr Shibru learned that she had tried to end the pregnancy herself using herbal medicine, inserted into her uterus and had bled to death.
Spurred on by an alarmingly high maternal mortality rate, the country repealed its harsh law in 2005. But, twenty years on, leading doctors are warning these gains could be reversed as Trump’s aid cuts decimate the country’s family planning and reproductive health services, and anti-abortion groups move in to fill the vacuum.
There has already been a shrinking in what is available to people in public facilities, including essential medicines and tests used during pregnancy and birth, The Independent has learned.
With the dust settling after Trump ordered all foreign aid work to stop in January of this year, Ethiopia has come out as one of the biggest losers in the cuts. By March, the country had seen the second biggest cut by dollar amount, tied with the Democratic Republic of Congo and exceeded only by funding cuts to Ukraine, according to the Center for Global Development. Dr Shibru says 85 per cent of NGOs, crucial in the delivery of many of the country’s health services, had stopped work or were shuttered.
Dr Shibru, now the Ethiopia country director for sexual health charity MSI Reproductive Choices, is acutely aware of what that could spell. Working as a nurse in the early 2000s, in a remote area 700km from the capital Addis Ababa, he saw countless of these women – without access to contraception or legal termination – resorting to traditional medicine. “Seeing women who had experienced rape or some form of violence and finally ended up pregnant…it was my day-to-day experience,” Dr Shibru recalls. They came into his clinic with perforated uteruses from inserting ivy vines into them, eyes purple from blood loss and unconscious from pain and infection, dying in hospital corridors from unsafe abortions.
Overhauled law
Alarmed by the sky-high death rate, in 2005 the then health minister Dr Tedros Adhanom Ghebreyesus, now head of the World Health Organization, and Ethiopia’s parliament overhauled the law and policy, permitting safe abortion for the first time in limited circumstances. Terminations could be sought in cases of rape, incest, development problems with the foetus, or if the pregnancy endangered a woman’s life or health. At the same time, Dr Tedros worked to radically expand access to contraception too.
The results were swift and dramatic. Within three years, the maternal mortality rate plummeted from 879 per 100,000 live births to 276 per 100,000 by 2008.
“After this law there was a big shift in terms of knowledge. There was a big shift in terms of commitment, ” Dr Shibru says.
Much of the country’s maternal and reproductive health system, from contraception to emergency obstetric care, however, was built on international aid. Now that progress is under threat. Doctors across Ethiopia are warning of an escalating funding crisis that is hollowing out reproductive health services.
Alongside heavy cuts from the US, the UK’s aid spending plan published in July revealed funding cuts to Ethiopia of 25 per cent coming for the next year.
Aid cuts reversing gains
President of the Ethiopian Society of Obstetrics and Gynaecology, Dr Hailemariam Segni, says the aid suspension from the US government had already, “significantly affected accessibility of services including family planning, maternal health services, even newborn, child health, adolescent, and youth health services.”
“These services in public facilities were mainly supported with aid money and the main funder was the US government,” he says.
And when it comes to the gains made in bringing down maternal and newborn deaths in the past two decades: “We feel may be reversed in the coming few years”
Some health facilities have started requesting clients share the costs of previously free services, for example to access family planning or pay privately for their own diagnostic tests. Some patients are even being told to buy drugs used in labour from private facilities, he says.
Dr Segni says he expects that if services like family planning or even basic tests and medicines are not available for free, many will not be able to access those services at all.
“The number of pregnancies will increase. So we know with the number of pregnancies [increasing], the complications are going to increase,” he says.
And with additional difficulties getting drugs like oxytocin, used to prevent life-threatening bleeding, “many mothers may die from haemorrhage”.
Antibiotics to prevent sepsis in newborns and drugs to prevent premature birth and treat the complications of prematurity could all be under threat.
