Background
Methods
Design
Study area and population
Hospital | Number of Midwives in gynaecological units | Number of doctors in gynaecological units | Number of unsafe abortion patients in 3 months |
---|---|---|---|
Site 1 | 20 | 5 | 35 |
Site 2 | 25 | 6 | 30 |
Site 3 | 23 | 7 | 20 |
Site 4 | 26 | 4 | 18 |
Total | 94 | 22 | 103 |
Data collection
Data analysis
Rigour
Ethics approval and consent to participate
Results
Thematic results
Lack of knowledge of safe abortion services
I didn’t know where to go and terminate the pregnancy. I knew that it is illegal to have an abortion in Ghana and so I could not have gone to any facility to have by pregnancy terminated. All my friends that I asked only recommended some herbal mixture called agbeve for me. They also did not know of any hospital where I could boldly go and abort safely. I read on the label that agbeve is not to be taken by pregnant women. When I read that I had hope that it will get rid of my pregnancy. Although I know I could bleed to death from terminating my own pregnancy, I didn’t have a choice or options. So I used the agbeve herbal mixture [PP11].I know abortions are illegal in Ghana so I couldn’t go to any hospital looking for a safe abortion. I did not want to be caught doing an illegal thing such as abortion which people see as murder here. I could not also keep the pregnancy because it will be a disgrace to me and my parents. No one has ever informed me of safe abortion services in any part of Ghana. I wish that existed and I will not have to try aborting my pregnancy myself. I have heard that some women have become infertile. I had to use aunty mercy herbal mixture to terminate my pregnancy. Unfortunately I stated bleeding plenty and a friend brought me here [PP22].Well I am a registered midwife here and no one has ever taught me that abortion in Ghana is legal. In fact what I know is that it is illegal to have an abortion in Ghana. I feel that doctors who perform abortions are undertaking illegal activities so I don’t even feel like helping them. They normally charge the women lots of money to perform the abortions. I think they are taking the risk because of the money they get from these clients. The patients sometimes tell you the truth of the kind of drug they tried using. Many of them have used the agbeve herbal mixture. Agbeve is not supposed to be taken by pregnant women but instead they take it to abort their pregnancies [FGM3].I only know about family planning services but not abortion services. As for abortion it is a sin. Every life is precious to God. We are not supposed to take life in a form of abortion. In psalms, God said the human beings are his people and he cares for us. It is not humans who should be taking lives. Even in Isaiah, God showed us that he cares for even unborn children so no one is supposed to take the life of these babies. In Jeremiah God made it clear that before we were born he knew us and cared about us. And I know our constitution is based on the bible so this country and its constitution will never allow for abortion in our land [FGR37].Abortion is not allowed in Ghana. I have heard there is some law that permits abortion under some circumstances. As for abortion policy, I don’t know of any. People see abortion as a sin here. I do too. Usually our view in Ghana is that it is murder of babies. These are the reasons why young women who get pregnant feel they have to find other means of terminating their pregnancies rather than coming to us for help [MO 9].
Socio-economic conditions as perceived influence for unsafe abortion practices
I can’t look after a baby if I carry it to term. I took a home pregnancy test and it came out positive. I am not with the guy nor do I want to be with him. I considered an abortion because I could not afford to carry the pregnancy to term. I don’t want to be a single mother because I don’t have the money to look after myself and a child at this time of my life. I did not hesitate to abort it by taking concoction of aunty mercy herbal drug which was suggested by a friend [PP8].There was no question of me keeping the pregnancy because I knew I was going to be admitted to the university. I would have a good education and I had a career path to go down. It was all laid down for me. I couldn’t sacrifice my schooling for motherhood. I could not combine the two because I don’t have the money to do that now. I am not ready for motherhood. I do not think lack of money is a good reason to have an abortion but the reality is that you can’t take care of a baby without a job and money so I found a way to abort the baby by myself [PP12].I have seen many patients who have reported here when they have already attempted to abort their pregnancies and had complications. I think they fear the cost that they will have to bear when they come here, apart from the criminal aspect of it. Apart from being afraid that they are doing criminal things, and stigma, money is an issue for these young people who get pregnant and want their pregnancies terminated [FGM134].Normally when they come like that, you can see that they don’t have money to buy the medications that we need to use to help them. Even the procedure to completely remove the remains of what they started, some of them find it difficult to pay for it. As for this one the national health insurance will not pay so they have to pay themselves [MO7].
