Role-players in abortion decision-making in the Accra Metropolis, Ghana

Reproductive Health, Volume 11, No. 1, Year 2014

Interprétation

Background: Making the final decision to terminate a pregnancy can be influenced by different circumstances involving various individuals. This paper describes the key players involved in the decision-making process regarding abortions among women who elected to undergo an induced abortion in a cosmopolitan urban setting in Ghana. Methods: A retrospective cross-sectional mixed method study was conducted between January and December 2011. A total of 401 women with records in abortion logbooks were selected for an interviewer-administered questionnaire and an in-depth interview. Descriptive and multinomial logistic regression analyses were used to assess the quantitative data, and a thematic analysis was applied to the qualitative data. Results: The findings of the study reveal that pregnant individuals, mothers of abortion-seekers, male partners, and “Others” (for example, friends, employers) were instrumental in making a decision to terminate unplanned/unwanted pregnancies. Several key factors influenced the decision-making processes, including aversion from the men responsible for the pregnancy, concerns about abnormalities/deformities in future births due to unprofessionally conducted abortions, and economic considerations. Conclusion: A number of individuals, such as friends, mothers, and male partners, influence the decision-making process regarding abortion among the participants of the study. Various targeted messages are needed for the various participants in the decision. This study was conducted in the Accra Metropolis, which has an estimated population of 2,242,505, of which 841,533 are within reproductive age [18]. As of 2010, there were 481 health facilities in the metropolis, consisting of four government hospitals, seven polyclinics, four quasi-government hospitals, 49 private hospitals, 270 clinics, 39 company clinics, 79 private maternity homes and 29 NGO/Mission hospitals. In 2008, approximately 17% (range: 8.1%-22.4%) of women (15–49 years) throughout the country reported a terminated pregnancy in the preceding five years. Disaggregated by region, 22.4% of women in the Greater Accra Region, where this study was conducted, had undergone an abortion [19], making it the region with the highest incidence of abortion in the country. In 2006, the Ghana Health Service, in collaboration with a consortium of five multinational organizations (EngenderHealth, Ipas, Marie Stopes International, Population Council, and the Willows Foundation) initiated the Reducing Maternal Mortality and Morbidity (R3M) project in the Greater Accra, Eastern and Ashanti regions following initial piloting in 17 districts in 2007. The R3M provides financial and technical assistance to enable the government to significantly expand access to modern family planning (FP) and comprehensive abortion care (CAC). The Accra Metropolis, a municipality within the Greater Accra that was involved in the pilot project, was purposively selected because of its cosmopolitan nature. Three accredited R3M health facilities, consisting of one private-not-for profit and two publicly owned and managed, were purposively selected. These were Marie Stopes International Ghana, BlueStar HealthCare Network, La and Ridge Hospitals. They were selected because of the high number of abortion cases registered in the metropolis in addition to the fact that they were the largest health facilities accredited to perform abortions under the R3M project. This context provides ‘friendly’ conditions for a safe abortion. This study employed a retrospective cross-sectional approach. Both qualitative and quantitative data were collected. This was done to complement the strengths and mitigate the limitations of the respective paradigms by using both questionnaires and in-depth interview (IDI) guides [20]. Neither the quantitative nor the qualitative data were given more weight [21], and the findings are presented concurrently. The questionnaire [22] and IDI guides [23, 24] were adapted from prior studies on abortion in Ghana. The questionnaire was structured around induced abortion decision-making processes, key individuals whose counsel was sought in the decision-making process, factors influencing choice of place for abortion and familiarity with the policy and legal frameworks, which influence induced abortion procedures in Ghana. The IDI guide, which was unstructured, focused on the following: pregnancy characteristics (e.g., person responsible), decision on whether to terminate, place of abortion, and choice of method, among others. Both questionnaires and interview guides were available in English but were translated into local languages for respondents who could not speak English. On average, each interview lasted approximately 60 min. At the first stage of the sampling, a purposive method was used to select three abortion service providers accredited by R3M. The total number of women who had undergone an abortion between January and December 2010 was collated, resulting in an overall total of 9,494. This served as the sampling frame for the study, and individual women with a record of abortion served as the unit of analysis. With this, a sample size of 370 was drawn based on OpenEpi [25]. An additional 10% upward adjustment was made to correct for non-response. The sample was distributed among the facilities based on population (share of abortion cases) proportional to size (PPS). Thus, the proportions of the 9,494 women were allocated as follows: Marie Stopes (61), BlueStar (217), Ridge (53) and La (39) hospitals. Respondents were then selected randomly to respond to the interviewer-administered questionnaires. Another 35 respondents consisting of five previously married women, 10 unmarried women and 20 married women were selected to further explore the reasons for involving other individuals in abortion decision-making. Ten trained nurses served as research assistants. The fieldwork was conducted between June and December 2011. The Ghana Health Service Ethics Review Committee reviewed and approved the study. All research subjects provided verbal and written informed consent. Four main groups of role-players were derived from the data: abortion seekers (self/personal autonomy), parents/mothers of abortion seekers, male partners, and less frequently mentioned role-players categorized as “Others”. Descriptive statistics with corresponding Chi-Square values were derived, followed by multinomial regression. Multinomial regression was used for inferential analysis because the dependent variable (role-players) has more than two outcomes, which makes it the most appropriate statistical tool for isolating the independent effects of the various categories of the background factors of abortion-seekers in abortion decision-making. The background factors captured in the quantitative data were occupation, age, marital status, religion, ethnicity, parity and number of previous abortions. These variables were entered concurrently because there was no intention to determine the impact of any single explanatory factor on the role-players. The qualitative data were analysed inductively by identifying main themes. FYG first undertook preliminary coding of the data. AKK and JAA independently reviewed all codes, followed by identification, discussion and resolution of the inconsistencies in the themes by all of the authors. All three authors had to agree upon a particular theme before it was included in the codebook. Finally, a colleague with expertise in qualitative analysis reviewed our codes, comparing these to the transcripts, field notes and tape recordings. STATA version 12 (College Station, Texas 77845 USA) was used to analyse the quantitative data, while the qualitative data were analysed manually.

