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Abortion care in Ghana: a critical review of the literature.

Introduction

Maternal mortality is a large and un-abating problem, mainly occurring in the developing world. According to the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), UNFPA and the World Bank, 287,000 women die each year worldwide from pregnancy-related causes (1). Sub-Saharan Africa has the highest maternal mortality ratio in the world of 500 per 100,000 births. WHO estimates 47,000 of these deaths per year are attributable to unsafe abortion, making abortion a leading cause of maternal mortality (2). Not all unsafe abortions result in death, disability or complications. The morbidity and mortality associated with unsafe abortion depend on the method used, the skill of the provider, the cleanliness of the instruments and environment, the stage of the woman's pregnancy and the woman's overall health (3). It is estimated that 5 million women per year from the developing world are hospitalized for complications resulting from unsafe abortions, resulting in long and short-term health problems (4). The health consequences and burdens resulting from unsafe abortion disproportionately affect women in Africa (5).

Unsafe abortion is defined by WHO as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimum medical standards, or both (6). Approximately 21.2 million unsafe abortions occur each year in developing regions of the world (1,7). Over 99% of all abortion-related deaths occur in developing countries. In sub-Saharan Africa, one in 150 women will die from complications of this procedure (6).

Although only 24% of abortions worldwide are performed in sub-Saharan Africa, almost half of deaths related to this procedure occur in the region (4,8). In many countries in sub-Saharan Africa women's access to safe abortion and post-abortion care for complications is hampered by restrictive laws, socio-cultural barriers, and inadequate resources to provide safe abortion (4,9-12).

The UN Millennium Development Goal (MDG) number 5 aims to reduce by three quarters the number of maternal deaths in the developing world. Without tackling the problems of unsafe abortion MDG 5 will not be reached (13,14).

Ghana

Ghana, a country in West Africa, has a population of approximately 24 million people. The average per capita income is approximately $1810 (15), placing Ghana in the middle income bracket. Ghana has a similar pattern of health as other countries in the region, characterized by a persistent burden of infectious disease among poor and rural populations, and growing non-communicable illness among the urban middle class. Following generalized progress in child vaccination rates through the 1980s and 1990s, and corresponding declines in infant and child mortality (from 120/1000 in 1965 to 66/1000 in 1990), progress has stalled maternal and under 5 indicators in rural areas in the past decade. The national under-five mortality rate remains at 78 deaths/1,000 live births (16). Maternal death is currently estimated at 350 per 100,000 live births (17). In Ghana, abortion complications are a large contributor to maternal morbidity and mortality. According to the Ghana Medical Association, abortion is the leading cause of maternal mortality, accounting for 15-30% of maternal deaths (18,19). Further, for every woman who dies from an unsafe abortion, it is estimated that 15 suffer short and long-term morbidities (20).

Compared to other countries in the region, the laws governing abortion in Ghana are relatively liberal. Safe abortion, performed by a qualified healthcare provider, has been part of the Reproductive Health Strategy since 2003 (19,21). When performed by well-trained providers in a clean environment, abortion is one of the safest medical procedures with complications estimated at 1 in 100,000 (8).

Currently in Ghana, abortion is a criminal offense regulated by Act 29, section 58 of the Criminal code of 1960, amended by PNDCL 102 of 198522. However, section 2 of this law states abortion may be performed by a registered medical practitioner when; the pregnancy is the result of rape or incest, to protect the mental or physical health of the mother, or when there is a malformation of the fetus. The government of Ghana has taken steps to mitigate the negative effects of unsafe abortion by developing a comprehensive reproductive health strategy that specifically addresses maternal morbidity and mortality associated with unsafe abortion (23).

Further, since midwives have been shown to safely and effectively provide post-abortion care in South Africa (24) and Ghana (19) a 1996 policy reform has allowed midlevel providers with midwifery skills to perform this service in Ghana (25). To ensure these providers have the skills necessary to perform the service, in 2009, Manual Vacuum Aspiration (MVA) was added to the national curriculum for midwifery education to train additional providers in this life-saving technique.

However, even with the liberalization of the law and the training of additional providers, abortion-related complications remain a problem. This integrated literature review aims to present findings from empirical research directly related to abortion provision, complete abortion care, or post-abortion care in Ghana and identify gaps for future research.

Search Strategy

The Pubmed, Ovid Medline, Global Health and Popline databases were searched with the keywords "Ghana & abortion". Pubmed returned 80 articles, Ovid Medline returned 70, Global Health returned 40 articles and Popline returned 78 articles, many of which overlapped. All titles and abstracts were reviewed. Inclusion criteria were: 1) English-language research articles; 2) published in a peer-reviewed journal after 1995; and 3) directly measured abortion services or provision. Manuscripts that only briefly mentioned abortion, commentaries, and literature reviews were not included in the final sample. A total of 39 articles met inclusion criteria and are included in this review (Figure 1).

Results

Complications and Admissions to Gynecology Ward: Abortion-related complications are repeatedly found to represent a large component of admissions to gynecological wards in hospitals in Ghana. Abortion complications resulted in 38.8%, 40.7%, 42.7% and 51%26-29 of all admissions to these wards in the articles reviewed for this paper. The majority of admissions were for the treatment of spontaneous abortion, although induced abortion is notoriously under-reported (4,12,26,30), and many women who reported spontaneous abortions had history that indicated induced abortion (31). Sundaram and colleagues (32) estimated that only 40% of abortions were reported in the 2007 Ghana Maternal Health Survey, even when participants were explicitly asked about their experiences with inducted abortions. Full results are provided in Table 1.

Demographic Factors Associated with Abortion Care

Many studies investigated demographic factors associated with abortion-care seeking with conflicting results. Several manuscripts found women of higher socioeconomic status, with more education, who are married, older, and living in urban areas to be more likely to obtain induced abortions. However, others reported younger, unmarried women were more likely to obtain induced abortions, when compared to women seeking care for spontaneous abortion (28,31,33,36).

Prevalence of Obtaining an Induced Abortion

The prevalence of obtaining an induced abortion varied greatly in the studies reported here. The highest rate reported was by Agyei and colleagues (37) who found 47% of the female respondents in their study reporting at least one pregnancy underwent an abortion sometime in her life. Morhe et al (38) found 36.7 of the adolescents in their sample outside of Kumasi had experienced an abortion. Ahiadeke (36,39) reports an abortion rate of 27 per 100 live births using data from the Maternal Survey Project. Krakowiak-Reed et al (40) found 20% of their community-based sample outside Kumasi had had at least one abortion. Oliveras et al. (34) found between 10% and 17.6% of women in their study reported their previous pregnancy ended in induced abortion. Geelhoed and colleagues (41) found a prevalence of induced abortion of 22.6%, which falls in the range reported elsewhere (42). Glover et al (43) found that 70% of ever-pregnant youth in their sample reported attempting an abortion. Sundaram et al (32) state approximately 10% of the sample for the 2007 Maternal Health Survey reported having had an abortion in the five years prior to the survey. However, the authors note that this rate is likely highly under-reported.

Abortion and Maternal Mortality

Many studies sought to estimate the proportion of maternal mortality associated with unsafe abortion. Mills and colleagues (44) found abortion-related causes to be the leading cause of maternal death in rural northern Ghana, as did Baiden and colleagues (10). Ohene et al (45) discovered that the majority of adolescent maternal deaths at Korle Bu Teaching Hospital in Accra were due to complications from unsafe abortion. Abortion complications were the leading cause of death among the youngest women in a sample of maternal deaths at Tamale Teaching Hospital, and the fourth leading cause overall (45). Abortion complications were the second leading cause of death due to maternal causes, behind post-partum hemorrhage, between 2004-2009, a period which spans the introduction of the policy changes around abortion care, in the Eastern region (47). Lee et al (48) discovered that genital tract sepsis, often as a result of an abortion, had the highest case-fatality rate of all the causes of maternal death in their study. In the Brong Ahafo region, Geelhoed et al (41) found that abortion complications were the leading cause of maternal death at the Berekum District Hospital.

