Abortion knowledge and experiences among young women and men in Accra, Ghana

Study design and sample

From September to December 2013, two paired teams of trained fieldworkers administered cross-sectional surveys, available as Extended data¹⁵, to eligible participants of the same sex and approximate age. Survey interviews were conducted in private locations at the recruitment sites, which included market places, social clubs, and sports venues in Accra, Ghana (Kokomlemle and Tema New Town). Eligible participants were aged 18–24 years, spoke English, Twi, or Ga, and were sexually active in the six months prior to the survey. The survey collected information about socio-demographic and reproductive health characteristics, contraceptive knowledge, use, and perceptions, and experience with unintended pregnancy and abortion. Questions differed slightly between male and female questionnaires to account for personal versus sexual partner experiences. Field workers obtained informed consent from each participant prior to initiation of the survey, which took approximately 45–60 minutes to complete. Participants were reimbursed 10 Ghanaian Cedi (GH¢) (approximately $3.00 USD). The study instruments were piloted prior to initiation of data collection, and periodic quality control checks were done throughout data collection. The study received institutional review board approval from the Nouguchi Memorial Institute for Medical Research at the University of Ghana, Legon (114/12-13) and the Marie Stopes International Ethical Review Committee (011-13). Sampling methodology and findings on contraception use and unintended pregnancy are reported elsewhere¹⁶.

Data analysis

For this study, our primary outcomes of interest were the percentage of women who reported prior abortion and the proportion of women using each specific abortion method. Other variables reported in this study included demographic and sexual and reproductive health characteristics, knowledge of abortion law, and details about abortion utilizers’ most recent experience: reason for abortion, method, provider, location, support, satisfaction, post-abortion contraception, and adverse events. Information was also collected from young men regarding any sexual partners’ abortion experiences.

Participants’ self-reported abortion methods used were categorized into medication abortion, which included responses of misoprostol or unspecified “tablets”; surgical abortion, which included unspecified surgical methods and dilation and curettage (D&C) (no respondent specifically selected vacuum aspiration); or unsafe methods considered “least safe,” which are “provided by untrained individuals using dangerous methods, such as ingestion of caustic substances, insertion of foreign bodies, or use of traditional concoctions.”¹⁵ While we recognize that abortion safety is a spectrum, contingent not only upon the utilized method, but also the skills of the provider, medical standards of the facility, and use of proper evidence-based protocols and medications, we were unable to assess such information. Thus, in this study, we assessed use of a “least safe” abortion method at any time during participants’ most recent abortion. We coded the following methods that were used as “least safe” methods: injection, ingestion of specific liquids or herbal concoctions, insertion of herbs or other objects into the vagina and heavy massage.

Descriptive statistics and chi-square tests were calculated. Fisher's exact test was used when any cell count was less than or equal to five. A level of p<0.05 was considered as statistically significant. All statistical analyses were conducted using Stata 14 (StataCorp, College Station, Texas).

Study population

In total, 250 women and 100 men participated in the survey. Underlying data are available from Harvard Dataverse¹⁵. Demographic and reproductive health characteristics of the participating women and men are shown in Table 1 and Table 2, respectively. More than half of the participants were between 21–24 years old (58% women; 54% men) and most identified as Christian (81% women; 83% men) and had Junior High School as the highest education level (55% women; 40% men). Most respondents were unmarried with a steady non-cohabitating partner (67% women; 73% men) and had never given birth (58%) or fathered a child (90%). The mean age of sexual debut was 17 for women and 16 for men, and both on average had been sexually active for four years. In total, 57% of men reported current modern contraceptive use with their partner whereas most women (54%) reported not using any contraceptive method. Women mostly had one to two lifetime sexual partners (71%), while men reported number of partners varied more widely with 36% reporting five or more lifetime sexual partners.

Abortion knowledge and experience among women

While abortion in Ghana is legal in cases of rape, incest, risk to the life or health of the woman, or fetal abnormality when performed by a medical registered practitioner³, 87% of women thought abortion was illegal or stated they did not know the law. Only 12% of women who had a prior abortion and 5% without a prior abortion thought it was legal in some cases. Of female respondents, 30% (n=74) reported ever having an abortion (Table 1), with 21% (n=15) of them reporting more than one abortion over their lifetime (data not shown).

In univariate analyses (Table 1), women who ever had an abortion were older (aged 21–24 versus 18–20, p=0.006), had an earlier sexual debut (aged 8–14 versus 15–19 versus 20–24, p=0.008), and reported more lifetime sexual partners (1-2 versus 3-4 versus 5+ partners, p≤0.001) compared to those who had never had an abortion. There were no significant univariate differences by education, religion, relationship status, parity, prior STI testing, past family planning discussion, family planning method, or knowledge of the abortion law.

