Optimizing task-sharing in abortion care in Ghana: Stakeholder perspectives

International Journal of Gynecology and Obstetrics, Volume 150, No. S1, Year 2020

Interpretation

Ghana has made progress in expanding providers in abortion care but access to the service is still a challenge. We explored stakeholder perspectives on task-sharing in abortion care and the opportunities that exist to optimize this strategy in Ghana. We purposively sampled 12 representatives of agencies that played a key role in expanding abortion care to include midwives for key informant interviews. All interviews were audio recorded, transcribed verbatim, and then coded for thematic analysis. Stakeholders indicated that Ghana was motivated to practice task-sharing in abortion care because unsafe abortion was contributing significantly to maternal mortality. They noted that the Ghana Health Service utilized the high maternal mortality in the country at the time, advancements in medicine, and the lack of clarity in the definition of the term “health practitioner” to work with partner nongovernmental organizations to successfully task-share abortion care to include midwives. Access, however, is still poor and provider stigma continues to contribute significantly to conscientious objection. This calls for further task-sharing in abortion care to include medical or physician assistants, community health officers, and pharmacists to ensure that more women have access to abortion care. The study was implemented in Ghana, which has a population of about 25 million.20 About 20% of women of reproductive age (15–49 years) have ever had an abortion.21 In 2017, 53 114 abortions occurred and, of these, 13 918 were characterized as unsafe. Nonmedical methods (e.g. drinking milk/coffee/alcohol/other liquid with sugar, drinking a herbal concoction, drinking other home remedies, using a herbal enema, inserting a substance into the vagina, heavy massage, excessive physical activity, and use of all kinds of unknown tablets) used to induce abortion make up more than 27% of abortions carried out.21 More than one in 10 pregnancy‐related deaths occur as a result of an unsafe abortion and for every woman who dies from an unsafe abortion it is estimated that 15 suffer short‐ and long‐term morbidities.21 Countrywide estimates may mask regional differences; for example, 14% of pregnancies among women in urban areas end up in an induced abortion compared with 7% among women in rural areas. Women in poor and rural communities in northern Ghana have less access to comprehensive abortion care; for instance, only 3% of women in the northern part of the country have ever had an induced abortion compared with 22% of women in the more urban middle and coastal areas.21 This was an exploratory, descriptive study designed to gain insights into the policy decision to include all cadres of health workers with midwifery skills in the provision of abortion care, and to learn about stakeholder opinions regarding opportunities for further expansion. We purposively sampled individuals in the public and private sector who had themselves contributed (or whose agencies had contributed) to the policy on the expansion of abortion care to include midwives. Selection was based on an individual’s or agency’s role in advocating for the policy or contributing to the policy framework, implementation, monitoring, or evaluation. Respondents were typically heads of the agencies but, where necessary, members who were more familiar with the agency’s role in task‐sharing in abortion care were invited for the interview. Identification of the agencies was primarily via snowball sampling. The lead researcher (RAA) conducted most of the interviews. A research assistant (EK) with more than 2 years’ experience in conducting qualitative interviews assisted him. In all, 12 key informant interviews were conducted. On two occasions, the study team had to talk to two individuals from an agency to better understand the agency’s contribution to the policy shift. Consent was sought from the respondents to audio record the interviews. The interviews lasted 1–1.5 hours. All interviews were conducted in June 2018. All interviews were audio recorded and transcribed verbatim. The transcripts were imported into NVivo version 11 software (QSR International; Melbourne, Vic., Australia) for coding and thematic analysis. We predetermined codes using the interview guide and additional codes were developed for concepts that were not initially captured by the guide but emerged inductively from the data. We segmented the data into similar groups to form preliminary categories of information or themes on the expansion of health worker roles in abortion care. We examined the segments of data related to each theme and where necessary refinements were made. RAA coded all transcripts and ES coded six of those transcripts separately. The two coding sets were compared to ensure validity. Discrepancies were discussed and coding was adjusted where necessary. A coding comparison query to determine the inter‐rater reliability returned a Kappa coefficient of 0.84.

AI Digest

Study Justification:

– Ghana has made progress in expanding providers in abortion care, but access to the service is still a challenge.
– Unsafe abortion contributes significantly to maternal mortality in Ghana.
– Task-sharing in abortion care has been implemented to address this issue, but further optimization is needed.
– This study aims to explore stakeholder perspectives on task-sharing in abortion care and identify opportunities for improvement.

