Our findings suggest that although abortion is stigmatized and social norms remain largely negative, some signs of a shift in attitudes toward abortion surfaced during our discussions. Several main themes emerged from the FGDs: negative attitudes toward unplanned, premarital pregnancy remain strong; attitudes about abortion are shifting to include consideration of the context in which the pregnancy took place; and the perception of abortion providers is variable. First, we will present the evidence on persistent negative attitudes around unplanned pregnancy and abortion; next, we will present our findings on how attitudes around abortion are slowly changing; finally, we will discuss some of the divided perceptions of the abortion law and abortion providers.
Norms of stigma, shame, and rejection
Prevailing negative attitudes around unplanned pregnancy
An important antecedent to abortion for many women and girls in the study communities was the stigma and social backlash of unplanned pregnancy, mainly for young, unmarried women and girls. Across the various urban and rural communities where this study took place, the resulting behaviors toward unplanned pregnancy is one of extreme rejection, judgment, and isolation. Slightly less than half of participants mentioned the society’s negative opinion of unplanned pregnancy—mostly attributed to younger age (e.g., being a student and occurring before marriage); lack of awareness or use of family planning methods; or rape—and almost three-quarters mentioned either a negative opinion or subsequent life problems. No respondent mentioned that unplanned pregnancy for an unmarried woman would result in a positive societal perception (Additional file 1).
When a pregnancy occurs to a woman who isn’t married or is a student, the community considers this to be very shameful, as well as terrifying for the woman and disappointing to the family and kin group. Female, Oromia, age 22
[I]f the unintended pregnancy occurs out of marriage or before marriage, it will be a big problem for the girl. She will be worried as a result and shamed by her community and relatives. Male, Addis Ababa, age 21
The society won’t help her, they will only point their fingers at her. They will try to solve the puzzle of who the father might be, they will spread the gossip to every corner they can find. If she can deal with this, she will have a baby in her arms. But the society’s reaction might throw her off, so she might consider abortion. Male, Hawassa, age 21
Participants commonly expressed how this stigma included outright denunciation and ridicule of the girl by community members. Participants discussed whether she was seen as a “good girl” or a “bad girl” in the minds of community members. Many respondents confirmed that a girl would be seen as bad or could even damage a previously good reputation with an unintended pregnancy.
People will consider her unintended pregnancy as resulting from her behavioral problem. People will consider her as a slut. People will see her as a bad girl, as promiscuous. They will not have love for her and see her as not a good girl. Male, Bole, age 27
If she was considered as a good girl, if she has a good behavior in the eye of the community, and if she experiences unintended pregnancy and abortion, people’s opinion about her will change. They will no more consider her as a good girl. They will not see her as they used to. Female, Tirunesh, age 19
Very often, respondents mentioned that girls would be used as cautionary tales or made examples of in the community to warn others of the perils of unintended pregnancy.
The people would hate her, or would dislike even to see her, and they wouldn’t want to approach her. The society would mainly think that she will teach this bad thing to others, and hence they would instruct their children to stay far from her, and due to such awful connotation on her, her future life would be distorted wherein she could be unable to get a marriage partner. This is because, it is mainly assumed that she has destroyed a life. Male, Oromia, age 30
Harsh societal reaction against unplanned pregnancies among unmarried women or girls was commonly perceived as resulting in devastating outcomes for the pregnant woman. As mentioned above, many people described life problems that would extend beyond societal pressures like rejection or isolation. Discussants frequently recalled stories of depression, poverty, stopping education, homelessness, excommunication, and even suicide among girls who had been rejected because of an unplanned pregnancy. This stigma was described as following a girl into her future, putting her prospects of marriage and social cohesion at risk.
In the case of most adolescent students, if a girl encountered unintended pregnancy and her families knew that, she could be hated and discriminated. This may cause her to flee away from home and in these situations, she may deliver her baby in the streets, may lose her education as well as her life dreams. Not only being separated from her family and relatives, even the guy who impregnated her may not want to accept her and for this reason, she may suffer a lot. Female, Oromia, age 21
Even in cases where the family may initially support the girl, community shaming would add considerable pressure on families to reject their own daughters. Many participants relayed stories of families that sent their pregnant daughters away to avoid the humiliation brought on by the unplanned pregnancy. Others mentioned that families might force the girl to hide and secretly have an abortion to preserve the family’s reputation.