Abortion Law

Although the law governing abortion in Ghana is relatively liberal, and the 2006 policy change has made abortion services part of the national reproductive health strategy, no literature was found evaluating the impact of that policy change. The fact that admissions to the gynecological wards due to complications from abortion does not appear to have dramatically declined since the implementation of the 2006 policy suggests that women are not accessing safe abortion services, if they exist (26,49). Different cadres of health providers were found to be unsure of the law governing abortion services (50,51) and women who were interviewed were also unsure of the law (26,52). In the Brong Ahafo region, Hill and colleagues (52) found that abortion was deemed illegal, dangerous and bringing public shame, but also being perceived as common, understandable, and necessary. Although Clark et al (25) found that post-abortion care (PAC) services remain limited, despite wide-spread training in the service, while Baird et al (53) report that PAC training for midwives is an effective way to increase access to the service. Including post-abortion care as part of comprehensive family planning training for midwives has the potential to empower these providers and the women they serve to make choices about contraception (54). Graff & Amoyaw (11) identified sustainable access to MVA equipment as a major barrier to MVA services. Laar (55) found in an analysis of Ghanaian print media that less than 1% of total newspaper coverage was dedicated to family planning, abortion, and HIV, underscoring the dearth of information available to many in the Ghanaian public.

Abortion and Contraception

One of the main findings in many of the papers reviewed is the lack of modern contraception being used by the majority of Ghanaian women. Many of the papers found a high unmet need for contraception defined as currently engaging in sexual activity without using contraception but without intending to get pregnant (9,32,33,56). There is an urgent need to improve access to reliable contraception for Ghanaian women. Many Ghanaian women report being wary of using contraception for fear of side effects that may impair future fertility (9). Biney (56) noted that women in her study viewed contraception as more harmful to their health than abortion. Obed & Wilson (57) reported 81% of their sample of women being treated for abortion complications desired further children, although almost one-third had to have a hysterectomy to treat the complications from their abortion and were thus unable to have further children. Mac Domhnaill and colleagues (58) found schoolgirls in their sample were much more aware of abortion methods than of contraception and many explicitly mentioned not using contraception because they knew how to abort if necessary. Adanu and colleagues (33) reported women seeking care for induced abortion were more aware of modern contraception than their counterparts seeking care for spontaneous abortion, although this did not translate into higher usage rates.

Identified Gaps for Further Research

The biggest gaps identified through this review are the experiences of women with securing an induced abortion to end an unwanted pregnancy. Hospital-based chart reviews are important to understand the types of cases being treated. Surveys examining the reasons for securing an induced abortion shed some light on this issue. However, information regarding the process by which a woman seeks an induced abortion is still lacking. Gathering information from women regarding their experiences securing safe and legal abortions and reasons for resorting to unsafe methods will enable policy makers to pinpoint interventions to prevent life-threatening complications. Specifically, why do women resort to dangerous methods of aborting unwanted pregnancies?

Discussion

Complications from unsafe abortion have been and remain a large component of maternal mortality and morbidity in Ghana. Although responding to international calls to liberalize the law governing abortion and training more providers in the service, Ghana has not yet realized a large reduction in complications from unsafe abortions. Knowledge of the law appears to remain limited, among both healthcare providers and the general population. Work to improve this is warranted.

There appears to be a robust literature around abortion in Ghana. However, this review did identify gaps in the literature and future directions for research. The heavy reliance on hospital-based retrospective chart reviews, while an important step to establish the general burden of disease attributable to abortion-related complications, needs to be expanded. The studies completed were generally of a high scientific standard, although the data were often limited by what was documented in charts or log books. The few purposefully-designed surveys elucidated interesting observations that need to be augmented by qualitative work to answer some of the deeper questions of the process by which women undertake unsafe abortions. It has been documented that many women are seeking care outside (59) the formal healthcare system in unsafe locations from unsafe providers (33), however reasons why have not been investigated. Is it a lack of awareness of the legality of this procedure? Are there not enough providers in communities close to where the women live? Is cost prohibitive? Both women seeking care for post-abortion care and providers of abortion have been shown to be unclear of the law governing abortion in Ghana. Konney et al (26) found 92% of women being treated for abortion complications at Komfo Anokye Teaching Hospital were unaware of the law and Voetagbe et al (51) noted an alarmingly high proportion of midwifery tutors were not aware of the full law governing the provision of safe abortion services. If teachers are not sure of the law, the midwives who they train will also likely be uncertain of the conditions under which they are legally allowed to provide complete abortion care.

Accessibility of abortion care was defined by Billings et al (19) as 1) distance from a woman's home; 2) cost of services and payment options; 3) waiting time for services/total length of stay; and 4) social proximity to the provider. All of these accessibility issues require further investigation, with an operations-research design that could address many of them.

The repeated finding of the high incidence of abortion complications and resulting hospitalizations in the tertiary care centers, as well as some smaller district-level hospitals in the country, highlights the need to adequately train providers to treat complications resulting from abortions, whether these abortions are spontaneous or induced. Assessing the ability of public hospitals to safely provide treatment for post-abortion complications, as well provide a safe and affordable place for women to access comprehensive abortion care, is necessary. Women in urban areas appear to have greater access to safe abortion services, although the availability country-wide has not been assessed. The government of Ghana has responded to the need to provide treatments for post-abortion complications by recently adding training in MVA to the curriculum of midwifery training colleges. An assessment to assure midwives are graduating knowing how to handle these complications will be a necessary next step to ensure the safety of Ghanaian women who suffer from post-abortion complications.

Although demographic differences were found in many of the papers, it is conceivable the differences found could be explained by selection bias, as most of the studies reporting this information are hospital-based surveys conducted at the large referral centers, either Korle Bu in Accra or Komfo Anokye Teaching Hospital in Kumasi. Women in rural areas without the means to travel to and be treated at these tertiary care centers will therefore not be included in the sample. It is unclear from these studies whether the differences reported are due to differences in sampling techniques and survey populations or to true differences in the need for abortion services. In the 2007 Maternal Health Survey, as reported by Sundaram and colleagues (32), which is nationally representative, women in their twenties who have never been married, have no children, have terminated a pregnancy before, are Protestant or Pentecostal/Charismatic, of higher SES, and know the legal status of abortion are more likely to seek an abortion. Further, they found younger women were less 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.

The repeated findings of how few women are using contraception both preceding and following an abortion are worrisome. There is an urgent need to improve access to reliable contraception for Ghanaian women. However, the results from many studies indicate simply improving access to modern contraception may not improve utilization if women are more afraid of the side effects of contraception than of complications from unsafe abortion (9,56). This fear is ironic considering the very real negative health implications that follow unsafe abortions. Those who know more about contraception were found not to be more likely to use it, suggesting that simply providing information does not seem adequate to substantially increase usage (33).

Although not directly investigated in the studies reported here, unfamiliarity with the legal status of abortion appears to be a driver of women seeking care in unsafe locations outside the formal healthcare system. Future work needs to be done to evaluate the best ways to educate health workers and the public on the law and availability of services. Qualitative work interviewing healthcare providers, policymakers, and community members to elucidate interventions to improve the provision of safe abortion services and post-abortion care is necessary. Billings and colleagues (19) note that to understand the role midwives can play in providing safe abortion, further research should be conducted at the community level. Hill and colleagues (51) suggest purposefully designing qualitative studies to assess the perceptions of healthcare workers towards providing safe abortion services, as well as asking participants to report on friends' use of abortion services to determine rates. Aniteye and Mayhew (9) recommend qualitative work with women undergoing treatment for abortion complications to elucidate reasons they are not using family planning methods.

Conclusion

The government of Ghana has made the important initial steps of reducing legal barriers to safe abortion services and increasing the training of qualified personnel (30) in order to reduce the burden of disease attributable to unsafe abortion. However, complications from unsafe abortion are still a large contributor to women's mortality and morbidity. Future work is needed to investigate barriers that prevent women from accessing safe abortion services and to ensure that Ghanaian women have access to safe abortion as fully allowed by the law.

