Support for Scale-Up of Comprehensive Care in Northern Ghana: Technical Update

Abortion in Ghana is less restricted than in other sub-Saharan African The Comprehensive Abortion countries, yet very few women are aware of their legal right to safe abortion Care (CAC) project (2007–2012) and more than one in ten maternal deaths are attributed to .1 operates with a budget of approxi- mately USD 600,000, and works Since 2007, Pathfinder International has implemented a comprehensive to increase access to and provision abortion care (CAC) project across the country’s three northern regions of high-quality CAC services in to promote the availability and expansion of quality CAC services and three regions of northern Ghana. combat abortion-related stigma. Led by Pathfinder International, in partnership with Ghana Health In 2012, the Ghana Health Service (GHS) Incidence of abortion is highest among Service, the Ghana CAC project Directorate of the Northern Region committed younger women 20–24 years old, and women is part of a three-country effort to sustaining and scaling up Pathfinder’s 15–24 years old are at greatest risk from unsafe funded by the Safe Abortion Action CAC model. This technical update highlights abortion.2 At 17 percent, modern contraceptive Fund (SAAF) administered by the project’s community and health systems prevalence in Ghana is low, and data from the International Planned Parenthood strengthening approach that precipitated 2008 Ghana Demographic and Health Survey Federation, and the Richard and GHS’s commitments to sustainability and indicate that 37 percent of all births in Ghana 3 Rhoda Goldman Fund. Pathfinder’s scale in Ghana’s Northern Region. are unintended. other CAC efforts are underway in Ghana’s is liberal in comparison Mozambique and South Africa. Context to many countries in the region, including In 2009, the Ghana Maternal Health Survey permission for abortion when there is risk to (GMHS) estimated Ghana’s national mater- a woman’s mental or physical health.4 Trans- nal mortality ratio at 580 per 100,000 live lation of the law into policy, service protocols, births, with more than 11 percent of maternal and standards has been slow, however, and deaths attributed to unsafe abortion. Health System Community System Structural Advocacy Strengthening Strengthening

• Promote broad interpretation • Support quality CAC service • Ensure capacity to demand of abortion law provision at provider and access to quality services, in • Prioritize vulnerable groups’ institutional levels accordance with national law legal access to abortion • Ensure services are compre- • Support community-led • Establish national hensive across facilities and stigma reduction efforts protocols and curricula integrated into all SRH services • Promote sustained commu- • Engage professional and • Create compassionate, nity involvement through civil society organizations stigma-free service delivery key leaders, norm influencers, environments and vulnerable groups

Enabling environment supportive of women’s access to quality CAC

figure 1. pathfinder’s global cac approach

both community and provider understanding of the CAC programs pursue their interventions within the law and its implications are limited in most of the country. parameters of existing legal and funding requirements, In 2007, only 4 percent of Ghanaian women were reducing stigma and improving access to quality aware of their legal right to abortion. An Ipas study service while prioritizing necessary change for youth from the same year finds that fewer than one in seven and other vulnerable groups. The core elements of facilities surveyed offered abortion services, and Pathfinder’s CAC model are depicted in Figure1 . that 23 percent of responding providers incorrectly reported that the abortion law requires written consent from the woman’s partner. Nearly half of providers CAC Experience in Ghana surveyed reported reluctance to provide The project operates in 21 districts, covering 9 of the abortion services due to religious beliefs.5 vast Northern Region’s 20 districts, and all but 2 districts upper west upper east Studies in rural areas of Ghana suggest of the Upper East and Upper West Regions (see Figure 2). 4 Sub-District that up to two-thirds of are Health Centers 7 District conducted outside of the medical system 6 District Hospitals health system strengthening Hospitals by untrained providers or by women for sustainability themselves, contributing to women’s The project prioritized a close capacity building northern risk of morbidity and mortality.6 9 District Hospitals partnership with GHS from the beginning, working with the government to plan, implement, and monitor Pathfinder’s the program. As sustainability was a priority for both the project and GHS, preparations for Pathfinder’s Global CAC eventual phase-out were part of planning from the Approach project’s inception. First, Pathfinder conducted par- rrong-ahafo ticipatory facility assessments with GHS to identify Pathfinder’s approach strives to health system gaps in skills, services, and equipment. build enabling national environ- Results informed procurement of manual vacuum GHANA ments in support of women’s aspiration kits, procedure beds, and other equipment, access to safe CAC. Toward this as well as facility upgrades to allow for private coun- ashanti goal, the approach employs seling, abortion, and postabortion family planning (FP). volta a three-pillar strategy: eastern advocacy at the central, Building capacity of health care providers greater regional, and district levels western accra Pathfinder’s capacity building approach in Ghana to promote necessary policy is informed by assessment findings and focuses on central and operational changes in support Ghana’s long-term goals for the sustainability of CAC of CAC; support to the health system for high- services in the country. Through CAC trainings led jointly quality, comprehensive, and compassionate CAC by Pathfinder and GHS, providers are supported to service provision; and targeted community mobiliza- build and refine their clinical CAC skills as they receive figure 2. cac tion to build supportive, stigma-free local contexts in targeted guidance to integrate stigma reduction into project coverage which women can seek CAC services. All Pathfinder everyday service delivery. Trainees receive instruction

