Community education efforts enhance postabortion care program in Ghana

Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review

At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.

Postpartum contraceptive choices among women attending a well-baby clinic in Ghana

OBJECTIVE

To assess postpartum contraceptive choices among women attending a well-baby clinic in Ghana.

METHODS

From April 1 to May 31, 2011, a descriptive cross-sectional survey was conducted among women who attended the well-baby clinic of Komfo Anokye Teaching Hospital, Kumasi, at 6-24 months after delivery. Participants were consecutively recruited and interviewed using semi-structured questionnaires. Data were collected on demographics, exposure to family planning counseling, message content, and postpartum contraceptive choices. Differences between the profiles of women who did or did not take up postpartum family planning were assessed.

RESULTS

Of the 200 women enrolled, 44 (22.0%) wanted no more children and the last pregnancy was unintended among 88 (44.0%). In all, 110 (55.0%) women took up postpartum contraception, with the calendar method (n=57; 51.8%) and injectable contraceptives (n=22; 20.0%) cited as popular choices. Family planning counseling was received at the prenatal clinic by 47 (23.5%) women, with 12 (6.0%) given written referrals on the postnatal ward. More previous contraceptive users than previous non-users chose long-acting or permanent postpartum methods (P<0.001).

CONCLUSION

Inadequate postpartum family planning counseling and referrals during maternity care were recorded, suggesting that a comprehensive educational intervention is required to improve uptake.

Attitudes toward abortion among students at the University of Cape Coast, Ghana

OBJECTIVES

This study aimed to describe the attitudes toward abortion of Ghanaian University students and to determine factors which are associated with supporting a woman's right to an abortion.

METHODS

This cross-sectional survey was administered to residential students at the University of Cape Coast. Participants were posed a series of 26 statements to determine to what extent they were supportive of abortion as a woman's right. An exploratory factor analysis was used to create a scale with the pertinent factors that relate to abortion attitudes and a multivariable linear regression model explored the relationships among significant variables noted during exploratory factor analysis.

RESULTS

1038 students completed the survey and these students had a generally negative view of abortion. Two factors emerged: (1) the Abortion as a Right scale consisted of five questions (α = .755) and (2) the Moral Objection to Abortion scale consisted of three questions (α = .740). In linear regression, being older (β = 1.9), sexually experienced (β = 1.2), having a boyfriend/girlfriend (β = 1.4), and knowing someone who has terminated a pregnancy (β = 1.1) were significantly associated with a more liberal view of a right to an abortion.

DISCUSSION

This work supports the idea that students who have personal exposure to an abortion experience hold more liberal views on abortion than those who have not had a similar exposure.

What makes a likely abortion provider? Evidence from a nationwide survey of final-year students at Ghana's public midwifery training colleges

BACKGROUND

Even in countries where the abortion law is technically liberal, the full application of the law has been delayed due to resistance on the part of providers to offer services. Ghana has a liberal law, allowing abortions for a wide range of indications. The current study sought to investigate factors associated with midwifery students' reported likelihood to provide abortion services.

METHODS

Final-year students at 15 public midwifery training colleges participated in a computer-based survey. Demographic and attitudinal variables were tested against the outcome variable, likely to provide comprehensive abortion care (CAC) services, and those variables found to have a significant association in bivariate analysis were entered into a multivariate model. Marginal effects were assessed after the final logistic regression was conducted.

RESULTS

A total of 853 out of 929 eligible students enrolled in the 15 public midwifery schools took the survey, for a response rate of 91.8%. In multivariate regression analysis, the factors significantly associated with reported likeliness to provide CAC services were having had an unplanned pregnancy, currently using contraception, feeling adequately prepared, agreeing it is a good thing women can get a legal abortion and having been exposed to multiple forms of education around surgical abortion.

DISCUSSION

Midwifery students at Ghana's public midwifery training colleges report that they are likely to provide CAC. Ensuring that midwives-in-training are well trained in abortion services, as well as encouraging empathy in these students, may increase the number of providers of safe abortion care in Ghana.