When women were asked how they felt about being pregnant prior to their most recent or only abortion, most reported wanting to be pregnant later (69%), 15% reported they never wanted to be pregnant, and 15% reported wanting to be pregnant then (Table 3). Women reported multiple reasons for seeking abortion, with the majority (74%) weighing the timing of their pregnancy as a driving factor. Timing included not being ready to be a mother (n=37), being too young to have a child (n=16), wanting to delay child bearing (n=7), and/or desiring child spacing (n=3). Other top reasons were for their career (36%), including that they wanted to stay in school (n=20) or continue working (n=6). Many also reported relationship reasons for ending their pregnancy (34%), which included the partner not wanting the child (n=21) or denying the pregnancy (n=2), not being in a serious relationship (n=1), or that the participant did not love the biological father (n=2). Others had concerns about resources (15%), including the lack of help (n=5) or money (n=6) for raising a child. In total, 15% said they sought their abortion due to their parents, either owing to fear of them (n=9) or because of their insistence (n=2) and 8% wanting to avoid shame. Only one participant mentioned concerns of health as a reason, which was due to risk of birth defects (1%).

Regarding support, most women spoke to someone about their abortion (89%), and 78% felt supported by their partner and/or 58% by their friends for their abortion. However, most (73%) also reported that their family did not know about or did not support their abortion.

Abortion methods

Women selected their initial or only abortion method for multiple reasons (Table 3), with the most common reasons being the recommendation of family or friends (39%), their partner (22%), and/or a health provider (19%). Other reasons also included safety (16%), effectiveness (10%), privacy (3%), and/or because it was their only known method (14%).

Among the 74 women who reported prior abortion, the most common initial or only attempted method of abortion was medication abortion (n=45, 61%) (Table 3). Specific methods initially sought included medication abortion (including misoprostol alone, referred to by the brand name “Cytotec” (n=34, 46%), and unspecified tablets (n=11, 15%)), surgical abortion (including D&C (n=14, 19%) and unspecified surgical abortion (n=5, 7%)), and least safe methods (including consuming various drinks or liquids, ingesting herbal substances, inserting of herbs, objects, or substances into the vagina, and heavy massage (n=10, 14%)). Accounting for multiple methods used during women’s most recent abortion, 62% of women took tablets (n=46) and 32% had a D&C (n=24) (data not shown).

Generally, most women were very or somewhat satisfied with their initial or only chosen method (Table 3). In total, 25% (n=18) reported any dissatisfaction in their initial method of surgical abortion (n=1), medication abortion (n=12), or least safe methods (n=5). All those who reported being very dissatisfied with their initial method (n=10, 14%) used more than one method to end their pregnancy (data not shown).

Of the women who had abortions, one-fifth used more than one method (n=16, 22%). All women in this subset initially used medication abortion (n=11, 69) or least safe methods (n=5, 31) with the other method reported to be D&C (n=10, 63%), misoprostol (n=1, 6%), unspecified tablets (n=1, 6%), and least safe methods (injection, drank herbal concoction, or heavy massage) (n=4, 25%). Nearly a quarter (n=11, 24%) of women who initially took tablets (misoprostol or unspecified) used more than one method, with most of them following up with D&C (n=7) (data not shown).

Abortion providers

Women’s provider experiences for their most recent abortion are shown in Table 4. Among the 10 women whose initial method was least safe, 50% saw no one, 10% saw a family member or friend, 20% saw a traditional practitioner, and 20% saw a doctor, nurse, or midwife. All women whose initial method was surgical abortion saw a doctor (n=17, 90%) or nurse/midwife (n=2, 9%) for their procedure at a medical facility. Conversely, only a few women (n=5, 11%) whose initial or only method was medication abortion visited a doctor, nurse, or midwife. Most of these women initially saw a pharmacist (n=18, 40%), while others consulted with friends/family (n=7, 16%) or no one (n=15, 33%). Overall, among all women with prior abortion, 55% (n=41) accessed medication abortion at some point outside of the formal medical system for their most recent abortion through a pharmacist (n=19), friends and family (n=7), or no one (n=15).

For the 73% of women (n=54) who reported visiting or consulting with someone (including non-professionals) for their abortion, most reported that recommendations from their family/friends (52%) factored into their decision regarding who they initially consulted with and where they went (Table 4). Other common reasons were perceived quality of the provider (26%) and/or the recommendation of their partner (15%). Women who had surgical abortions were significantly more likely than those who had medication or other abortions to have considered quality when choosing their provider (p≤0.001).

When asked about satisfaction with where they went for their abortion, most women reported feeling satisfied, with satisfaction varying by method used (p=0.002) (Table 4). All those who had surgical abortions were very or somewhat satisfied, while those who had medication abortions were more mixed. Only five respondents expressed any dissatisfaction with their initial location. Four had initially used medication abortion at home after visiting a pharmacist, while one saw a traditional healer for an herbal remedy. All five dissatisfied women used multiple methods to complete their recent abortion (data not shown).