Résumé de l’IA

Study Justification:

This study aims to understand the key players involved in the decision-making process regarding abortions among women in the Accra Metropolis, Ghana. The study is important because it sheds light on the various individuals who influence the decision to terminate a pregnancy, and the factors that contribute to this decision. Understanding these dynamics can help inform policies and interventions aimed at reducing the incidence of unsafe abortions and improving reproductive health outcomes.

Highlights:

– The study reveals that pregnant individuals, mothers of abortion-seekers, male partners, and “Others” (such as friends and employers) play a significant role in the decision to terminate unplanned/unwanted pregnancies.
– Factors influencing the decision-making process include aversion from the men responsible for the pregnancy, concerns about abnormalities/deformities in future births due to unprofessionally conducted abortions, and economic considerations.
– The study was conducted in the Accra Metropolis, which has a high incidence of abortion compared to other regions in Ghana.
– The findings emphasize the need for targeted messages and interventions tailored to the different individuals involved in the decision-making process.

Recommendations:

– Develop targeted educational campaigns to increase awareness and knowledge about safe abortion practices and reproductive health among pregnant individuals, mothers, male partners, and other influential individuals.
– Strengthen access to comprehensive abortion care services, including counseling and post-abortion care, in order to reduce the incidence of unsafe abortions.
– Enhance the involvement of healthcare providers, community leaders, and religious leaders in promoting reproductive health and safe abortion practices.
– Advocate for policies and programs that address the socio-economic factors influencing the decision to terminate a pregnancy, such as poverty and lack of social support.