Contribution of Authors

SR conceptualized the research and performed the initial searches. JR reviewed search results. SR wrote the first draft of the manuscript. JR edited the manuscript. Both authors reviewed the final version of the manuscript.

References

(1.) World Health Organization (WHO). 2012 Safe abortion: technical and policy guidance for health systems. 2nd ed. Geneva: WHO.

(2.) Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, 3rd ed. Geneva, World Health Organization, 2011.

(3.) World Health Organization (WHO). 2004. Unsafe abortion. Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000. 4th ed. Geneva: WHO.

(4.) Singh S. Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet 2006; 368(95550): 1887-1892.

(5.) Shah I, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences and challenges. Journal of Obstetrics and Gynecology Canada, 2009, 31 (12): 1149-1158.

(6.) World Health Organization (WHO). 1997. Unsafe abortion. Global and regional estimates of incidence of and mortality due to unsafe abortion with a listing of available country data. 3rd ed. Geneva: WHO.

(7.) Aahman E, Shah I. Unsafe abortion: global and regional estimates of unsafe abortion and associated mortality in 2000, 4th edition. Geneva: WHO, 2004.

(8.) World Health Organization. Unsafe abortion: global and regional estimates of incidence of unsafe abortion and associated mortality in 2003. Geneva: WHO, 2007.

(9.) Aniteye P, Mayhew S. Attitudes and experiences of women admitted to hospital with abortion complications in Ghana. Afri J Reprod Health. 2011. 15(1): 47-55

(10.) Baiden F, Amponsa-Achiano K, Oduro AR, Mehsah TA, Baiden R, Hodgson A. Unmet need for essential obstetric services in a rural district hospital in northern Ghana: complications of unsafe abortions remain a major cause of mortality. Journal of the Royal Institute of Public Health. 2006. 120(5): 421-426.

(11.) Graff M, Amoyaw DA. Barriers to sustainable MVA supply in Ghana: challenges for the low-volume, low-income providers. Afri J Reprod Health. 2009. 13(4): 73-80.

(12.) Lithur NO. Destigmatizing abortion: expanding community awareness of abortion as a reproductive health issue in Ghana. Afri J Reprod Health. 2004. 8(1): 70-74.

(13.) Hu D, Grossman D, Levin C, Blanchard K, Adanu R, Goldie SJ. Cost-effectiveness analysis of unsafe abortion and alternative first-trimester pregnancy termination strategies in Nigeria and Ghana. Afri J Reprod Health 2010; 14(2): 85-103.

(14.) Facts on induced abortion Worldwide. World Health Organization, Department of Reproductive Health and Research. Geneva, 2012.

(15.) Global Health Observatory, 2009. Accessed from http://www.who.int/countries/gha/en/. July 23, 2013.

(16.) UNICEF Country Statistics, Ghana. Accessed from http://www.unicef.org/infobycountry/ghana_statistics. html January 9, 2014.

(17.) The State of World's Midwifery 2011: Delivering Health, Saving Lives. UNFPA, 2011

(18.) Asamoah BO, Moussa KM, Stafstrom M, Musinguzi G. Distribution of causes of maternal mortality among different socio-demographic groups in Ghana; a descriptive study. BMC Public Health. 2011, 11: 159

(19.) Billings DL, Ankrah V, Baird TL, Taylor JE, Ababio KPP, Ntow S. (1999) Midwives and comprehensive postabortion care in Ghana. In Postabortion Care: Lessons from Operations Research. Huntington and Piet-Pelon (eds). New York, New York; Population Council.

(20.) Eades CA, Brace C, Osei L, LaGuardia KD Traditional birth attendants and maternal mortality in Ghana. Soc. Sci. Med. 1993;36(11):1503-1507

(21.) Sedge G, Abortion in Ghana. In Brief. New York: Guttmacher Institute, 2010, No. 2

(22.) Morhe RAS, Morhe ESK. Overview of the law and availability of abortion services in Ghana. Ghana Medical Journal. 2006; 40(1): 80-86.

(23.) Taylor J, Diop A, Blum J, Dolo O, Winikoff B. Oral misoprostol as an alternative to surgical management for incomplete abortion in Ghana. International Journal of Gynecology and Obstetrics. 2011; 112: 40-44

(24.) Sibuyi MC. Provision of safe abortion services by midwives in Limpopo Province of South Africa. Afr J Reprod Health. 2004; 8(1):75-78

(25.) Clark KA, Mitchell EhM, Aboagye PK. Return on investment for essential obstetric care training in Ghana: do trained public sector midwives deliver postabortion care? Journal of Midwifery and Women's Health. 2010; 55(2):153-161

(26.) Konney TO, Danso KA, Odoi AT, Opare-Addo HS, Morhe ESK. Attitude of women with abortion-related complications toward provision of safe abortion services in Ghana. J Womens Health. 2009;18(11):1863-6.

(27.) Srofenyoh EK, Lassey AT. Abortion care in a teaching hospital in Ghana. International Journal of Gynecology and Obstetrics. 2003. 82: 77-78.

(28.) Turpin CA, Danso KA, Odoi AT. Abortion at Komfo Anokye Teaching Hospital. Ghana Medical Journal. 2002; 36(2): 60-64.

(29.) Yeboah RwN, Kom MC. Abortion: The case of Chenard Ward, Korle Bu from 2000 to 2001. Research Review. 2003. 57-66.

(30.) Cohen SA. Access to safe abortion services in the developing world: Saving lives while advancing rights. Guttmacher Policy Review. 2012 15(4): 2-6.

(31.) Adanu RMK, Tweneboah. Reasons, fears and emotions behind induced abortions in Accra, Ghana. Research Review. 2004: 20(2): 1-9.

(32.) Sundaram A, Juarez F, Bankole A, Singh S. Factors associated with abortion-seeking and obtaining a safe abortion in Ghana. Studies in Family Planning 2012; 43(4): 273-286.

(33.) Adanu RMK, Ntumy MN, Tweneboah E. Profile of women with abortion complications in Ghana. Tropical Doctor. 2005; 35(3): 139-142.

(34.) Oliveras E, Ahiadeke C, Adanu RM, Hill AG. Clinic based surveillance of adverse pregnancy outcomes to identify induced abortions in Accra, Ghana. Studies in Family Planning. 2009; 39(2): 133-140

(35.) Schwandt HM, Creanga AA, Danso KA, Adanu RMK, Agbenyega T, Hindin MJ. A comparison of women with induced abortion, spontaneous abortion and ectopic pregnancy in Ghana. Contraception. 2011. 84(1): 87-93

(36.) Ahiadeke C. The incidence of self-induced abortion in Ghana: What are the facts? Research Review. 2002; 18(1): 33-42

(37.) Agyei WKA, Biritwum RB, Ashitey AG, Hill RB. Sexual behavior and contraception among unmarried adolescents and young adults in Greater Accra and Eastern Regions of Ghana. Journal of biosocial Science. 2000; 32(4): 495-512.

(38.) Morhe ESK, Tagbor HK, Ankobea F, Danso KA. Reproductive experiences of teenagers in the Ejisu-Juabeng district of Ghana. International Journal of Gynecology and Obstetrics. 2012; 118(2): 137-40

(39.) Ahiadeke C. Incidence of induced abortion in Southern Ghana. International Family Planning Perspectives. 2001; 27(2): 96-108.

(40.) Krakowiak-Redd D, Ansong D, Otupiri E, Tran S, Klanderud D, Boakye I, Dickerson T, Crookston B. Family planning in a sub-district near Kumasi, Ghana: Side effect fears, unintended pregnancies and misuse of medication as emergency contraception. Afri J Reprod Health. 2011; 15 (3): 121

(41.) Geelhoed DW, Nayembil D, Asare K, Schagen van Leeuwen JH, van Roosmale J. Contraception and induced abortion in rural Ghana. Tropical Medicine and International Health. 2002. 70(8): 708-716.

