Rominski & Lori care in Ghana Abortion care in Ghana REVIEW ARTICLE

Abortion Care in Ghana: A Critical Review of the Literature

Sarah D Rominski1* and Jody R Lori2

1Global REACH, University of Michigan Medical School; 2School of Nursing, University of Michigan.

* For Correspondence: E-mail: [email protected], Phone: 001-734-717-5930.

Abstract

The Government of Ghana has taken important steps to mitigate the impact of . However, the expected decline in maternal deaths is yet to be realized. This literature review aims to present findings from empirical research directly related to abortion provision in Ghana and identify gaps for future research. A total of four (4) databases were searched with the keywords “Ghana and abortion” and hand review of reference lists was conducted. All abstracts were reviewed. The final include sample was 39 articles. Abortion-related complications represent a large component of admissions to gynecological wards in hospitals in Ghana as well as a large contributor to maternal mortality. Almost half of the included studies were hospital-based, mainly chart reviews. This review has identified gaps in the literature including: interviewing women who have sought unsafe and with healthcare providers who may act as gatekeepers to women wishing to access safe abortion services. (Afr J Reprod Health 2014; 18[3]: 17-35)

Keywords: Abortion, Ghana, Review

Résumé

Le gouvernement du Ghana a pris des mesures importantes pour atténuer l'impact de l'avortement à risque. Cependant, la baisse attendue de la mortalité maternelle est encore à réaliser. Cette revue de la documentation a pour but de présenter les résultats de recherches empiriques directement liés à la prestation de l'avortement au Ghana et d'identifier les lacunes de la recherche future. Un total de quatre (4) bases de données ont été recherchées avec les mots clés "Ghana et l'avortement" et la révision à main des listes de référence a été menée. Tous les résumés ont été examinés. Le dernier échantillon comprenait 39 articles. Les complications liées à l'avortement représentent une composante importante des admissions en services de gynécologie dans les hôpitaux au Ghana ainsi que d'un grand contributeur à la mortalité maternelle. Presque la moitié des études incluses ont été en milieu hospitalier, principalement l'examen des dossiers. Ce compte rendu a identifié des lacunes dans la documentation, y compris: interviewer les femmes qui ont recherché des avortements à risque et avec les fournisseurs de soins de santé qui peuvent agir comme gardiens de femmes qui souhaitent avoir accès aux services d'avortement sans risque. (Afr J Reprod Health 2014; 18[3]: 17-35)

Mots-clés: avortement, Ghana, Revue

Introduction complications. The morbidity and mortality associated with unsafe abortion depend on the Maternal mortality is a large and un-abating method used, the skill of the provider, the problem, mainly occurring in the developing cleanliness of the instruments and environment, world. According to the World Health the stage of the woman’s pregnancy and the Organization (WHO), the United Nations woman’s overall health3. It is estimated that 5 Children’s Fund (UNICEF), UNFPA and the million women per year from the developing World Bank, 287,000 women die each year world- world are hospitalized for complications resulting wide from pregnancy-related causes1. Sub-Saharan from unsafe abortions, resulting in long and short- Africa has the highest maternal mortality ratio in term health problems4. The health consequences the world of 500 per 100,000 births. WHO and burdens resulting from unsafe abortion estimates 47,000 of these deaths per year are disproportionately affect women in Africa5. attributable to unsafe abortion, making abortion a Unsafe abortion is defined by WHO as a leading cause of maternal mortality2. Not all procedure for terminating an unintended unsafe abortions result in death, disability or pregnancy carried out either by persons lacking the African Journal of Reproductive Health September 2014; 18(3):17

Rominski & Lori Abortion care in Ghana Abortion care in Ghana necessary skills or in an environment that does not Compared to other countries in the region, the conform to minimum medical standards, or both6. laws governing abortion in Ghana are relatively Approximately 21.2 million unsafe abortions liberal. Safe abortion, performed by a qualified occur each year in developing regions of the healthcare provider, has been part of the world1,7. Over 99% of all abortion-related deaths Reproductive Health Strategy since 200319,21. occur in developing countries. In sub-Saharan When performed by well-trained providers in a Africa, one in 150 women will die from clean environment, abortion is one of the safest complications of this procedure6. medical procedures with complications estimated Although only 24% of abortions worldwide are at 1 in 100,0008. performed in sub-Saharan Africa, almost half of Currently in Ghana, abortion is a criminal deaths related to this procedure occur in the offense regulated by Act 29, section 58 of the region4,8. In many countries in sub-Saharan Africa Criminal code of 1960, amended by PNDCL 102 women’s access to safe abortion and post-abortion of 198522. However, section 2 of this law states care for complications is hampered by restrictive abortion may be performed by a registered medical laws, socio-cultural barriers, and inadequate practitioner when; the pregnancy is the result of resources to provide safe abortion4,9-12. or , to protect the mental or physical The UN Millennium Development Goal health of the mother, or when there is a (MDG) number 5 aims to reduce by three quarters malformation of the fetus. The government of the number of maternal deaths in the developing Ghana has taken steps to mitigate the negative world. Without tackling the problems of unsafe effects of unsafe abortion by developing a abortion MDG 5 will not be reached13,14. comprehensive reproductive health strategy that specifically addresses maternal morbidity and Ghana mortality associated with unsafe abortion23. Further, since midwives have been shown to Ghana, a country in West Africa, has a population safely and effectively provide post-abortion care in of approximately 24 million people. The average 24 19 South Africa and Ghana a 1996 policy reform per capita income is approximately $181015, has allowed midlevel providers with midwifery placing Ghana in the middle income bracket. 25 skills to perform this service in Ghana . To ensure Ghana has a similar pattern of health as other these providers have the skills necessary to countries in the region, characterized by a perform the service, in 2009, Manual Vacuum persistent burden of infectious disease among poor Aspiration (MVA) was added to the national and rural populations, and growing non- curriculum for midwifery education to train communicable illness among the urban middle additional providers in this life-saving technique. class. Following generalized progress in child However, even with the liberalization of the vaccination rates through the 1980s and 1990s, law and the training of additional providers, and corresponding declines in infant and child abortion-related complications remain a problem. mortality (from 120/1000 in 1965 to 66/1000 in This integrated literature review aims to present 1990), progress has stalled maternal and under 5 findings from empirical research directly related to indicators in rural areas in the past decade. The abortion provision, complete abortion care, or national under-five mortality rate remains at 78 post-abortion care in Ghana and identify gaps for deaths/1,000 live births16. Maternal death is future research. currently estimated at 350 per 100,000 live 17 births . In Ghana, abortion complications are a Search Strategy large contributor to maternal morbidity and mortality. According to the Ghana Medical The Pubmed, Ovid Medline, Global Health and Association, abortion is the leading cause of Popline databases were searched with the maternal mortality, accounting for 15-30% of keywords “Ghana & abortion”. Pubmed returned maternal deaths18,19. Further, for every woman who 80 articles, Ovid Medline returned 70, Global dies from an unsafe abortion, it is estimated that Health returned 40 articles and Popline returned 78 15 suffer short and long-term morbidities20. articles, many of which overlapped. All titles and African Journal of Reproductive Health September 2014; 18(3):18

