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My Friend Who Bought It for Me, She Has Had an Abortion Before.” the Influence of Ghanaian Women’S Social Networks in Determining the Pathway to Induced Abortion

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My Friend Who Bought It for Me, She Has Had an Abortion Before.” the Influence of Ghanaian Women’S Social Networks in Determining the Pathway to Induced Abortion J Fam Plann Reprod Health Care: first published as 10.1136/jfprhc-2016-101502 on 22 March 2017. Downloaded from RESEARCH “My friend who bought it for me, she has had an abortion before.” The influence of Ghanaian women’s social networks in determining the pathway to induced abortion Sarah D Rominski,1 Jody R Lori,2 Emmanuel SK Morhe3 1Department of Obstetrics ABSTRACT Key message points and Gynecology, University of Background Even given the liberal abortion law Michigan, Ann Arbor, MI, USA 2Department of Health Behavior in Ghana, abortion complications are a large ► Women in Ghana consult members of and Biological Sciences, contributor to maternal morbidity and mortality. their social networks when faced with University of Michigan School of This study sought to understand why young Nursing, Ann Arbor, MI, USA an unwanted pregnancy. women seeking an abortion in a legally enabling 3Kwame Nkrumah University of ► Due to multiple factors, including the Science and Technology, Kumasi, environment chose to do this outside the formal wide availability of misoprostol, the Ghana healthcare system. poor quality of care women receive in Methods Women being treated for complications facilities, and wrongly believing abortion Correspondence to arising from a self-induced abortion as well as Dr Sarah D Rominski, Univ is illegal, self-inducing abortions has for elective abortions at three hospitals in Ghana copyright. Michigan, 1111 E. Catherine St. been normalised. Ann Arbor 48109, Michigan, were interviewed. Community-based focus groups USA; sarahrom@ umich. edu were held with women as well as men, separately. Interviews and focus group discussions were Received 18 March 2016 unsafe abortion cause approximately Revised 20 January 2017 conducted until saturation was reached. Accepted 6 March 2017 Results A total of 18 women seeking care for 10% of maternal deaths in sub-Saharan 1 Published Online First complications from a self-induced abortion and 11 Africa, although these numbers are likely 22 March 2017 seeking care for an elective abortion interviewed. underreported in areas where abortion 2 The women ranged in age from 13 to 35 years. is illegal and/or highly stigmatised. An There were eight focus groups; two with men and unsafe abortion is defined by the World six with women. The reasons women self-induce Health Organization (WHO) as a proce- http://jfprhc.bmj.com/ are: (1) abortion is illegal; (2) attitudes of the dure which is provided by a person who healthcare workers; (3) keeping the pregnancy has not been trained or in a location a secret; and (4) social network influence. The which does not meet minimal medical 3 meta-theme of ‘normalisation of self-inducing’ an standards, or both. Deaths resulting abortion was identified. from unsafe abortion exist almost exclu- sively in low-income countries where Discussion When women are faced with an unplanned and unwanted pregnancy, they consult there are often highly restrictive laws on September 25, 2021 by guest. Protected individuals in their social network whom they know governing abortion provision and where have dealt with a similar situation. Misoprostol is there are scant providers trained and 4 widely available in Ghanaian cities and is successful willing to provide safe procedures. at inducing an abortion for many women. In this Abortion-related mortality remains high way, self-inducing abortions using medication in many sub-Saharan African countries procured from pharmacists and chemical sellers has where abortions are legally restricted, become normalised for women in Kumasi, Ghana. and while the overall number of abor- tions is reducing worldwide, the number of unsafe abortions is increasing.5 To cite: Rominski SD, Lori JR, In countries where abortion laws Morhe ESK. J Fam Plann INTRODUCTION are restrictive, women faced with an Reprod Health Care Unsafe abortion is a major cause of unwanted pregnancy have little choice 2017;43:216–221. maternal mortality. Complications from but to induce clandestinely and often 216 Rominski SD, et al. J Fam Plann Reprod Health Care 2017;43:216–221. doi:10.1136/jfprhc-2016-101502 J Fam Plann Reprod Health Care: first published as 10.1136/jfprhc-2016-101502 on 22 March 2017. Downloaded from Research unsafely. Ghana, however, has an abortion law that The interview and focus groups guides were open- the Guttmacher Institute calls ‘liberal’.6 Beyond the ended and included probes for additional issues that legal framework, the Ghana Health Service has made could emerge as concerns or issues arouse. Some of access to safe abortion care part of its policy. Safe abor- the key categories explored included: women’s and tion, performed by a qualified healthcare provider, has community members’ perception of the legal status of been part of the Reproductive Health Strategy since abortion in Ghana; comfort-seeking care in a hospital 2003.7 8 