The Baobab Research Programme Consortium (RPC), in collaboration with the Guttmacher Institute, implemented the application of the Abortion Incidence Complications Method (AICM) in refugee settings in Ethiopia. Little is known about the health system’s capacity to provide post-abortion care (PAC) or safe abortion care (SAC) services as these have been less studied, especially in the context of refugee settings. This brief assesses the availability of SAC and PAC for women living in humanitarian settings in Ethiopia

Baobab Research Programme Consortium

Guttmacher Institute

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Population Council Knowledge Commons 6-1-2025 Capacity of the health system to provide safe abortion and post-abortion care in refugee settings in Ethiopia: Evidence Brief Baobab Research Programme Consortium Guttmacher Institute Follow this and additional works at: https://knowledgecommons.popcouncil.org/hubs_humanitarian How does access to this work benefit you? Click here to let us know! Recommended Citation Baobab Research Programme Consortium and Guttmacher Institute. 2025. "Capacity of the health system to provide safe abortion and post-abortion care in refugee settings in Ethiopia: Evidence Brief." Nairobi: Population Council, Kenya; African Population and Health Research Center; Population Council, Inc. New York: Guttmacher Institute. Licensed under CC BY-NC-ND 4.0 This Brief is brought to you for free and open access by the Population Council. EVIDENCE BRIEFJUNE, 2025Context Abortion care services are less restrictive in Ethiopia compared to many other countries in sub-Saharan Africa, including legal access to safe abortion services for a broader range of circumstances. The provision of high-quality comprehensive abortion care is essential for reducing maternal morbidity and mortality. However, little is known about the health system’s capacity to provide post-abortion care (PAC) or safe abortion care (SAC) services as these have been less studied, especially in the context of refugee settings.This brief assesses the availability of SAC and PAC for women living in humanitarian settings in Ethiopia using a Health Facilities Survey (HFS). Data for this analysis was collected in 2024 in 22 of the 24 refugee camps across Ethiopia. A total of 75 facilities (12 hospitals and 63 health centers and private clinics) that are expected to provide comprehensive abortion care to women in refugee settings in Ethiopia were surveyed. Nearly three-quarters (71%) of facilities included in our census were operating outside of refugee camps. Facilities (12 hospitals and 63 health centers and private clinics) that are expected to provide comprehensive abortion care to women in refugee settingsFacilities operating outside of refugee camps7571%Capacity of the health system to provide safe abortion and post-abortion care in refugee settings in Ethiopia1Table 1. Essential Signal Functions needed to provide basic and comprehensive safe abortion care (SAC) and post-abortion care (PAC)Basic Signal Function IndicatorsServices only needed for basic SAC: •  Surgical and medical uterine evacuation •  Family planning counseling once per week•  At least one health professional capable of PAC is registeredServices only needed for basic PAC: •  Surgical or medical removal of retained products of conception •  Family planning counseling 24/7•  At least one health professional capable of PAC is on duty always or most of the time •  Hours of operation are 24/7 •  Parenteral antibiotics •  Uterotonics/oxytocics • 	IV	fluidsServices needed for both: •  At least one short-acting contraceptive method•  A method of referring patients to higher level care (phone or referral vehicle) Comprehensive Signal Function IndicatorsServices only needed for comprehensive SAC:•  Dilation and evacuationServices only needed for comprehensive PAC:•  Abdominal surgical procedures (such as laparotomy)•  Blood transfusionServices needed for both: •  At least one long-acting reversible contraceptive methodProvision of individual services • Among primary-level facilities, all had at least one person trained in PAC on staff, family planning at least once per week, parenteral antibiotics, at least one type of method for removing retained products of conception, and at least one short-acting contraceptive (Figure 1). Despite the fact that all primary-level facilities have the capacity to provide at least one type of uterine evacuation procedure, only 38% of them met the criteria for uterine evacuation services for SAC.•  All referral-level facilities met the criteria for most of the SAC and PAC signal functions (Figure 2). One notable exception was that only 42% of facilities offered dilation and evacuation services, which is necessary for providing comprehensive SAC.Needed for bothOnly needed for basic PACOnly needed for basic SAC100%100%38%78%78%78%84%98%100%100%78%100%Medical and surgical uterine evacuationFP at least once per week1+ PAC provider is registeredOpen 24/7FP 24/71+ PAC provider is always or mostly on duty 24/7Uterotonics / OxytocicsIV FluidsParental antibioticsRemoval of retained products of Phone or Emergency vehicle1+ short-acting contraceptiveKey findings12Figure 1: Proportion of primary-level facilities providing each basic PAC and SAC serviceDefinitionsThe HFS collected information on the recent provision of services needed to perform safe abortions and provide care for abortion-related complications. In addition, it measured the current availability of equipment, supplies, and staff necessary to provide those services. We used the Signal Functions framework to classify facilities as able to provide basic or comprehensive SAC and PAC1. According to this framework, primary-level facilities (health centers and private clinics) are expected to provide basic SAC and PAC. Referral-level facilities (hospitals) are expected to provide comprehensive SAC and	PAC.	