Rominski & Lori Abortion care in Ghana Abortion care in Ghana abstracts were reviewed. Inclusion criteria were: commentaries, and literature reviews were not 1) English-language research articles; 2) published included in the final sample. A total of 39 articles in a peer-reviewed journal after 1995; and 3) met inclusion criteria and are included in this directly measured abortion services or provision. review (Figure 1). Manuscripts that only briefly mentioned abortion,

Figure 1. Search result

of spontaneous abortion, although induced Results 4,12,26,30 abortion is notoriously under-reported , and Complications and Admissions to Gynecology many women who reported spontaneous abortions Ward: Abortion-related complications are had history that indicated induced abortion31. repeatedly found to represent a large component of Sundaram and colleagues32 estimated that only admissions to gynecological wards in hospitals in 40% of abortions were reported in the 2007 Ghana Ghana. Abortion complications resulted in 38.8%, Maternal Health Survey, even when participants 40.7%, 42.7% and 51%26-29 of all admissions to were explicitly asked about their experiences with these wards in the articles reviewed for this paper. inducted abortions. Full results are provided in The majority of admissions were for the treatment Table 1. African Journal of Reproductive Health September 2014; 18(3):19

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Authors and Title, Journal Findings Study Design Study Setting Strengths and limitations Database Year retrieved from 1. Morhe ESK, Reproductive Teenagers have their sexual debuts at Cross-sectional survey Ejisu-Juabeng district There were no questions asked Global Tagbor HK, experiences of young ages. 36.7% of the females community-based of Ghana. as to the processes undertaken Health, Ankobea F, teenagers in the Ejisu- have had at least one abortion. survey. to obtain abortions. Popline Danso KA. Juabeng district of 2012 Ghana. International Journal of Gynecology and Obstetrics 2. Lee QY, Maternal mortality in Genital tract sepsis, often as a result of Secondary data analysis Komfo Anokye Comments are made that are Reference Odoi AT, Ghana: a hospital- an abortion, had the highest case- of patient charts Teaching Hospital not supported by data or List Opare-Addo H, based review. Acta fatality rate of all the causes of references, such as, “Social Dassah ET. Obstetricia et maternal death in this study. stigma plays a role in 2012 Gynecologica preventing vulnerable women Scandinavica from accessing safe abortion services.” Reasons behind not accessing safe abortion services need to be investigated. 3. Ganyaglo A 6-year (2004-2009) Abortion complications were the Secondary analysis of Koforidua Regional This is the first hospital-based Global GYK, Hill WC. review of maternal second leading cause of maternal Obstetrics and Hospital, Eastern study outside a major teaching Health 2012 mortality at the East mortality, behind post-partum Gynecology ward Region hospital. Regional Hospital, hemorrhage. The largest proportions admission and discharge Koforidua, Ghana. of post-abortion deaths were due to books, triangulated Seminars in sepsis (29 of the 37 post-abortion against minutes from Perinatology deaths). maternal death audit meetings and midwifery returns. Patient folders were available for 2009 only. 4. Sundaram A, Factors associated Almost half of all reported abortions Nationally representative Maternal Health Survey This study uses nationally- Ovid Juarez F, with abortion-seeking were conducted unsafely. The profile survey representative data to Medline, Bankole A, and obtaining an of women who seek an abortion is: investigate safe and unsafe Global Singh S. 2012 unsafe abortion in unmarried, in their 20s, have no abortion seeking. However, Health Ghana. Studies in children, have terminated a pregnancy abortion is under-reported, and PubMed

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Family Planning before, are Protestant or there were no questions about Pentecostal/Charismatic, of higher unwanted pregnancy, or SES, and know the legal status of reasons for seeking safe versus abortion. Younger women were less unsafe abortions. likely to seek a safe abortion, as were women of low SES and those in rural areas. A partner paying for the procedure was associated with seeking a safe abortion. 5. Krakowiak- Family planning in a 20% of the sample had had at least Cross-sectional Barekese sub-district in A relatively small sample size Global Redd D, sub-district near one abortion community-based survey the Ashanti Region (n=85) of only women. There Health Ansong D, Kumasi, Ghana: Side was a qualitative component, Otupiri E, Tran effect fears, but not about abortion-related S, Klanderud unintended issues. D, Boakye I, pregnancies and Dickerson T, misuse of medication Crookston B as emergency 2011 contraception. African Journal of Reproductive Health 6. Aniteye P, Attitudes and Great majority of women were young Structured survey with Gynecology ward, The authors note a need for Ovid Mayhew S. experiences of women and single. The majority of women 131 women with Korle Bu and Ridge qualitative work especially Medline, 2011 admitted to hospital had help performing their abortion and incomplete abortions. Hospitals. around the reasons why Global with abortion most accessed post-abortion care at a women are not using family Health, complications in health facility shortly after planning as well as to discover PubMed, Ghana. African experiencing complications. who the unsafe providers are. Popline Journal of Reproductive Health 7. Gumanga Trends in maternal The institutional maternal mortality Hospital records from Tamale Teaching Documented the causes of Global SK, Kolbila mortality in Tamale rate was 1018 per 100,000 live births January 1 2006- Hospital maternal death in the Northern Health DZ, Gandau Teaching Hospital, was recorded between 2006 and 2010. December 2010. Region of Ghana. BBN, Munkaila Ghana. Ghana Complications from unsafe abortion A, Malechi H, Medical Journal was the leading cause of maternal Kyei-Aboagye death for youngest women, and the 4th K leading cause overall. 2011