Currently in Ghana, abortion is a criminal or health centre for abortion care; use of contracep- offence regulated by Act 29, Section 58 of the Crim- tion; and the existence of community-based abortion inal code of 1960, amended by PNDCL 102 of 1985.7 providers. The interview and focus-group guides were However, Section 2 of this law states abortion may be pilot-tested in advance among a smaller sample from performed by a registered medical practitioner when: the target population and revised to ensure flow and the pregnancy is the result of rape or incest, to protect clarity. the mental or physical health of the mother, or when Ethical approval was received by the Univer- there is a malformation of the fetus. The government sity of Michigan Institutional Review Board of Ghana has taken steps to mitigate the negative (HUM00087225) and the Komfo Anokye Teaching effects of unsafe abortion by developing a compre- Hospital/Kwame Nkrumah University of Science and hensive reproductive health strategy that specifically Technology Committee on Human Research Publica- addresses maternal morbidity and mortality associated tion and Ethics. All participants gave verbal informed with unsafe abortion.9 Despite these steps, however, consent, and for those who were under the age of abortion complications are a large contributor to 18 years, parental consent was given. All participants maternal morbidity and mortality.10 11 Complications were given a written participant information sheet and from unsafe abortion are the leading cause of maternal informed of the confidentiality of the research. mortality for young women (aged 19 years and below) and the second leading cause of maternal mortality for Data collection procedure all women of reproductive age.12 The individual interviews took place in a private room Given the liberal legal and policy framework near the ward where the women were being treated. surrounding access to safe abortion in Ghana, this Only the participant and the research assistant were in study sought to understand the perspective of women the room. The focus groups were held with women and copyright. who decide to terminate their pregnancy in a manner men separately, in market areas where participants were the WHO and other international organisations clas- generally engaged in their daily work, allowing people sify as unsafe. from different communities and other social background to be recruited. Potential participants were approached by members of the study team and the purpose of the METHODS study was described. Those who were interested in Research design and participants participating were taken through a comprehensive Using a qualitative, grounded theory design, interviews consent procedure. The FGDs were held in various and focus groups were conducted. Women meeting the locations away from others at times when the markets inclusion criteria (receiving treatment for complica- were not particularly busy, both for privacy as well as http://jfprhc.bmj.com/ tions arising from a self-induced abortion or coming for quality recording. The interviews and focus groups for an elective induced abortion) at three hospitals in were conducted and recorded in the local language, Twi, the Ashanti region of Ghana were offered participa- and transcribed in English by a research assistant fluent tion in the study by the nurse-midwife on duty. If the in both languages. Transcription was conducted on an woman was interested, the research assistant came to ongoing schedule, with the transcripts being reviewed the hospital to interview the participant. All women by the study team at regular intervals and data capture were informed of the research objectives and were continued until saturation was reached. on September 25, 2021 by guest. Protected assured of confidentiality and anonymity. No identi- fying information was collected. All of the participants Data analysis were informed of the voluntary nature of the research Qualitative data were reviewed in Microsoft Word and were interviewed only after their treatment was (Microsoft Corp., Redmond, WA) by the study team. completed and before they were discharged. Descriptive statistical and qualitative analyses were Additionally, focus group discussions (FGDs) with performed using Microsoft Excel and SPSS Version between six and 10 participants were held in the 22.0 (IBM Corp., Armonk, NY). The qualitative community to further contextualise how members data were analysed using the constant comparative of the community conceptualise and access abortion approach to identify key themes.13 The researchers services in the case of unwanted pregnancies. Partic- undertook line-by-line coding of the transcripts, after ipants were approached by a research assistant and initial high-level reading of all the transcripts. From asked if they would like to participate and voluntarily the initial coding, a large number of codes emerged. recruited. From this large number of initial codes, reappearing Rominski SD, et al. J Fam Plann Reprod Health Care 2017;43:216–221. doi:10.1136/jfprhc-2016-101502 217 J Fam Plann Reprod Health Care: first published as 10.1136/jfprhc-2016-101502 on 22 March 2017. Downloaded from Research and similar codes were identified and consolidated.
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