2 Support for Scale-Up of Comprehensive Abortion Care in Northern Ghana: Technical Update | Pathfinder International on Ghana’s abortion law and discuss the role stigma mobilization strategy built on the social ecological plays in driving Ghanaian women’s risk of adverse model for behavior change. Through its multiple health outcomes related to unsafe abortion. Build- intervention levels, the project engages communities ing on this larger understanding of the social factors around abortion rights and available services, and surrounding abortion, providers are then led through facilitates community-led initiation of efforts to a values clarification process to identify and address address local barriers to improved SRH outcomes. their own abortion-related biases. Together, providers Bringing together decision makers, health profession- interrogate these biases with the goal of cultivating als, and communities, this community mobilization nonjudgmental attitudes toward women’s rightful strategy supports communities to break traditions access to CAC services. Across the training experi- of silence around abortion, with the ultimate goal of ence, providers are supported to see CAC as a part increasing women’s ability to freely access services. of a larger spectrum of sexual and reproductive health (SRH) services, so that key needs such as FP, One of Ghana’s primary policy-related barriers to sexually transmitted infection and HIV prevention abortion access is the public’s limited knowledge of and care, and gender-based violence are addressed the rights afforded under the law. At the structural as CAC services are provided. level, the strategy works to address this by ensuring

Pathfinder and GHS have further addressed Ghana’s capacity building needs through a range of efforts • Print and radio journalists are trained to address the public's limited knowledge supporting long-term sustainability of CAC service Structural of Ghanaian abortion policy. provision. A master trainers program, run by a local cadre of midwives and regional gynecologists, now

• Nurses facilitate discussion of SRH issues at ... .. trains both community and facility health workers durbars and other community dialogue forums. in community dialogue and clinical CAC service • Villages hold movie nights dedicated to SRH provision, respectively. Fully equipped CAC training Social and unsafe abortion, followed by dialogue. centers have now been established in two regional hospitals in Upper East and Northern Regions, creat- • Trained community volunteers link community ing a permanent platform for the continuation of members to facility-based services. CAC and safe motherhood initiatives. Finally, to ensure • Peer educators support youth and out-of- school youth to access FP and CAC services. new cadres of providers are able to initiate CAC from Individual the start of their medical careers, the project has also facilitated the integration of its CAC curriculum into figure 3. pathfinder’s cac community mobilization strategy in ghana pre-service training at two of Ghana’s three regional midwifery schools. As part of this pre-service training, that influential media, such as print and radio journal- participants undergo a practicum at project facilities ists, are trained to accurately represent the law in their to establish firsthand experience providing the news coverage. At the social level, the strategy works procedure. A tutorial program further ensures their to foster supportive community environments by quality service provision, providing one-on-one creating occasions for villages to convene and discuss support to participants throughout their training. accurate information about the procedure, relevant SRH issues, and the risks associated with unsafe Private sector involvement abortion. Through community durbars (traditional To ensure a holistic approach to the factors community meetings) and movie nights, trained surrounding CAC access in Ghana, the project also community nurses and project staff facilitate discus- intervenes in the private sector. As is sions with community members and their leaders sold over the counter in Ghana, the project employs about these issues, exploring the role stigma plays a harm reduction strategy to increase proper use in driving risk for adverse health outcomes. Finally, of misoprostol for .* Through a at the individual level, youth receive targeted one- partnership with the Ghana Pharmacists Association, on-one support through school-based peer education Pathfinder builds the capacity of local chemical sellers programs and outreach at vocational training centers. to correctly communicate to clients the risks associated Community volunteers are similarly trained to act with misuse of misoprostol, as well as appropriate as a bridge between communities and their facilities, dosages for use as an . Sellers are also providing accurate, timely information to those in supported to make timely referrals to CAC facilities. need, and referring for CAC services. community system strengthening performance Working at the community level to improve access Pathfinder’s CAC approach has shown promise as a and demand for quality CAC services, the project sustainable means of advancing safe abortion in Ghana. has employed a comprehensive community To date, the project is active across 21 districts and,

