Globalisation and transitions in abortion care in Ghana

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Study Justification:
– Access to safe abortion is a globally contested policy and social justice issue.
– Ghana has a relatively liberal abortion law but policy implementation has been slow.
– Understanding the role of globalization in the transition to practice is important for institutionalizing the transition in Ghana and for other countries seeking to implement similar policies.
– Analysis on this topic is lacking.
Study Highlights:
– Global influences have converged to start a transition in the culture of abortion care in Ghana.
– The transition includes a shift from a restrictive interpretation of the law to facilitating more widespread access to legal, safe abortion services.
– Global influences can be categorized as a global governance architecture of reproductive rights-obligations and global communication of ideas and mobility of health providers.
– These influences create pressure on signatory governments to act and facilitate global cultural interaction on the benefits of safe abortion services.
Study Recommendations:
– Institutionalize the transition in abortion care in Ghana by fully implementing comprehensive abortion care policies and guidelines.
– Learn lessons from Ghana’s experience to inform other countries seeking to implement similar policies.
– Strengthen global governance architecture of reproductive rights-obligations to further protect women’s rights.
– Promote global communication of ideas and mobility of health providers to facilitate knowledge exchange and training on safe abortion services.
Key Role Players:
– Government officials and policymakers in Ghana responsible for implementing and enforcing abortion care policies.
– Health professionals, including obstetricians, midwives, and pharmacists, involved in providing reproductive health services and training.
– Development agencies and NGOs working on reproductive health issues in Ghana.
– International organizations and advocates for reproductive rights.
Cost Items for Planning Recommendations:
– Training programs for health professionals on comprehensive abortion care.
– Development and dissemination of policies and guidelines on abortion care.
– Public awareness campaigns on safe abortion services.
– Capacity building for healthcare facilities to provide safe abortion services.
– Monitoring and evaluation of the implementation of abortion care policies.
– Research and data collection on the impact of the transition in abortion care in Ghana.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study utilized a qualitative design with in-depth interviews and policy document analysis, which provides rich data. Ethical approval was obtained, and data were collected after obtaining written informed consent. The study included a diverse range of participants, including health professionals, policy makers, and representatives of development agencies/NGOs. The data analysis process involved content analysis and Framework Analysis. Trustworthiness was ensured through respondent validation, analysis of deviant cases, and triangulation of data sources and methods. To improve the strength of the evidence, the study could have included a larger sample size and conducted interviews with a more diverse range of participants. Additionally, the study could have used a mixed-methods approach to complement the qualitative findings with quantitative data.

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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Based on the information provided, it seems that the study “Globalisation and transitions in abortion care in Ghana” focuses on understanding the role of global influences in the transition to providing comprehensive abortion care in Ghana. The study utilized in-depth qualitative methods such as interviews and policy document analysis to gather data.

In terms of potential innovations to improve access to maternal health, based on the study’s findings, the following recommendations could be considered:

1. Strengthening Global Governance: Enhance the global governance architecture of reproductive rights-obligations to create more pressure on signatory governments, including Ghana, to fully implement comprehensive abortion care policies and guidelines.

2. Promoting Cross-Cultural Training: Increase opportunities for health providers in Ghana to receive cross-cultural training and interact with international NGOs to facilitate global cultural interaction on the benefits of safe abortion services. This can help change attitudes and practices of health providers towards providing safe abortion services.

3. Information Sharing and Communication: Improve the global communication of ideas and information related to safe abortion services. This can include sharing success stories and best practices from other countries that have successfully implemented comprehensive abortion care policies.

4. Addressing Stigma and Confidentiality: Develop strategies to address the stigma attached to abortion in Ghana, which can hinder access to safe abortion services. Ensuring confidentiality and protecting the privacy of women seeking abortion care is crucial to encourage them to seek safe services.

5. Strengthening Policy Implementation: Support Ghana in implementing and monitoring the policies and guidelines related to comprehensive abortion care. This can involve providing technical assistance, capacity building, and resources to ensure effective implementation.

It is important to note that these recommendations are based on the information provided in the study and should be further explored and evaluated for their feasibility and effectiveness in improving access to maternal health in Ghana.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health in Ghana would be to further develop and implement comprehensive abortion care services. This can be achieved by:

1. Strengthening policy implementation: Ghana has relatively liberal abortion laws, but policy implementation has been slow. Efforts should be made to ensure that policies and guidelines on comprehensive abortion care are effectively implemented at all levels of the healthcare system.

2. Increasing awareness and education: There is a need to raise awareness and educate both healthcare providers and the general public about the importance of safe abortion services in reducing maternal mortality. This can be done through targeted campaigns, training programs, and community engagement.

3. Improving access to services: Access to safe abortion services should be expanded, particularly in rural areas where access is limited. This can be achieved by increasing the number of healthcare facilities that provide abortion services and ensuring that these services are affordable and accessible to all women.

4. Addressing stigma and discrimination: The stigma attached to abortion in Ghana can prevent women from seeking safe and legal services. Efforts should be made to address and reduce stigma through public awareness campaigns and advocacy.

5. Strengthening partnerships: Collaboration between government agencies, NGOs, and international organizations is crucial in improving access to maternal health services. Partnerships can help mobilize resources, share best practices, and support the implementation of comprehensive abortion care services.

By implementing these recommendations, Ghana can further improve access to maternal health and reduce the consequences of unsafe abortions, ultimately protecting the health and well-being of women and their children.
AI Innovations Methodology
Based on the provided description, it seems that the focus is on understanding the role of global influences in the transition to practice of abortion care in Ghana. The study utilized an in-depth qualitative design, including detailed interviews and policy document analysis. The methodology involved the following steps:

1. Ethical approval: The study obtained ethical approval from the London School of Hygiene & Tropical Medicine and the Ghana Health Service. Written informed consent was obtained from each respondent.

2. Data collection: Fifty-eight in-depth interviews were conducted between November 2006 and July 2007. The interviews included obstetricians, midwives, other health professionals, policy makers, and representatives of development agencies/NGOs. The participants were purposively sampled from a range of public and private facilities in the Greater Accra Region. The interviews were conducted in English, audio recorded (except for one), and transcribed verbatim. Field notes were taken to capture non-verbal cues.

3. Data analysis: Content analysis was used to analyze the data with the assistance of qualitative software NVIVO Version 6. Framework Analysis was used for analysis after code clusters were exported from the software into Excel sheets for manual analysis. One researcher analyzed all interviews in depth, in consultation with two other researchers. Recurring themes were identified, grouped, and analyzed for patterns. A code frame was developed to index the entire data set.

4. Document review: The study critically reviewed policy documents related to abortion care in Ghana, including the abortion law, the National Reproductive Health Service Policy and Standards, and the Comprehensive Abortion Care Services Standards and Protocols.

5. Credibility and trustworthiness: To ensure credibility, respondent validation was conducted by showing transcripts to participants to confirm the accuracy of their statements. Deviant cases were also analyzed, and an audit trail was maintained to document decisions, biases, and prejudices. Triangulation of data sources and methods, as well as prolonged field engagement and checking findings with participants, supported trustworthiness.

In summary, the methodology involved conducting in-depth interviews, analyzing the data using qualitative analysis software, reviewing policy documents, and ensuring credibility and trustworthiness through various strategies.

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