In Brief 2010 Series, No.2 Abortion in Ghana
Maternal mortality is the second most common cause of incidence. Nevertheless, we must rely on such surveys where other sources of death among women in Ghana, and more than one in 10 information on abortion are sparse. maternal deaths (11%) are the result of unsafe induced According to the GMHS, 7% of all 1 abortions. In addition, a substantial proportion of women pregnancies end in abortion (Figure 1, who survive an unsafe abortion experience complications page 2), and 15% of women aged 15–49 have ever had an abortion.1 About 15 from the procedure. This suffering is all the more tragic abortions are performed for every 1,000 women of reproductive age (15–44) each because it is unnecessary: Many women likely turn to un- year. According to a study conducted in safe providers or do not obtain adequate postabortion care the late 1990s in southern Ghana, 17 abortions were observed for every 1,000 when it is needed because they are unaware that abortion women of reproductive age.5 The level of is legal on fairly broad grounds in Ghana. abortion in Ghana appears to be lower than in Western Africa as a whole, where the rate stands at 28 procedures per The abortion law in Ghana, enacted in a program to reduce maternal morbid- 1,000 women.6 1985, states that an abortion performed ity and mortality—particularly that due by a qualified medical practitioner is le- to unsafe abortion—in Ghana.4 The While underreporting might compro- gal if the pregnancy is the result of rape, program’s goals include ensuring that mise the accuracy of induced abortion incest or “defilement of a female idiot;” contraceptives and comprehensive abor- estimates, there is fairly clear evidence if continuation of the pregnancy would tion care are routinely available at all that 37% of births in the country are un- risk the life of the woman or threaten levels of the public and private health planned—23% are mistimed and 14% are her physical or mental health; or if there service delivery system. To be effectively unwanted.7 This means that, each year, is a substantial risk the child would suf- implemented, the policies and programs more than 300,000 infants are born as a fer from a serious physical abnormality supporting safe abortion require the result of unintended pregnancies. or disease.2 backing of the government, health care providers and other stakeholders. Characteristics of Women Having To help ensure that legal abortions are an Abortion provided safely, the Ghana Health Service This report provides a factual basis for The incidence of abortion is highest (25 and Ministry of Health developed proto- continued efforts to reduce the incidence per 1,000 women) among 20–24-year- cols for the provision of safe abortions. and consequences of unsafe abortion. It olds and is lower in each successive These guidelines, adopted in 2006, out- brings together findings from a recent, age-group (Figure 2, page 3).1 The line the components of comprehensive nationally representative study—the abortion rate is higher among educated abortion care, including counseling and 2007 Ghana Maternal Health Survey and wealthy women than among women the provision of contraceptives; define (GMHS)—and a number of other stud- with no education and those who are mental health conditions that could ies to present what is known about the very poor. Likewise, it is twice as high qualify a patient for an abortion; and incidence of abortion, the characteristics in urban areas (21 per 1,000 women) as call for expanding the base of abortion of women who seek them, the types of in rural areas (10 per 1,000). The rate providers by authorizing midwives providers women turn to and the proce- is especially high (34 per 1,000) among and nurses to perform first-trimester dures used. 20–24-year-old women in urban areas. procedures.3 The Level of Abortion in Ghana A study in southern Ghana also found In 2007, a consortium of international Because many women do not wish to that educated and urban women were and domestic organizations launched report having had an abortion, surveys of more likely than their less educated and women tend to underestimate abortion rural counterparts to seek an abortion, Figure 1 Pregnancy Outcomes In contrast, a 1997–1998 are both indications of infec- About four in 10 pregnancies in Ghana are unintended. study in southern Ghana found tion; and 1% reported that that only about 12% of women they suffered a perforation or who obtained an abortion did other injury as a result of the 11% 7% so with the help of a physi- procedure. Some of the most Induced abortions 13% cian.5 More than two-thirds of severe complications were not Unwanted births women who sought an abor- reported in this survey because
