Over the past two decades, through a series of concerted policies, programs, and commitments, Ethiopia has made notable advances in improving the reproductive health of its population, including expanding family planning (FP) information and services to larger segments of the population. Starting with the first Health Sector Development Plan in 1997, the Ethiopian government has invested heavily in health system strengthening and fostered a supportive policy environment for the expansion of access to health services and sexual and reproductive health (SRH) programming. The national health extension program and the accelerated expansion of primary health care services to increase both the availability and accessibility of essential services have both proven pivotal to expanding FP access, most notably among the country’s rural population. The government’s FP2020 commitments signaled its prioritization of increased funding for FP services and focus on adolescents and youth. The National Youth Policy enacted in 2004 and subsequent adolescent and youth (AY) SRH strategies—which expanded services to Ethiopia’s large youth population—provided a supportive AYSRH policy environment that has fostered improved reproductive health outcomes among this population. Similarly, the liberalization of the abortion law in 2005 expanded the conditions under which safe abortion care can be provided and expanded access to abortion care by authorizing midwives to provide abortion services.
These policies and programs have resulted in impressive gains. FP use has increased more than fivefold over the past two decades, with use of modern contraceptives rising from 6.6% among married women of reproductive age in 2000 to 40.5% in 2019. Over that same period, the total fertility rate dropped from 5.5 to 4.1 children per woman. Other notable changes included a decline in the maternal mortality ratio from 871 to 401 women per 100,000 live births between 2000 and 2017 [1, 2], in large part because of the liberalization of abortion. The median age at first marriage also rose from 16.0 years in 2000 to 17.1 in 2016 .Footnote 1
Despite these remarkable achievements, however, coverage of reproductive health information and services remains low, with a large gap between current coverage rates and the universal health coverage (UHC) targets laid out in the country’s 2016–2020 Health Sector Transformation Plan (HSTP) [1, 4, 5]. More than one in five Ethiopian women still have an unmet need for FP; among adolescents, information on reproductive health is still largely shared through friends and is often inaccurate .
With the launch of FP2030 and less than a decade left for countries worldwide to meet their Sustainable Development Goals (SDGs) and the SDG UHC target, the coming years will require high quality information—a key pillar of the current HSTP—to inform the development and implementation of impactful SRH programs and initiatives to accelerate progress [6, 7]. Thus, we are at an opportune moment to pause, gather, and reflect on lessons learned around Ethiopia’s improvement efforts for FP, reproductive health, and adolescent health outcomes and identify what is required in the next decade to achieve the country’s goal to meet the SRH needs of its entire population.
This supplement endeavors to capture some of the key SRH lessons learned over the past two decades. It brings together the work and experience of researchers, practitioners, and policy makers engaged in FP and reproductive health work in Ethiopia. This supplement includes diverse perspectives, types of evidence, and insights on Ethiopia’s reproductive health context and the way forward. The supplement is structured around three main issue areas: (1) FP and contraceptive use, (2) AYSRH, and (3) abortion. First, the contributors present evidence on overall trends in FP and contraceptive use and examine determinants of use, both of which vary tremendously across regions and population groups. Getinet Yirtaw et al. identify important geographic differences in contraceptive ideation and future intention to use FP . Other articles in this supplement provide insights into the sociocultural determinants of contraceptive use. Sedlander et al. explore determinants of misconceptions around contraceptive methods and provide insight into pathways to self-efficacy for FP use . Smith et al. and Kapadia-Kundu et al. explore social and gender norms that influence FP use, highlighting the role of men’s support and equitable couples’ communication and decision making as key facilitators of FP use [10, 11].
The following section presents research focused on the adolescent and youth population—exploring the rapidly changing environment and social norms that affect their attitudes and behaviors and guide the debut and early stages of their reproductive lives. Akwara et al. review the progress made on adolescent reproductive health indicators over the past two decades . Erulkar and Lindstrom et al. provide evidence on how these changing norms impact the ages of first marriage and first sex [13, 14]. Effective programming that reaches youth is critical. To that end, Chowdhary et al. explore the factors that influence the sustainability of a peer education program .
Finally, this supplement reflects on progress and remaining challenges in abortion care. Holcombe et al. provide a detailed analysis of the actors and processes that contributed to the reform of Ethiopia’s abortion law, culminating with its liberalization in 2005 . Vernaelde et al. describe how the United States’ reinstatement and expansion in 2017 of the Global Gag Rule threatened Ethiopia’s national commitment to make abortion available . Finally, social mores and opinions around abortion continue to present barriers to access, even when abortion is legal. Fekadu et al. and O’Connell et al. address stigma at the provider and community level, exploring barriers that this stigma creates to those seeking abortion care [18, 19].
Across the supplement’s compilation of articles, several common themes emerge. Demographic determinants related to FP use specifically, and women’s empowerment more broadly, point to remaining challenges to continued FP progress. Notably, national-level improvements in the modern contraceptive prevalence rate (mCPR) mask important geographic disparities, both urban–rural and across different regions of the country. Women in rural areas have an mCPR of 38.2% and tend to adopt an FP method later than their urban counterparts: their first use is after giving birth to an average of 2.2 children, compared to an average of 0.8 among women in urban areas [6, 20]. In addition, the four emerging regions (Afar, Benishangul-Gumu, Gambella, and Somali) have mCPRs below the national average, with Afar and Somali having particularly low rates of 12.7% and 3.4%, respectively .
Important gaps also remain in contraceptive and reproductive health knowledge and self-efficacy. Sociocultural barriers to contraception, AYSRH, and abortion information and services continue to be pervasive, with FP and reproductive health topics remaining taboo for much of the population.