(42.) Mote CV, Otupiri E, Hindin M. Factors associated with induced abortion among women in Hohoe, Ghana. African Journal of Reproductive Helath. 2010; 14(4): 115-121.

(43.) Glover EK, Bannerman A, Pence BW, Jones H, Miller R, Weiss E, Nerquaye-Tetteh J. Sexual health experiences of adolescents in three Ghanaian towns. International Family Planning Perspectives. 2003; 29(1): 32-40.

(44.) Mills S, Williams JE, Wak G, Hodgson A. Maternal mortality decline in the Kassena-Nankana district of northern Ghana. Maternal and Child Health Journal. 2008; 12: 577-585.

(45.) Ohene SA, Tettey Y, Kumoji R. Cause of death among Ghanaian adolescents in Accra using autopsy data. BMC Research Notes. 2011; 12(4):353

(46.) Gumanga SK, Kolbila DZ, Gandau BBN, Munkaila A, Malechi H, Kyei-Aboagye K. Trends in maternal mortality in Tamale Teaching Hospital, Ghana. Ghana Medical Journal. 2011; 45(3); 105-110.

(47.) Ganyaglo GYK. A 6-year (2004-2009) review of maternal mortality at the Eastern Regional Hospital, Koforidua, Ghana. Seminars in Perinatology. 2012; 36(1): 79-83.

(48.) Lee QY, Odoi AT, Opare-Addo H, Dassah ET. Maternal mortality in Ghana: a hospital-based review. Acta Obstetricia et Gynecologica Scandinavica. 2012; 91(1):87-92

(49.) Henaku RO, Horiuchi S, Mori A. Review of unsafe/ induced abortions in Ghana: Development of reproductive health awareness materials to promote adolescents health. Bulletin of St. Luke's College of Nursing. 2007; 33(3): 93-102

(50.) Morhe ES, Morhe RA, Danso KA. Attitudes of doctors towards establishing safe abortion units in Ghana. International Journal of Gynecology and Obstetrics. 2007; 98(1):70-74

(51.) Voetagbe G, Yellu N, Mills J, Mitchell E, Adu Amankway A, Jehu-Appiah K, Nyante F. Midwifery tutors' capacity and willingness to teach contraception, post-abortion care, and legal pregnancy termination in Ghana. Human Resources for Health. 2010. 8(2).

(52.) Hill ZE, Tawiah-Agyemang C, Kirkwood B. The context of informal abortions in rural Ghana. Journal of Women's Health. 2009; 18(12); 2017-2022.

(53.) Baird TL, Billings DL, Demuyakor B. Community education efforts enhance postabortion care program in Ghana. American Journal of Public Health. 2000; 90(4): 631-632.

(54.) Fullerton J, Fort A, Johal K. A case/comparison study in the Eastern region of Ghana on the effects of incorporating selected reproductive health services on family planning services. Midwifery. 2002; 19: 17-26.

(55.) Laar AK. Family planning, abortion and HIV in Ghanaian print media: A 15-month content analysis of a national Ghanaian newspaper. Afri J Reprod Health. 2010; 14(1): 80.

(56.) Biney AAE. Exploring contraceptive knowledge and use among women experiencing induced abortion in the Greater Accra region, Ghana. Afri J Reprod Health. 2011; 15(1): 37-46.

(57.) Obed SA, Wilson JB. Uterine perforation from induced abortion at Korle Bu Teaching Hospital, Accra, Ghana: A five year review. West African Journal of Medicine. 1999; 18(4): 286-289.

(58.) Mac Domhnaill B, Hutchinson G, Milev A, Milev Y. The social context of schoolgirl pregnancy in Ghana. Vulnerable Children and Youth Studies. 2011; 6(3): 201-207.

(59.) Lassey AT. Complications of induced abortions and their preventions in Ghana. East African Medical Journal. 1995. 72(12): 774-777.

Sarah D Rominski [1] * and Jody R Lori [2]

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

* For Correspondence: E-mail: sarahrom@umich.edu, Phone: 001-734-717-5930.

Authors           Title, Journal              Findings
and Year

1. Morhe ESK,     Reproductive                Teenagers have
Tagbor HK,        experiences of              their sexual
Ankobea F,        teenagers in the Ejisu-     debuts at young
Danso KA.         Juabeng district of         ages. 36.7% of
2012              Ghana. International        the females have
                  Journal of Gynecology       had at least
                  and Obstetrics              one abortion.

2. Lee QY,        Maternal mortality in       Genital tract
Odoi AT,          Ghana: a hospital-          sepsis, often as
Opare-Addo H,     based review. Acta          a result of an
Dassah ET.        Obstetricia et              abortion, had the
2012              Gynecologica                highest case-fatality
                  Scandinavica                rate of all the
                                              causes of maternal
                                              death in this study.

3. Ganyaglo       A 6-year (2004-2009)        Abortion complications
GYK, Hill WC.     review of maternal          were the second
2012              mortality at the East       leading cause of
                  Regional Hospital,          maternal mortality,
                  Koforidua, Ghana.           behind post-partum
                  Seminars in                 hemorrhage. The
                  Perinatology                largest proportions
                                              of post-abortion
                                              deaths were due to
                                              sepsis (29 of the
                                              37 post-abortion
                                              deaths).

4. Sundaram A,    Factors associated          Almost half of all
Juarez F,         with abortion-seeking       reported abortions
Bankole A,        and obtaining an            were conducted
Singh S. 2012     unsafe abortion in          unsafely. The profile
                  Ghana. Studies in           of women who seek an
                  Family Planning             abortion is:
                                              unmarried, in their
                                              20s, have no
                                              children, have
                                              terminated a
                                              pregnancy before,
                                              are Protestant or
                                              Pentecostal/
                                              Charismatic, of higher
                                              SES, and know the
                                              legal status of
                                              abortion. Younger
                                              women were less
                                              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
Redd D,           sub-district near           had had at least
Ansong D,         Kumasi, Ghana: Side         one abortion
Otupiri E, Tran   effect fears,
S, Klanderud      unintended
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
Mayhew S.         experiences of women        women were young and
2011              admitted to hospital        single. The majority
                  with abortion               of women had help
                  complications in            performing their
                  Ghana. African              abortion and most
                  Journal of                  accessed post-
                  Reproductive Health         abortion care at
                                              a health facility
                                              shortly after
                                              experiencing
                                              complications.

7. Gumanga        Trends in maternal          The institutional
SK, Kolbila       mortality in Tamale         maternal mortality
DZ, Gandau        Teaching Hospital,          rate was 1018 per
BBN, Munkaila     Ghana. Ghana                100,000 live births
A, Malechi H,     Medical Journal             was recorded between
Kyei-Aboagye                                  2006 and 2010.
K                                             Complications from
2011                                          unsafe abortion was
                                              the leading cause of
                                              maternal death for
                                              youngest women, and
                                              the 4th leading
                                              cause overall.

8. Biney AAE      Exploring                   Many respondents noted
2011              contraception               that prior to their
                  knowledge and use           induced abortion, they
                  among women                 had no knowledge about
                  experiencing induced        contraception, but
                  abortion in the Greater     since the abortion
                  Accra region, Ghana.        they had been using
                  African Journal of          it. Women also
                  Reproductive Health         mentioned feeling
                                              contraception was
                                              more dangerous to
                                              their health than
                                              was induced abortion.

9. Ohene SA,      Cause of death among        20/27 maternal deaths
Tettey Y,         Ghanaian adolescents        to adolescents were a
Kumoji R.         in Accra using autopsy      consequence of
2011              data. BMC Research          abortion.
                  Notes

10. Mac           The social context of       Student's knowledge
Domhnaill B,      school girl pregnancy       of abortive methods
Hutchinson G,     in Ghana. Vulnerable        was considerably more
Milev A, Milev    Children and Youth          detailed than their
Y.                Studies                     knowledge of
2011                                          contraception. Many
                                              explicitly mentioned
                                              not using
                                              contraception 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
HM, Creanga       women with induced          reported spontaneous
AA, Danso KA,     abortion, spontaneous       abortion between June
Adanu RMK,        abortion and ectopic        and July 2008. Those
Agbenyega T,      pregnancy in Ghana.         with reported induced
Hindin MJ                                     abortion were more
2011              Contraception               likely to have more
                                              power in their
                                              relationships and to
                                              have not disclosed
                                              the index pregnancy
                                              to their partners.

