UC Berkeley

In 2005, Ethiopia enacted a rare reform, liberalizing 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 reformed their laws to permit safer, legal abortion, and medical associations typically avoid reform advocacy. The three studies presented in this dissertation examine the political origins and theoretical implications of this unusual reform in Ethiopia, as well as the roles of health providers and their medical societies in reform and implementation. The first study describes the political history of the reform and assesses the utility of theories of agenda setting. The second study explores why, counter to theoretical expectations and empirical accounts, a medical society actively supported reform of national law on abortion. Finally, as laws in resource-poor countries are often weakly implemented, the last study looks at midwives' roles in implementation by assessing what underlies their decisions about abortion service provision. Data for the three studies are drawn primarily from fifty-four interviews conducted in 2012 with obstetrician-gynecologists and governmental and non-governmental actors involved in, or familiar with, Ethiopia's reform. The other data sources were a 2013 survey of midwives (n=188) at a national professional meeting and 12 interviews with third-year midwifery students. The first study finds that the liberalization of the law on abortion was facilitated by the ruling party and its receptiveness to reform, civil society actors collaborating closely with government, the "open windows" offered by the vehicle of the Penal Code reform and the momentum of reforms to improve women's status. This suggests that agenda setting theories focusing on national rather than international actors conform better to Ethiopia's reform process. The unusual medical society participation in the reform process was motivated by obstetrician-gynecologists' personal and organizational commitments to reducing maternal mortality as well as organizational and political circumstances that relaxed or removed constraints on policy involvement. The study of midwives' attitudes about implementing reform found that most (72%) were willing or possibly willing to provide abortion services, and that this willingness was positively related to attitudes toward abortion, knowledge of the law and past provision of medication abortion. Willingness to provide services was negatively related to their number of years as a midwife and religiosity. Interview data suggest complex dynamics underlying these results, including conflict between strong professional norms and personal religious beliefs. These findings can deepen our knowledge of policy-making processes in Sub-Saharan Africa and give insight into how medical professionals participate and understand their roles in policy making and in implementing controversial health policies.