In my opinion it is not just about a family accepting the girl who has unintended pregnancy or not, it is mainly about what the community will feel and think about the girl. Families will not hate their daughter even though she has unintended pregnancy. But they will think about how they will be perceived if the members of the community know that the girl is pregnant. They will consider her pregnancy as a shame and disrespect. In our culture girls are expected to be married before having children. Otherwise, it is considered as disrespect. Female, Meshualekia, age 19
Persisting stigma around abortion
After participants discussed unplanned pregnancies, the discussion turned to the issue of abortion. Discussants were first asked what people in their community would think about a woman who had an abortion. Well over half of the participants responded that abortion would be considered in a negative light, with no qualifications (Additional file 1). No women in the younger age category thought that support would be given to a woman who had terminated a pregnancy. In these cases, a common perception across all participants was the belief that women and girls who abort their pregnancies were considered to be sinful, murderous, and not deserving of respect.
Several participants claimed they would not support a woman who chose to have an abortion and that such a woman would be looked down upon as compared to one who had never had an abortion. Here, as with those who had an unplanned pregnancy, women and girls may face stigma and isolation by their choice to terminate a pregnancy. Such stigma could also hinder a woman’s future, particularly her “marriageability” in the eyes of her community.
No [the community] won’t support [a woman who wants an abortion] at all. They even try to point fingers on her because…it is considered as she took life or committed a murder. There is a character of saying, “she took a life and who on earth is going to help or support her!?” Even there are people who don’t want her to even sit beside them. Female, Amhara, age 23
I haven’t seen people supporting a woman who had abortion after unintended pregnancy. In my opinion, I guess when abortion is done, a life is lost. It is difficult to ignore that. And people also accept that what is right is to be careful not to be pregnant initially. But to abort the fetus after the woman gets pregnant is unacceptable by many people. Male, Hiwot amba, age 32
The data suggest that this rejection of abortion and stigmatization of women may stem from a deeply religious culture that believes life is a sacred gift from God, whose plan must prevail over the preferences of women. So strong is this belief among some participants that they would actively encourage or pressure a woman to keep her pregnancy if she were considering abortion. For some, the sin of pregnancy termination was too great to justify abortion and would only compound the original offense of being pregnant outside of marriage.
Firstly, that is a mistake in God’s eyes; it is not allowed to abort a pregnancy in our religions. In addition, that child, secondly, can also grow up to be a person of many impacts on the society. Therefore, I will advise her to change her idea of aborting her pregnancy. I will try to get her to give birth to the child. I will do that. Not just for a family member, but that is also what I will do for a neighbor or a community member. Female, Hiwot amba, age 44
I will pressure her to have the baby. To have abortion is to make a mistake twice. The first mistake is when she had the unintended pregnancy. That is also a sin in God’s eyes. And in addition to have the abortion is also a mistake. It is like to stop a life. That is also a mistake and a sin. Therefore, even though she had committed the first mistake by having the unintended pregnancy, there is no need to make the second mistake. Therefore, I will not agree with her wanting to have an abortion. Male, Meshualekia, 24
Some participants, though a minority, do not believe that abortion should be allowed under any circumstances. Even in the case of rape, for example, these individuals may see it as a duty to bear the child and not to compound the event with “murder” of the fetus.
Even if it is like that, I will not advise her to have an abortion. It can be unintentional or rape, but it is better for her to raise the kid. Since she is going to take a human life, I will tell her to give birth to it. Female, Amhara, age 27
Interestingly, an oft-cited reason for not supporting abortion was that the child may grow up to be an important person in the country, like a leader or ruler. This idea cut across respondents and made it clear that for many in Ethiopia, any fetus should be treated with great respect.
There are people who are incapable of conceiving a child; a child is a gift from God. To abort a child—meaning to end a life—is a major sin. This child might turn out to be a very important person for the world. However, due to the couple’s reason he cannot experience life at all. Male, SNNPR, age unknown
Turning tides and mixed views on abortion
As mentioned above, most of the initial reactions to abortion were negative. However, our results show that attitudes are not as unforgiving as they first seem. Notably, for all questions regarding abortion, there were a significant number of responses exhibiting mixed views—mainly, that positions depended upon the circumstances surrounding the abortion (Additional file 2). This suggests that when prompted, most participants did not actually see abortion as a black or white issue but were willing to consider conditions under which abortion would be appropriate or even preferred. Thus, despite the presence of abortion stigma among the participants, many community members also recognized recent, positive societal shifts in perceptions around abortion.
For example, many discussants expressed support for abortion for rape survivors, but a number of those expressed the need to “verify” the rape before offering acceptance or support. Responses from discussants suggested an underlying suspicion of women who claimed rape in order to abort and that sufficient evidence of the rape must be provided in order to validate a woman’s assertion and decision to abort. If such verification were provided, they felt that the woman would be supported.