12. Mote CV,      Factors associated          One-fifth (21.3%) of
Otupiri E,        with induced abortion       respondents reported
Hindin MJ.        among women in              having had an induced
2010              Hohoe, Ghana.               abortion. Most common
                  African Journal of          reasons for having an
                  Reproductive Health.        abortion: "not to
                                              disrupt education or
                                              employment" and "too
                                              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
G, Yellu N,       capacity and                tutors surveyed knew
Mills J,          willingness to teach        all the legal
Mitchell E,       contraception, post-        indications under
Adu-              abortion care, and          which safe abortion
Amankway A,       legal pregnancy             could be provided.
Jehu-Appiah K,    termination in Ghana.       These tutors were
Nyante F.         Human Resources for         not taught manual
2010              Health                      vacuum aspiration
                                              during their
                                              training.

14. Laar AK       Family planning,            This analysis showed
2010.             abortion and HIV in         that family planning,
                  Ghanaian print media:       abortion and HIV
                  A 15-month content          received less than
                  analysis of a national      1% of total newspaper
                  Ghanaian newspaper.         coverage in one
                  African Journal of          national Ghanaian
                  Reproductive Health         newspaper.

15. Clark KA,     Return on investment        The availability
Mitchell EHM,     for essential obstetric     of PAC in Ghana
Aboagye PK        care training in Ghana:     remains limited. Far
2010              Do trained public           fewer midwives than
                  sector midwives             physicians offer PAC,
                  deliver postabortion        even after having
                  care? Journal of            received PAC clinical
                  Midwifery and               training, although an
                  Women's Health              analysis of the
                                              curriculum and
                                              training was outside
                                              the scope of
                                              this study.

16. Graff M,      Barriers to sustainable     Sustainable access to
Amoyaw DA         MVA supply in               MVA equipment has
2009              Ghana: Challenges for       been challenging
                  the low-volume, low-        particularly for
                  income providers.           low-volume, low-
                  African Journal of          income providers.
                  Reproductive Health.        Although many of the
                                              midwives in rural
                                              areas had the skills
                                              to provide MVA, they
                                              did not have the
                                              equipment and thus
                                              continued to refer
                                              women to district or
                                              regional hospitals.

17. Hill ZE,      The context of              Key themes were
Tawiah-           informal abortions in       related to the
Agyemang C,       rural Ghana. Journal        perception of
Kirkwood B.       of Women's Health.          abortions as illegal,
2009                                          dangerous, and
                                              bringing public shame
                                              and stigma but also
                                              being perceived as
                                              common,
                                              understandable, and
                                              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
TO, Danso KA,     with abortion-related       complications
Odoi AT,          complications toward        accounted for 42.7%
Opare-Addo        provision of safe           of admissions to the
HS, Morhe         abortion services in        gynecological ward at
ESK.              Ghana. Journal of           KATH, 28% of whom
2009              Women's Health              indicated an induced
                                              abortion. 92% of the
                                              women interviewed were
                                              not aware of the law
                                              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
Ahiadeke C,       surveillance of adverse     the questions.
Adanu RM,         pregnancy outcomes          Younger, better
Hill AG           to identify induced         educated and
2008              abortion in Accra,          unmarried women are
                  Ghana. Studies in           more likely to have
                  Family Planning.            had an induced
                                              abortion. Between
                                              10-17.6% of women
                                              report having had
                                              an abortion. Women
                                              seeking care at a
                                              private facility
                                              were more than twice
                                              as likely to have
                                              ended their previous
                                              pregnancy by induced
                                              abortion.

20. Mills S,      Maternal Mortality          Abortion-related
Williams JE,      Decline in the              deaths were the most
Wak G,            Kassena-Nankana             frequent cause of
Hodgson A         District of Northern        maternal deaths in
2008              Ghana. Maternal and         this sample in the
                  Child Health Journal        Northern Region.

21. Morhe         Attitudes of doctors        Most physicians were
ESK, Morhe        toward establishing         supportive of playing
RAS, Danso        safe abortion units in      some role in
KA                Ghana. International        developing safe
2007              Journal of Obstetrics       abortion units in
                  and Gynecology              hospitals in Ghana.
                                              However, only 54% of
                                              maternal and child
                                              health-related health
                                              workers were aware of
                                              the true nature of the
                                              abortion law, 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
RMK, Ntumy        abortion complications      for complications
MN,               in Ghana. Tropical          from induced abortion.
Tweneboah E.      Doctor                      Those seeking care for
2005                                          induced abortion were
                                              younger, or lower
                                              parity, more
                                              education, less
                                              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
Amponsa-          essential obstetric         abortion were the
Achiano K,        services in a rural         leading cause of
Oduro AR,         district northern           maternal mortality.
Mehsah TA,        Ghana: Complications        Although abortion is
Baiden R,         of unsafe abortions         considered taboo
Hodgson A.        remain a major cause        in NKD, according
2006              of mortality. Public        to clinic evidence,
                  Health                      there is a high
                                              incidence of
                                              backstreet and unsafe
                                              practices. The
                                              district hospital
                                              did not have any
                                              access to formal
                                              safe abortion
                                              services.

24. Adanu         Reasons, fears and          Women having induced
RMK &             emotions behind             abortion were younger,
Tweneboah E       induced abortions in        better educated, less
2004              Accra, Ghana.               likely to be married.
                  Research Review             31.3% were reported
                                              to be induced
                                              abortion. Many who
                                              reported 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
RWN & MC          Chenard Ward, Korle         admissions are due
Kom.              Bu from 2000 to 2001.       to incomplete
2003              Research Review             abortions, although
                                              there were not
                                              classified by
                                              spontaneous or
                                              induced. Reported
                                              cases of induced
                                              abortions are high.

26. Glover EK,    Sexual health               35% of the female
Bannerman A,      experiences of              respondents reported
Pence BW,         adolescents in three        ever being pregnant,
Jones H, Miller   Ghanaian towns.             and 70% of those
R, Weiss E,       International Family        reported having had
Nerquaye-         Planning Perspectives.      or attempted an
Tetteh J.                                     abortion.
2003

27. Srofenyoh     Abortion care in a          30% of induced
EK, Lassey AT     teaching hospital in        abortions had
2003              Ghana. International        complications while
                  Journal of                  10% of spontaneous
                  Gyneaecology and            abortions had
                  Obstetrics                  complications. 15%
                                              of maternal deaths
                                              over the study period
                                              were due to
                                              complications from
                                              abortion. Abortion
                                              complications were
                                              the leading cause of
                                              admission to the
                                              maternity ward
                                              (40.7% of all
                                              admissions).

28. Geelhoed      Trends in maternal          Institutional
DW, Visser LE,    mortality: a 13-year        maternal mortality
Asare K,          hospital-based study in     rate of 1077 per
Schagen van       rural Ghana. European       100,000 live births.
Leeuwen JH,       Journal of Obstetrics       Abortion
van Roosmalen     and Gynecology.             complications were
J.                                            the leading cause
2003                                          (43 of the 229
                                              deaths)

29. Srofenyoh     Abortion care in a          40% of
EK, Lassey AT     teaching hospital in          admissions
2003              Ghana. International        over the study
                  Journal of Gynecology       period were
                  and Obstetrics              related to
                                              abortion
                                              complications.
                                              Almost 77% were
                                              spontaneous
                                              abortions. 30%
                                              with induced
                                              abortion had
                                              serious
                                              complications
                                              while 10% of
                                              spontaneous
                                              abortion had
                                              similar
                                              complications.