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8. Biney AAE Exploring Many respondents noted that prior to 24 semi-structured Gynecology wards, This study was mainly about Ovid 2011 contraception their induced abortion, they had no individual interviews Tema General Hospital contraception, and so access to Medline, knowledge and use knowledge about contraception, but were conducted with and Korle Bu Teaching abortion services were not Global among women since the abortion they had been using women who were being Hospital investigated. Health, experiencing induced it. Women also mentioned feeling treated and reported PubMed, abortion in the Greater contraception was more dangerous to having experience with Popline Accra region, Ghana. their health than was induced abortion. induced abortion. African Journal of Reproductive Health 9. Ohene SA, Cause of death among 20/27 maternal deaths to adolescents Autopsy data Korle Bu Teaching Demonstrated the burden of PubMed Tettey Y, Ghanaian adolescents were a consequence of abortion. Hospital disease attributable to Kumoji R. in Accra using autopsy adolescent death 2011 data. BMC Research Notes 10. Mac The social context of Student’s knowledge of abortive Focus group discussions Ho, Ghana The focus-group methodology Global Domhnaill B, school girl pregnancy methods was considerably more in both rural and peri- enables students to talk among Health Hutchinson G, in Ghana. Vulnerable detailed than their knowledge of urban settings. themselves about sexual Milev A, Milev Children and Youth contraception. Many explicitly relationships. Y. Studies mentioned not using contraception 2011 because they knew how to abort a pregnancy if necessary. Participants note local and herbal methods of abortions, although they admitted they were dangerous. Abortion is seen by these participants as an unfortunate fact of being sexually active. 11. Schwandt A comparison of N= 585. Majority reported Surveys administered by Gynecology emergency This is one of the only studies Ovid HM, Creanga spontaneous abortion between June nursing and midwifery wards, Korle Bu and to look at male-female Medline, women with induced AA, Danso KA, and July 2008. Those with reported students with women KATH. relationships and how these Global abortion, spontaneous Adanu RMK, induced abortion were more likely to being treated for impact reproductive health Health, abortion and ectopic Agbenyega T, pregnancy in Ghana. have more power in their relationships abortion complications. decision making. PubMed Hindin MJ and to have not disclosed the index 2011 Contraception pregnancy to their partners. 12. Mote CV, Factors associated One-fifth (21.3%) of respondents 408 community-based Hohoe, Volta Region Using community-based Global Otupiri E, with induced abortion reported having had an induced surveys surveys gets a broader Health, Hindin MJ. among women in abortion. Most common reasons for population than hospital-based. PubMed

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2010 Hohoe, Ghana. having an abortion: “not to disrupt African Journal of education or employment” and “too Reproductive Health. young to have bear a child.” 65.5% performed by a medical doctor, 31% by partners or friends. 60.9% in a hospital, 29.9% at home. 50.6% used sharps or hospital instruments, 31% used herbs. 13. Voetagbe Midwifery tutors’ Only 18.9% of the tutors surveyed 74 midwifery tutors Midwifery training 74 of 123 selected tutors PubMed G, Yellu N, capacity and knew all the legal indications under from all 14 public colleges country-wide returned the survey, giving a Mills J, willingness to teach which safe abortion could be midwifery schools were response rate of 60.2%. Mitchell E, contraception, post- provided. These tutors were not taught surveyed. Importantly documented the Adu- abortion care, and manual during their lack of complete knowledge of Amankway A, legal pregnancy training. the law, even among Jehu-Appiah K, termination in Ghana. midwifery tutors. Nyante F. Human Resources for 2010 Health 14. Laar AK Family planning, This analysis showed that family Content analysis of the Newspaper This analysis shows that local Global 2010. abortion and HIV in planning, abortion and HIV received Daily Graphic speculations that the quantity Health, Ghanaian print media: less than 1% of total newspaper newspaper. and prominence of PubMed A 15-month content coverage in one national Ghanaian reproductive health issues are analysis of a national newspaper. neglected in local newspapers Ghanaian newspaper. are warranted. African Journal of Reproductive Health 15. Clark KA, Return on investment The availability of PAC in Ghana Secondary data analysis Nationally- Information about supplies Ovid Mitchell EHM, for essential obstetric remains limited. Far fewer midwives of 2002 Ghana Service representative sample available at the clinics, as well Medline, Aboagye PK care training in Ghana: than physicians offer PAC, even after Provision Assessment of health facilities and as whether the providers were PubMed, 2010 Do trained public having received PAC clinical training, survey. 428 health health providers offering CAC services, were Popline sector midwives although an analysis of the curriculum facilities working in not available in the dataset. deliver postabortion and training was outside the scope of 1448 health facilities care? Journal of this study. were surveyed. Midwifery and Women’s Health 16. Graff M, Barriers to sustainable Sustainable access to MVA equipment Interviews with 24 Data gathered in seven Interviews with a wide range Ovid Amoyaw DA MVA supply in has been challenging particularly for midwives and 16 of the ten regions of the of stakeholders is a major Medline,