Facilities	have	to	fulfill	all	basic	signal	functions,	as	well	as	additional	comprehensive	indicators,	in	order	to	be	classified	as	being	able	to	provide	comprehensive care*.	Table	1	displays	the	definitions	used	to	determine	whether	facilities	met	the	signal	functions	criteria	for	providing	SAC	and	PAC.*With the exception of referral capabilities for comprehensive PAC, as referral-level facilities are expected to treat severe complications1Campbell OMR, Aquino EML, Vwalika B, Gabrysch S. Signal functions for measuring the ability of health facilities to provide abortion services: an illustrative analysis using a health facility census in Zambia. BMC Pregnancy Childbirth. 2016;16: 105. doi:10.1186/s12884-016-0872-52Needed for bothOnly needed for basic PACOnly needed for  basic SAC100%100%100%100%100%100%100%100%100%100%100%100%84%92%83%42%* Comprehensive care serviceFigure 2. Proportion of referral-level facilities providing each basic and comprehensive PAC and SAC serviceIV FluidsParental antibioticsRemoval of retained products of conceptionBlood transfusion*Abdominal surgical procedures*Phone or emergency vehicle1+ Short-acting contraceptive1+ Long-acting contraceptive*Uterotonics / Oxytocics1+ PAC provider is always or mostly on duty 24/7FP 24/7Open 24/7Dilation and evacuation*Medical and surgical uterine evacuation1+ PAC provider is registeredFP at least once per week•  Overall, 62% of health centers and private clinics provided all basic PAC services, and 33% provided all basic SAC services (Figure 3).•  83% of referral-level facilities were able to provide comprehensive PAC, but only 5 (42%) provided comprehensive SAC, which was largely due to an inability to provide D&E.  • The low proportion of primary-level facilities able to offer basic SAC was primarily driven by the fact that 30 of these facilities did not offer safe abortion care. Respondents stated SAC was against the facility’s policy or the morals/ethics of facility staff.• Focusing only on primary-level facilities that provide any SAC, 64% meet the criteria for providing basic care (Figure 4). Further, we estimate that 53% of facilities that reported not offering SAC due to facility policies or conscientious objections would be capable of providing basic SAC if these internal policies were changed. This is because most already provide family planning, have trained staff, and provide surgical and medical removal of retained products of conception for PAC patients.Capacity to provide basic and comprehensive SAC and PAC1234Comprehensive (referral-level facilities)Basic (primary-level facilities)Basic SAC overall Basic SAC among facilities that offer SACTheoretical provison of basic SAC among facilities that don’t offer SAC33%33%64%53%62%42%83%Safe abortion care Post-abortion careFigure 3. Proportion of facilities offering Basic and Comprehensive SAC and PACFigure 4: Proportion of primary-level facilities with basic SAC of primary-level facilities met the criteria for uterine evacuation services for SACof referral-level facilities offered dilation and evacuation services, which is necessary for providing comprehensive SAC38%42%3Acknowledgements This	work	was	supported	by	the	Foreign,	Commonwealth	&	Development	Office	(FCDO)	and	the	Norwegian	Agency	for	Development	Cooperation	(NORAD).	The	findings	and	conclusions	in	this	report	are	those	of	the	authors	and	do	not	necessarily	reflect	the	positions	and	policies	of	the	funding	agencies.Suggested Citation: Baobab Research Programme Consortium and Guttmacher Institute, 2025. Capacity of the health system to provide safe abortion and post-abortion care.Conclusion Our	findings	show	that	most	facilities	in	humanitarian	settings	can	provide	basic	and/or	comprehensive	PAC	services.	This	is	an	important	finding,	as access to quality PAC is an essential intervention for women experiencing complications from pregnancy loss. A key intervention that would improve the proportion of health centers and clinics able to provide basic PAC would be to improve their ability to communicate with referral-level facilities and transport patients in critical condition. Once at referral-level facilities, women in humanitarian settings must also have access to blood transfusions and safe abdominal surgeries in case of a life-threatening complication. Strengthening the supply chain to ensure referral-level facilities have continuous stock of blood and the equipment necessary to perform advanced surgeries is key. Access to facilities that provide basic and comprehensive SAC was limited in settings where many refugees live even though safe abortion care services are legally permissible in Ethiopia. We found almost half of health centers and clinics in refugee camps do not offer SAC though many likely have the ability to do so. RecommendationsImplementationEnsure the full implementation of existing SAC & PAC policies and guidelines, such as the Technical and Procedural Guidelines for safe abortion care.StrengthenStrengthen the supply chain of medical supplies and commodities: this requires coordinating between different aid organizations and government health service supply chain systems. TrainingProvide specialized training opportunities and	financially	support	equipment and commodities to increase access to both basic and comprehensive SAC.SystemsStrengthen referral systems and the hospital platform by upgrading health centers located in refugee camps.43214

Capacity of the health system to provide safe abortion and post-abortion care in refugee settings in Ethiopia: Evidence Brief

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Capacity of the health system to provide safe abortion and post-abortion care in refugee settings in Ethiopia: Evidence Brief

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