On the top floor of a crumbling four-storey building in downtown Addis Ababa, Birhani Haile holds the floor in front of a 30-strong audience. "I was a housemaid when I became pregnant," she says. "Unmarried and afraid to be found out, I took some pills to get rid of it. But they were pills for a cow." She woke up in the night, vomiting blood and bleeding heavily. "I went to a man who said he was familiar with this case. He gave me more pills but they were for malaria." She was lucky to survive.

In 2005, a year before Haile's desperate effort to abort her pregnancy, the Ethiopian government liberalised abortion laws. This effectively made treatment free and available to all women. But in a country where one third of pregnancies are thought to be unwanted, backstreet abortions continue to happen.

One of Addis Ababa's poorest neighbourhoods is Addis Ketema. The majority of its inhabitants work as house servants or weavers; it is a hand-to-mouth existence and many must beg to survive. Having a child outside marriage is taboo. Haile knows what would have become of her: "I would be outcast."

That is why she is here. Amid the heavy charcoal mist and fumes of roasting coffee beans, she and fellow members of the Addis Ababa Women's Association have called this coffee ceremony, to get down to the serious business of chat. Today they are talking not just about abortion, but reproductive health and family planning. In the climate of misinformation that is the backdrop to Haile's story, conversations like this can save a life.

Ethiopia is among the most dangerous places in the world to give birth: every year 25,000 women die from pregnancy-related problems. In a country that is predominantly rural, 94% of women deliver at home. "Lack of emergency obstetric services is a crucial factor," says Zewditu Kebede of Ethiopia's Consortium of Reproductive Health Associations. "Many women give birth too young and don't space their children, giving their bodies little time to recover between deliveries. On top of this, low levels of education in rural areas, hard work and poor diet contribute to poor maternal outcomes."

Government initiatives

But a progressive Ethiopian Ministry of Health is tackling this problem head-on, with a five-year plan to reduce maternal deaths drastically. At the forefront is a policy to make sure every child is wanted and every pregnancy planned.

The past five years have seen an innovative restructuring of the healthcare system. Special emphasis has been placed on the problems facing rural areas where 83% of the population live, distances are vast and infrastructure is non-existent. To challenge this, 30,000 trained and salaried Health Extension Workers (HEW) have been deployed all over the country.

"The extraordinary thing here is the high level of commitment that you see from the government in meeting Millennium Development Goals and the level of ambition," says Ali Forder, head of Department for International Development (DfID) Ethiopia. "When they said they wanted to train 30,000 health workers, people said it was impossible – but they have done it."

Wolita Mogosi is one of these health workers. Mogosi excelled at school in the remote south-westerly Oromiya region, and was recruited and trained for a year by her local health bureau. Now back in her village, she travels from house to house administering preventative healthcare. Today Mogosi has been enlisted by Marie Stopes International (MSI) to bring women from her area to a local health centre for long-term contraceptives. It is a four-hour walk and, with children to feed, farms to tend, and husbands to contend with, it is not one many women will do willingly or often.

In 2005 only 14.7% of women had access to contraception. In the past five years a government scheme to provide pills and three-month injectables freely has meant this number is likely to have doubled. Still, short-term methods like these are wholly unreliable when the nearest health centre is up to eight hours away. Implanon, an implant that protects women from pregnancy for three years, could revolutionise family planning for Ethiopian women and is part of a new government drive to increase access.

Fatuma Shekasim is walking with Mogosi today; she has nine children and has brought two of her married daughters with her. "They are using injectables," she says, "but heavy rain meant we couldn't come [to the centre]. Now my daughter may be pregnant again. We are poor and it is not a good time for a baby." She has brought her daughters to get Implanon. "This way I can ensure all my grandchildren will go to school."

Government schemes work for determined women such as Shekasim. But the vast majority are not in contact with such schemes. "People in Ethiopia rarely go to a health facility," says Grethe Petersen, country director of MSI Ethiopia. "When they do, we need to grab them. Every time a woman goes to a clinic for a cold or an injury, or treatment for malaria, it is an opportunity to talk about family planning."

Subsidised services

In the town of Minjar, 150km south-east of Addis Ababa, nurse Josef Asefa Mekonnen, has tapped into a new movement that could transform public perceptions of reproductive health. He runs a private health clinic accredited by MSI's pioneering BlueStar social franchise scheme. His contraceptive services are subsidised by the NGO, allowing him to supply comprehensive counselling for a nominal fee. Like most of Ethiopia, Minjar is not wealthy. "Last year there was a drought," Mekonnen recalls, "and people could not pay." But since joining the BlueStar network, his monthly income from contraceptive services has more than tripled. The network also runs roadshows, public performances and publicity campaigns, and even has its own catchy theme tune to draw in clientele.

