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Background: Access to safe abortion is a globally contested policy and social justice issue – contested because of its religious and moral dimensions regarding the right to life and personhood of a foetus vs. the rights of women to make decisions about their own bodies. Many nations have agreed to address the health consequences of unsafe abortion, though stopped short of committing to providing comprehensive services. Ghana has a relatively liberal abortion law dating from 1985 and has ratified most international agreements on provision of care. Policy implementation has been very slow, but modest efforts are now being made to reduce maternal mortality caused by unsafe abortions. Understanding whether globalisation has played a role in this transition to practice is important to institutionalise the transition in Ghana and to learn lessons for other countries seeking to implement policies, but analysis is lacking. Methods: Drawing on 58 in-depth key informant interviews and policy document analysis we describe the development of de jure law and policies on comprehensive abortion care in Ghana, de facto interpretation and implementation of those policies, and assess what role globalization played in the transition in abortion care in Ghana. Results: We found that an accumulation of global influences has converged to start a transition in the culture of abortion care and service provision in Ghana, from a restrictive interpretation of the law to facilitating more widespread access to legal, safe abortion services through development of policies and guidelines and a slow change in attitudes and practices of health providers. These global influences can be categorised as: a global governance architecture of reproductive rights-obligations which creates pressure on signatory governments to act; and global communication of ideas and mobility of health providers (particularly through cross-cultural training opportunities and interaction with international NGOs) which facilitate global cultural interaction on the benefits of safe abortion services for reducing consequences of unsafe abortions. Conclusion: Globalisation of information, debate and training experience as well as of international rights frameworks can together create a powerful force for good to protect women and their children from the needless pain and death resulting from unsafe abortions.
To gather rich data we utilised an in-depth qualitative design that included detailed interviews and also a policy document review. Ethical approval was obtained from the London School of Hygiene & Tropical Medicine, where the study was designed, and from the Ghana Health Service. Data were collected only after obtaining written informed consent from each respondent. Because of the nature of the topic, and the stigma attached to it in Ghana [15], protecting the confidentiality of participants was a primary consideration. Fifty-eight in-depth interviews were conducted between November 2006–July 2007. Respondents had both knowledge of and interest in the issue of abortion care and included obstetricians (n = 15), midwives (n = 14), other health professionals (pharmacists and trainers) (n = 12), policy makers (parliamentarians and MoH officials) (n = 14) and three (3) representatives of development agencies/NGOs. Health professionals were purposively sampled from a range of public and private facilities in the Greater Accra Region, from MOH list of facilities in the region. All the health centres had units (reproductive and child health (RCH) and family planning (FP)) that offer reproductive health services where women with abortion complications are treated. Staff were identified with the help of the unit/facility heads and were selected because they had substantial knowledge, exposure and experience of abortion. In addition to obstetrician/gynaecologists, who provided clinical abortion services, midwives (rather than nurses) were included because it is they who staff the RCH units providing antenatal, post-natal and family planning services where women in need of reproductive health care services most commonly present. Pharmacists were included in the study because in Ghana studies have shown that community pharmacy shops sell abortifacients (e.g., Cytotec or Misoprostol) and are the first point of call when women have an unwanted pregnancy since abortion services are not openly available in public hospitals and private clinics are very expensive. Health professionals involved in training were also included. Policy makers included parliamentarians (7) and MoH officials (7) and were purposively selected based on their involvement in or knowledge of abortion policies and services. Interview questions and prompts were based on the background of each participant but all were asked about their knowledge of the abortion law and how they regarded unsafe abortion. Interviewees were probed on their sources of knowledge and the reasons for the views and attitudes they held. This included discussion of training and information from other countries, knowledge and perceptions of international treaties and abortion-related laws in other countries. Further details on the research instruments have been published elsewhere [15]. Each semi-structured interview lasted between 60 and 90 min. All interviews were conducted in English and all but one audio recorded and transcribed verbatim. The one that was not recorded was fully transcribed from notes immediately after the interview. Field notes captured all that transpired during the interview including the body language of the participants. Data were analysed using content analysis with the assistance of the qualitative software NVIVO Version 6 (QSR International) and Framework Analysis was used for analysis after code clusters from the software had been exported from the software into excel sheets for manual analysis. One researcher (PA) analysed all interviews in depth in consultation with two other researchers (in particular SM). Transcripts were repeatedly read and recurring themes noted and grouped. Themes were recorded and scrutinized for patterns. Based on identified patterns, the themes were grouped in a hierarchical manner. A code frame was developed and used to index the entire data set. Following indexing, all data under a sub-theme were pulled together and descriptive accounts were written on each sub-theme. Documents critically reviewed included the abortion law as well as the policy documents of the Ministry of Health and the Ghana Health Service on reproductive health and related to the topic under investigation. The key policy documents included ‘The Criminal Code of Ghana’ (GoG, 1985 Amendment), ‘The National Reproductive Health Service Policy and Standards’ (GHS, 1996 and 2003), ‘The Prevention and Management of Unsafe Abortion: Comprehensive Abortion Care Services Standards and Protocols’ (GHS, 2006). Credibility or trustworthiness, an important hallmark of qualitative inquiry, was ensured through: respondent validation, where transcripts of respondents were shown to them to ascertain whether what they said have been correctly represented in the transcripts; a conscious search for and analysis of deviant cases; and an audit trail, which refers to a record of all decisions made to guide data collection and analysis as well as a record of researchers’ biases and prejudices about the study topic before, during and after data collection. Trustworthiness was also supported through triangulation of data sources and methods. Data sources (health providers; policymakers; other key informants) and data collection methods (in-depth interviews and document analysis) were used to confirm and ensure completeness of the findings. The researcher’s prolonged field engagement (nine months, in addition to personal knowledge of the context) and checking the correctness of findings with participants supported credibility.
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