Abortion care in Ghana: a critical review of the literature

The Government of Ghana has taken important steps to mitigate the impact of unsafe abortion. However, the expected decline in maternal deaths is yet to be realized. This literature review aims to present findings from empirical research directly related to abortion provision in Ghana and identify gaps for future research. A total of four (4) databases were searched with the keywords "Ghana and abortion" and hand review of reference lists was conducted. All abstracts were reviewed. The final include sample was 39 articles. Abortion-related complications represent a large component of admissions to gynecological wards in hospitals in Ghana as well as a large contributor to maternal mortality. Almost half of the included studies were hospital-based, mainly chart reviews. This review has identified gaps in the literature including: interviewing women who have sought unsafe abortions and with healthcare providers who may act as gatekeepers to women wishing to access safe abortion services.

Factors associated with abortion-seeking and obtaining a safe abortion in Ghana

Although Ghana's abortion law is fairly liberal, unsafe abortion and its consequences remain among the largest contributors to maternal mortality in the country. This study analyzes data from the 2007 Ghana Maternal Health Survey to identify the sociodemographic profiles of women who seek to induce abortion and those who are able to obtain safe abortion services. We hypothesize that women who have access to safe abortion will not be distributed randomly across different social groups in Ghana; rather, access will be influenced by social and economic factors. The results confirm this hypothesis and reveal that the women who are most vulnerable to unsafe abortions are younger, poorer, and lack partner support. The study concludes with policy recommendations for improving access to safe abortion for all subgroups of women, especially the most vulnerable.

Return on investment for essential obstetric care training in Ghana: do trained public sector midwives deliver postabortion care?

INTRODUCTION

In Ghana, the provision of postabortion care (PAC) by trained midwives is critical to the efficient and cost-effective reduction of unsafe abortion morbidity and mortality.

METHODS

We performed a secondary analysis of provider data from a representative sample of Ghanaian health facilities in order to consider the determinants of PAC provision among both physicians and midwives.

RESULTS

In the previous 5 years, more than 58% of providers had participated in at least one type of essential obstetric training. Overall, 28% of clinicians were offering PAC services (80% of physicians as compared to 20% of midwives). Bivariately, the provision of PAC services was associated with in-service training. After adjusting for select provider and facility characteristics, PAC/MVA training, working in a facility with the National Reproductive Health Standards and Policy available, and not working in a publicly run facility were associated with midwives offering PAC services.

DISCUSSION

Although the provision of PAC by midwives is an efficient and cost-effective strategy for reducing maternal morbidity and mortality, clinical training of midwives leads to a lower yield of PAC providers when compared to physicians. Policy and practice should continue to support PAC expansion by trained midwives in the public sector and by understanding the barriers to provision of services by midwives working in public facilities.

The context of informal abortions in rural Ghana

AIMS

This qualitative study explores the context of unsafe abortion in rural Ghana with the aim of identifying areas that should be considered when operationalizing abortion-related reproductive health strategies.

METHODS

Data come from eleven narratives about planned or attempted abortions and seven narratives of abortion-related deaths. These individual data are supplemented by data from ten focus group discussions.

RESULTS

Communities describe abortions as dangerous and, if they become public knowledge, shameful. Despite this, abortions were understood as necessary for some women in some situations, but secrecy was paramount. Women carefully chose their confidants based on the anticipated reaction and did so for advice about cheap and effective methods or for financial assistance. Complications were usually managed at home. When complications were taken to the health facility, the abortion was often not disclosed. Women reported trying sequential abortion methods, starting with cheaper milder methods and, if these attempts failed, resorting to harsher more expensive methods. Access to pharmaceuticals and finances also determined the method used. Financial hardship, interruption of education, and being unmarried were the most frequently cited reasons for abortions.

CONCLUSIONS

Unsafe abortion is an important public health issue in Ghana. Current strategies to reduce abortion-related deaths include increasing the provision of safe abortion services. For the strategy to be successful, services should be accessible, affordable, and confidential, and discourse with communities and health workers to break the public silence about abortion is needed.