Key Role Players:

– Healthcare providers: They play a crucial role in providing safe and comprehensive abortion care services, including counseling and post-abortion care.
– Community leaders: They can help raise awareness and promote reproductive health education within their communities.
– Religious leaders: They can influence attitudes and beliefs surrounding abortion and provide guidance and support to individuals facing unplanned pregnancies.
– NGOs and government agencies: They can provide funding, technical assistance, and policy support to improve access to safe abortion services and reproductive health education.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers to ensure they have the necessary skills and knowledge to provide safe abortion care.
– Development and implementation of educational campaigns targeting different role players, including the production of informational materials and media campaigns.
– Strengthening of healthcare facilities to ensure they have the necessary equipment and resources to provide comprehensive abortion care services.
– Research and monitoring to evaluate the effectiveness of interventions and inform future policies and programs.
– Collaboration and coordination among different stakeholders, which may require funding for meetings, workshops, and other activities.

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study employed a mixed method approach, collecting both qualitative and quantitative data, which adds depth to the findings. The sample size of 401 women is relatively large, and the study was conducted in a cosmopolitan urban setting in Ghana, which increases the generalizability of the results. However, the study was conducted in a specific geographic area and may not be representative of the entire population of Ghana. To improve the strength of the evidence, future studies could consider conducting a larger-scale study across multiple regions in Ghana to capture a more diverse sample. Additionally, using a randomized sampling method instead of a purposive method would further enhance the validity of the findings.

Abstrait

This study was conducted in the Accra Metropolis, which has an estimated population of 2,242,505, of which 841,533 are within reproductive age [18]. As of 2010, there were 481 health facilities in the metropolis, consisting of four government hospitals, seven polyclinics, four quasi-government hospitals, 49 private hospitals, 270 clinics, 39 company clinics, 79 private maternity homes and 29 NGO/Mission hospitals. In 2008, approximately 17% (range: 8.1%-22.4%) of women (15–49 years) throughout the country reported a terminated pregnancy in the preceding five years. Disaggregated by region, 22.4% of women in the Greater Accra Region, where this study was conducted, had undergone an abortion [19], making it the region with the highest incidence of abortion in the country. In 2006, the Ghana Health Service, in collaboration with a consortium of five multinational organizations (EngenderHealth, Ipas, Marie Stopes International, Population Council, and the Willows Foundation) initiated the Reducing Maternal Mortality and Morbidity (R3M) project in the Greater Accra, Eastern and Ashanti regions following initial piloting in 17 districts in 2007. The R3M provides financial and technical assistance to enable the government to significantly expand access to modern family planning (FP) and comprehensive abortion care (CAC). The Accra Metropolis, a municipality within the Greater Accra that was involved in the pilot project, was purposively selected because of its cosmopolitan nature. Three accredited R3M health facilities, consisting of one private-not-for profit and two publicly owned and managed, were purposively selected. These were Marie Stopes International Ghana, BlueStar HealthCare Network, La and Ridge Hospitals. They were selected because of the high number of abortion cases registered in the metropolis in addition to the fact that they were the largest health facilities accredited to perform abortions under the R3M project. This context provides ‘friendly’ conditions for a safe abortion. This study employed a retrospective cross-sectional approach. Both qualitative and quantitative data were collected. This was done to complement the strengths and mitigate the limitations of the respective paradigms by using both questionnaires and in-depth interview (IDI) guides [20]. Neither the quantitative nor the qualitative data were given more weight [21], and the findings are presented concurrently. The questionnaire [22] and IDI guides [23, 24] were adapted from prior studies on abortion in Ghana. The questionnaire was structured around induced abortion decision-making processes, key individuals whose counsel was sought in the decision-making process, factors influencing choice of place for abortion and familiarity with the policy and legal frameworks, which influence induced abortion procedures in Ghana. The IDI guide, which was unstructured, focused on the following: pregnancy characteristics (e.g., person responsible), decision on whether to terminate, place of abortion, and choice of method, among others. Both questionnaires and interview guides were available in English but were translated into local languages for respondents who could not speak English. On average, each interview lasted approximately 60 min. At the first stage of the sampling, a purposive method was used to select three abortion service providers accredited by R3M. The total number of women who had undergone an abortion between January and December 2010 was collated, resulting in an overall total of 9,494. This served as the sampling frame for the study, and individual women with a record of abortion served as the unit of analysis. With this, a sample size of 370 was drawn based on OpenEpi [25]. An additional 10% upward adjustment was made to correct for non-response. The sample was distributed among the facilities based on population (share of abortion cases) proportional to size (PPS). Thus, the proportions of the 9,494 women were allocated as follows: Marie Stopes (61), BlueStar (217), Ridge (53) and La (39) hospitals. Respondents were then selected randomly to respond to the interviewer-administered questionnaires. Another 35 respondents consisting of five previously married women, 10 unmarried women and 20 married women were selected to further explore the reasons for involving other individuals in abortion decision-making. Ten trained nurses served as research assistants. The fieldwork was conducted between June and December 2011. The Ghana Health Service Ethics Review Committee reviewed and approved the study. All research subjects provided verbal and written informed consent. Four main groups of role-players were derived from the data: abortion seekers (self/personal autonomy), parents/mothers of abortion seekers, male partners, and less frequently mentioned role-players categorized as “Others”. Descriptive statistics with corresponding Chi-Square values were derived, followed by multinomial regression. Multinomial regression was used for inferential analysis because the dependent variable (role-players) has more than two outcomes, which makes it the most appropriate statistical tool for isolating the independent effects of the various categories of the background factors of abortion-seekers in abortion decision-making. The background factors captured in the quantitative data were occupation, age, marital status, religion, ethnicity, parity and number of previous abortions. These variables were entered concurrently because there was no intention to determine the impact of any single explanatory factor on the role-players. The qualitative data were analysed inductively by identifying main themes. FYG first undertook preliminary coding of the data. AKK and JAA independently reviewed all codes, followed by identification, discussion and resolution of the inconsistencies in the themes by all of the authors. All three authors had to agree upon a particular theme before it was included in the codebook. Finally, a colleague with expertise in qualitative analysis reviewed our codes, comparing these to the transcripts, field notes and tape recordings. STATA version 12 (College Station, Texas 77845 USA) was used to analyse the quantitative data, while the qualitative data were analysed manually.