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2009 Ghana: Challenges for low-volume, low-income providers. physicians country. strength. Global the low-volume, low- Although many of the midwives in Health, income providers. rural areas had the skills to provide PubMed African Journal of MVA, they did not have the Reproductive Health. equipment and thus continued to refer women to district or regional hospitals. 17. Hill ZE, The context of Key themes were related to the Qualitative interviews in Ovid Tawiah- informal abortions in perception of abortions as illegal, Kintampo, Brong-Ahafo. Medline, Agyemang C, rural Ghana. Journal dangerous, and bringing public shame Global Kirkwood B. of Women’s Health. and stigma but also being perceived as Health, 2009 common, understandable, and MedLine necessary. None of the respondents knew the legal status of abortion, with most reporting that it was illegal. 18. Konney Attitudes of women Abortion-related complications Interviews of women Gynecology ward at The first study to investigate Ovid TO, Danso KA, with abortion-related accounted for 42.7% of admissions to being treated for KATH the attitudes of women being Medline, Odoi AT, complications toward the gynecological ward at KATH, abortion complications treated for abortion Global Opare-Addo provision of safe 28% of whom indicated an induced at KATH between May complications towards the Health, HS, Morhe abortion services in abortion. 92% of the women 1 and June 30, 2007. provision of safe abortion PubMed, ESK. Ghana. Journal of interviewed were not aware of the law services in Ghana. Popline 2009 Women’s Health regarding abortion in Ghana. Most felt that there was a need to establish safe abortion services in Ghana. 19. Oliveras E, Clinic-based 1,636 women completed the Using previous birth Three public and two Although this technique does Ovid Ahiadeke C, surveillance of adverse questions. Younger, better educated technique, during private clinics in Accra not measure prevalence or Medline, Adanu RM, pregnancy outcomes and unmarried women are more likely prenatal care, nurses that provide antenatal lifetime exposure to abortion, Global Hill AG to identify induced to have had an induced abortion. asked 5 questions to and maternity services. it is another way to investigate Health, 2008 abortion in Accra, Between 10-17.6% of women report illicit how their previous abortion. Further work to PubMed, Ghana. Studies in having had an abortion. Women pregnancy ended. elucidate differential responses Popline Family Planning. seeking care at a private facility were based on healthcare provider more than twice as likely to have asking is important. ended their previous pregnancy by induced abortion. 20. Mills S, Maternal Mortality Abortion-related deaths were the most Family members of all Northern Region Relying on verbal autopsy Ovid Williams JE, Decline in the frequent cause of maternal deaths in maternal deaths between requires survivors to know of Medline,

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Wak G, Kassena-Nankana this sample in the Northern Region. January 2002 and pregnancy status. There may PubMed, Hodgson A District of Northern December 2004 were have been more abortion- Popline 2008 Ghana. Maternal and interviewed related deaths than reported if Child Health Journal those interviewed did not know the woman was pregnant. 21. Morhe Attitudes of doctors Most physicians were supportive of Cross sectional survey of Komfo Anokye The attitudes of health care Ovid ESK, Morhe toward establishing playing some role in developing safe 74 physicians at KATH Teaching Hospital, providers is an important area Medline, RAS, Danso safe abortion units in abortion units in hospitals in Ghana. Kumasi. to investigate due to the Global KA Ghana. International However, only 54% of maternal and barriers these people can Health, 2007 Journal of Obstetrics child health-related health workers represent. PubMed and Gynecology were aware of the true nature of the , with 35% believing that the law permits abortion only to save the life of the woman. More than 50% of the workers reported they would be unwilling to play a role in performing pregnancy terminations. 22. Adanu Profile of women with 31% of the study population presented Cross-sectional survey Korle Bu Teaching The determination of induced Reference RMK, Ntumy abortion complications for complications from induced of 150 patients being Hospital versus spontaneous abortion list MN, in Ghana. Tropical abortion. Those seeking care for treated for abortion was reliant on self-report, Tweneboah E. Doctor induced abortion were younger, or complications. which the authors note may be 2005 lower parity, more education, less under-reported. likely to be engaged in income- generating activity, in less stable relationships and had more knowledge of modern contraception than those presenting for treatment from spontaneous abortion. 23. Baiden F, Unmet need for Complications from abortion were the Secondary data analysis Kassena-Nankana Established abortion-related Ovid Amponsa- essential obstetric leading cause of maternal mortality. from chart review of all district in the Northern deaths are the leading cause of Medline, Achiano K, services in a rural Although abortion is considered taboo maternal deaths from Region maternal deaths. Further Global Oduro AR, district northern in NKD, according to clinic evidence, January 2001 to research including all members Health, Mehsah TA, Ghana: Complications there is a high incidence of backstreet December 2003 at the of a woman’s community PubMed, Baiden R, of unsafe abortions and unsafe practices. The district district hospital in needs to be conducted to fully Popline Hodgson A. remain a major cause hospital did not have any access to Kassena-Nankana understand the social and