Safe abortion as a perceived religious and cultural taboo in Ghana
Many participants (99 out of 111) in this study also indicated that abortion is against Ashanti and Ghanaian culture. Many participants stated that they practised unsafe abortions because their society did not approve abortion even if it was a safe one. Participants were afraid their families and friends would be disappointed and call them names if they found out that they were pregnant and wanted to abort their babies. The cultural detestation was expressed in the following statements by participants:Abortion is not permitted in my religion because it is an offence against God. It is the killing of a human being which can even lead you to jail. I had an unsafe abortion by myself and I regret it more than ever and get depressed about it anytime I think about it. Abortion is bad because my religious doctrines speak against it. Abortion is the same as killing. It is a killing of a living breathing baby that God created. Life is not ours to give and take away. I feel God will not forgive me for what I have done [PP 7].I am a Muslim and I can tell you that we don’t agree to abortions. Taking the life of an unborn child is a sin against God and man and when one commits abortion the person kills which is against our beliefs. My religion completely frowns on the practice of all kinds of abortions [FGR1].I am a Christian and abortion whether safe or unsafe is seen as murder. We are not even supposed to get pregnant out of wedlock. It is a sin to have sex with someone you are not married to. We preach against these things all the time. People must change and ask for forgiveness otherwise they are lost souls [FGR6].Abortion is not allowed here. It is a sin. Personally my religious beliefs don’t allow for me to just abort a pregnancy for a client. I stay away from such acts. I only get involved when it is a life and death issue. When the patient has already attempted and is in danger of dying, that one I have no choice but to help save life. People feel why do you take a life that you didn’t create? And I think it is a legitimate question. All Christians and Muslims in this community see it as religiously wrong. It is just not acceptable [MO 4].Religions in Ghana don’t support abortion. We have two main religions in Ghana and I know that none support abortion. I don’t support it because of my religion. No good Christian or Muslim will allow for abortion of an unborn baby [FGM 12]
Our culture here is very much against abortion. I don’t think anyone here agrees with people having abortions. It is seen as killing so people do not condone it at all here. If people get to know you aborted a baby, they will always be pointing fingers towards you when you are passing. So you have to find a way of doing it without people knowing, to avoid the stigma [PP33].Our community perceives abortion to be a bad practice and anyone who engages herself in it suffers as a result of people stigmatising her. This is because it brings disgrace to victim’s family and the whole community. My society and culture see abortion as very criminal, unacceptable and an abomination. They see it as a taboo. It brings disgrace to the family and if care is not taken it can lead to embarrassment for the woman and people around her [MO5].Sexual intercourse is only legitimate in marriages. Therefore, when a woman gets pregnant without a husband, it becomes a disgrace to the woman. Apart from religions reasons for not allowing abortions, the culture here does not allow abortions. The whole society here is against abortion [FGR57].As a nurse I know our culture does not support abortion. We see it as killing in Ghana. I am sure anyone you talk to in Ghana will tell you that abortion is not good. To be honest with you, it is always seen as killing [FGM11]
Stigma of unplanned pregnancy
The society perceives pregnancy outside wedlock as fornication because the person is not being married but has given birth from nowhere. Sexual intercourse is only legitimate in marriages. Therefore, when a woman gets pregnant without a husband to cater for the unborn child, it is a disgrace to the woman and her family. This forces the woman to abort the pregnancy in order to avoid disgrace and social stigma. In my case I was thinking about what people will think of me knowing how my society is [PP7].Pregnancy outside wedlock in my society is perceived as fornication. The child when it is born becomes a bastard. The woman who gets married before having babies is always admired but the person who gets pregnant without marriage is seen as a spoilt girl. Though no civilized society permits one human to intentionally harm or take the life of another human through abortions, women sometimes have no choice because of the embarrassment unplanned pregnancy brings. The stigma is serious here [FGM33].It is nice to attend engagement and wedding ceremonies where women get married before they get pregnant and have babies. That is what is accepted in this community. Anything aside this is a disgrace to the woman and her family. Apart from being religiously wrong, the society does not accept such behaviours. We don’t want our young women getting pregnant without marrying. If they are not ready for marriage, they should not be doing what marriage people are supposed to be doing. Sex is for only married people. For me when I see a girl pregnant without marriage, I see her as a bad girl [FGR12].We usually see people who get pregnant outside wedlock as prostitutes. You have to marry before you get pregnant and have babies. Some young women these days get pregnant without getting married and our society does not respect them at all. The way people will be looking at the pregnant girl, she herself will feel very embarrassed. They normally regret these pregnancies and so attempt to abort them [MO1].