*Misoprostol is sold in Ghana as an over-the-counter drug for treatment of gastric ulcers. 3 with a limited budget, has supported nearly the GHS Directorate of Northern Region began cover photo: Community durbar 350 Ghanaian providers to initiate and institu- planning to expand CAC services across its event for CAC and SRH issues tionalize quality CAC services through its new remaining 11 districts. Bringing together GHS pre- and in-service trainings. GHS counter- officials, project staff, and providers and facility parts have progressively assumed responsibil- managers from across Northern Region, the ity for CAC programming, sharing costs with meetings were an official forum for discussion contributors* the project for equipment, facility refurbish- of the role of unsafe abortion and abortion- Claire B. Cole, MPH ments, supervision visits, refresher trainings, related stigma in maternal mortality and mor- Ellen Israel, CNM, MPH and—in two districts—exploring ways to cover bidity. At the end of the proceedings, attendees Farouk M. Jega, MD, MPH CAC under the national health insurance plan. called for continued technical support to opera- Irene Kitzantides, MPH At the community level, anecdotal evidence tionalize CAC service provision across districts, John Lazame Tindanbil, MPH

points to a reduction in stigma. Young women, and endorsed the proposal for scale-up. *in alphabetical order who had previously been discriminated against This endorsement represents a significant when attempting to access services, are step toward sustainable institutionalization now widely supported by providers to access of the CAC approach in northern Ghana. In CAC. In addition, many providers and com- munity members now act as safe abortion “champions,” proactively advocating for CAC. 50% Project clients receiving 45% A chief high point of the CAC approach’s FP method post-abortion performance in Ghana has been in the project’s 40% National percentage 35% efforts to integrate SRH—and particularly of women receiving contraception and FP— into providers’ CAC 30% FP post-abortion 25% service provision. Between July 2008 and 20% June 2012, the percentage of abortion clients 15% accepting a contraceptive method across 10% target facilities increased from 15 to 43 percent, 5% as depicted in Figure 4. This performance is 0% July ‘08 July ‘09 July ‘10 July ‘11 significant when put in the context of national –June ’09 –June ’10 –June ’11 –June ’12 survey data, which reflected in2007 that 70 percent of respondents who had had figure 4. abortion clients accepting an abortion were not using a contraceptive a contraceptive method method at the time of their last pregnancy. Given Ghana’s low rate of postabortion Moreover, just 5 percent of respondents who FP uptake, this is a promising trend. The had an abortion in the five years preceding decline noted in 2009–2010 is attributed the survey were provided with a contraceptive to insufficient data reporting. method after their procedure.7 Given this situation, the CAC approach appears to be a promising means of addressing multiple factors its final months, the project will support driving adverse SRH outcomes in the country. Upper West Region in its own sustainability and scale-up planning meetings, and continue next steps: government to assist GHS to concretize finance and action commitment to scale plans for service delivery scale-up, beginning Since 2011, GHS has voiced increasing with facility assessments in four new sites. commitment to scaling up the Pathfinder CAC Overall, Pathfinder will continue to build on pathfinder international approach in northern Ghana. In anticipation of Ghana’s implementation experience, sharing headquarters the project’s close in 2012, the GHS Directorate programmatic lessons across each of its CAC 9 Galen Street, Suite 217 of Upper East Region initiated its own planning programs to further advance the impact of this Watertown, MA 02472, USA to sustain CAC services and, in June 2012, approach in the countries in which we work. Phone: 1-617-924-7200

1 Ghana Statistical Service (GSS), Ghana Health Service (GHS), and Macro International, Ghana Maternal Health Survey 2007 (Calverton, MD: GSS, GHS, and Macro Int., 2009). 2 Ibid. 3 GSS, GHS, and ICF Macro, Ghana Demographic and Health Survey 2008 (Accra, Ghana: GSS, GHS, and ICF Macro, 2009). 4 Center for Reproductive Rights, The World’s Abortion Laws 2012 accessed Oct 5, 2012, http://worldabortionlaws.com/map/. 5 Patrick Kuma Aboagye, et al., An Assessment of the Readiness to Offer Contraceptives and Comprehensive Abortion Care in the Greater Accra, Eastern, and Ashanti Regions of Ghana (Chapel Hill, NC: Ipas, 2007). 6 Zelee Elizabeth Hill, Charlotte Tawiah-Agyemang, and Betty Kirkwood, “The Context of Informal Abortions in Rural Ghana,” Journal of Women’s Health 18, no. 12 (2009): 2017-2022. 7 GSS, GHS, and ICF Macro, Ghana Maternal Health Survey 2007.