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2006 of mortality. Public formal safe abortion services. cultural factors associated with Health seeking maternal healthcare. 24. Adanu Reasons, fears and Women having induced abortion were Interviews with 150 Gynecology ward, Only qualitative paper Reference RMK & emotions behind younger, better educated, less likely to women experiencing Korle Bu investigating the reasons list Tweneboah E induced abortions in be married. 31.3% were reported to be abortion complications. behind and actions taken to 2004 Accra, Ghana. induced abortion. Many who reported terminate pregnancies. Research Review spontaneous abortion had stories that seemed to show induced. Most induced abortions were obtained outside the formal health system. 25. Yeboah Abortion: The case of The majority of admissions are due to Chart review of all Gynecology emergency No follow-up or interviewing Popline RWN & MC Chenard Ward, Korle incomplete abortions, although there abortion-related ward, Korle Bu of patients to determine Kom. Bu from 2000 to 2001. were not classified by spontaneous or admissions between Teaching Hospital, reasons for abortion. 2003 Research Review induced. Reported cases of induced January 1, 2000 and Accra, Ghana. abortions are high. December 31, 2001; nurse interviews 26. Glover EK, Sexual health 35% of the female respondents Community-based Tamale, Takoradi and Using a community-based Global Bannerman A, experiences of reported ever being pregnant, and 70% surveys of never-married Sunyani technique sampled previously Health, Pence BW, adolescents in three of those reported having had or youth about general under-represented groups. PubMed, Jones H, Miller Ghanaian towns. attempted an abortion. sexual experiences. Popline R, Weiss E, International Family Nerquaye- Planning Perspectives. Tetteh J. 2003 27. Srofenyoh Abortion care in a 30% of induced abortions had Chart review of all Gynecology ward, Important documentation of Ovid EK, Lassey AT teaching hospital in complications while 10% of patients admitted to Korle Bu the burden of abortion Medline 2003 Ghana. International spontaneous abortions had Korle Bu for abortion complications at Korle Bu. Journal of complications. 15% of maternal deaths complications between Gyneaecology and over the study period were due to January 1 and December Obstetrics complications from abortion. Abortion 31, 2001. complications were the leading cause of admission to the maternity ward (40.7% of all admissions). 28. Geelhoed Trends in maternal Institutional maternal mortality rate of Records from all Berekum District Global DW, Visser LE, mortality: a 13-year 1077 per 100,000 live births. Abortion maternal deaths between hospital, Brong Ahafo Health, Asare K, hospital-based study in complications were the leading cause 1987 and 2000 were Region Popline

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Schagen van rural Ghana. European (43 of the 229 deaths) reviewed Leeuwen JH, Journal of Obstetrics van Roosmalen and Gynecology. J. 2003 29. Srofenyoh Abortion care in a 40% of admissions over the study Retrospective chart Korle Bu Teaching Documents the high level of Ovid EK, Lassey AT teaching hospital in period were related to abortion review of all patients Hospital burden represented by abortion Medline, 2003 Ghana. International complications. Almost 77% were treated for abortion complications at Korle Bu. Global Journal of Gynecology spontaneous abortions. 30% with complications in 2000. Health and Obstetrics induced abortion had serious complications while 10% of spontaneous abortion had similar complications. 30. Turpin CA, Abortion at Komfo Abortion complications accounted for 1,301 of 1,313 cases of Obstetrics and Established the large Danso KA, Anokye Teaching 38.8% of admissions to the KATH abortion admissions to Gynecology ward, proportion of cases of post- Odoi AT Hospital. Ghana Ob/Gyn ward in 1994. Induced KATH were analyzed Komfo Anokye abortion complications treated 2002 Medical Journal abortions were more common in retrospectively. Teaching Hospital at KATH. Purely descriptive younger, unmarried women. The and reliant on information majority of induced abortions included in patient charts. occurred in the 15-19 year old group. 31. Blanc A, Greater than expected The total fertility rate in Ghana has Demographic and Health Representative sample. As there are no reliable Popline Grey S. 2002 fertility decline in declined at a higher rate than would be Surveys from 1988, measures of abortion Ghana: Untangling a expected by the contraception 1993 and 1998. prevalence, the authors cannot puzzle. Journal of prevalence rate. The authors find rule out abortion being the Biosocial Science evidence of widespread abortion to reason behind the observed control fertility, although accurate gap. Further, the authors note rates are hard to determine. The that abortion was, at the time authors also note that the gap between or writing, illegal except to expected fertility given contraception save the life of the mother or in utilization and actual fertility is greater the case of rape or incest. in urban areas than rural areas lends support to couples using abortion to limit or space births.

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32. Geelhoed Gender and unwanted Induced abortions were reported by 2137 community -based Berekum, Brong Ahafo Interviewing both men and Ovid DW, Nayembil pregnancy: a 22.6% of the surveyed population. surveys Region. women gives a broader Medline D, Asare K, community-based 28.2% of women reported having had perspective. Questions Schagen van study in rural Ghana. an induced abortion. More women investigating the process to Leeuwen JH, Journal of than med reported an unwanted obtain an abortion were not van Roosmale Psychosocial pregnancy ending in abortion, perhaps asked. J. Obstetrics and signaling female independence in 2002 Gynecology deciding on abortion care. 33. Ahiadeke C The incidence of self The rates identified here suggest that Data come from the These data come from before Global 2002 induced abortion in over a lifetime, 900 abortions per cross-sectional abortion policies were Health Ghana: What are the 1,000 women will be performed. The community-based liberalized. facts? Research majority of women reported receiving Maternal Health Survey Review. their abortion from outside the formal in four regions healthcare system (30% from a pharmacist, 11% from self- medication, 16% from a “quack doctor” and 3% from other means). 34. Geelhoed Contraception and About 40% of participants had Community-based Berekum District, Using anonymous, privately Ovid D, Nayembil D, induced abortion in experienced an unwanted pregnancy surveys with 2137 Brong Ahafo Region administered surveys yielded a Medline, Asare K, rural Ghana. Tropical in their lives. Socioeconomic reasons participants high response rate. Global Schagen JH, Medicine and were the most common for why a Interviewing both men and Health, van Roosmalen International Health. pregnancy was unwanted women is a strength. Popline J. 2002 35. Ahiadeke Incidence of induced 317/1,689 women aborted pregnancies As part of Maternal 4 of the country’s 10 Community-based survey Global 2001 abortion in southern (19/100, 27/100 live births, 17/1,000 Health Survey Project; regions: Central, offers a different perspective Health Ghana. International women of reproductive age). Majority 1,689 pregnant women Eastern, Volta and than hospital-based, although Family Planning of women were under 30, married, were interviewed Greater Accra. further questions regarding the Perspectives Christian. Abortions happened outside process are still necessary. the formal health sector. 36. Agyei Sexual behaviour and A majority of the young adults Fertility survey data with Greater Accra and Investigated the knowledge Ovid WKA, contraception among surveyed were sexually experienced, 953 males and 829 Eastern regions and practices of adolescents Medline Biritwum RB, unmarried adolescents although few were using females. regarding their sexual health. Ashitey AG, and young adults in contraception. Approximately 47% of Large community-based Hill RB Greater Accra and those adolescents who had been sample allows for 2000 Eastern Regions of sexually active reporting having had generalization of findings. Due