A desire to bear children only after marriage
In this community, it is a pride for a woman to have a man marry her in a nice ceremony and be recognised as officially married. Every woman wants such an honour and will even prefer aborting an unplanned pregnancy so that someone can marry her. My parents have always wanted me to get married to a man before getting to have babies so I was embarrassed when I found out that I was pregnant. It is difficult to get a good man to marry you when you are a born one. People think you are already used. I talked to a trusted friend and she led me to a place where someone tried to abort the baby for me. It was however not successful because I started having severe abdominal pain and passed out and had to be brought here [PP31]It is an honour for women to get married in Ghana. Marriage ceremonies here are more or less a ceremony to glorify women in our society. Most women would want to be married before they have children so they can enjoy that respect and honour given to other women who have done that. Sometimes when you talk to the young women who attempt abortions and are brought here, they tell you that their friends, and families will stop respecting them when they have babies out of wedlock. All of them want marriage before bearing children [FGM30].Everyone woman here will always wish that she gets married before having children because of the respect for women who do that. Your dignity as a woman is seen when you marry before getting pregnant. That is how it is here. Many women will prefer aborting on their own to avoid the embarrassment of having babies without a husband [MO9].Our religious inclinations tell us that people must marry before having babies. Right from the era of Adam and Eve, it has been shown that men and women cannot just start having sex and having babies without officially getting the recognition as husband and wives. It is not acceptable. Whether you are Muslim or Christian you will need to do the official thing before having children. I think this is part of the reason why some of our women will prefer to avoid the embarrassment by taking away the life of their unborn children. That one too is against God’s rules [FGR28].
Avoiding parental disappointment and resentment
I didn’t know what my parents will think of me getting pregnant whilst in school. My mum for instance has always talked to me about the need to remain a virgin until I get married. In fact she believes I am still a virgin so I didn’t want her disappointment about the pregnancy so I had to take steps to do something about it. She will always tell me finish school, have a good job and marry and have beautiful babies. She would have even gotten angry with me. I was scared about the reaction of both my Dad and Mum [PP14].I am still in school and being looked after by my guardian. My parents brought me to the city to stay with my aunty who is looking after me in school and in everything. My aunty expects me to finish school and get married before thinking about babies. I cannot all of a sudden tell her that I am pregnant. She may get angry and take me back to the village or ask me to leave the house. To avoid all these I just had to find a way of terminating my pregnancy since I had no other option. My boyfriend too is a student and does not have the money to look after me and the child now [PP17].When you take history of illness from these young women, you realise that their parents were not aware of their attempts to terminate their pregnancies. They always want to hide it from their parents because of the embarrassment, disappointment or anger from parents or guardians. They will always prefer confiding in friends when they want to terminate their pregnancies rather than talking to their parents [MO10].Honestly the ladies who attempt termination of pregnancies before coming here most often than not don’t tell their parents. Sometimes it is even their friends that bring them here. May be they don’t feel comfortable talking to their parents about it. May be to avoid any ill feelings from parents they would rather tell their trusted friends. They probably fear the disgrace and disappointment from parents who are still looking after them [FGM3].They will always feel embarrassed by getting pregnant because it not part of our culture or religion to have women getting pregnant before marriage. Most of these girls are still in school and still get pregnant. It is not good enough. Their parents should definitely feel disappointed. I will feel same way too. I think they need more education. As for me when I hear and see these things I feel bad within my spirit [FGR5].
