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Abortion in Ghana.

Maternal mortality is the second most common cause of death among women in Ghana, and more than one in 10 maternal deaths (11%) are the result of unsafe induced abortions. (1) In addition, a substantial proportion of women who survive an unsafe abortion experience complications from the procedure. This suffering is all the more tragic because it is unnecessary: Many women likely turn to unsafe providers or do not obtain adequate postabortion care when it is needed because they are unaware that abortion is legal on fairly broad grounds in Ghana.

The abortion law in Ghana, enacted in 1985, states that an abortion performed by a qualified medical practitioner is legal if the pregnancy is the result of rape, incest or "defilement of a female idiot;" if continuation of the pregnancy would risk the life of the woman or threaten her physical or mental health; or if there is a substantial risk the child would suffer from a serious physical abnormality or disease. (2)

To help ensure that legal abortions are provided safely, the Ghana Health Service and Ministry of Health developed protocols for the provision of safe abortions. These guidelines, adopted in 2006, outline the components of comprehensive abortion care, including counseling and the provision of contraceptives; define mental health conditions that could qualify a patient for an abortion; and call for expanding the base of abortion providers by authorizing midwives and nurses to perform first-trimester procedures. (3)

In 2007, a consortium of international and domestic organizations launched a program to reduce maternal morbidity and mortality--particularly that due to unsafe abortion--in Ghana. (4) The program's goals include ensuring that contraceptives and comprehensive abortion care are routinely available at all levels of the public and private health service delivery system. To be effectively implemented, the policies and programs supporting safe abortion require the backing of the government, health care providers and other stakeholders.

This report provides a factual basis for continued efforts to reduce the incidence and consequences of unsafe abortion. It brings together findings from a recent, nationally representative study--the 2007 Ghana Maternal Health Survey (GMHS)--and a number of other studies to present what is known about the incidence of abortion, the characteristics of women who seek them, the types of providers women turn to and the procedures used.

The Level of Abortion in Ghana

Because many women do not wish to report having had an abortion, surveys of women tend to underestimate abortion incidence. Nevertheless, we must rely on such surveys where other sources of information on abortion are sparse.

According to the GMHS, 7% of all pregnancies end in abortion (Figure 1, page 2), and 15% of women aged 15-49 have ever had an abortion. (1) About 15 abortions are performed for every 1,000 women of reproductive age (15-44) each year. According to a study conducted in the late 1990s in southern Ghana, 17 abortions were observed for every 1,000 women of reproductive age. (5) The level of abortion in Ghana appears to be lower than in Western Africa as a whole, where the rate stands at 28 procedures per 1,000 women. (6)

While underreporting might compromise the accuracy of induced abortion estimates, there is fairly clear evidence that 37% of births in the country are unplanned--23% are mistimed and 14% are unwanted. (7) This means that, each year, more than 300,000 infants are born as a result of unintended pregnancies.

Characteristics of Women Having an Abortion

The incidence of abortion is highest (25 per 1,000 women) among 20-24-yearolds and is lower in each successive age-group (Figure 2, page 3). (1) The abortion rate is higher among educated and wealthy women than among women with no education and those who are very poor. likewise, it is twice as high in urban areas (21 per 1,000 women) as in rural areas (10 per 1,000). The rate is especially high (34 per 1,000) among 20-24-year-old women in urban areas.

A study in southern Ghana also found that educated and urban women were more likely than their less educated and rural counterparts to seek an abortion, and that Christian women were more likely than Muslim women to seek the procedure. (5)

The most common reason given by women for seeking an abortion is not having the financial means to take care of a child (21%). (1) Other common reasons include wanting to delay childbearing (13%), continue schooling (11%) and continue working (9%). Six percent of women said their partner did not want the child or denied responsibility for the pregnancy. Health reasons for terminating the pregnancy were cited by about 5% of women.

Abortion Methods and Providers

Studies have produced conflicting evidence regarding the types of providers women turn to and the procedures they undergo to terminate a pregnancy.

According to the GMHS, many women who procure abortions do so with the help of a doctor and in a hospital setting, although significant proportions do not undergo the safest procedures available. (1) Among women reporting on their most recent abortion in the five years before the survey, 40% underwent dilation and curettage (D&C). About 16% of women said they terminated their pregnancy by taking tablets, and another 5-6% of women specified that they took Cytotec (misoprostol) tablets. Twelve percent of women underwent manual vacuum aspiration (MVA), which is generally considered safer than D&C for early termination of pregnancy. (8) less common methods included inserting an object, herbs or other substances in the vagina; receiving an injection; and drinking an herbal concoction. (1) Although local anesthesia is recommended for surgically induced abortion, (8) only 14% of women who obtained an abortion reported receiving local anesthesia; most women received "pain relievers," and 25% received general anesthesia. (1)

According to the same survey, 57% of women sought a doctor to perform an abortion, 16% went to a pharmacist or chemical seller, and 19% turned to a friend or relative or induced the abortion themselves. (1) The remaining women sought the help of a traditional practitioner (4%) or a nurse, midwife or auxiliary midwife (3%).