For a girl that was raped and pregnant from the rape I believe it should be allowed. Abortion should be allowed for her. But it has to be based on reason. If there is evidence that indicates that she was raped, then she should be allowed to have the abortion. But it should not be allowed without evidence indicating that she was raped. The evidence should indicate that the girl was physically forced and raped and not just was out there having alcohol and taking drugs. Female, Tirunesh, age 19
In such cases, the society would support her. Where there is tangible evidence particularly, for instance where she has shouted for help, the people would not sleep until those responsible for the rape were brought to justice in addition to providing her with all the necessary support. As such, there is a due emphasis from the society on such issues. Male, Oromia, age 40
Likewise, although some participants implied that rape in the context of “bad behavior” would not be a satisfactory cause for acceptable abortion, others suggested that such a perception of so-called bad girls or good girls would determine the community’s reaction: those previously seen as good by the community would not be blamed for an unintended pregnancy.
I think the reaction of the community will depend on the situation; it depends on the behavior of the girl and how the pregnancy happened. If the girl was considered as a good girl and as a girl that respects her parents and people in the neighborhood, then even if she has unintended pregnancy the community may not have a bad attitude towards her. But if she is a girl that falls out of line and if she used to show desires to engage in unacceptable behavior, then people will blame her and talk bad things about her. Female, Meshualekia, age 21
Therefore, many of the views around abortion were nuanced, suggesting that societal reactions would often depend upon context. This finding was particularly clear when discussants were asked how they would react if the person who wanted the abortion was a family member. Although the majority suggested that they would still prefer for the family member to give birth or would somehow try to convince her not to have an abortion—even helping her financially if her reason behind wanting the abortion was poverty—many also agreed that this would depend upon the situation. Particularly in cases of incest, rape, or health risk, many suggested that they would support her in her decision to terminate a pregnancy.
My decision will depend on what a doctor will say about the pregnancy. I will also ask her why she wanted to have the abortion. If she wanted to have the abortion because of economic reasons, then I will not allow her to have the abortion. I will do everything to support her. But if it is because of health reasons, then I will agree with the abortion if it can be safely done. Male, Meshualekia, age 19
Perception of support around abortion
As described above, societal perspectives on abortion were not simply negative, and many reactions depended upon particular qualifications (e.g., proof of rape or prior opinion of the girl within the community). This demonstrates Ethiopians’ willingness to consider the circumstances under which an abortion might take place. However, these were not the only responses that indicated a shift in attitudes toward abortion, and many responses—particularly under certain conditions—were positive, even without such qualifications.
Acceptability of abortion in case of health risk or rape
Encouragingly, when asked about particular conditions—rape and risk to the mother’s life—most discussants were far more supportive than about abortion more generally. For example, there were five times more supportive responses when participants were asked about abortions conducted when pregnancy was a result of rape, and eight times more supportive responses (i.e., more than three-quarters of responses) when participants were asked about abortion to save the mother’s life. Additionally, although gender and age group did not result in significant differences on level of support, respondents from urban areas suggested societal support for abortion in the cases of rape or health threat much more often than did those from rural areas (Additional file 2).
Many participants recognized the difficulty that a raped woman might face in bearing and raising the child borne out of violence and would offer support to her if she made that choice.
A woman who performed an abortion due to rape will receive better acceptance and better treatment among the society than the others who normally perform abortion. The society will be very understanding and will try to make the girl feel much better by giving her different life advice. Even family will be very supportive throughout the process, telling her they will be there for her. Female, SNNPR, age 25
Furthermore, discussants viewed abortion due to health risk to be out of the woman’s control and recognized it as a tragic necessity rather than an act of volition. Furthermore, they commonly acknowledged that the mother’s life was to be protected, even if it was at the expense of the fetus. In these situations, women would be treated with compassion and understanding rather than with the judgment or derision reserved for those who abort because of personal choice. Indeed, participants shared that women facing this type of abortion would be treated just as a woman who had given birth, with family and community members visiting her and supporting her in the post-abortion period. One discussant even shared her own experience following an abortion due to a high-risk pregnancy, reporting feeling very cared for by her community members.