Study Highlights:

– 12 representatives of agencies involved in expanding abortion care were interviewed.
– Stakeholders indicated that task-sharing was motivated by the high maternal mortality rate and advancements in medicine.
– The lack of clarity in the definition of “health practitioner” allowed for successful task-sharing with midwives.
– Access to abortion care is still poor, and provider stigma contributes to conscientious objection.
– Further task-sharing is recommended to include medical or physician assistants, community health officers, and pharmacists.

Study Recommendations:

– Expand task-sharing in abortion care to include medical or physician assistants, community health officers, and pharmacists.
– Address provider stigma and conscientious objection to improve access to abortion care.

Key Role Players:

– Ghana Health Service
– Partner non-governmental organizations
– Midwives
– Medical or physician assistants
– Community health officers
– Pharmacists

Cost Items for Planning Recommendations:

– Training and capacity building for medical or physician assistants, community health officers, and pharmacists
– Equipment and supplies for expanded abortion care services
– Outreach and awareness campaigns to address provider stigma and conscientious objection
– Monitoring and evaluation of the expanded task-sharing program

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on stakeholder perspectives and qualitative interviews. While the study provides valuable insights into the motivations and opportunities for task-sharing in abortion care in Ghana, it lacks quantitative data and statistical analysis. To improve the strength of the evidence, the study could include a larger sample size and incorporate quantitative data on access to abortion care and its impact on maternal mortality. Additionally, conducting a comparative analysis between regions and exploring the perspectives of women who have sought abortion care would further enhance the evidence.

Abstract

The study was implemented in Ghana, which has a population of about 25 million.20 About 20% of women of reproductive age (15–49 years) have ever had an abortion.21 In 2017, 53 114 abortions occurred and, of these, 13 918 were characterized as unsafe. Nonmedical methods (e.g. drinking milk/coffee/alcohol/other liquid with sugar, drinking a herbal concoction, drinking other home remedies, using a herbal enema, inserting a substance into the vagina, heavy massage, excessive physical activity, and use of all kinds of unknown tablets) used to induce abortion make up more than 27% of abortions carried out.21 More than one in 10 pregnancy‐related deaths occur as a result of an unsafe abortion and for every woman who dies from an unsafe abortion it is estimated that 15 suffer short‐ and long‐term morbidities.21 Countrywide estimates may mask regional differences; for example, 14% of pregnancies among women in urban areas end up in an induced abortion compared with 7% among women in rural areas. Women in poor and rural communities in northern Ghana have less access to comprehensive abortion care; for instance, only 3% of women in the northern part of the country have ever had an induced abortion compared with 22% of women in the more urban middle and coastal areas.21 This was an exploratory, descriptive study designed to gain insights into the policy decision to include all cadres of health workers with midwifery skills in the provision of abortion care, and to learn about stakeholder opinions regarding opportunities for further expansion. We purposively sampled individuals in the public and private sector who had themselves contributed (or whose agencies had contributed) to the policy on the expansion of abortion care to include midwives. Selection was based on an individual’s or agency’s role in advocating for the policy or contributing to the policy framework, implementation, monitoring, or evaluation. Respondents were typically heads of the agencies but, where necessary, members who were more familiar with the agency’s role in task‐sharing in abortion care were invited for the interview. Identification of the agencies was primarily via snowball sampling. The lead researcher (RAA) conducted most of the interviews. A research assistant (EK) with more than 2 years’ experience in conducting qualitative interviews assisted him. In all, 12 key informant interviews were conducted. On two occasions, the study team had to talk to two individuals from an agency to better understand the agency’s contribution to the policy shift. Consent was sought from the respondents to audio record the interviews. The interviews lasted 1–1.5 hours. All interviews were conducted in June 2018. All interviews were audio recorded and transcribed verbatim. The transcripts were imported into NVivo version 11 software (QSR International; Melbourne, Vic., Australia) for coding and thematic analysis. We predetermined codes using the interview guide and additional codes were developed for concepts that were not initially captured by the guide but emerged inductively from the data. We segmented the data into similar groups to form preliminary categories of information or themes on the expansion of health worker roles in abortion care. We examined the segments of data related to each theme and where necessary refinements were made. RAA coded all transcripts and ES coded six of those transcripts separately. The two coding sets were compared to ensure validity. Discrepancies were discussed and coding was adjusted where necessary. A coding comparison query to determine the inter‐rater reliability returned a Kappa coefficient of 0.84.

Materials

N/A

Innovations

The recommendation to improve access to maternal health in Ghana is to further expand task-sharing in abortion care. This involves involving different cadres of health workers, such as midwives, medical or physician assistants, community health officers, and pharmacists, in providing abortion care. By expanding task-sharing to include additional health workers, access to abortion care can be improved, particularly in poor and rural communities where access is currently limited.