In contrast, a 1997-1998 study in southern Ghana found that only about 12% of women who obtained an abortion did so with the help of a physician. (5) More than two-thirds of women who sought an abortion turned to an untrained provider or induced the abortion on their own, according to this study.

It is possible that the circumstances under which abortions were obtained improved in the interval between the two studies. Another possible reason for the discrepancy between the studies is that respondents in the GMHS underreported abortions obtained through dubious means, while reporting more fully on abortions performed by medical professionals. By contrast, the researchers in southern Ghana used lab tests to identify all pregnancies in the community and followed women until all the pregnancies were resolved; thus, induced abortions and their circumstances were recorded regardless of the means of termination.

Complications from Unsafe Abortion

Abortion, when performed by a qualified professional under safe conditions, is an extremely safe procedure. However, clandestine abortions are often unsafe. (6,9)

Among Ghanaian women who had had an abortion in the five years prior to the GMHS, 13% reported experiencing one or more health problems after their most recent abortion. (1) Ten percent of women experienced pain, half of whom reported that the pain was severe; 8% reported bleeding; 6% each experienced fever and foul-smelling discharge, which are both indications of infection; and 1% reported that they suffered a perforation or other injury as a result of the procedure. Some of the most severe complications were not reported in this survey because women did not survive to report them.

Of women who experienced a problem following their abortion, 41% received no treatment. (1) Almost half (47%) of women with a problem received antibiotics, and 19% received an unspecified treatment.

The Cost of Abortion

There is very little known research on the cost of abortion in Ghana. In one in-depth study in Accra, young women reported paying anywhere from three to 30 new Ghana cedis * for a hospital or private clinic abortion. (10) More generally, it has been reported that a safe abortion is prohibitively expensive for many women because few practitioners are available to perform the procedure, and they charge very high fees. (2) As a consequence, poor women may be forced to seek risky abortions from untrained providers.

An abortion carries costs beyond the price of the procedure itself. These include the economic burden on the families of women whose abortion complications lead to medical expenses and a loss of productivity; social costs, including stigma and isolation; and expenses to the health care system and society. There is no known research into these costs of abortion to Ghanaian society.

The Need for Effective Contraceptives

While contraceptive use has been on the rise in Ghana for the past two decades, levels of use are still quite low and seem to have stagnated in recent years. About 13% of married women were using contraceptives in 1988; the level of use increased to 25% by 2003, but was only 24% in 2008. (7)

Some 35% of married women in Ghana have an unmet need for contraceptives. (7) That is, they do not want a child soon or at all and are not using a contraceptive method. This represents little change since 2003 (34%) (7) and is much higher than the average of 22% for Africa as a whole. (11) Evidence from developing countries indicates that the vast majority of unintended pregnancies occur among women with an unmet need. (12)

Compared with their counterparts in other African countries, women in Ghana with an unmet need for contraceptives are relatively unlikely to oppose contraception or to face opposition from their husbands, but a large proportion--34% of married women with unmet need--cite concerns about health risks or side effects associated with contraceptives. (13) These concerns are especially prevalent among relatively well-educated women and women living in urban areas.

Attitudes Toward Abortion and Knowledge of Abortion law

The GMHS found that, in 2007, only 4% of women thought that abortion was legal in Ghana. (1) Even among women with at least a secondary school education, only 11% were aware of this fact. Knowledge of the country's moderately liberal abortion law seems to be substantially higher, but still not widespread, among medical professionals. In one small study, 54% of physicians were aware that abortion is legal if indicated to preserve the health of the woman. (14)

[FIGURE 2 OMITTED]

Abortion is widely stigmatized in Ghanaian society, but it appears that many people consider it acceptable under certain conditions. In in-depth interviews with adolescent females in Accra, the majority of participants were strongly opposed to abortion, but nearly all described situations, such as being in an unstable relationship or not having enough money to raise a child, in which they considered abortion to be acceptable or necessary. (10)

Among doctors at a teaching hospital in Ghana, 80% favored establishing safe abortion units within national health facilities. (14) Only 19% of physicians--the majority of whom did not work in obstetrics or gynecology--said they would play no role in abortion care; some in this group indicated that they would perform the procedure if they were properly trained.

