Attitude of Women with Abortion-Related Complications toward Provision of Safe Abortion Services in Ghana

Introduction

The World Health Organization (WHO) defines unsafe abortion as a procedure to terminate an unintended pregnancy undertaken by individuals lacking the necessary skills or in an environment not meeting the basic medical standards or both. ¹ Regardless of whether abortion is spontaneous or induced, subsequent events and the care received also determine whether the abortion is safe or unsafe. ² Unsafe abortion accounts for about 13% of the global maternal mortality burden, and 95% of unsafe abortions occur in developing countries where abortion is restricted by outdated laws. ³ In Ghana, unsafe abortion accounts for 12%–15% of maternal mortality. ^{4 –6} Although pregnancy termination and the care of miscarriage share the common goal of safe evacuation of the uterus, pregnancy termination is profoundly distanced from miscarriage care ⁷ and is highly stigmatized. ⁸

Worldwide, hospital admissions for treatment of complications from unsafe abortion vary widely: from low levels of 3/1000 among women aged 15–44 years in Bangladesh, to 5–6/1000 in Mexico, Nigeria, and the Philippines, to high levels of 8–16/1000 in other countries. ⁹ For much of the 20th century, termination of pregnancy was illegal in most countries. This was associated with high rates of unsafe abortion and maternal mortality and morbidity. ¹⁰ Now, the law in many countries permits termination of pregnancy to save a woman's life or to preserve the physical and mental health of the woman. ¹¹

Until recently, the Ghana National Reproductive Health Policy dwelt on the provision of contraceptives and postabortion care as strategies to reduce abortion-related maternal morbidity and mortality. ¹² However, the current law allows abortion if:

…caused by a medical practitioner specializing in gynaecology or other registered practitioner in a government hospital or registered private hospital or clinic, when the pregnancy is the result of rape, defilement of a female idiot, or incest; when continuation of the pregnancy would involve risk to life of the pregnant woman or injury to her physical or mental health; or where there is substantial risk that if the pregnancy were carried to term the child would suffer from or later develop a serious abnormality or disease. ^13,14

During review of the Ghana National Reproductive Health Policy and Standards Document in 2003, an additional objective “to provide abortion care services as permitted by law” was added. Accordingly, comprehensive abortion care standards and protocols have been developed within the context of the law to offer safe abortion services at public health facilities throughout the country, ¹⁵ in line with the International Conference on Population and Development (ICPD) recommendation that where abortion is not against the law, such abortion should be safe. ¹⁶

Worldwide awareness and knowledge of existing laws on abortion vary among the population and healthcare providers. The estimate for awareness among women is 45% in Mexico, 57% in Latvia, and 78% in the Gauteng Province of South Africa. ^{17 –19} In Ghana, 89% of physicians randomly selected from a teaching hospital were aware of the law on abortion, and 81% of them were willing to play a role in the provision of safe abortion services. ¹²

Despite the existence of family planning units in public and private health facilities in Ghana, only 22% of women of reproductive age use modern contraception. ⁴ Hence, induced abortions as well as abortion-related complications remain a major public health problem in the country. The success of safe abortion services depends largely on its acceptance and availability and the willingness of women to patronize such services.

The main objectives of the study were to determine the attitude and perception of women with abortion-related complications attending Komfo Anokye Teaching Hospital (KATH) toward the provision of safe abortion services. Secondary objectives were to determine the sociodemographic characteristics of these women and to determine awareness about the law on abortion in Ghana and the provisions in this law.

Subjects and Methods

This was a cross-sectional study of all patients with abortion-related complications admitted to the Department of Obstetrics and Gynaecology of KATH, Kumasi, Ghana, from May 1 to June 30, 2007. The study was approved by the Ethics Committee of the hospital.

KATH is the second largest teaching hospital in Ghana. It is a 1000-bed tertiary referral hospital that cares for patients in the middle and northern belts of Ghana, with a population of more than 6 million in this catchment area. It is the main hospital to which patients with abortion-related complications are referred, whether arising from spontaneous or induced abortions. Care given is usually in the form of emergency resuscitation; evacuation of the uterus; administration of oxytocics, antibiotics, and analgesics; and posttreatment reproductive health counseling. Of the 304 such patients admitted within this period, 8 were excluded for the following reasons: 4 (1.3%) died from complications of septic-induced abortion, and another 4 (1.3%) went home before they could be interviewed. The remaining 296 (97.4%) were interviewed.

The purpose of the study was explained to patients with abortion-related complications who had been given treatment and were due for discharge. Verbal consent was sought, and confidentiality was assured. Consent for the interview was voluntary. All 296 women consented and were interviewed privately and individually using a standardized questionnaire administered on the Gynaecology Ward by trained interviewers who had not been involved in their care; hence, acceptance or refusal to participate in the study did not affect subsequent care.

Data on sociodemographic and obstetrical history, including induction of abortion in the index pregnancy, were obtained. The patients were then asked about the law on abortion in Ghana. Those who were aware of the law were asked to describe the conditions under which the law could be applied. The actual conditions under which the law could be applied were then explained, after which their views were sought with respect to the provision of safe abortion services; their preferred facility for the service; payment options for the service; perception of stigmatization of safe abortion care providers; the possibility of the impact of the service on the level of promiscuity, family planning, and contraceptive practice, and, finally, willingness to patronize the service. The data were entered on a Microsoft Excel spreadsheet. Data analyses were conducted using SPSS version 15.0 (SPSS Inc., Chicago, IL). Descriptive statistics (median, range, and percentages) were calculated. Chi-square tests were performed to compare the characteristics of women with induced abortion vs. those with spontaneous abortion. In addition, we compared the characteristics of women who were aware of the abortion law vs. those who were not, as well as women who were willing to patronize safe abortion services vs. those who were not, using chi-square tests. p values <0.05 were considered statistically significant.