Matériaux

N/A

Innovations

The study conducted in the Accra Metropolis, Ghana, identified several recommendations to improve access to maternal health. These recommendations can be developed into innovations to address the challenges faced in this area. Here are the innovations based on the recommendations:

1. Targeted Messaging Innovation: Develop a mobile application or SMS service that provides targeted messages to different individuals involved in the decision-making process regarding abortion. This innovation can deliver accurate information about safe abortion procedures, the importance of professional care, and the potential risks associated with unsafe abortions directly to the target audience’s mobile devices.

2. Community Engagement Innovation: Create a community engagement platform, such as a website or social media group, where community members can access information, participate in discussions, and ask questions about maternal health and safe abortion practices. This innovation can help reduce stigma and misconceptions surrounding abortion by providing a safe and supportive environment for open dialogue.

3. Training and Capacity Building Innovation: Develop an online training program for healthcare providers on comprehensive abortion care. This innovation can provide healthcare providers with the necessary skills and knowledge through interactive modules, virtual simulations, and case studies. Additionally, virtual counseling services can be incorporated into the program to enhance the quality and accessibility of maternal health services.

4. Strengthening Healthcare Facilities Innovation: Implement a digital health system in healthcare facilities accredited to provide safe abortion services. This innovation can streamline the process of accessing and managing patient records, improve communication between healthcare providers, and ensure the availability of necessary equipment and supplies for safe abortion procedures. Additionally, telemedicine services can be integrated into the system to expand access to maternal health services in remote areas.

5. Policy and Legal Framework Innovation: Establish a digital advocacy platform that raises awareness about the importance of reproductive rights and supports safe and accessible abortion services. This innovation can provide resources, tools, and information to policymakers, activists, and the general public to promote evidence-based policies and legal frameworks that protect women’s reproductive rights. Additionally, the platform can facilitate online campaigns and petitions to drive change and destigmatize abortion.

By implementing these innovations, it is possible to leverage technology and digital solutions to improve access to maternal health and reduce the incidence of unsafe abortions in the Accra Metropolis, Ghana.

