Background
Abortion is a global phenomenon carried out for diverse reasons and with an array of consequences that affect women, their families, societies and health systems [
1]. By World Health Organization (WHO) standards, abortions procured in locations with minimal medical standards and/or provided by unskilled health professions are defined as
unsafe [
2,
3]. The global burden of unsafe abortion is huge with 49% of all abortions being unsafe; in Africa more than 97% are unsafe [
4]. Unsafe abortions may result in outcomes with enormous cost to health services [
5]. Globally 13% of all maternal deaths are attributed to unsafe abortion and almost all abortion-related deaths occur in developing countries with the highest number in Africa [
4]. Many more women who survive experience morbidity and disability that diminish their quality of life [
3].
In Ghana unsafe abortion contributes to the high maternal mortality rate of between 310 and 402 deaths per 100,000 live births [
6]. Yet unsafe abortions are preventable and the solutions, including sex education and effective family planning to avert unplanned pregnancies, are well documented, practical and affordable [
7]. More directly, Comprehensive Abortion Care (CAC) which provides access to safe abortion and post-abortion care, is strongly advocated by the World Health Organisation as best practice [
3]. Even donors who will not support safe abortion services (like USAID) do support post-abortion care as part of a comprehensive approach [
8]. The situation in Ghana is changing slowly. In 1997 a study in four regions in Southern Ghana estimated there were 17 induced abortions for every 1000 women of childbearing age [
9]. In 2007 the nationally representative Ghana Maternal Health Survey found that 15% women aged 15–49 had ever had an induced abortion with 5% having one in the five years preceding the survey [
10]. In 2017 the survey found 20% women 15–49 had ever had an abortion, with 7% reported one in the preceding five years [
6]. This small increase may indicate increasing awareness of services.
Globalisation refers to interconnectedness and interdependence of the human community. Events in one nation increasingly appear to have ripple effects (negative or positive) on other nations globally [
11], both at a national, policy level and the individual, social level. Access to safe abortion is a globally contested policy and social justice issue – contested because of its religious and moral dimensions vis-à-vis the right to life and personhood of a foetus vs. the rights of women to make decisions about their own bodies. International consensus meetings have been held to define and agree action on unsafe abortion. At the International Conference on Population and Development (ICPD) in 1994, governments were urged to ensure widespread availability of post abortion care (PAC) and safe abortion services; the latter to be delivered within the framework of national abortion laws. Many nations agreed to address the health
consequences of unsafe abortion, though stopped short of committing to providing comprehensive safe abortion services [
1]. The Fourth World Conference on Women in Beijing in 1995 called on governments to review restrictive abortion laws in line with protecting the rights of women. Consequently, between 1995 and 2003, many countries in Africa where most abortion laws are restrictive, including Benin, Burkina Faso, Chad, Guinea and Mali, reformed their laws to allow for abortions where pregnancies result from rape, incest, foetal impairment or risks to women’s health [
12].
Legal reform is important because there is a strong correlation between restrictive abortion laws, high levels of unsafe abortions and high maternal mortality and morbidity [
1]. On the other hand, in countries, where laws and policies allow abortion under broad indications, the incidence of, and mortality from, unsafe abortions are relatively low. Worldwide, abortion is permitted in law for social or economic reasons in only 16% of low income countries as opposed to about 80% of high income countries [
3]. There are many influences on abortion laws: depending on the country these may include civil, common and religious laws, which in many African countries including Ghana, frequently derive from the inherited laws of their colonisers [
13].
In Ghana abortion was restricted under common law, being criminalised in the penal code, as inherited from the UK colonial government. During the years of military dictatorship in the 1980s, however, when the influence of institutionalised religion was perhaps lessened, this law was modified and liberalised. The 1985 law (Government of Ghana PNDC Law 102) permits abortion in cases of rape, incest, foetal abnormalities or where the pregnancy is a risk to the woman’s physical or mental health, although these remain exceptions within in the criminal code. Since then, Ghana ratified most of the international treaties and has made modest efforts at reducing maternal mortality by tackling the problem of unsafe abortions. Post abortion care forms an integral part of the Safe motherhood initiative that was implemented in 1990, though operational service guidelines were only finalised in 2006. The reality of the provision of accessible safe abortion services has been very different. Historically safe abortion services were largely available in private clinics so not financially accessible to all women. Some abortions were provided clandestinely in public hospitals and were hard to access. Over the past decade, however, changes have occurred at the level of individual providers, in line with the law, and safe abortion services are now being provided more frequently in health centres and public hospitals by obstetricians and midwives who are trained and willing to provide the services, though coverage remains patchy [
14]. Understanding whether globalisation has played a role in this transition to practice is important to institutionalise the transition in Ghana as well as to learn lessons for other countries seeking to implement policies, but analysis of globalisation elements in this respect is lacking. The purpose of this paper is to draw on key informant interviews and document analysis to describe the development of
de jure law and policies on comprehensive abortion care in Ghana, the de facto interpretation and implementation of those policies, and assess what role globalization played in the transition in abortion care in Ghana.