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Ghana. Journal of an abortion. While most participants to quantitative nature, hard to Biosocial Science were aware of modern methods of establish the processes contraception, few used them. undertaken by pregnant girls to end their pregnancies or how many were safe versus unsafe. 37. Baird TL, Community education Post-abortion care training for Post-abortion care Eastern Region. No comprehensive evaluation Ovid Billings DL, efforts enhance midwives was effective. Community- training for midwives to of effectiveness was Medline, Demuyakor B. postabortion care outreach was effective at educating the increase their skills, conducted. Public 2000 program in Ghana. public about the new services being coupled with community Health American Journal of offered by midwives. outreach to educate Public Health women about where to access safe abortion services. 38. Obed SA & Uterine perforation 21.1% of the 10,518 cases of abortion Prospective study of all Korle Bu Teaching Reference Wilson JB from induced abortion complication treatments for abortion patients being treated at Hospital list 1999 at Korle Bu Teaching were considered to be induced. 79 Korle Bu for perforated Hospital, Accra, (3.6%) of those had uterine uterus following an Ghana: A five year perforation. 40.9% (n=29) induced abortion (n=79) between review. West African their abortion because they were not 1990-1994. Patient Journal of Medicine ready to have a baby, 36.6% (26) cited interviews and chart the index pregnancy being too close to review. previous deliver. 81% (64) reported wishing to have future children, although almost 1/3 of the patients had a hysterectomy to treat the complications. 39. Lassey AT Complications of 58% of induced abortions were Chart review of 200 Gynecology ward, Data limited by being a chart Ovid 1995 induced abortion and performed outside the health system patients admitted to the Korle Bu Teaching review, although this early Medline their prevention in and about 30% were complications gynecology ward at Hospital study highlighted the problem Ghana. East African from self-induced abortions using Korle Bu for abortion of unsafe abortion in the Medical Journal sticks, needles and herbal (often complications. Greater Accra area. corrosive) inserted into the vagina. Only 9/212 were referrals, the rest were self-referred.

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Rominski & Lori Abortion care in Ghana Abortion care in Ghana Demographic Factors Associated with Abortion colleagues10. Ohene et al45 discovered that the Care majority of adolescent maternal deaths at Korle Bu Teaching Hospital in Accra were due to Many studies investigated demographic factors complications from unsafe abortion. Abortion associated with abortion-care seeking with complications were the leading cause of death conflicting results. Several manuscripts found among the youngest women in a sample of women of higher socioeconomic status, with more maternal deaths at Tamale Teaching Hospital, and education, who are married, older, and living in the fourth leading cause overall45. Abortion urban areas to be more likely to obtain induced complications were the second leading cause of abortions. However, others reported younger, death due to maternal causes, behind post-partum unmarried women were more likely to obtain hemorrhage, between 2004-2009, a period which induced abortions, when compared to women spans the introduction of the policy changes seeking care for spontaneous abortion28,31,33-36. around abortion care, in the Eastern region47. Lee et al48 discovered that genital tract sepsis, often as Prevalence of Obtaining an Induced Abortion a result of an abortion, had the highest case-fatality rate of all the causes of maternal death in their The prevalence of obtaining an induced abortion study. In the Brong Ahafo region, Geelhoed et al41 varied greatly in the studies reported here. The found that abortion complications were the leading highest rate reported was by Agyei and cause of maternal death at the Berekum District colleagues37 who found 47% of the female Hospital. respondents in their study reporting at least one pregnancy underwent an abortion sometime in her Abortion Law life. Morhe et al38 found 36.7 of the adolescents in their sample outside of Kumasi had experienced an Although the law governing abortion in Ghana is abortion. Ahiadeke36,39 reports an abortion rate of relatively liberal, and the 2006 policy change has 27 per 100 live births using data from the Maternal made abortion services part of the national Survey Project. Krakowiak-Reed et al40 found reproductive health strategy, no literature was 20% of their community-based sample outside found evaluating the impact of that policy change. Kumasi had had at least one abortion. Oliveras et The fact that admissions to the gynecological al.34 found between 10% and 17.6% of women in wards due to complications from abortion does not their study reported their previous pregnancy appear to have dramatically declined since the ended in induced abortion. Geelhoed and implementation of the 2006 policy suggests that 41 women are not accessing safe abortion services, if colleagues found a prevalence of induced 26,49 abortion of 22.6%, which falls in the range they exist . Different cadres of health providers reported elsewhere42. Glover et al43 found that were found to be unsure of the law governing abortion services50,51 and women who were 70% of ever-pregnant youth in their sample 26,52 32 interviewed were also unsure of the law . In the reported attempting an abortion. Sundaram et al 52 state approximately 10% of the sample for the Brong Ahafo region, Hill and colleagues found 2007 Maternal Health Survey reported having had that abortion was deemed illegal, dangerous and an abortion in the five years prior to the survey. bringing public shame, but also being perceived as common, understandable, and necessary. Although However, the authors note that this rate is likely 25 highly under-reported. Clark et al found that post-abortion care (PAC) services remain limited, despite wide-spread 53 Abortion and Maternal Mortality training in the service, while Baird et al report that PAC training for midwives is an effective way Many studies sought to estimate the proportion of to increase access to the service. Including post- maternal mortality associated with unsafe abortion care as part of comprehensive family abortion. Mills and colleagues44 found abortion- planning training for midwives has the potential to related causes to be the leading cause of maternal empower these providers and the women they death in rural northern Ghana, as did Baiden and serve to make choices about contraception54. Graff African Journal of Reproductive Health September 2014; 18(3):30