Midwifery tutors' capacity and willingness to teach contraception, post-abortion care, and legal pregnancy termination in Ghana

BACKGROUND

Ghana has a high maternal mortality rate of 540 per 100 000. Although abortion complications usually are treatable, the risks of morbidity and death increase when treatment is delayed. Delay in care may occur when women have difficulty accessing treatment because health care providers are not trained, equipped, or willing to treat the complications of abortion. Gaps in the midwifery tutors' knowledge on comprehensive abortion care (CAC) have resulted in most midwives in Ghana not knowing the legal indications under which safe abortion care can be provided, and lacking the skills and competencies for CAC services. The aim of this study is to assess the capacity and willingness of midwifery tutors to teach contraception, post abortion care and legal termination in Ghana.

METHODS

This study focused on all 14 midwifery schools in the country. A total of 74 midwifery tutors were interviewed for this study. Structured self-administered questionnaires were used for data collection. The data were entered and checked for consistencies using Epiinfo 6.04 and analyzed using Stata 8. Descriptive analysis was used and frequencies reported with percentages.

RESULTS

In total, 74 midwifery tutors were interviewed. Of these, 66 (89.2%) were females. The tutors had mainly been trained as midwives (51.4%) and graduate nurses (33.8%). Respondents were predominantly Christians (97.3%).The study discovered that only 18.9% of the tutors knew all the legal indications under which safe abortion care could be provided. The content of pre-service training of tutors did not include uterine evacuation with manual vacuum aspirator (MVA).The study also highlighted some factors that influence midwifery tutors' willingness to teach comprehensive abortion care. It was also revealed that personal and religious beliefs greatly influence teaching of Comprehensive Abortion Care.

CONCLUSION

The findings of this survey suggest that the majority of tutors did not know the abortion law in Ghana as well as the Ghana Health Service Reproductive Health Standards and Protocol. Thus, there is a need to enhance their capacities to teach the present pre-service students the necessary skills to offer CAC after school and to understand related issues such as related legal matters.

Evolution of the postabortion care program in Nepal: the contribution of a national Safe Motherhood Project

The objective of this review is to present the findings and lessons learned over the first 4 years (1999-2002) of implementation of postabortion care (PAC) services outside of major urban centers in Nepal, where a significant proportion of services are provided by nurses. The contributions made by a national Safe Motherhood project to the establishment of the National Postabortion Care Program including the promotion of nurse providers within an integrated program of emergency obstetric care services are highlighted. Clinical competency assessments and service utilization data from three district hospital-based postabortion service sites supported by the Nepal Safer Motherhood Project are analyzed. The relationship between the findings of this assessment and two previous assessments, one covering two districts and one nationwide, are discussed. This review found that nurses are at least as competent as physicians in providing postabortion care services. The inclusion of postabortion care into the emergency treatment of obstetric complications provided the environment needed for successful introduction of nurse-led PAC services. Competency-based training of nurse providers is the key to making life-saving postabortion care services accessible and affordable in Nepal. Ensuring that these nurse providers are able to implement services requires strategic planning, careful advocacy and support from physician colleagues as well as the presence of adequate infrastructure and equipment. The successful introduction of postabortion care services into three district hospitals also offering emergency obstetric care provides an example of how a nurse-led service can be integrated into an emergency obstetric care support project. The project's learning has influenced national policy on the expansion of the postabortion care program throughout Nepal.

Strategies to reduce maternal mortality worldwide

The challenge of reducing maternal mortality is increasingly being addressed by area-based efforts to improve access to care of obstetric emergencies. Improving coverage and quality of skilled attendance at birth is also being increasingly emphasized. Post-abortion care, better reproductive health services for adolescents, and improved family planning care are important ingredients in maternal mortality reduction. New developments in malaria, nutrition, violence and HIV/AIDS in relation to maternal health are highlighted, as well as measurement issues. Maternal mortality reduction is also being promoted today by using a human rights approach.