In Ethiopia, women under the age of 20 face a high risk of dying from preventable pregnancy-related causes. Back-street abortions have now emerged as the second highest killer of women.
Unsafe illegal abortion has emerged as the second leading killer of young women in Ethiopia after tuberculosis, according to a recent statement by the Ethiopian Society of Gynaecologists and Obstetricians.
Although no comprehensive national statistics have been compiled on annual death rates due to unsafe abortions, the picture is grim.
The maternal mortality rate is high: Over a lifetime, one in seven women faces the risk of dying from pregnancy-related causes. Many experts identify illegal abortion as the single most common cause.
Deputy Health Minister Dr Lamisso Hayesoo told a public symposium on abortion reform, held in Addis Ababa in March, that 52 per cent of obstetric admissions are due to unsafe abortions performed in "dubious circumstances".
More than half of those who die needlessly from illegal abortion are poor and unemployed young women under the age of 20, including many students and unmarried city-dwellers, adds the Ethiopian Women's Law Association (EWLA).
Both EWLA and the Ethiopian Society of Gynaecologists and Obstetricians are now calling for urgent changes to the country's penal code to give vulnerable groups access to safe, legal abortion. Currently abortion is only legal if it is performed by a doctor to save the life or health of the woman.
But few outside a handful of health professionals and women's rights advocates are prepared to listen to recommendations made at the public symposium. Although the media attended the event, coverage was sparse.
"Abortion is a very controversial issue," says Helen Seifu, an EWLA spokeswoman. "Most people are against it because they are influenced by their religion which strongly argues for its illegality." Ethiopia's main religions are Islam, Christianity, and Falasha (a form of Judaism).
Reform is contentious even within the health profession.
"I believe that legalising abortion before fulfilling some pre-conditions, like educating women, will not save women's lives," says Dr Tesfanesh Belay, a staunch opponent of abortion reform and the director of the government's Department of Family Health.
Doctors disagree, saying that fear of interrupting their education is one reason young women have abortions. "Mostly, it is youngsters who have abortion clandestinely. This is so because they don't want to quit their education, have no income to raise their babies, or are not married," says community health consultant Dr Adanech Kidanemariam.
Belay is also concerned about costs. "The country does not have the human or capital resources to provide health centres with the required personnel and material for performing safe abortion," she says.
Ethiopia is poor, wracked by cycles of drought and political instability, with a GNP per capita of $100 and a health infrastructure accessible to only half the population.
Only 14 per cent of women are literate, as opposed to 46 per cent of men, and life expectancy is low -41 and 42 years for men and women respectively, according to United Nations statistics.
Nonetheless, even poor countries can take action, according to the World Health Organization, which argues that of all the complications during pregnancy and childbirth which cause death disability, unsafe abortion is one of the easiest to prevent and treat.
One 17-year-old schoolgirl barely escaped with her life: "I had no money and there was nobody [in] whom I could confide my problems, so I went to a man who performs abortion for a very low price," she told Panos Features. "I was bleeding very much and there was a lot of pain. Had my family not taken me to a hospital, I would have died."
The Society of Gynaecologists and Obstetricians says that Ethiopia's high termination rate is mainly due to women's lack of access to contraception. A meagre percentage of women aged 15-49 years use modern contraceptive methods (estimates range from 3-10 per cent). This is a legacy of religious and social taboos which triggered widespread public resistance to the introduction of contraceptives in the 1970s, according to Assistant Professor Solomon Kumbi, of Addis Ababa University Medical School.
Belay agrees: "Although reproductive health education, especially the use of contraceptives, started 35 years ago, nobody, including health professionals, wanted to use them or advocate their advantages."
Ethiopia's population is now dominated by young people -its average age is 17 years. However, the country's few family planning clinics do not offer services to unmarried women under the age of 18, and there is no sex education. Instead, young people must learn about sex and sexuality from novels, films, and exchanges with friends who may be equally misinformed.
Misconceptions abound. Few understand bodily changes at puberty such as menstruation, or how to prevent an unwanted pregnancy. "Unmarried youngsters start to engage in a sexual relationship and this is not healthy since most of them don't know anything about it," says Belay.
EWLA, the first organisation to break this silence, supports a campaign of abortion reform. "Criminalising abortion means violating the human rights of a woman," Seifu asserts.
The Ethiopian Society of Obstetricians and Gynaecologists recommends revisions to the penal code so that safe abortion services are made available to vulnerable groups like young students. "The magnitude of abortion by young unmarried students and dependent women is increasing," Kumbi argues.
But there is strong opposition to EWLA and its allies. Some of the country's elite believe abortion reform is a misplaced attempt to copy Western values, and that Ethiopia has far greater considerations. One professional who asked for anonymity argues: "the country's first priority is education for all".