Rominski & Lori Abortion care in Ghana Abortion care in Ghana & Amoyaw11 identified sustainable access to However, information regarding the process by MVA equipment as a major barrier to MVA which a woman seeks an induced abortion is still services. Laar55 found in an analysis of Ghanaian lacking. Gathering information from women print media that less than 1% of total newspaper regarding their experiences securing safe and legal coverage was dedicated to family planning, abortions and reasons for resorting to unsafe abortion, and HIV, underscoring the dearth of methods will enable policy makers to pinpoint information available to many in the Ghanaian interventions to prevent life-threatening public. complications. Specifically, why do women resort to dangerous methods of aborting unwanted Abortion and Contraception pregnancies?

One of the main findings in many of the papers Discussion reviewed is the lack of modern contraception being used by the majority of Ghanaian women. Complications from unsafe abortion have been and Many of the papers found a high unmet need for remain a large component of maternal mortality contraception defined as currently engaging in and morbidity in Ghana. Although responding to sexual activity without using contraception but international calls to liberalize the law governing without intending to get pregnant9,32,33,56. There is abortion and training more providers in the an urgent need to improve access to reliable service, Ghana has not yet realized a large contraception for Ghanaian women. Many reduction in complications from unsafe abortions. Ghanaian women report being wary of using Knowledge of the law appears to remain limited, contraception for fear of side effects that may among both healthcare providers and the general impair future fertility9. Biney56 noted that women population. Work to improve this is warranted. in her study viewed contraception as more harmful There appears to be a robust literature around to their health than abortion. Obed & Wilson57 abortion in Ghana. However, this review did reported 81% of their sample of women being identify gaps in the literature and future directions treated for abortion complications desired further for research. The heavy reliance on hospital-based children, although almost one-third had to have a retrospective chart reviews, while an important hysterectomy to treat the complications from their step to establish the general burden of disease abortion and were thus unable to have further attributable to abortion-related complications, children. Mac Domhnaill and colleagues58 found needs to be expanded. The studies completed were schoolgirls in their sample were much more aware generally of a high scientific standard, although of abortion methods than of contraception and the data were often limited by what was many explicitly mentioned not using contraception documented in charts or log books. The few because they knew how to abort if necessary. purposefully-designed surveys elucidated Adanu and colleagues33 reported women seeking interesting observations that need to be augmented care for induced abortion were more aware of by qualitative work to answer some of the deeper modern contraception than their counterparts questions of the process by which women seeking care for spontaneous abortion, although undertake unsafe abortions. It has been this did not translate into higher usage rates. documented that many women are seeking care outside59 the formal healthcare system in unsafe Identified Gaps for Further Research locations from unsafe providers33, however reasons why have not been investigated. Is it a The biggest gaps identified through this review are lack of awareness of the legality of this procedure? the experiences of women with securing an Are there not enough providers in communities induced abortion to end an unwanted pregnancy. close to where the women live? Is cost Hospital-based chart reviews are important to prohibitive? Both women seeking care for post- understand the types of cases being treated. abortion care and providers of abortion have been Surveys examining the reasons for securing an shown to be unclear of the law governing abortion induced abortion shed some light on this issue. in Ghana. Konney et al26 found 92% of women African Journal of Reproductive Health September 2014; 18(3):31

Rominski & Lori Abortion care in Ghana Abortion care in Ghana being treated for abortion complications at Komfo Kumasi. Women in rural areas without the means Anokye Teaching Hospital were unaware of the to travel to and be treated at these tertiary care law and Voetagbe et al51 noted an alarmingly high centers will therefore not be included in the proportion of midwifery tutors were not aware of sample. It is unclear from these studies whether the full law governing the provision of safe the differences reported are due to differences in abortion services. If teachers are not sure of the sampling techniques and survey populations or to law, the midwives who they train will also likely true differences in the need for abortion services. be uncertain of the conditions under which they In the 2007 Maternal Health Survey, as reported are legally allowed to provide complete abortion by Sundaram and colleagues32, which is nationally care. representative, women in their twenties who have Accessibility of abortion care was defined by never been married, have no children, have Billings et al19 as 1) distance from a woman’s terminated a pregnancy before, are Protestant or home; 2) cost of services and payment options; 3) Pentecostal/Charismatic, of higher SES, and know waiting time for services / total length of stay; and the legal status of abortion are more likely to seek 4) social proximity to the provider. All of these an abortion. Further, they found younger women accessibility issues require further investigation, were less likely to seek a safe abortion, as were with an operations-research design that could women of low SES and those in rural areas. A address many of them. partner paying for the procedure was associated The repeated finding of the high incidence of with seeking a safe abortion. abortion complications and resulting The repeated findings of how few women are hospitalizations in the tertiary care centers, as well using contraception both preceding and following as some smaller district-level hospitals in the an abortion are worrisome. There is an urgent need country, highlights the need to adequately train to improve access to reliable contraception for providers to treat complications resulting from Ghanaian women. However, the results from many abortions, whether these abortions are spontaneous studies indicate simply improving access to or induced. Assessing the ability of public modern contraception may not improve utilization hospitals to safely provide treatment for post- if women are more afraid of the side effects of abortion complications, as well provide a safe and contraception than of complications from unsafe affordable place for women to access compre- abortion9,56. This fear is ironic considering the very hensive abortion care, is necessary. Women in real negative health implications that follow urban areas appear to have greater access to safe unsafe abortions. Those who know more about abortion services, although the availability contraception were found not to be more likely to country-wide has not been assessed. The use it, suggesting that simply providing government of Ghana has responded to the need to information does not seem adequate to provide treatments for post-abortion complications substantially increase usage33. by recently adding training in MVA to the Although not directly investigated in the curriculum of midwifery training colleges. An studies reported here, unfamiliarity with the legal assessment to assure midwives are graduating status of abortion appears to be a driver of women knowing how to handle these complications will seeking care in unsafe locations outside the formal be a necessary next step to ensure the safety of healthcare system. Future work needs to be done Ghanaian women who suffer from post-abortion to evaluate the best ways to educate health complications. workers and the public on the law and availability Although demographic differences were found of services. Qualitative work interviewing in many of the papers, it is conceivable the healthcare providers, policymakers, and differences found could be explained by selection community members to elucidate interventions to bias, as most of the studies reporting this improve the provision of safe abortion services information are hospital-based surveys conducted and post-abortion care is necessary. Billings and at the large referral centers, either Korle Bu in colleagues19 note that to understand the role Accra or Komfo Anokye Teaching Hospital in midwives can play in providing safe abortion,