Results

Over the 2-months period, there were 711 admissions to the Gynaecology Ward of KATH. Of these, 304 (42.7%) were due to complications of abortion, which represented the leading cause for admission. The median age was 26 years, with a range of 14–45 years. The median parity was 1. Forty percent of the women were nullipara. Fifty-three percent of the women had previously had at least one induced abortion. Table 1 shows the background characteristics of the women and the type of abortion.

Of the 296 cases analyzed, 83 (28%) reported induced abortion in the index pregnancy, of which 69 (83%) reported self-induction with misoprostol. The other 213 (72%) patients reported spontaneous abortions or did not admit having had induced abortion. Among women who were admitted to KATH for abortion-related complications, those who reported having had induced abortion were significantly more likely to be unmarried than women with spontaneous abortion (Table 1). Those who reported induced abortion were more likely to have had formal education (Table 1). The most commonly reported reason for induced abortion was not being ready for a family. Of the 71 women with formal education, 32 (45%) were students, and 24 (75%) of these students stated they had induced abortion because they were still in school.

Regarding the law, 271 (92%) of the women were not aware that abortion was permitted by law under certain circumstances in Ghana. Of those who were not aware of the law, 79 (29.2%) and 192 (70.8%) reported induced and spontaneous abortions, respectively. The remaining 25 (8%) of the women were aware of the law and were able to indicate some conditions under which the law permitted abortion. Table 2 shows the background characteristics of the women and their awareness of the law on abortion. Two hundred seventy-two women (92%) thought there was a need to provide safe abortion services, and their preferred health facility for the service was regional/teaching hospitals.

One hundred forty-five women (49%) were of the opinion that patients should bear the full cost for safe abortion services. Two hundred forty women (81%) did not expect health workers providing safe abortion services to receive harassment or threats. One hundred twenty-seven women (43%) were of the opinion that the provision of safe abortion services could lead to an increase in promiscuity, and 94 women (32%) thought it could lead to a decline in the use of contraceptives. Two hundred seventy (91%) of the women would patronize safe abortion services for termination of an unwanted pregnancy (Table 3).

Discussion

To the best of our knowledge, this is the first study in Ghana focusing on the attitude of women with abortion-related complications toward the provision of safe abortion services. The median age of 26 years is indicative of the fact that abortion is an issue among sexually active and peak reproductive age women. The burden of abortion-related complications among admissions to the Gynaecology Ward of KATH is comparable to the 40.7% and 38.8% found in two earlier studies in Ghana. ^20,21

The findings suggest that women who had complications from induced abortion were more likely to be unmarried than those with complications from spontaneous abortion, and the most common reason for induced abortion was not being ready for a family. It is possible that some of the women who reported induced abortion falsely indicated they were married to avoid stigma. Those who had induced abortion were more likely to have formal education than women with spontaneous abortion. This may be explained by the fact that many of them were students who induced abortion because they were still in school.

About 92% of the women were not aware of the law permitting induced abortion under specific circumstances in Ghana. It is, however, encouraging that an equal proportion of the women are of the opinion that there was a need to provide safe abortion services and they were ready to patronize such a service. These findings, coupled with the fact that most doctors are willing to provide complementary roles in providing safe abortion services in Ghana, ¹² set the stage for successful provision of safe abortion services. The findings that about 32% of the women were of the opinion that the provision of safe abortion services would discourage the use of contraceptives and 42% thought that it would promote promiscuity are of concern. There is clearly a need to intensify education on the law regarding abortion and on contraceptives and family planning so that safe abortion services are not misconstrued as a method of family planning. ¹⁶ This notwithstanding, it is important for healthcare facilities to be available and fully equipped so as to make abortion safe and accessible.

Recently, it has been observed that misoprostol has emerged among women in the Kumasi metropolis as a popular abortifacient that is self-administered. It is relatively cheap, stable at ambient temperatures, procured over the counter, and usually administered vaginally, orally, or using a combination of both routes. This practice is corroborated by the findings in this study, where 83% of the women who reported having induced abortion in the index pregnancy self-administered misoprostol tablets. This practice of medical abortion among the public is difficult to distinguish from spontaneous abortions; thus, the percentage of patients in this study who actually had induced abortion but did not report it is unknown.

In terms of safe evacuation of the uterus, the management of women with incomplete spontaneous abortion is not different from those who have incomplete induced abortion. In both situations, vacuum aspiration or sharp curettage or a combination of both is used. A proposal has been made to clarify the medical language around pregnancy termination and uterine evacuation in general to better reflect clinical reality and to consistently classify all uterine evacuations using the characteristics of gestational age, technique, and indication. ⁷

This study involved only a selected subgroup of reproductive age women in Ghana. Their attitude toward the provision of safe abortion services may not be representative. Further community-based research on knowledge of and attitudes toward provision of safe abortion services among both sexes is being considered. Additional large-scale study of the abortion-seeking behavior and contraceptive use among women in Ghana is needed.