The Next Steps Toward Ending Unsafe Abortion

The Ghanaian government and other key stakeholders must continue to address unsafe abortion in order to save women's lives and improve maternal health. The following measures can further advance these aims:

* Address unmet need for contraceptives and barriers to contraceptive use. Ensuring that health care providers offer a range of methods, educate patients on contraceptive options, address women's concerns about side effects, and help women identify and obtain the methods that work best for them would contribute to increased and improved contraceptive use.

* Educate young people. Improved education for young women and men about sexual and reproductive health would help them understand and avoid the risks associated with unprotected intercourse and prevent unintended pregnancies that might otherwise lead to abortion.

* Raise awareness about Ghana's abortion law. A large-scale public education effort that takes into account the sensitive, often secretive, nature of abortion could increase the proportion of abortions that are carried out safely.

* Conduct more research. Reliable evidence of the costs of unsafe abortion to women, their families and the health care system, compared with the costs of providing safe abortions and contraceptive care; qualitative research on women's experiences with abortion; and investigation into the attitudes of key stakeholders and the sources of stigma surrounding abortion would help inform policies and bolster the political will to prevent unsafe abortion.

As one of the few countries in Sub-Saharan Africa where abortion is available on broad grounds, Ghana is particularly well positioned to remedy the problem of unsafe abortion and its consequences. By identifying the barriers to the implementation of the abortion law and overcoming them through responsive interventions--and by helping women avoid unintended pregnancies in the first place--Ghana can make substantial progress toward achieving the fifth Millennium Development Goal of improving maternal health, and toward saving women's lives.

REFERENCES

(1.) Ghana Statistical Service (GSS), Ghana Health Service (GHS) and Macro International, Ghana Maternal Health Survey 2007, Accra, Ghana: GSS and GHS; and Calverton, MD, USA: Macro International, 2009.

(2.) Morhee RAS and Morhee ESK, Overview of the law and availability of abortion services in Ghana, Ghana Medical Journal, 2006, 40(3):80-86.

(3.) Ipas, Ipas in Ghana, Chapel Hill, NC, USA: Ipas, 2008.

(4.) Reducing Maternal Mortality and Morbidity, The R3M Program in Ghana, 2009, <http://www.r3mghana.org/index.html>, accessed Dec. 1, 2009.

(5.) Ahiadeke C, Incidence of induced abortion in southern Ghana, International Family Planning Perspectives, 2001, 27(2):96-101&108.

(6.) World Health Organization (WHO), Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2003, fifth ed., Geneva: WHO, 2007.

(7.) GSS, GHS and ICF Macro, Ghana Demographic and Health Survey 2008, Accra, Ghana: GSS and GHS; and Calverton, MD, USA: ICF Macro, 2009.

(8.) WHO, Safe Abortion: Technical and Policy Guidance for Health Systems, Geneva: WHO, 2003.

(9.) Grimes DA et al., Unsafe abortion: the preventable pandemic, lancet, 2006, 368(9550): 1908-1919.

(10.) Henry R and Fayorsey C, Coping with Pregnancy: Experiences of Adolescents in Ga Mashi, Accra, Calverton, MD, USA: ORC Macro, 2002.

(11.) Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.

(12.) Singh S et al., Adding It Up: The Costs and Benefits of Investing In Family Planning and Maternal and Newborn Health Care, New York: Guttmacher Institute, 2009.

(13.) Sedgh G et al., Women with an unmet need for contraception in developing countries and their reasons for not using a method, Occasional Report, New York: Guttmacher Institute, 2007, No. 37.

(14.) Morhe ESK, Morhe RAS and Danso KA, Attitudes of doctors toward establishing safe abortion units in Ghana, International Journal of Gynecology and Obstetrics, 2007, 98(1):70-74.

CREDITS

This In Brief was written by Gilda Sedgh and edited by Haley Ball, both of the Guttmacher Institute. The author thanks Akinrinola Bankole, Ann Biddlecom and leila Darabi, all of the Guttmacher Institute, for their comments and suggestions. She also thanks the following reviewers for their invaluable input: Joy D. Fishel, Macro International; Koma Jehu-Appiah, Ipas; and Joana Nerquaye-Tetteh, formerly of the Planned Parenthood Association of Ghana.

Suggested citation: Sedgh G, Abortion in Ghana, In Brief, New York: Guttmacher Institute, 2010, No. 2.

* Equal to US$9-90 in January 2000, the approximate time of the study.
Figure 1

Pregnancy Outcomes

About four in 10 pregnancies in Ghana are unintended.

Induced abortions 7%
Unwanted births 13%
Mistimed births 20%
Wanted births 49%
Stillbirths and miscarriages 11%

Source: reference 1.

Note: Table made from pie chart.
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Publication:In Brief (Series)
Geographic Code:6GHAN
Date:Jul 1, 2010
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