Given every Republic president since Ronald Reagan in 1984 has brought in a law banning US aid dollars from funding abortion, these services in Ethiopia are already funded from different sources. Nevertheless, the last time the law was brought in under Trump’s first presidency, it had knock-on effects on wider reproductive health services including significantly reducing contraception use in the country.
As well as cuts in funding going directly from the US to Ethiopia, Trump has withdrawn from the United Nations Population Fund (UNFPA) which – previously alongside the now axed US Agency for International Development (USAID) – is the biggest provider of contraception in the world.
“We are expecting within a short period of time we are going to encounter a huge [contraception] shortages because UNFP is the one who is providing commodities to our family planning service in Ethiopia,” says MSI’s Dr Shibru.
In 2022, the Ethiopian government signed an agreement with UNFPA and USAID to gradually increase the percentage it contributes to funding family planning over several years up to 2030. The country now finds itself having to fill in that gap much more quickly.
Dr Alemayehu Hunduma, the Ethiopian Ministry of Health’s head of reproductive health, family planning and adolescent and youth health programmes, says while the government is trying to take on the funding of as many services as it can: “We are a developing country. As much as we mobilize more resource, still there will be a gap because the demand is high”.
He says family planning is one of the country’s health funding priorities because of its role in reducing maternal mortality.
Internal Ministry of Health data seen by The Independent shows there had already been a slight downward trend emerging in the numbers of women accessing abortions in public facilities in recent years. It’s not clear why, and conflict and instability in parts of the country could well play a role. But there is another threat too: a resurgent anti-rights movement intent on rolling back the 2005 law and with it access to safe abortion.
Over the past few years, activists opposed to reproductive rights have returned with new energy, emboldened by the US Supreme Court’s decision to overturn Roe v Wade. Some are local while others are linked to ultraconservative US organisations.
They park vehicles outside abortion clinics with messages accusing those using their services and their workers of murder, Dr Shibru explained. They use Facebook, Telegram and YouTube to get their message out. And they have been successful in getting their spokespeople quoted in public media and interviewed on national TV and radio. They will even try to approach members of parliament and individual policy makers, he says.
“Before they were focusing on abortion, but now they are focusing on the entire family planning program,” Dr Shibru says.
They are well-funded and aggressive, he adds, seeing Ethiopia as a target precisely because it was pioneering in the region in terms of its safe abortion law.
Aid cuts have created a vacuum, giving anti-rights groups new energy and an opportunity to fill the gap, he says.
“Now the local NGOs are being affected by this new Trump administration policy, that means there is a huge [opportunity] for anti-choice movement to come and just to say whatever they want to say.
“Our bargaining power is now shrinking,” he adds, “that means there is a space for anti-choice movement…to agitate [for] what they want to achieve in Ethiopia. So, absolutely there is a direct link, a visible link between the anti-choice movement now and the Trump administration’s…new policy funding cut”.
For now, the country’s health ministry remains supportive of existing laws, even as budgets tighten. While few believe Ethiopia’s abortion law will be repealed soon, campaigners fear incremental victories for conservative campaigners.
“I’m not pessimistic that they are going to succeed in revoking the abortion law within a short period of time,” Dr Shibru says. “But they might manage to influence the policy makers to restrict the guideline of safe abortion services”. This and the rising stigma that surrounds it would drive women back to unsafe methods, he fears.
For clinicians like Dr Shibru, the stakes are painfully clear. Ethiopia once ranked among the most dangerous places in the world to give birth. The reforms of the mid‑2000s, and the international aid that bolstered it, turned the tide.
Looking at how the cuts are biting, Dr Shibru can’t help but hold in mind the daily tragedy he witnessed all those years ago: the 14-year-old girl’s needless death; the woman having to undergo an unwanted hysterectomy, robbing her of the chance to have future children, after inserting herbal medicine into her uterus. “Had there been a policy? Had there been a trained person?” he ponders, “we might save the lives of these women and others.”
As for whether the policies and people now in place will remain: “the future is uncertain”.
This article is part of The Independent’s Rethinking Global Aid project