30. Turpin CA,    Abortion at Komfo           Abortion
Danso KA,         Anokye Teaching             complications
Odoi AT           Hospital. Ghana             accounted for
2002              Medical Journal             38.8% of
                                              admissions to
                                              the KATH Ob-Gyn
                                              ward in 1994.
                                              Induced
                                              abortions were
                                              more common in
                                              younger,
                                              unmarried women.
                                              The majority of
                                              induced
                                              abortions
                                              occurred in the
                                              15-19 year old
                                              group.

31. Blanc A,      Greater than expected       The total
Grey S. 2002      fertility decline in        fertility rate
                  Ghana: Untangling a         in Ghana has
                  puzzle. Journal of          declined at a
                  Biosocial Science           higher rate than
                                              would be
                                              expected by the
                                              contraception
                                              prevalence rate.
                                              The authors find
                                              evidence of
                                              widespread
                                              abortion to
                                              control
                                              fertility,
                                              although
                                              accurate rates
                                              are hard to
                                              determine. The
                                              authors also
                                              note that the
                                              gap between
                                              expected
                                              fertility given
                                              contraception
                                              utilization and
                                              actual fertility
                                              is greater in
                                              urban areas than
                                              rural areas
                                              lends support to
                                              couples using
                                              abortion to
                                              limit or space
                                              births.

32. Geelhoed      Gender and unwanted         Induced
DW, Nayembil      pregnancy: a                abortions were
D, Asare K,       community-based             reported by
Schagen van       study in rural Ghana.       22.6% of the
Leeuwen JH,       Journal of                  surveyed
van Roosmale      Psychosocial                population.
J. 2002           Obstetrics and Gynecology   28.2% of women
                                              reported having
                                              had an induced
                                              abortion. More
                                              women than med
                                              reported an
                                              unwanted
                                              pregnancy ending
                                              in abortion,
                                              perhaps
                                              signaling female
                                              independence in
                                              deciding on
                                              abortion care.

33. Ahiadeke C    The incidence of self       The rates
2002              induced abortion in         identified here
                  Ghana: What are the         suggest that
                  facts? Research             over a lifetime,
                  Review.                     900 abortions
                                              per 1,000 women
                                              will be
                                              performed. The
                                              majority of
                                              women reported
                                              receiving their
                                              abortion from
                                              outside the
                                              formal
                                              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
D, Nayembil D,    induced abortion in         participants had
Asare K,          rural Ghana. Tropical       experienced an
Schagen JH,       Medicine and                unwanted
van Roosmalen     International Health.       pregnancy in
J.                                            their lives.
2002                                          Socioeconomic
                                              reasons were the
                                              most common for
                                              why a pregnancy
                                              was unwanted

35. Ahiadeke      Incidence of induced        317/1,689 women
2001              abortion in southern        aborted
                  Ghana. International        pregnancies (19/
                  Family Planning             100, 27/100 live
                  Perspectives                births, 17/
                                              1,000 women of
                                              reproductive
                                              age). Majority
                                              of women were
                                              under 30,
                                              married,
                                              Christian.
                                              Abortions
                                              happened outside
                                              the formal
                                              health sector.

36. Agyei         Sexual behaviour and        A majority of
WKA,              contraception among         the young adults
Biritwum RB,      unmarried adolescents       surveyed were
Ashitey AG,       and young adults in         sexually
Hill RB           Greater Accra and           experienced,
2000              Eastern Regions of          although few
                  Ghana. Journal of           were using
                  Biosocial Science           contraception.
                                              Approximately
                                              47% of those
                                              adolescents who
                                              had been
                                              sexually active
                                              reporting having
                                              had an abortion.
                                              While most
                                              participants
                                              were aware of
                                              modern methods
                                              of
                                              contraception,
                                              few used them.

37. Baird TL,     Community education         Post-abortion
Billings DL,      efforts enhance             care training
Demuyakor B.      postabortion care           for midwives was
2000              program in Ghana.           effective.
                  American Journal of         Community-
                  Public Health               outreach was
                                              effective at
                                              educating the
                                              public about the
                                              new services
                                              being offered by
                                              midwives.

38. Obed SA &     Uterine perforation         21.1% of the
Wilson JB         from induced abortion       10,518 cases of
1999              at Korle Bu Teaching        abortion
                  Hospital, Accra,            complication
                  Ghana: A five year          treatments for
                  review. West African        abortion were
                  Journal of Medicine         considered to be
                                              induced. 79
                                              (3.6%) of those
                                              had uterine
                                              perforation.
                                              40.9% (n=29)
                                              induced their
                                              abortion because
                                              they were not
                                              ready to have a
                                              baby, 36.6% (26)
                                              cited the index
                                              pregnancy being
                                              too close to
                                              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
1995              induced abortion and        abortions were
                  their prevention in         performed
                  Ghana. East African         outside the
                  Medical Journal             health system
                                              and about 30%
                                              were
                                              complications
                                              from self-
                                              induced
                                              abortions using
                                              sticks, needles
                                              and herbal
                                              (often
                                              corrosive)
                                              inserted into
                                              the vagina. Only
                                              9-212 were
                                              referrals, the
                                              rest were self-
                                              referred.

Authors           Study Design                 Study Setting
and Year

1. Morhe ESK,     Cross-sectional survey       Ejisu-Juabeng
Tagbor HK,        community-based              district of Ghana.
Ankobea F,        survey.
Danso KA.
2012

2. Lee QY,        Secondary data analysis      Komfo Anokye
Odoi AT,          of patient charts            Teaching Hospital
Opare-Addo H,
Dassah ET.
2012

3. Ganyaglo       Secondary analysis of        Koforidua Regional
GYK, Hill WC.     Obstetrics and               Hospital, Eastern
2012              Gynecology ward              Region
                  admission and discharge
                  books, triangulated
                  against minutes from
                  maternal death audit
                  meetings and midwifery
                  returns. Patient folders
                  were available for 2009
                  only.

4. Sundaram A,    Nationally representative    Maternal
Juarez F,         survey                       Health Survey
Bankole A,
Singh S. 2012

5. Krakowiak-     Cross-sectional              Barekese
Redd D,           community-based survey       sub-district in
Ansong D,                                      the Ashanti
Otupiri E, Tran                                Region
S, Klanderud
D, Boakye I,
Dickerson T,
Crookston B
2011

6. Aniteye P,     Structured survey with       Gynecology ward,
Mayhew S.         131 women with               Korle Bu and Ridge
2011              incomplete abortions.        Hospitals.

7. Gumanga        Hospital records from        Tamale Teaching
SK, Kolbila       January 1 2006-              Hospital
DZ, Gandau        December 2010.
BBN, Munkaila
A, Malechi H,
Kyei-Aboagye
K
2011

8. Biney AAE      24 semi-structured           Gynecology wards,
2011              individual interviews        Tema General
                  were conducted with          Hospital and Korle
                  women who were being         Bu Teaching
                  treated and reported         Hospital
                  having experience with
                  induced abortion.

9. Ohene SA,      Autopsy data                 Korle Bu Teaching
Tettey Y,                                      Hospital
Kumoji R.
2011

10. Mac           Focus group discussions      Ho, Ghana
Domhnaill B,      in both rural and
Hutchinson G,     periurban settings.
Milev A, Milev
Y.
2011

11. Schwandt      Surveys administered by      Gynecology
HM, Creanga       nursing and midwifery        emergency wards,
AA, Danso KA,     students with women          Korle Bu
Adanu RMK,        being treated for            and KATH.
Agbenyega T,      abortion complications.
Hindin MJ
2011

12. Mote CV,      408 community-based          Hohoe, Volta
Otupiri E,        surveys                      Region
Hindin MJ.
2010

13. Voetagbe      74 midwifery tutors          Midwifery
G, Yellu N,       from all 14 public           training colleges
Mills J,          midwifery schools were       country-wide
Mitchell E,       surveyed.
Adu-
Amankway A,
Jehu-Appiah K,
Nyante F.
2010

14. Laar AK       Content analysis of the      Newspaper
2010.             Daily Graphic
                  newspaper.

15. Clark KA,     Secondary data analysis      Nationally-
Mitchell EHM,     of 2002 Ghana Service        representative
Aboagye PK        Provision Assessment         sample of health
2010              survey. 428 health           facilities and
                  facilities working in        health providers
                  1448 health facilities
                  were surveyed.

