Stigmatized by association: challenges for abortion service providers in Ghana
The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating a pregnancy that is performed by an individual lacking the necessary skills, or in an environment that does not conform to minimal medical standards, or both [1]. In Ghana, unsafe abortion contributes significantly to maternal morbidity and mortality, especially among adolescents [2]. Ghana’s maternal mortality rate is considered poor at 319 per 100,000 live births [3]. While globally unsafe abortion is thought to contribute to between 8 or 12 % of maternal deaths, in Ghana it is estimated that up to 30 percent of all maternal deaths may result from unsafe abortion, making it a leading direct cause of maternal mortality [4].
In 1985, a group of doctors in Ghana spearheaded an amendment of the Criminal Code on abortion. This led to an amendment in the law in 1985 with the following provisions: 1) Abortion is illegal unless carried out in a hospital or designated clinic by a registered medical practitioner or gynaecological specialist; 2) Abortion is permitted when continuation of the pregnancy will pose serious risk to the life of the pregnant woman or injury to her physical or mental health; 3) Abortion is also permitted where the pregnancy is the result of rape, defilement of a female idiot or incest or where there is substantial risk of a serious physical abnormality or disease in the foetus [5]. (PNDC, 1985). The abortion law did not explicitly mention gestational age limits or methods to be employed for the procedure. The law states that “medical practitioners” are permitted to provide surgical abortions, for both spontaneous and induced abortion, in designated health facilities; they also provide post-abortion care. Problematically, it does not clearly define who “medical practitioners” are and it was widely interpreted as meaning only doctors.
Not until 2006 did the Ghana Health Service produce operational protocols which included unsafe abortion management as well as abortion and post-abortion care procedures [6, 7]. This operational document clarified that medical practitioners (doctors), obstetricians nurse-midwives, community health officers and medical assistants with midwifery training are allowed to provide either medical or surgical abortions, at different levels of the health care system (community, sub-district, district, regional and national). Nurse/midwives and community health officers are allowed to perform medical abortions with pregnancies less than nine (9) weeks. Where pregnancies are over nine (9) weeks, these cadres are only allowed to conduct medical abortion at levels where doctors are available to supervise them (e.g. district level). In Ghana, abortions are carried out through manual vacuum aspiration (MVA), medical abortion, dilation and curettage (DC) and dilation and evacuation (DE). Only medical practitioners and obstetricians practise DC and DE. The protocols have not been widely disseminated. Although this study took place after the protocols had been published, many health providers working in obstetric and gynaecological units, especially nurse-midwives, were not aware of the contents.
Despite the publication of the abortion protocols, which included post-abortion care provisions, there was very limited availability of abortion services at the time of the study [2, 7]. Private hospitals are known to carry out safe abortions (mainly MVA, though increasingly medical abortion) for high fees, some NGOs like Marie Stopes International and Ipas provide services at a reduced fee and offer both MVA and medical abortion (depending on gestation), but are not widely known. Abortions are not usually openly available in public health facilities for fear of prosecution though they are provided by doctors in a clandestine manner and often labelled as ‘incomplete’ (spontaneous abortions) or diagnostic dilatation and curettage. Some health and paramedical staff, including nurses (especially male nurses), and some doctors also carry out abortions clandestinely in private undesignated premises, but these are against the law and are liable to face prosecution, although prosecutions are few and rare. Ghanaian women who seek abortion may do so from pharmacy shops (buying misoprostal, although at the time of the study it had not been formally licenced but was undergoing country trials), private hospitals, some public hospitals and other areas, such as clandestinely in the ‘providers’ homes and usually for high fees [8]. Information from an international NGO (Ipas) reports that the cost of abortion care in Ghana ranges from US$30 toUS$40 in public health facilities [9]. This cost is high because few doctors provide services and those who do consider it professionally risky (because of stigma associations) to perform abortion. The consequence of high fees is to make this service inaccessible for poor women and especially adolescents [9]. The fees women pay for procuring abortions are unofficial; they are amounts women are estimated to pay in practice. They are not fees stipulated by the Ghana Health Service or Ministry of Health. The abortion providers usually charge women arbitrarily, based on the gestational age of the pregnancies. Due to the secrecy surrounding abortion provision at the time of the study in both public and private health facilities, no official fees were available.
A clear barrier to accessing abortion services is that abortion is frequently characterized by intense stigma and shame associated with criminalization of the procedure as well as moral and religious condemnation [10–14]. Stigma is an attribute of a profoundly discrediting nature that marks or taints an individual as one who should be socially avoided [15]. Link and Phelan [16] describe stigma as a multifaceted process that operates at multiple levels. Stigma by association or courtesy stigma refers to family, friends and caregivers of women procuring abortion who are discredited merely because of their connection to a stigmatized person [17, 18]. In addition to mental illness, HIV/AIDS, tuberculosis, leprosy, obesity and abortion are phenomena that are commonly stigmatized [19–23]. Individuals who have had an abortion, performed one, or become involved in abortion controversy are vulnerable to stigmatization. These societal attitudes may have ramifications for patients, health providers and even researchers who work to facilitate the safety and comfort of women who seek/experience abortion.
Problems are best solved when different dimensions are investigated and understood. In Ghana, little evidence was found regarding abortion stigma, especially “stigma by association” encountered by providers and researchers [24]. Martin et al. [24] in their study on abortion stigma (from the perspectives of some Ghanaian doctors), found the operation and manifestations of abortion stigma in Ghana as multi-dimensional. The pervasive social stigma influenced the content and implementation of the abortion law and policy; the relatively liberal but ambiguous law made its interpretation and application problematic. Availability and access to safe abortion services was limited leading to clandestine, unsafe abortions with their attendant complications including maternal mortality. Women procuring abortions and doctors providing the services were highly stigmatized in Ghanaian society with untold ramifications, yet there was paucity of research to elucidate the heavy burden stigma places on women, doctors and researchers. The aim of this paper is to critically analyse health providers’ perspectives on challenges to providing safe abortion services in Ghana in order to provide a better and deeper understanding of how stigma is experienced and what might be done to reduce it. Investigating the impact of stigma, especially on different cadres of health providers would shed more light on the observed attitudes of providers towards abortion services and training as well as availability, access and safety of the services. The lead author of this manuscript, a health provider (nurse/midwife) and researcher of the subject also shares her lived experiences of stigma of association, adding a novel dimension of researchers’ experiences of abortion stigma. Furthermore, deeper socio-cultural dimensions of abortion stigma were revealed in the current study.