Methods
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.
Discussion
We have described the development and interpretation of the law and policies addressing access to abortion services in Ghana, with a view to illustrating the influences on these and the role that globalisation has played in shaping the transition from restrictive access to abortion services to more equitable access.
Ghana’s legal framework on abortion, the 1985 amendment which was the result of a dictatorship, was in a way ahead of its time (it is supported by the Cairo Platform of Action nearly a decade later) – despite being in the criminal code (which avoids more controversial discussion of “legalisation”) it is vague and liberal enough to allow practitioners to work within it (again without attracting too much attention). This can have negative consequences too whereby legitimate providers are not aware of the wide circumstances within which they can legally provide abortion services. Furthermore, the social and political climate in Ghana until around 2006 was such that the law was never operationalized into policy guidelines. The fact that guidelines were eventually developed is partly due to a range of socio-political global influences as Ghana consolidated itself as a multi-party democracy with vibrant economic growth and global social exchange.
A number of frameworks have emerged for analysing the globalisation of influences on health, though none particularly focused on the policy level. We found a useful one to be that suggested by Huynen et al. (2005) in
Globalisation and Health which was developed to categorise the global influences on population health [
23]. Four of the six hypothesised “features” are relevant to our policy case study on abortion (global environmental influences and global markets are not relevant).
First, new global governance structures, defined in the Huynen paper as globalisation influencing the interdependence among nations as well as the nation state’s sovereignty which leads to new global governance structures. In our case study “new” governance structures have developed in relation to the right to health. International treaties and declarations, including those arising from the 1994 International Conference on Population and Development (ICPD) and N’s 1995 Beijing Conference on Women, embed a shifting understanding of legal rights that protect reproductive choices for women. Ghana’s signing of these international agreements holds weight beyond sovereign legislation, creating an internationally witnessed obligation of the signatory government to be seen to respond in its own laws and policies. In fact Ghana’s laws predated its signing of the international agreements but the signing added weight to the need to translate legal rights into practical policies and guidelines – a process that took another 10 years and came about because of pressure – and action – from international NGOs as well as a variety of other global exchanges. The re-imposition of the Mexico City Policy – or Global Gag Rule –by the present US administration post-dates our fieldwork, has made the environment more difficult for related service providers. The “gag” rule refuses funding to NGOs that provide information about or services for safe abortion. Although Ghana did not suffer unduly from the previous gag rule imposed by President Bush Junior it did result in the Planned Parenthood Association of Ghana, which received significant USAID funding, having to withdraw outreach services and lay off workers as a result of losing funding through not signing the “gag” rule. However, since safe abortion services in Ghana are largely provided by government clinics and pharmacies we would not expect it to have a significant effect on availability of safe abortion services, though users of NGO-provided services may well find their choices more limited.
Second,
global communication, defined as globalisation making the sharing of information and the exchange of experiences around common problems possible. In our case study some respondents had been exposed through training and their own use of the internet, to more liberal views of abortion which they claimed had changed the way they viewed safe abortion service provision. The communication of global scientific evidence and debate persuaded them that saving women’s lives (as opposed to foetuses) was an important, though a difficult choice. The woman is the full person alive now who might die without access to safe abortion and then not only she but her other existing children would suffer, thus the greater good would be to allow women a choice. This has helped to temper the negative influences of institutionalised religion. We have shown elsewhere that while doctrinal religious beliefs contribute to stigmatisation of abortion providers, this is mainly feared by lower-educated practitioners who have had little training on or exposure to more liberal social and medical norms in other countries [
15].
International NGOs have been critical players in Ghana for communicating – and advocating on – these global rights perspectives and frameworks. For example, R3M, taking up global debates on abortion rights pushed for evidence, reviews and piloting of interventions as well as providing training and support to influence service provision in Ghana. Ipas was particularly influential at a global level, having a big role coordinating the Addis Ababa meeting for all African Ministers for Health and in supporting the national follow-up after those agreements – to which Ghana was a signatory. WHO added its weight as a global agency tasked with disseminating best practice and service-delivery guidance.
While global communication has clearly contributed to a transition in care practices among Ghanaian providers, the same cannot be said for women and girls who should be the beneficiaries of that care. In 2017 the Ghana Maternal Health Survey found that only 11% women knew that abortion was legally available in Ghana [
6]. This may explain the apparent lack of significant change in women accessing clinic-based services. In 2017 38% of women undergoing abortion reported using medical pills; 34% used a clinic-based medical procedure (mostly dilation and curettage or dilation and evacuation) but 27% still used non-medical methods [
10]. This appears to be only a fractional decrease from the findings from the (non-representative) 1997 study from Southern Ghana in which 32% respondents used non-medical methods, the rest using clinic based staff or pharmacies [
9]. Nevertheless, it should be noted that respondents in southern Ghana will have had significantly better access to services than their counterparts in the underserved middle and northern regions of the country, so a nationally representative percentage would have been lower. Furthermore, in the past, the clandestine provision of “safe” services by clinicians but for private fees was widespread which may account for a large part of the “medical” services reported in the earlier study. What this shows is a clear need for communications to focus on improving women and girls understanding of their rights to safe, legal abortion services that are increasingly available in Ghana.