But providing access is only half the battle. "Women at the grassroots level do not have adequate information on reproductive health. The services may be there but women do not know about them," says Mussie Yussein of the Addis Ababa Women's Association. "We need to raise this awareness." With 145,000 women and 4,000 associate male members working at every level in the city, the association is doing its best to achieve this.

Back at the meeting another woman speaks. She has a neighbour who took contraceptives. "She heard that if you take more pills your uterus will be spoiled. She stopped taking the pills and now she has twins." As the group gets more and more animated, Haile smiles. She thinks it is time to bring this discussion out into the community. "Look," she gestures to the room. "The women are ready."

Underage marriages

Outside a cluster of shacks in the rural village of Cholga a group of women chat and laugh as conversation turns to weddings. "I was 16 years old when I got married," says Seada Abdella, "but the first baby didn't come for three years". When asked why she says: "I wasn't bleeding yet."

While officially illegal in Ethiopia since 1995, early marriage is still common practice. In the northern and most populous Amhara region, 40% of marriages are to girls under 15. As in Abdella's case, a baby will follow as soon as is physically possible. For many women, having a child so young can lead to complications in giving birth. Even more damaging for some is the effect early motherhood has on their education and empowerment. Abdella, for instance, left school after grade three and can barely read or write.

Statistics show that the less formal education a woman has, the less likely she will be to use family planning and, in turn, to have the means to send each of her children to school. But Abdella refuses to let the cycle continue. Unlike most of her neighbours she has only two children – the average in her village is six – and is here at this health centre to get a three-year implant. "If life is good I will have more [children], if not I won't."

Rural staffing difficulties

The government health centre at Moye is a quiet outpost halfway up a hill in the village of Cholga outside the bustling market town. In the height of the rainy season it is marooned by a sea of muck from the main road. This is where Kimem Eshetu spends her working day. At 23, she has just finished five years' training as a nurse and midwife, and has been deployed here, 400km away from home. Wages are low at 760birr (£40) a month and Eshetu is isolated here in this farming community where most woman her age are already married. "I like the job," she whispers, "but I don't want to stay here".

A small bespectacled figure, Eshetu's quiet presence belies the invaluable role she plays at the centre. She pulls out a crumpled list of medical supplies: "Delivery gowns, masks, resuscitation bags, chlorine, soap, blankets… It has been five months since I requested these things from the regional bureau and still nothing."

Ethiopia has a surplus of nurses, but skilled midwives like Eshetu are scarce. If circumstances don't improve here, it is likely she will leave for the city, or go to a private facility or abroad, contributing to the brain drain in the country's health sector. Asked where she will go she confides: "I want to work in an NGO."

Coupons for life

Shuffling through the mucky damp alleys of the Semeneida slum in Addis Ababa's Merkato area, Marie Stopes International's Sister Gennet is searching for expectant mothers. She finds Tigist Kefala sitting in the one-room shelter she shares with her husband and 16-year-old sister.

Tigist, 28 and pregnant, is afraid, and she explains why through shy gasps. Four years ago she was expecting her first child. When she went into labour, she travelled to her local health centre but – for reasons still unclear to her – was referred to Addis's main obstetrics hospital. When staff couldn't see her there, she was sent home. Tigist and her husband Meskalu have trouble recalling whether it was after two or three days of labour that she returned to the hospital. There, she gave birth to a stillborn child. She was sent home again that day.

Even in the capital, where most women give birth in a health facility, resources for the very poor are shockingly deficient. Health services are nominally free but facilities are under-staffed and when supplies run out families are expected to supply their own medicines or pay for tests. For women like Tigist who survive on less than 200birr (£10) a month, this is not an option.

Lucky to have survived the trauma of stillbirth once, Tigist is at high risk of complication again. But a flagship initiative launched by MSI has given her a voucher for free ante-natal and delivery care in the NGO's private obstetrics clinic. "Hopefully," she says, rubbing her enormous bump, "it will be better this time."

Sex-workers, contraception and HIV

"Mimi?" the nurse asks disbelievingly, and leans to me. "This is what we call a little girl." "That is my name," Mimi replies, punctuating her speech with confident and defiant gasps. Mimi sells tella, a homemade beer, in the local market at Minjar but it does not bring in enough money. "I am a sex worker," she announces unabashedly to a room of giggling women lined up on the upholstered chairs of Josef Asefa Mekonnen's waiting area. She is here for a three-year implant that he has provided for free, in the hope she will encourage more women to come. Mimi gave birth to her second child two years ago after missing by one day an appointment to have her injectible contraceptive renewed. She is alone and living on less than 250birr (£12) a month, so getting pregnant again is not an option.

When we talk outside, Mimi's bright eyes darken. "I am sick," she admits. Mimi has been diagnosed with HIV and doesn't want to sleep with men anymore. "But if they come I will." And if they refuse to use a condom? "What choice do I have?" she says. "At least this way I can protect myself."

Stephanie Hegarty's assignment in Ethiopia was hosted by Marie Stopes International