Among all women with prior abortion, a minority (39%) reported receiving any contraceptive information post-abortion; however, women who had surgical abortions were more likely to report talking about family planning with their providers compared to those who had medication abortions or used other methods (p=0.04). Overall, 62% of women who saw a health professional spoke to them before (n=6, 23%), after (n=8, 31%), or before and after (n=2, 8%) about post-abortion contraception. Of those who saw a pharmacist, 44% spoke about post-abortion contraception before (n=4) or after (n=4) their abortion. The majority (n=16, 80%) of women who saw no one received no post-abortion contraceptive counselling. Those who saw a traditional practitioner did not receive contraception counseling, while just one woman who saw a friend/relative reported talking with a health professional before her abortion about contraception (n=1, 13%) (data not shown).

Regarding costs, 54% reported their partners paid for the procedure, while 26% reported they paid for their own abortions. The cost for abortions varied widely. Surgical methods cost a median 150 GH¢ (n=15), significantly more than the median 30 GH¢ (n=26) for medication abortion and 55 GH¢ (n=6) for least safe methods. Those who did not ever visit a provider were not asked about cost.

Abortion safety

Of the 74 women who reported ever having an abortion, 18% (n=13) reported using a least safe method at some time during their recent abortion process, such as drinking substances, herbal remedies, inserting objects, taking an injection, or receiving a heavy massage. Among those who reported one of these least safe methods, all of those who answered (n=12) did not know that abortion was legal. In fact, there was a significant difference in correct understanding of the law between those who reported using least safe abortion methods versus surgical or medication abortion (p=0.046) (data not shown).

However, there were otherwise few significant differences between women who used a least safe method versus surgical or medication abortion methods. Those who reported a least safe method were more likely to have more than two lifetime sexual partners (p=0.008). Also, women using least safe abortion methods compared to medication abortion or surgical methods were more likely to report using more than one method to end their pregnancy (p=0.001), and to have reported seeing no one for their abortion (p=0.002). Women more often reported selecting a least safe method due to assumed privacy (p=0.03) and/or effectiveness (p=0.02) of the method but were also more likely to be very dissatisfied with their method (p=0.003).

Despite unsafe methods being used, adverse events did not differ whether a least safe method was used at any point for the abortion or not. Regarding additional required treatment, no one reported needing surgical intervention and two women reported receiving blood transfusions following a surgical abortion and a medication abortion respectively. Four women, two in each safety group, required antibiotics (data not shown). Four respondents reported health problems associated with the abortion after six months from their most recent abortion, while seven women had their abortion less than six months ago. Complaints included lack of period (n=1, 1%), abdominal pain (n=1, 1%), irregular period (n=3, 4%), more painful periods (n=1, 1%), and reported anemia (n=1, 1%) after six months. This included a woman who had a medication abortion, one who had a D&C, and two who used medication abortion followed by D&C or “injection” respectively (data not shown).

Partner abortion characteristics

Among males, 64% thought abortion was illegal or stated they did not know the law (Table 2). Only 14 (14%) reported that a partner had a prior abortion (Table 2), with three (21%) of them reporting more than one prior abortion. Most respondents’ partners’ abortions were provided by a medical professional (n=9, 69%) and took place at a private clinic or hospital (n=8, 62%). Others noted that their partners saw a pharmacist (n=2, 15%) or a relative/friend (n=2, 15%) for their abortions (data not shown). Males reported that their partners had a medication (n=4, 29%) or surgical abortion (n=2, 14%); however, 57% (n=8) did not know or report what specific method was used (data not shown). Males who reported having a partner who had an abortion were more likely to have fathered a child (p=0.004) and ever been tested for an STI (p=0.03), and less likely to have ever spoken to anyone about family planning (p=0.04), compared to those who did not report a partner ever having an abortion (Table 2). The majority (n=9, 64%) did not support their partner’s decision for abortion because they believed that it was dangerous for the woman (n=3), they wanted the child (n=1), they were not in a relationship with the pregnant person at the time of the abortion (n=2), or for no specified reason (n=4). None of the men said they believed their family would support the abortion, and only one mentioned talking to any family about it (data not shown).

Underlying data

Harvard Dataverse: Replication Data for: Abortion knowledge and experiences among young women and men in Accra, Ghana. https://doi.org/10.7910/DVN/ZBZT1N¹⁹.

This project contains the following underlying data:

Extended data

Harvard Dataverse: Replication Data for: Abortion knowledge and experiences among young women and men in Accra, Ghana. https://doi.org/10.7910/DVN/ZBZT1N¹⁹.

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).