Third,
global mobility, defined as a major increase in the intensity and velocity of movement and by a wide variety in ‘types’ of mobility. In our case study the higher trained specialised cadres of staff (obstetrician-gynaecologists) had been trained in Europe (mainly Eastern Europe) where they had been exposed to, taught about, and practiced provision of, safe abortion services. Various American schools have also established advanced training programmes, including the University of Michigan Department of Obstetrics and Gynecology began postgraduate training of Ghanaian obstetricians in 1986. One graduate is quoted as saying: “
You saw how things are being done in the developed world. It gave me an opportunity to compare methods there with those here. And I concluded that after all, what they are doing in the developed world is not miles ahead of what they are doing here, so I became more confident in what we are doing as OB-GYNs.” [
24]
. Like most, if not all, international training programmes, these opportunities are not available to lower cadres of staff. In our study it was noticeable that the midwives, lower in the medical hierarchy, who had not had such opportunities consequently had much more limited exposure to different approaches, debates and practices. Their views were correspondingly more traditional and more defined by doctrinal religious beliefs. Nevertheless, there are also attempts in-country to build capacity more broadly for reproductive health care provision. For example, the University of Michigan in collaboration with Ghana College of Physicians and Surgeons and two teaching hospitals established International Family Planning Fellowship Program in 2008, to locally train fellows in family planning and reproductive health.
Finally,
cross-culture interaction, defined as the globalisation of cultural flows resulting in interactions between global and local cultural elements. This is linked to the previous two categories – communication and mobility facilitate the interaction of different cultural perspectives. In relation to reproductive rights this means that international norms of acceptability of these rights become normalised in local settings through the sharing of ideas and the gradual change of perspective, particularly when that is combined with experience of the health benefits of a different approach. International NGOs, neglected in the original theory, are an important conductor for intercultural interaction. Most are headquartered in developed countries but maintain country offices. Their international staff bring with them globally-informed ideas and practices. In our case study the INGOs active in the abortion field were providing services, supporting training to public sector staff and advocating to government agencies to bring their policy guidelines in line with both their own legal position and their obligations under international declarations. In Ghana the country offices of the international NGOs are usually staffed by Ghanaians making them appear more “home grown” but advocating strongly on the lines of internationally agreed obligations. Another complementary study shows how the INGOs working in Ghana on sensitive abortion issues took a “softly, softly” approach, getting the ear of key policy and social thought-leaders, focusing on preventing the consequences of unsafe abortion rather than pushing for controversial “rights” [
25].
In Ghana the law itself was not sufficient to achieve a change in practice, partly because its embedding in the penal code makes it appear inaccessible, but an accumulation of global influences has converged to start a transition in the culture of abortion care and service provision among those cadres of health providers who have interacted with other cultures. The existence of policy implementation guidelines, whose formulation was led by INGOs, means that there is now, additionally, a clear professional obligation on all cadres of staff to transition to a more equitable, non-judgemental provision of abortion services.
There is a debate in the globalisation and health literature on the extent to which globalisation is helpful or harmful to health. Richard Feachem in his 2001 British Medical Journal article bucked the trend when he suggested it was mostly helpful [
26]. This was hotly contested by others who pointed to neo-colonialist tendencies exacerbated by globalisation ([
27,
28] and many others in the Letters section of British Medical Journal Vol. 324, 5 January 2002). Some years later Schrecker et al. in the Lancet (2008) held that globalisation creates inequities for health (as well as more generally) [
29]. Our case study provides very clear refutation of this in relation to abortion. We show that where cultural interactions on health and rights issues, global mobility of staff and global governance architecture converge to protect contested rights for vulnerable people, then globalisation can very clearly work in favour of these rights and create more equitable access to stigmatised or hard-to-access services, particularly for the poor. This view is supported by London and Schneider (2012) who argue that global human rights provide a normative framework enabling active civil society engagement to challenge inequities [
30]. In our case study INGOs challenged government inaction on practice guidelines for delivery of safe-abortions and post-abortion care services, which eventually triggered a transition of practice. A similar example comes from Mexico where globalisation enabled the creation of space for NGOs to work to develop new ways to ensure access to safe abortions for cases qualifying under their quite restrictive laws as well as advocate for the review of punitive laws, building on civic interest and international accords [
31].