AI Innovations Description

Based on the study conducted in the Accra Metropolis, Ghana, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Targeted Messaging: Develop targeted messages for different individuals involved in the decision-making process regarding abortion. This includes pregnant individuals, mothers of abortion-seekers, male partners, and other influential individuals such as friends and employers. These messages should provide accurate information about safe abortion procedures, the importance of professional care, and the potential risks associated with unsafe abortions.

2. Community Engagement: Engage with the community to raise awareness about maternal health and safe abortion practices. This can be done through community meetings, workshops, and educational campaigns. By involving community members, including religious leaders and traditional authorities, in the conversation, it can help reduce stigma and misconceptions surrounding abortion.

3. Training and Capacity Building: Provide training and capacity building programs for healthcare providers on comprehensive abortion care. This includes training on safe abortion procedures, post-abortion care, and counseling services. By ensuring that healthcare providers are well-equipped with the necessary skills and knowledge, it can improve the quality and accessibility of maternal health services.

4. Strengthening Healthcare Facilities: Invest in strengthening healthcare facilities, particularly those accredited to provide safe abortion services. This includes improving infrastructure, equipment, and supplies necessary for safe abortion procedures. Additionally, ensuring that these facilities have well-trained staff and are easily accessible to women seeking abortion services.

5. Policy and Legal Framework: Advocate for policies and legal frameworks that support safe and accessible abortion services. This includes ensuring that laws are in place to protect women’s reproductive rights and that healthcare providers are able to provide abortion services without fear of legal repercussions. It is important to work towards destigmatizing abortion and promoting a supportive environment for women seeking these services.

By implementing these recommendations, it is possible to improve access to maternal health and reduce the incidence of unsafe abortions, ultimately contributing to better maternal health outcomes.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, the following methodology can be used:

1. Targeted Messaging: Develop targeted messages for different individuals involved in the decision-making process regarding abortion. This can be done by conducting focus group discussions and surveys to understand the information needs and preferences of each target group. The impact of the targeted messages can be measured by conducting pre- and post-intervention surveys to assess changes in knowledge, attitudes, and behaviors related to safe abortion practices.

2. Community Engagement: Engage with the community through community meetings, workshops, and educational campaigns. Before implementing the intervention, conduct a baseline survey to assess the community’s knowledge, attitudes, and practices related to maternal health and safe abortion. After the intervention, conduct a follow-up survey to measure changes in knowledge, attitudes, and practices. Additionally, track the number of community members reached through the intervention and monitor any changes in community norms and stigma related to abortion.

3. Training and Capacity Building: Provide training and capacity building programs for healthcare providers on comprehensive abortion care. Before the training, assess the knowledge and skills of healthcare providers through pre-training assessments. After the training, conduct post-training assessments to measure changes in knowledge and skills. Additionally, monitor the number of healthcare providers trained and track any changes in the quality and accessibility of maternal health services provided by these trained providers.

4. Strengthening Healthcare Facilities: Monitor the improvements made in healthcare facilities, including infrastructure, equipment, and supplies necessary for safe abortion procedures. Track the number of facilities that have been strengthened and assess the availability and accessibility of safe abortion services in these facilities. Additionally, monitor any changes in the number of women seeking abortion services and their satisfaction with the services provided.

5. Policy and Legal Framework: Monitor any changes in policies and legal frameworks that support safe and accessible abortion services. Track any improvements in the protection of women’s reproductive rights and the ability of healthcare providers to provide abortion services without fear of legal repercussions. Additionally, assess changes in public opinion and support for safe abortion practices.

By implementing these methodologies, it will be possible to assess the impact of the recommendations on improving access to maternal health in the Accra Metropolis, Ghana. The data collected through surveys, assessments, and monitoring will provide valuable insights into the effectiveness of the interventions and help guide future efforts to further improve access to maternal health services.

Auteurs et co-auteurs

Statistics:

Citations: 17

Authors: 3

Identifiers:

DOI: 10.1186/1742-4755-11-70

Research Areas:

Health System and Policy, Maternal and Child Health, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ghana

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Male & Female

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