What is the relationship between contraceptive services and knowledge of abortion availability and legality? Evidence from a national sample of women and facilities in Ethiopia

In Ethiopia, abortions are legal for minors and for rape, incest, foetal impairment or maternal disability. Knowledge of abortion legality and availability is low, and little effort has been made to disseminate this information for fear of invoking anti-abortion sentiment; instead, systems rely on health providers as information gatekeepers. This study explores how exposure to and interaction with family planning service delivery environment, specifically (1) availability of contraceptive and facility-based abortion services within 5 km of one’s residence and (2) contact with a health provider in the past 12 months, relate to women’s knowledge of the legality of accessing abortion services and of where to access facility-based abortion services. We used data from a nationally representative sample of 8719 women in Ethiopia and a linked health facility survey of 799 health facilities. Our outcome of interest was a categorical variable indicating if a woman had (1) knowledge of at least one legal ground for abortion, (2) knowledge of where to access abortion services, (3) knowledge of both or (4) knowledge of neither. We conducted multilevel, multinomial logistic regressions, stratified by residence. Approximately 60% of women had no knowledge of either a legal ground for abortion or a place to access services. Women who visited a health provider or who were visited by a health worker in the past 12 months were significantly more likely to know about abortion legality and availability. There were no differences based on whether women lived within 5 km of a facility that offered contraception and abortion services. We find that health workers are likely valuable sources of information; however, progress to disseminate information may be slowed if it relies on uptake of services and limited outreach. Efforts to train providers on legality and availability are critical, as is additional research on knowledge dissemination pathways.