Mistimed births tion turned to an untrained women did not survive to provider or induced the abor- report them. 20% Wanted births tion on their own, according Stillbirths and 49% miscarriages to this study. Of women who experienced a problem following their It is possible that the circum- abortion, 41% received no stances under which abortions treatment.1 Almost half (47%) Source: reference 1. were obtained improved in the of women with a problem interval between the two stud- received antibiotics, and 19% and that Christian women the survey, 40% underwent ies. Another possible reason received an unspecified were more likely than Muslim dilation and curettage (D&C). for the discrepancy between treatment. women to seek the procedure.5 About 16% of women said they the studies is that respondents terminated their pregnancy by in the GMHS underreported The Cost of Abortion The most common reason taking tablets, and another abortions obtained through There is very little known given by women for seeking 5–6% of women specified that dubious means, while report- research on the cost of abor- an abortion is not having the they took Cytotec (misopro- ing more fully on abortions tion in Ghana. In one in-depth financial means to take care of stol) tablets. Twelve percent performed by medical pro- study in Accra, young women a child (21%).1 Other com- of women underwent manual fessionals. By contrast, the reported paying anywhere from mon reasons include wanting vacuum aspiration (MVA), researchers in southern Ghana three to 30 new Ghana cedis* to delay childbearing (13%), which is generally considered used lab tests to identify all for a hospital or private clinic continue schooling (11%) and safer than D&C for early ter- pregnancies in the community abortion.10 More generally, continue working (9%). Six mination of pregnancy.8 Less and followed women until all it has been reported that a percent of women said their common methods included the pregnancies were resolved; safe abortion is prohibitively partner did not want the child inserting an object, herbs thus, induced abortions and expensive for many women or denied responsibility for or other substances in the their circumstances were re- because few practitioners are the pregnancy. Health reasons vagina; receiving an injec- corded regardless of the means available to perform the pro- for terminating the pregnancy tion; and drinking an herbal of termination. cedure, and they charge very were cited by about 5% concoction.1 Although local high fees.2 As a consequence, of women. anesthesia is recommended Complications from poor women may be forced for surgically induced abor- Unsafe Abortion to seek risky abortions from Abortion Methods tion,8 only 14% of women who Abortion, when performed by untrained providers. and Providers obtained an abortion reported a qualified professional under Studies have produced con- receiving local anesthesia; safe conditions, is an extreme- An abortion carries costs flicting evidence regarding most women received “pain ly safe procedure. However, beyond the price of the pro- the types of providers women relievers,” and 25% received clandestine abortions are often cedure itself. These include turn to and the procedures general anesthesia.1 unsafe.6,9 the economic burden on the they undergo to terminate a families of women whose pregnancy. According to the same survey, Among Ghanaian women who abortion complications lead 57% of women sought a doctor had had an abortion in the to medical expenses and a According to the GMHS, many to perform an abortion, 16% five years prior to the GMHS, loss of productivity; social women who procure abor- went to a pharmacist or chemi- 13% reported experiencing one costs, including stigma and tions do so with the help of cal seller, and 19% turned to or more health problems after isolation; and expenses to the a doctor and in a hospital a friend or relative or induced their most recent abortion.1 health care system and society. setting, although significant the abortion themselves.1 The Ten percent of women expe- There is no known research proportions do not undergo remaining women sought the rienced pain, half of whom into these costs of abortion to the safest procedures avail- help of a traditional practi- reported that the pain was Ghanaian society. 1 able. Among women reporting tioner (4%) or a nurse, midwife severe; 8% reported bleeding; on their most recent abor- or auxiliary midwife (3%). 6% each experienced fever and *Equal to US$9–90 in January 2000, tion in the five years before foul-smelling discharge, which the approximate time of the study.
