Safe abortion services are an essential component of sexual and reproductive healthcare.1 Yet, it is estimated that 45% of abortions occurring annually around the world, and 75% of abortions in Africa, are unsafe.2 Abortion-related complications contribute to preventable maternal mortality and morbidity, accounting for 9.8% of maternal deaths globally, and 15.6% of maternal deaths in sub-Saharan Africa.3 Timely and high-quality postabortion care (PAC) can greatly mitigate the negative health outcomes associated with unsafe abortion. PAC refers to a set of services provided to women who present with complications from unsafe or incomplete abortions, and includes the medical treatment of complications as well as the provision of postabortion contraceptive services and counseling. All countries have committed to providing PAC to reduce the burden of abortion-related morbidity and mortality,4 however, sufficient health system capacity to provide PAC is not universal.5
Abortion care was targeted as part of the Trump Administration’s Protecting Life in Global Health Assistance policy, also known as the Global Gag Rule (GGR).6 This iteration of the GGR prohibited non-U.S. non-government organizations (NGOs) that receive U.S. government global health assistance (as well as subgrantees of the organizations) from using their own non-U.S. funds to provide, refer to, or advocate for safe abortion care (SAC) services. Despite this seemingly narrow focus, the policy may affect other areas of sexual and reproductive health service provision given the comprehensive suite of services provided by affected NGOs and the critical role these NGOs play in supporting public sector services. There is some evidence to suggest that this is the case; previous quantitative research assessing the impacts of the GGR has documented impacts on the delivery of family planning services in both the public and private sector,7–9 subsequent impacts on women’s sexual and reproductive health outcomes that are likely a result of changes in family planning service delivery,8,10−12 and changes in the delivery of HIV services.13 Very little is known about the policy’s impact on the facility-based provision of PAC or SAC itself, especially for health systems that are already at a disadvantage in being able to provide the standard care required for PAC. While the policy does not prohibit the provision of PAC, others have argued that overinterpretation of the policy – often referred to as a “chilling effect” wherein service providers avoid even permitted services due to fears of withdrawal or loss of funding – has resulted in impacts on these services.14 Further, implementation has likely affected access to abortion services even in settings where abortion is widely available by disrupting health system partnerships (where affected NGOs provide training and supplies to public health facilities), referral mechanisms, access to information and safe services.
Shedding light on the policy’s real-world effects on the availability, quality, and utilization of PAC and SAC services is important for informing the design of policies and programs aimed at reducing maternal morbidity and mortality. In this paper we compare health systems’ capacities to provide safe abortion and/or postabortion care, as well as trends in these indicators while the GGR was in effect for two countries: Ethiopia and Uganda. These countries represent differing legal contexts for safe abortion care and the impacts of the GGR on abortion care in these countries may vary. Both countries are uniquely susceptible to changes in U.S. global health funding policies as The U.S. is the largest donor of global health funding to both Ethiopia and Uganda, and the second-largest donor for Ethiopia’s family planning budget.15,16 Since the expansion of the abortion law in Ethiopia in 2015, there have been significant increases in the availability and quality of abortion services. Between 2008 and 2014, use of appropriate technology for conducting first and second trimester abortions, as well as provision of postabortion family planning, has increased, while abortion-related complications have decreased.17 However, regional disparities persist, and NGOs play a critical role in delivering high quality sexual and reproductive health services, including abortion, both directly and through public-private partnerships. In Uganda, abortion remains highly restricted, prohibited under all circumstances unless the woman’s life is at risk.18 Given the links between abortion restrictions and safety, PAC is especially critical in Uganda.2 To this point, a recent study of maternal near-miss and abortion complications data from health facilities in Central and Eastern Uganda in 2016–2017 found a high burden of abortion-related morbidity and mortality.19
One way to measure health facilities’ capacity to provide services is through a signal functions approach. The signal functions methodology was originally developed by the United Nations to assess the provision of emergency obstetric care, delineating several medical functions that comprise basic and comprehensive Emergency Obstetric Care (EmOC).20 The methodology typically consists of a list of indicators used to assess health facilities’ capability to provide the most effective or life-saving interventions for managing the most common complications. In 2006, Healy et al. adapted the signal functions approach for basic and comprehensive SAC,21 and Campbell et al. further adapted signal functions to measure capacity for SAC and PAC.22 This framework has since been applied to assess service provision across various geographical contexts.5,23−26
In this study, we use abortion care data collected between 2018 and 2020 from health facilities in Ethiopia and Uganda. Using a signal functions approach, this paper aims to assess the availability and capacity of facilities to provide PAC services in Uganda and PAC/SAC services in Ethiopia at two points in time. We investigate if and how these services changed during the period in which the GGR was in effect and document overall gaps in the quality of services. We hypothesize that 1) during this time-period there would have been a reduction in the availability of supplies needed for safe abortion as well as postabortion care services in facilities due to the chilling effect of the GGR; and 2) the need for postabortion care would have increased since the policy made abortions more difficult to access, potentially more stigmatized and, thus, less safe. The results of this study provide a basis for understanding abortion care service delivery in Uganda and Ethiopia, how these services were impacted during the years in which the GGR was in effect, and for identifying gaps in service provision that can be addressed to improve capacity within the health systems to prevent and treat abortion-related complications.