This recommendation is based on the findings of a study titled “Optimizing task-sharing in abortion care in Ghana: Stakeholder perspectives” published in the International Journal of Gynecology and Obstetrics in 2020. The study found that while Ghana has made progress in expanding providers in abortion care, access to the service is still a challenge. Stakeholders in the study indicated that task-sharing in abortion care was motivated by the high maternal mortality rate caused by unsafe abortions. The Ghana Health Service worked with partner non-governmental organizations to successfully task-share abortion care to include midwives. However, access to abortion care is still poor, and provider stigma contributes significantly to conscientious objection.

Implementing this recommendation would require collaboration between the Ghana Health Service, partner non-governmental organizations, and relevant stakeholders. It would also involve policy changes and training programs to ensure that the additional health workers are adequately prepared to provide abortion care.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health in Ghana is to further expand task-sharing in abortion care. The study found that while Ghana has made progress in expanding providers in abortion care, access to the service is still a challenge. Task-sharing involves involving different cadres of health workers, such as midwives, medical or physician assistants, community health officers, and pharmacists, in providing abortion care.

The stakeholders in the study indicated that task-sharing in abortion care was motivated by the high maternal mortality rate caused by unsafe abortions. The Ghana Health Service worked with partner non-governmental organizations to successfully task-share abortion care to include midwives. However, access to abortion care is still poor, and provider stigma contributes significantly to conscientious objection.

Expanding task-sharing to include additional health workers, such as medical or physician assistants, community health officers, and pharmacists, can help ensure that more women have access to abortion care. This would involve training and equipping these health workers to provide safe and comprehensive abortion services. By involving a wider range of health workers, access to abortion care can be improved, particularly in poor and rural communities where access is currently limited.

Implementing this recommendation would require collaboration between the Ghana Health Service, partner non-governmental organizations, and relevant stakeholders. It would also involve policy changes and training programs to ensure that the additional health workers are adequately prepared to provide abortion care.

This recommendation is based on the findings of the study titled “Optimizing task-sharing in abortion care in Ghana: Stakeholder perspectives” published in the International Journal of Gynecology and Obstetrics in 2020.

AI Innovations Methodology

To simulate the impact of the main recommendations mentioned in the abstract on improving access to maternal health in Ghana, the following methodology could be employed:

1. Data Collection: Collect data on the current state of access to maternal health services in Ghana, including information on the availability of abortion care and the cadres of health workers involved in providing these services. This data can be obtained from national health surveys, reports from the Ghana Health Service, and other relevant sources.

2. Stakeholder Engagement: Engage with stakeholders involved in maternal health care in Ghana, including representatives from the Ghana Health Service, partner non-governmental organizations, health workers, and women’s advocacy groups. Conduct interviews, focus group discussions, and surveys to gather their perspectives on the potential impact of expanding task-sharing in abortion care.

3. Modeling the Impact: Develop a mathematical model or simulation tool that incorporates the collected data and stakeholder perspectives. This model should consider factors such as the number of additional health workers to be involved in task-sharing, the training and equipping required, the geographical distribution of services, and the potential impact on access to abortion care.

4. Scenario Analysis: Use the developed model to simulate different scenarios based on the main recommendations. For example, simulate the impact of task-sharing with medical or physician assistants, community health officers, and pharmacists on access to abortion care in different regions of Ghana. Assess the potential increase in the number of women who can access safe and comprehensive abortion services.

5. Evaluation and Validation: Evaluate the results of the simulation against existing data and indicators related to maternal health in Ghana. Validate the model by comparing the simulated outcomes with real-world outcomes where available. This step will help assess the accuracy and reliability of the simulation.

6. Policy Recommendations: Based on the simulation results, provide policy recommendations to relevant stakeholders, including the Ghana Health Service, partner non-governmental organizations, and policymakers. These recommendations should highlight the potential benefits of expanding task-sharing in abortion care and provide guidance on the necessary steps to implement this strategy effectively.

7. Monitoring and Evaluation: Monitor the implementation of the recommendations and evaluate their impact over time. Continuously collect data on access to maternal health services, including abortion care, and assess whether the expansion of task-sharing has led to improved access and outcomes.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of expanding task-sharing in abortion care and make informed decisions to improve access to maternal health services in Ghana.

Author

Dima Health

Statistics:

Citations: 3

Identifiers:

DOI: 10.1002/ijgo.13000

ISSN: 00207292

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Sexual and Reproductive Health, Social Determinants, Substance Abuse, Workforce

Study Countries:

Ghana

Study Design:

Cross Sectional Study, Exploratory Study

Study Approach:

Qualitative

Participants Gender:

Female