Abortion in Ghana 2 Guttmacher Institute 45
40
35
30
25 Rural
20 Urban 15 Total 10
5
0 15–19 20–24 25–29 30–34 35–39 40–44 45–49
Figure 2 The Need for Effective Women who have abortions Contraceptives Many abortions in Ghana are obtained by young women and women in urban areas. While contraceptive use has been on the rise in Ghana for 45 the past two decades, levels Rural of use are still quite low and 40 seem to have stagnated in 35 Urban recent years. About 13% of married women were using 30 contraceptives in 1988; the Total level of use increased to 25% 25 by 2003, but was only 24% in 2008.7 20
Some 35% of married women 15
in Ghana have an unmet need Abortions per 1 ,000 women aged 15–49 for contraceptives.7 That is, 10 they do not want a child soon 5 or at all and are not using a contraceptive method. This 0 represents little change since 15–19 20–24 25–29 30–34 35–39 40–44 45–49 2003 (34%)7 and is much Age-group higher than the average of Total Urban Rural 22% for Africa as a whole.11 Evidence from developing Source: reference 1. countries indicates that the vast majority of unintended were aware of this fact. Among doctors at a teaching patients on contraceptive pregnancies occur among Knowledge of the country’s hospital in Ghana, 80% favored options, address women’s 12 women with an unmet need. moderately liberal abortion law establishing safe abortion concerns about side effects, seems to be substantially high- units within national health and help women identify and Compared with their coun- er, but still not widespread, facilities.14 Only 19% of physi- obtain the methods that work terparts in other African among medical professionals. cians—the majority of whom best for them would contribute countries, women in Ghana In one small study, 54% of did not work in obstetrics or to increased and improved with an unmet need for physicians were aware that gynecology—said they would contraceptive use. contraceptives are relatively abortion is legal if indicated play no role in abortion care; unlikely to oppose contracep- to preserve the health of the some in this group indicated •Educate young people. Im- tion or to face opposition from woman.14 that they would perform the proved education for young their husbands, but a large procedure if they were properly women and men about sexual proportion—34% of married Abortion is widely stigmatized trained. and reproductive health would women with unmet need—cite in Ghanaian society, but it help them understand and concerns about health risks or appears that many people The Next Steps Toward avoid the risks associated with side effects associated with consider it acceptable under Ending Unsafe Abortion unprotected intercourse and 13 contraceptives. These con- certain conditions. In in-depth The Ghanaian government and prevent unintended pregnan- cerns are especially prevalent interviews with adolescent other key stakeholders must cies that might otherwise lead among relatively well-educated females in Accra, the majority continue to address unsafe to abortion. women and women living in of participants were strongly abortion in order to save urban areas. opposed to abortion, but women’s lives and improve •Raise awareness about nearly all described situations, maternal health. The following Ghana’s abortion law. A large- Attitudes Toward Abortion such as being in an unstable measures can further advance scale public education effort and Knowledge of Abortion these aims: Law relationship or not having that takes into account the enough money to raise a child, sensitive, often secretive, na- The GMHS found that, in 2007, in which they considered •Address unmet need for ture of abortion could increase only 4% of women thought abortion to be acceptable or contraceptives and barriers to the proportion of abortions that abortion was legal in necessary.10 contraceptive use. Ensuring that are carried out safely. Ghana.1 Even among women that health care providers offer with at least a secondary a range of methods, educate school education, only 11%
Abortion in Ghana 3 Guttmacher Institute •Conduct more research. Reli- REFERENCES 9. Grimes DA et al., Unsafe CREDITS able evidence of the costs of 1. Ghana Statistical Service (GSS), abortion: the preventable pan- This In Brief was written by Gilda demic, Lancet, 2006, 368(9550): unsafe abortion to women, Ghana Health Service (GHS) and Sedgh and edited by Haley Ball, both 1908–1919. of the Guttmacher Institute. The their families and the health Macro International, Ghana Maternal Health Survey 2007, Accra, Henry R and Fayorsey C, author thanks Akinrinola Bankole, care system, compared with 10. Ghana: GSS and GHS; and Calver- Coping with Pregnancy: Experiences Ann Biddlecom and Leila Darabi, the costs of providing safe ton, MD, USA: Macro International, of Adolescents in Ga Mashi, Accra, all of the Guttmacher Institute, for their comments and sugges- abortions and contraceptive 2009. Calverton, MD, USA: ORC Macro, tions. She also thanks the following 2002. care; qualitative research on 2. Morhee RAS and Morhee ESK, reviewers for their invaluable input: women’s experiences with Overview of the law and availabil- 11. Singh S et al., Abortion World- Joy D. Fishel, Macro International; abortion; and investigation ity of abortion services in Ghana, wide: A Decade of Uneven Progress, Koma Jehu-Appiah, Ipas; and Joana into the attitudes of key Ghana Medical Journal, 2006, New York: Guttmacher Institute, Nerquaye-Tetteh, formerly of the 40(3):80–86. 2009. Planned Parenthood Association of stakeholders and the sources Ghana. of stigma surrounding abortion 3. Ipas, Ipas in Ghana, Chapel Hill, 12. Singh S et al., Adding It Up: NC, USA: Ipas, 2008. The Costs and Benefits of Investing Suggested citation: Sedgh G, would help inform policies and In Family Planning and Maternal 4. Reducing Maternal Mortality Abortion in Ghana, In Brief, New bolster the political will and Newborn Health Care, New York: and Morbidity, The R3M Program in York: Guttmacher Institute, 2010, Guttmacher Institute, 2009. to prevent unsafe abortion. Ghana, 2009,
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