African Journal of Reproductive Health September 2014; 18(3):32

Rominski & Lori Abortion care in Ghana Abortion care in Ghana further research should be conducted at the 5. Shah I, Ahman E. Unsafe abortion: global and regional community level. Hill and colleagues51 suggest incidence, trends, consequences and challenges. Journal of Obstetrics and Gynecology Canada, 2009, purposefully designing qualitative studies to assess 31 (12): 1149-1158. the perceptions of healthcare workers towards 6. World Health Organization (WHO). 1997. Unsafe providing safe abortion services, as well as asking abortion. Global and regional estimates of incidence of and mortality due to unsafe abortion with a listing participants to report on friends’ use of abortion rd services to determine rates. Aniteye and Mayhew9 of available country data. 3 ed. Geneva: WHO. 7. Aahman E, Shah I. Unsafe abortion: global and regional recommend qualitative work with women estimates of unsafe abortion and associated mortality undergoing treatment for abortion complications to in 2000, 4th edition. Geneva: WHO, 2004. elucidate reasons they are not using family 8. World Health Organization. Unsafe abortion: global and planning methods. regional estimates of incidence of unsafe abortion and associated mortality in 2003. Geneva: WHO, 2007. 9. Aniteye P, Mayhew S. Attitudes and experiences of Conclusion women admitted to hospital with abortion complications in Ghana. Afri J Reprod Health. 2011. 15(1): 47-55 The government of Ghana has made the important 10. Baiden F, Amponsa-Achiano K, Oduro AR, Mehsah TA, initial steps of reducing legal barriers to safe Baiden R, Hodgson A. Unmet need for essential abortion services and increasing the training of obstetric services in a rural district hospital in northern qualified personnel30 in order to reduce the burden Ghana: complications of unsafe abortions remain a of disease attributable to unsafe abortion. major cause of mortality. Journal of the Royal Institute of Public Health. 2006. 120(5): 421-426. However, complications from unsafe abortion are 11. Graff M, Amoyaw DA. Barriers to sustainable MVA still a large contributor to women’s mortality and supply in Ghana: challenges for the low-volume, low- morbidity. Future work is needed to investigate income providers. Afri J Reprod Health. 2009. 13(4): barriers that prevent women from accessing safe 73-80. 12. Lithur NO. Destigmatizing abortion: expanding abortion services and to ensure that Ghanaian community awareness of abortion as a reproductive women have access to safe abortion as fully health issue in Ghana. Afri J Reprod Health. 2004. allowed by the law. 8(1): 70-74. 13. Hu D, Grossman D, Levin C, Blanchard K, Adanu R, Goldie SJ. Cost-effectiveness analysis of unsafe Contribution of Authors abortion and alternative first-trimester pregnancy termination strategies in Nigeria and Ghana. Afri J SR conceptualized the research and performed the Reprod Health 2010; 14(2): 85-103. initial searches. JR reviewed search results. SR 14. Facts on induced abortion Worldwide. World Health wrote the first draft of the manuscript. JR edited Organization, Department of Reproductive Health and Research. Geneva, 2012. the manuscript. Both authors reviewed the final 15. Global Health Observatory, 2009. Accessed from version of the manuscript. http://www.who.int/countries/gha/en/. July 23, 2013. 16. UNICEF Country Statistics, Ghana. Accessed from http://www.unicef.org/infobycountry/ghana_statistics. References html January 9, 2014. 17. The State of World's Midwifery 2011: Delivering Health, 1. World Health Organization (WHO). 2012 Safe abortion: Saving Lives. UNFPA, 2011 technical and policy guidance for health systems. 2nd 18. Asamoah BO, Moussa KM, Stafstrom M, Musinguzi G. ed. Geneva: WHO. Distribution of causes of maternal mortality among 2. Unsafe abortion: global and regional estimates of the different socio-demographic groups in Ghana; a incidence of unsafe abortion and associated mortality descriptive study. BMC Public Health. 2011, 11: 159 in 2008, 3rd ed. Geneva, World Health Organization, 19. Billings DL, Ankrah V, Baird TL, Taylor JE, Ababio 2011. KPP, Ntow S. (1999) Midwives and comprehensive 3. World Health Organization (WHO). 2004. Unsafe postabortion care in Ghana. In Postabortion Care: abortion. Global and regional estimates of the Lessons from Operations Research. Huntington and incidence of unsafe abortion and associated mortality Piet-Pelon (eds). New York, New York; Population in 2000. 4th ed. Geneva: WHO. Council. 4. Singh S. Hospital admissions resulting from unsafe 20. Eades CA, Brace C, Osei L, LaGuardia KD Traditional abortion: estimates from 13 developing countries. birth attendants and maternal mortality in Ghana. Soc. Lancet 2006; 368(95550): 1887-1892. Sci. Med. 1993;36(11):1503-1507

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