In 2005, Ethiopia liberalized its abortion law and subsequently authorized midwives to offer abortion services. Using a 2013 survey of 188 midwives and 12 interviews with third-year midwifery students, this cross-sectional research examines midwives' attitudes toward abortion to understand their decisions about service provision. Most midwives were willing to provide abortion services. This willingness was positively and significantly related to clinical experience with abortion, but negatively and significantly related to religiosity, belief that providers have the right to refuse to provide services, and care of patients from periurban as opposed to rural areas. No significant relationship was found with perceptions of abortion stigma, years of work as a midwife, or knowledge of the law. Interview data suggest complex dynamics underlying midwives' willingness to offer services, including conflicts between professional norms and religious beliefs. Findings can inform Ethiopia's efforts to reduce maternal mortality through task-shifting to midwives and can aid other countries that are confronting provider shortages and high levels of maternal mortality and morbidity, particularly due to unsafe abortion.

Background Midwives are a large proportion of Ethiopia’s health care workforce, and their attitudes and practices shape the quality of reproductive health care, including safe abortion care (SAC) services. This study examines how midwives’ conceptions of their professional roles and views on women who have abortions relate to their willingness to provide respectful SAC. Methods This study uses a cross-sectional, mixed methods design to conduct a regionally representative survey of midwives in Ethiopia’s five largest regions (Oromia; Amhara; Southern Nations, Nationalities, and Peoples [SNNP]; Tigray; and Addis Ababa) with a multistage, cluster sampling design (n = 944). The study reports survey-weighted population estimates and the results of multivariate logistic regression analyzing factors associated with midwives’ willingness to provide SAC. Survey data were triangulated with results from seven focus group discussions (FGDs) held with midwives in the five study regions. Deductive and inductive codes were used to thematically analyze these data. Results The study surveyed 960 respondents. An estimated half of midwives believed that providing SAC was a professional duty. Slightly more than half were willing to provide SAC. A belief in right of refusal was common: two-thirds of respondents said that midwives should be able to refuse SAC provision on moral or religious grounds. Modifiable factors positively associated with willingness to provide SAC were SAC training (AOR 4.02; 95% CI 2.60, 6.20), agreeing that SAC refusal risked women’s lives (AOR 1.69; 95% CI 1.20, 2.37), and viewing SAC provision as a professional duty (AOR 1.72; 95% CI 1.23, 2.39). In line with survey findings, a substantial number of FGD participants stated they had the right to refuse SAC. Responses to client scenarios revealed “directive counseling” to be common: many midwives indicated that they would actively attempt to persuade clients to act as they (the midwives) thought was best, rather than support clients in making their own decisions. Conclusion Findings suggest a need for new guidelines to clarify procedures surrounding conscientious objection and refusal to provide SAC, as well as initiatives to equip midwives to provide rights-based, patient-centered counseling and avoid directive counseling.