16. Graff M,      Interviews with 24           Data gathered in
Amoyaw DA         midwives and 16              seven of the ten
2009              physicians                   regions of the
                                               country.

17. Hill ZE,      Qualitative interviews in
Tawiah-           Kintampo, Brong-Ahafo.
Agyemang C,
Kirkwood B.
2009

18. Konney        Interviews of women          Gynecology
TO, Danso KA,     being treated for            ward at KATH
Odoi AT,          abortion complications
Opare-Addo        at KATH between May
HS, Morhe         1 and June 30, 2007.
ESK.
2009

19. Oliveras E,   Using previous birth         Three public and
Ahiadeke C,       technique, during            two private
Adanu RM,         prenatal care, nurses        clinics in Accra
Hill AG           asked 5 questions to         that provide
2008              illicit how their previous   antenatal and
                  pregnancy ended.             maternity services.

20. Mills S,      Family members of all        Northern Region
Williams JE,      maternal deaths between
Wak G,            January 2002 and
Hodgson A         December 2004 were
2008              interviewed

21. Morhe         Cross sectional survey of    Komfo Anokye
ESK, Morhe        74 physicians at KATH        Teaching Hospital,
RAS, Danso                                     Kumasi.
KA
2007

22. Adanu         Cross-sectional survey       Korle Bu Teaching
RMK, Ntumy        of 150 patients being        Hospital
MN,               treated for abortion
Tweneboah E.      complications.
2005

23. Baiden F,     Secondary data analysis      Kassena-Nankana
Amponsa-          from chart review of all     district in the
Achiano K,        maternal deaths from         Northern Region
Oduro AR,         January 2001 to
Mehsah TA,        December 2003 at the
Baiden R,         district hospital in
Hodgson A.        Kassena-Nankana
2006

24. Adanu         Interviews with 150          Gynecology ward,
RMK &             women experiencing           Korle Bu
Tweneboah E       abortion complications.
2004

25. Yeboah        Chart review of all          Gynecology
RWN & MC          abortion-related             emergency ward,
Kom.              admissions between           Korle Bu Teaching
2003              January 1, 2000 and          Hospital, Accra,
                  December 31, 2001;           Ghana.
                  nurse interviews

26. Glover EK,    Community-based              Tamale, Takoradi
Bannerman A,      surveys of never-married     and Sunyani
Pence BW,         youth about general
Jones H, Miller   sexual experiences.
R, Weiss E,
Nerquaye-
Tetteh J.
2003

27. Srofenyoh     Chart review of all          Gynecology ward,
EK, Lassey AT     patients admitted to         Korle Bu
2003              Korle Bu for abortion
                  complications between
                  January 1 and December
                  31, 2001.

28. Geelhoed      Records from all             Berekum District
DW, Visser LE,    maternal deaths between      hospital, Brong
Asare K,          1987 and 2000 were           Ahafo Region
Schagen van       reviewed
Leeuwen JH,
van Roosmalen
J.
2003

29. Srofenyoh     Retrospective chart          Korle Bu Teaching
EK, Lassey AT     review of all patients       Hospital
2003              treated for abortion
                  complications in 2000.

30. Turpin CA,    1,301 of 1,313 cases of      Obstetrics and
Danso KA,         abortion admissions to       Gynecology ward,
Odoi AT           KATH were analyzed           Komfo Anokye
2002              retrospectively.             Teaching Hospital

31. Blanc A,      Demographic and Health       Representative
Grey S. 2002      Surveys from 1988,           sample.
                  1993 and 1998.

32. Geelhoed      2137 community -based        Berekum, Brong
DW, Nayembil      surveys                      Ahafo Region.
D, Asare K,
Schagen van
Leeuwen JH,
van Roosmale
J. 2002

33. Ahiadeke C    Data come from the
2002              cross-sectional
                  community-based
                  Maternal Health Survey
                  in four regions

34. Geelhoed      Community-based              Berekum District,
D, Nayembil D,    surveys with 2137            Brong Ahafo Region
Asare K,          participants
Schagen JH,
van Roosmalen
J.
2002

35. Ahiadeke      As part of Maternal          4 of the country's
2001              Health Survey Project;       10 regions:
                  1,689 pregnant women         Central, Eastern,
                  were interviewed             Volta and Greater
                                               Accra.

36. Agyei         Fertility survey             Greater Accra and
WKA,              data with 953 males          Eastern regions
Biritwum RB,      and 829 females.
Ashitey AG,
Hill RB
2000

37. Baird TL,     Post-abortion care           Eastern Region.
Billings DL,      training for midwives to
Demuyakor B.      increase their skills,
2000              coupled with community
                  outreach to educate
                  women about where to
                  access safe abortion
                  services.

38. Obed SA &     Prospective study of all     Korle Bu Teaching
Wilson JB         patients being treated at    Hospital
1999              Korle Bu for perforated
                  uterus following an
                  abortion (n=79) between
                  1990-1994. Patient
                  interviews and chart
                  review.

39. Lassey AT     Chart review of 200          Gynecology ward,
1995              patients admitted to         Korle Bu Teaching
                  the gynecology ward          Hospital
                  at Korle Bu for
                  abortion complications.

Authors           Strengths and         Database
and Year          limitations           retrieved
                                        from

1. Morhe ESK,     There were no         Global
Tagbor HK,        questions asked       Health,
Ankobea F,        as to the             Popline
Danso KA.         processes
2012              undertaken to
                  obtain
                  abortions.

2. Lee QY,        Comments are          Reference
Odoi AT,          made that are         List
Opare-Addo H,     not supported by
Dassah ET.        data or
2012              references, such
                  as, "Social
                  stigma plays a
                  role in
                  preventing
                  vulnerable women
                  from accessing
                  safe abortion
                  services."
                  Reasons behind
                  not accessing
                  safe abortion
                  services need to
                  be investigated.

3. Ganyaglo       This is the           Global
GYK, Hill WC.     first hospital-       Health
2012              based study
                  outside a major
                  teaching
                  hospital.

4. Sundaram A,    This study uses       Ovid
Juarez F,         nationally-           Medline,
Bankole A,        representative        Global
Singh S. 2012     data to               Health
                  investigate           PubMed
                  safe and unsafe
                  abortion
                  seeking.
                  However,
                  abortion is
                  under-reported,
                  and there were
                  no questions
                  about unwanted
                  pregnancy, or
                  reasons for
                  seeking safe
                  versus unsafe
                  abortions.

5. Krakowiak-     A relatively          Global
Redd D,           small sample          Health
Ansong D,         size (n=85)
Otupiri E, Tran   of only women.
S, Klanderud      There was a
D, Boakye I,      qualitative
Dickerson T,      component,
Crookston B       but not about
2011              abortion-
                  related issues.

6. Aniteye P,     The authors           Ovid
Mayhew S.         note a need for       Medline,
2011              qualitative           Global
                  work especially       Health,
                  around the            PubMed,
                  reasons why           Popline
                  women are not
                  using family
                  planning as
                  well as to
                  discover who
                  the unsafe
                  providers are.

7. Gumanga        Documented the        Global
SK, Kolbila       causes of             Health
DZ, Gandau        maternal death
BBN, Munkaila     in the Northern
A, Malechi H,     Region of Ghana.
Kyei-Aboagye
K
2011

8. Biney AAE      This study was        Ovid
2011              mainly about          Medline,
                  contraception,        Global
                  and so access         Health,
                  to abortion           PubMed,
                  services were         Popline
                  not
                  investigated.