A desire to pursue education
I have always wanted to finish school and be on my own and also work as my parents do. When I realised I was pregnant I thought about my schooling and I could not afford to sacrifice my education for family life as a single mother. The future looked bleak without my education. So I had to talk to by boyfriend who bought some herbal medicine for me. Unfortunately it didn’t work well [PP21].I am a students in the university. My whole future is ahead of me which can only be better with education. I can’t sacrifice that for a pregnancy whose father isn’t ready either. So I am left with no better decisions than try aborting this pregnancy. Hopefully I will finish school and get a job and live a better life [PP7].The patients that we see are mostly students either in senior secondary or in their tertiary education. They usually say that when they carry their pregnancy to term and deliver, it will disturb their education. They cannot imagine studying with pregnancies. Some also fear that they will be sacked from school because of the pregnancy [FGM19].The patients we have seen here are people who want to continue being in school and don’t want their pregnancies to make them stop schooling. In Ghana, some schools actually sack their students from school. These students see their colleagues being sacked especially from the junior high and senior high schools and so they don’t want to go through the same ordeal. I think now the ministry says school administrators should not sack their female pupils or students but I think it is still happening in some places. Normally they say they try using agbeve herbal tonic to abort so they can be free to continue their schooling [MO3].In this country, you are mostly withdrawn from school when you get pregnant. That is why they have to concentrate on their schooling and not getting pregnant. How can you be in school and get pregnant whilst your parents are trying to do their best to look after you? It is not the best. I have actually heard that some head teachers sack them from school [FGR10].
Discussion
Lack of knowledge of safe abortion services
Variable | Patients | Religious leaders | Midwives | Medical officers |
---|---|---|---|---|
N (%) | N (%) | N (%) | N (%) | |
Gender | ||||
Male | – | 33 (29.72) | – | 8 (7.2%) |
Female | 35 (31.5%) | 2 (1.8%) | 30 (27%) | 3 (2.7%) |
Age | ||||
15–25 | 20 (18%) | 3 (2.7%) | 2 (1.8%) | – |
26–35 | 10 (9%) | 6 (5.4%) | 20 (18%) | 4 (3.6%) |
36–45 | 4 (3.6%) | 10 (9%) | 3 (2.7%) | 4 (3.6%) |
46–55 | 1 (0.9%) | 10 (9%) | 3 (2.7%) | 2 (1.8%) |
56–65 | – | 6 (5.4%) | 2 (1.8%) | 1 (0.9%) |
Religion | ||||
Christianity | 25 (22.52) | 20 (18%) | 25 (22.5%) | 8 (7.2%) |
Islam | 10 (9%) | 15 (13.5%) | 5 (4.5%) | 3 (2.7%) |
Marital Status | ||||
Single | 33 (29.72) | 9 (8.1%) | 15 (13.51) | 8 (7.2%) |
Married | – | 24 (21.62) | 14 (12.61) | 3 (2.7%) |
Divorced | 2 (1.8%) | 2 (1.8) | 1 (0.9%) | – |
Educational Level | ||||
No formal education | 5 (4.5%) | – | ||
Primary school | 5 (4.5%) | 5 (4.5%) | – | – |
Secondary school | 10 (0.9%) | 15 (13.51) | – | – |
Tertiary level education | 15 (13.51) | 15 (13.51) | 30 (27%) | 11 (9.9%) |
Employment | ||||
Employed | 2 (1.8%) | 35 (31.5%) | – | 11 (9.9%) |
Unemployed | 33 (29.72) | – | 30 (27%) | – |