I have gone through the same experience some years ago. I was forced to go through abortion because doctors told me that the pregnancy would be dangerous for me. They referred me to Dinberua Hospital and I had to go through the process. And everyone in the community showed me care and support. They all came and visited me. I haven’t experienced any form of judgment or anything that I consider to be negative. Female, Bole, age 33
Increase in unqualified support for abortion
Even beyond such qualified (albeit positive) responses, an emerging theme among discussants was the perceived overall increase in the number of people capable of understanding a woman’s or girl’s choice to abort regardless of circumstance and that many of them may even provide material or moral support. This support was given in spite of the prevailing norms against abortion and in the face of stigma and pressure from others in the society. There was also evidence from participants to suggest that in certain communities there would be no negative reaction to a woman who chooses to terminate a pregnancy. This finding was seen as an important change from previous times and was largely attributed to an increased education among communities about abortion.
From the general trend that prevails in neighborhood or society or the country as a whole, [abortion] is something disgusting, an act that shouldn’t be thought of and that would drive a hostile reaction from the majority. However, there are a few people who think that it has already happened and who would show sympathy for her and provides support no matter what adverse attitude from others in the society could be there. Male, Oromia, age 30
There is no negative reaction to the girl today. Today people are educated and negative thinking and attitude towards abortion are nonexistent. In the past it was a big problem. Now people have awareness about the causes for the occurrence of unintended pregnancy. Male, Hiwot amba, 40
Variable knowledge of Ethiopian abortion law
After eliciting perspectives on abortion under various circumstances, participants were asked to recount their understanding of the legality of abortion in Ethiopia. The resulting responses revealed a muddled notion of legal indications of abortion in the country, with no notable differences according to the age, gender, or location of the participant. Knowledge of the Ethiopian abortion law varied widely, from those who believed it was not permissible under any circumstance (approximately one-third of responses) to those who recalled that it was allowed in some cases (e.g., rape, risk to the mother’s health, or incest; slightly fewer than half of responses).Footnote 1One-quarter of discussants openly admitted to not knowing the Ethiopian abortion law at all (Additional file 3). Some participants even interpreted the question to mean legal repercussions of abortion and were adamant that a woman would be prosecuted in the event of an abortion.
The law in Ethiopia doesn’t allow abortion. This is so because, since the aborted baby [the fetus in the womb] has a life and could be raised to become a man/woman, and for this reason, [abortion] is considered as a murder and is thus a criminal act. Female, Oromia, age 23
I think there is a law about abortion because the girl might be raped forcefully, her body might not able to carry the fetus, or the pregnancy might endanger her health. Therefore, I think there might be a law allowing abortion. Male, Amhara, age 20
Diverging views on abortion providers
Just as they held variable views on stigma against abortion, participants held conflicting opinions on the role of abortion providers. The responses to this question were evenly distributed across those who perceived them negatively, those who thought they were helping, and those who were either unsure or agreed that the societal perspective would be mixed (Additional file 3). For those who were opposed to abortion, providers were seen as an enabler of that which should not be permitted. This was particularly true of providers that offer abortion to women who were not in immediate danger. For some participants, abortion providers were seen as working actively against the will of God.
I personally view them as sinners. That is because they are participating in abortion and abortion is seen as stopping a life. Female, Amhara, age 37
Whatever their reason [for the abortion], the community sees only whether abortion is done or not. If it is done, they believe that [the provider] is destroying the building of God. Even, they will say if this kid is born, it may help the community when it grows up and also they will say it is the wish of God for this kid to come to the world but [the provider] terminated it. Therefore, the feeling is different, and it is not a good feeling that the community have. Male, Amhara, age 26
For others, legal abortion providers were seen as providing a helpful service, or at least just doing their job. However, participants often indicated that those who perform abortions illegally or with herbs, such as traditional healers, were condemned because such abortions can be very dangerous for the woman.
Abortion is done legally and illegally. Those who work legally are accepted and there is nothing against these people. But those who work illegally in the community are not accepted. People don’t have a good opinion on these people. Male, Hiwot Amba, age 32
On the other hand, a common theme to emerge from participants was the view that abortion providers offered essential services to save or protect women’s lives. These discussants understood that abortion providers were supplying necessary assistance according to the laws of the country and viewed them as benefitting the community. For some, abortion providers were considered God-like (an interesting contrast to the responses above) and making an indispensable contribution to society.
Instead of dying due to giving birth at a young age, it is a good deed if a doctor can abort the baby to save her life. For these exceptions, they are helpful and necessary; we should be thankful. We don’t know what the baby will turn out to be or what problem it will bring to the society and his mother…. If they refuse to help, she might suffer several problems to the point of ending her life. Their existence, the profession itself is necessary for the community. Female, SNNPR, 20
The people have good perception and adore the health professionals that help women to have the abortion; and it is even said “waaqa biraa doktaratuu jiraa” [literally to mean that a doctor is another God]. Male, Oromia, age 30