9. Ohene SA,      Demonstrated          PubMed
Tettey Y,         the burden of
Kumoji R.         disease
2011              attributable
                  to adolescent
                  death

10. Mac           The focus-group       Global
Domhnaill B,      methodology           Health
Hutchinson G,     enables students
Milev A, Milev    to talk among
Y.                themselves about
2011              sexual
                  relationships.

11. Schwandt      This is one of        Ovid
HM, Creanga       the only studies      Medline,
AA, Danso KA,     to look at male-      Global
Adanu RMK,        female                Health,
Agbenyega T,      relationships         PubMed
Hindin MJ         and how these
2011              impact
                  reproductive
                  health decision
                  making.

12. Mote CV,      Using community-      Global
Otupiri E,        based surveys         Health,
Hindin MJ.        gets a broader        PubMed
2010              population than
                  hospital-based.

13. Voetagbe      74 of 123             PubMed
G, Yellu N,       selected tutors
Mills J,          returned the
Mitchell E,       survey, giving a
Adu-              response rate of
Amankway A,       60.2%.
Jehu-Appiah K,    Importantly
Nyante F.         documented the
2010              lack of complete
                  knowledge of the
                  law, even among
                  midwifery
                  tutors.

14. Laar AK       This analysis         Global
2010.             shows that local      Health,
                  speculations          PubMed
                  that the
                  quantity and
                  prominence of
                  reproductive
                  health issues
                  are neglected in
                  local newspapers
                  are warranted.

15. Clark KA,     Information           Ovid
Mitchell EHM,     about supplies        Medline,
Aboagye PK        available at the      PubMed,
2010              clinics, as well      Popline
                  as whether the
                  providers were
                  offering CAC
                  services, were
                  not available in
                  the dataset.

16. Graff M,      Interviews with       Ovid
Amoyaw DA         a wide range of       Medline,
2009              stakeholders is       Global
                  a major               Health,
                  strength.             PubMed

17. Hill ZE,                            Ovid
Tawiah-                                 Medline,
Agyemang C,                             Global
Kirkwood B.                             Health,
2009                                    MedLine

18. Konney        The first study       Ovid
TO, Danso KA,     to investigate        Medline,
Odoi AT,          the attitudes         Global
Opare-Addo        of women being        Health,
HS, Morhe         treated for           PubMed,
ESK.              abortion              Popline
2009              complications
                  towards the
                  provision of
                  safe abortion
                  services in
                  Ghana.

19. Oliveras E,   Although this         Ovid
Ahiadeke C,       technique does        Medline,
Adanu RM,         not measure           Global
Hill AG           prevalence or         Health,
2008              lifetime              PubMed,
                  exposure to           Popline
                  abortion, it is
                  another way to
                  investigate
                  abortion.
                  Further work to
                  elucidate
                  differential
                  responses based
                  on healthcare
                  provider asking
                  is important.

20. Mills S,      Relying on            Ovid
Williams JE,      verbal autopsy        Medline,
Wak G,            requires              PubMed,
Hodgson A         survivors to          Popline
2008              know of
                  pregnancy
                  status. There
                  may have been
                  more abortion-
                  related deaths
                  than reported if
                  those
                  interviewed did
                  not know the
                  woman was
                  pregnant.

21. Morhe         The attitudes of      Ovid
ESK, Morhe        health care           Medline,
RAS, Danso        providers is an       Global
KA                important area        Health,
2007              to investigate        PubMed
                  due to the
                  barriers these
                  people can
                  represent.

22. Adanu         The                   Reference
RMK, Ntumy        determination of      list
MN,               induced versus
Tweneboah E.      spontaneous
2005              abortion was
                  reliant on self-
                  report, which
                  the authors note
                  may be under-
                  reported.

23. Baiden F,     Established           Ovid
Amponsa-          abortion-             Medline,
Achiano K,        related deaths        Global
Oduro AR,         are the leading       Health,
Mehsah TA,        cause of              PubMed,
Baiden R,         maternal deaths.      Popline
Hodgson A.        Further research
2006              including all
                  members of a
                  woman's
                  community needs
                  to be conducted
                  to fully
                  understand the
                  social and
                  cultural factors
                  associated with
                  seeking maternal
                  healthcare.

24. Adanu         Only qualitative      Reference
RMK &             paper                 list
Tweneboah E       investigating
2004              the reasons
                  behind and
                  actions taken
                  to terminate
                  pregnancies.

25. Yeboah        No follow-up or       Popline
RWN & MC          interviewing
Kom.              of patients to
2003              determine
                  reasons for
                  abortion.

26. Glover EK,    Using a               Global
Bannerman A,      community-based       Health,
Pence BW,         technique             PubMed,
Jones H, Miller   sampled               Popline
R, Weiss E,       previously
Nerquaye-         under-
Tetteh J.         represented
2003              groups.

27. Srofenyoh     Important             Ovid
EK, Lassey AT     documentation         Medline
2003              of the burden
                  of abortion
                  complications
                  at Korle Bu.

28. Geelhoed                            Global
DW, Visser LE,                          Health,
Asare K,                                Popline
Schagen van
Leeuwen JH,
van Roosmalen
J.
2003

29. Srofenyoh     Documents the         Ovid
EK, Lassey AT     high level of         Medline,
2003              burden                Global
                  represented by        Health
                  abortion
                  complications
                  at Korle Bu.

30. Turpin CA,    Established the
Danso KA,         large proportion
Odoi AT           of cases of
2002              post-abortion
                  complications
                  treated at KATH.
                  Purely
                  descriptive
                  and reliant on
                  information
                  included in
                  patient charts.

31. Blanc A,      As there are no       Popline
Grey S. 2002      reliable
                  measures of
                  abortion
                  prevalence, the
                  authors cannot
                  rule out
                  abortion being
                  the reason
                  behind the
                  observed gap.
                  Further, the
                  authors note
                  that abortion
                  was, at the time
                  or writing,
                  illegal except
                  to save the life
                  of the mother or
                  in the case of
                  rape or incest.

32. Geelhoed      Interviewing          Ovid
DW, Nayembil      both men and          Medline
D, Asare K,       women gives a
Schagen van       broader
Leeuwen JH,       perspective.
van Roosmale      Questions
J. 2002           investigating
                  the process
                  to obtain an
                  abortion were
                  not asked.

33. Ahiadeke C    These                 Global
2002              data come from        Health
                  before abortion
                  policies were
                  liberalized.

34. Geelhoed      Using anonymous,      Ovid
D, Nayembil D,    privately             Medline,
Asare K,          administered          Global
Schagen JH,       surveys yielded       Health,
van Roosmalen     a high response       Popline
J.                rate.
2002              Interviewing
                  both men and
                  women is a
                  strength.

35. Ahiadeke      Community-based       Global
2001              survey offers a       Health
                  different
                  perspective than
                  hospital-based,
                  although further
                  questions
                  regarding the
                  process are
                  still necessary.

36. Agyei         Investigated the      Ovid
WKA,              knowledge and         Medline
Biritwum RB,      practices of
Ashitey AG,       adolescents
Hill RB           regarding their
2000              sexual health.
                  Large community-
                  based sample
                  allows for
                  generalization
                  of findings. Due
                  to quantitative
                  nature, hard to
                  establish the
                  processes
                  undertaken by
                  pregnant girls
                  to end their
                  pregnancies or
                  how many were
                  safe versus
                  unsafe.

37. Baird TL,     No comprehensive      Ovid
Billings DL,      evaluation of         Medline,
Demuyakor B.      effectiveness         Public
2000              was conducted.        Health

38. Obed SA &                           Reference
Wilson JB                               list
1999

39. Lassey AT     Data limited by       Ovid
1995              being a chart         Medline
                  review, although
                  this early study
                  highlighted the
                  problem of unsafe
                  abortion in the
                  Greater Accra area.
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Article Details
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Author:Rominski, Sarah D.; Lori, Jody R.
Publication:African Journal of Reproductive Health
Article Type:Report
Geographic Code:6GHAN
Date:Sep 1, 2014
Words:9673
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