Int J Adolesc Med Health 2015; 27(1): 79–84
Nana Nimo Appiah-Agyekum*, Constance Sorkpor and Samuel Ofori-Mensah
Determinants of abortion decisions among Ghanaian university students Abstract Background: Unsafe abortion accounts for a significant proportion of maternal and reproductive health related mortalities and complications in developing countries. In Ghana and sub-Saharan Africa in general, abortion remains a significant barrier to achieving the health related MDGs. Yet, there exist a dearth of information on the determinants of abortion decisions among adolescents, students and other populations at risk. Objectives: This study explores the factors that are likely to influence abortion decisions among University students in Ghana. It also explores their knowledge and perceptions on abortion. Methods: Data were collected from 142 randomly sampled students of the University of Ghana through focus group discussions. Questions focused on their knowledge on abortion and the key determinants of their decisions to abort. The results were recorded, transcribed, and analysed qualitatively using the thematic analysis approach. Results: The students were knowledgeable on abortion. In making decisions on abortion, the students considered their education, religious beliefs, health, economic factors, and family. Conclusions: Factors such as societal pressure and peer influence that, to date, have been the backbone of sexual and reproductive health, anti-abortion stigma, and unsafe abortion education and interventions have minimal influence on abortion decisions among the students. Rather, these interventions must focus on their education, religious beliefs, health, economic factors, and family to make maximum impact. *Corresponding author: Nana Nimo Appiah-Agyekum, Department of Public Administration and Health Services Management, University of Ghana Business School PO Box LG 78 Legon, Accra Ghana, Phone: +0023 324 3748 218, E-mail: [email protected]; and Centre for Health Promotion Research, Leeds Metropolitan University, Leeds Constance Sorkpor: Department of Public Administration and Health Services Management, University of Ghana Business School, Accra-Ghana Samuel Ofori-Mensah: Department of Public Administration and Health Services Management, University of Ghana Business School, Accra-Ghana; and Ghana Education Service, Adonten Senior High School, Aburi, Ghana
Keywords: abortion; decisions; determinants; Ghana; students. DOI 10.1515/ijamh-2014-0011 Received February 23, 2014; accepted May 13, 2014; previously published online August 14, 2014
Introduction Each year nearly 42 million women facing an unplanned pregnancy get an abortion, and about 20 million of them resort to unsafe abortion – often self-induced or obtained clandestinely (1). This practice is especially true for women in developing countries who are faced with resource challenges, as well as negative social, religious, and cultural pressure. In fact, Grimes et al. (2) report that nearly all unsafe abortions (97%) are in developing countries with an estimated 68,000 women dying as a result, and millions more having complications, many permanent. Identified by Pachankis (3) as the major vulnerable group, students are most likely to have abortions and suffer abortion stigma in developing countries. In recognition of the aforementioned data and in response to the increasing incidence of unsafe abortions among students and other vulnerable groups (4), the Ghana Health Service and the Ministry of Health (MoH) developed comprehensive protocols and guidelines on abortion. These guidelines, adopted in 2006, aim to complement and address the deficiencies of the Ghanaian criminal code [(5), amended in 1985 (6)] that criminalises abortion in Ghana. The guidelines further outline the components of comprehensive abortion care, including counselling and the provision of contraceptives; define mental health conditions that could qualify a patient for an abortion; and call for expanding the base of abortion providers by authorising midwives and nurses to perform first-trimester procedures. More importantly, the guidelines encourage research into and the dissemination of relevant information on the determinants and effects of abortion, especially to students and other groups at risk. However, a preliminary investigation revealed a paucity of information on the Brought to you by | University of Exeter Authenticated Download Date | 10/5/16 10:55 PM
80 Appiah-Agyekum et al.: Determinants of abortion decisions among students determinants of abortion decisions among students in Ghana, in particular, and Sub-Saharan Africa, in general. Adanu and Tweneboah (7) also recount the incidence of anti-abortion stigma and the imperfect knowledge on the effects and causes of abortions among students attributable to the dearth of empirical research on abortions among higher education students in Ghana and other West African countries. Consequently, this study aims to fill the knowledge gap on the subject and further arm sexual and reproductive health educators, peer counsellors, and other stakeholders with relevant information for evidence-based interventions and policies on abortions among university students. Particular reference is made by the study to the key determinants of decisions to abort among university students.
Methods Data were collected through 18 focus group discussions (FGDs) involving 142 students randomly sampled from the main and city campuses of University of Ghana. The discussions were done on weekends to avoid conflicts with the class schedules of the participants, with each session lasting between 65 and 80 min. Appropriate permissions were sought from the relevant university authorities. The study was also reviewed and approved by the research and conference committee of the University of Ghana prior to data collection. The sampling procedure involved inviting voluntary participation from the students through posted notices and lecture room announcements on the nature, content, and use of the study. After 4 weeks, 158 students had volunteered to partake in the study. These students were again briefed on the purpose, the nature of information required, the mode of the FGDs, and the available FGD times. The students were then taken through and given copies of the information sheet and consent forms for the study. After a further two weeks, 142 students gave informed consent and 16 students declined further participation in the study. The 142 students were given the available schedules and venues of the discussions and asked to choose any slot at their convenience. In line with Mack et al. (8) and Fossey, Harvey, McDermott, and Davidson (9), the focus groups were restricted to a maximum of nine participants, thus students who chose groups that had reached the 9-member limit were made to choose another group. A modified version of the Knoxville Centre for Reproductive Health’s (10) abortion questionnaire was used for the study. The questions asked during the discussions were anonymous and focused on gathering information on the participants’ background, perceptions on abortion, and the factors that are likely to influence their decisions to abort. The questionnaire was pretested with a trial group of seven students and further modified before being validated for the study. The FGDs were recorded and transcribed and later shown to participants for signing-off before being analysed. The data were analysed qualitatively on the basis of Grbich’s (11) approach to data analysis. Furthermore, the thematic analysis approach was used because it offers an accessible and theoretically flexible approach to analysing qualitative data (12). Using this
approach, the data gathered were reviewed and sorted out under the relevant themes based on the study objectives. Subsequently, the data were discussed under each theme within the context of relevant literature and with the aim of identifying other subthemes and patterns under each theme. The data were also contrasted with information on abortion provided in the MoH guidelines for abortion, as well as abortion information leaflets distributed to students by the Planned Parenthood Association of Ghana. Particular attention was also paid to comments and answers to follow up questions by the respondents during the discussion.
Results As shown in Table 1, majority (62.4%) of the participants were female with 32.8% being in their teens, 43.2% were between 21 and 30 years, and only 7.2% were above 40 years. Sufficient numbers of participants were drawn from all levels of study on both campuses, with majority of the respondents (62.4%) being Christians, 25.6% were Muslims, and 12% did not indicate their religion. As for marital status, 36.8% of the participants were single, 29.6% were lawfully married, and 33.6% were dating. Also, majority (72.5%) of the respondents were sexually active at the time of the FGDs. Results show that the university students were knowledgeable on abortion. Whereas some viewed abortion Table 1 Details of participants. Gender Male Female Age Under 20 21–30 31–40 41 and above Level of study 100 200 300 400 Post-graduate Religion Christian Muslim Undisclosed Marital status Single Married Dating Sexually active Yes No
53(37.6%) 89(62.4%) 47(32.8%) 61(43.2%) 24(16.8%) 10(7.2%) 25(17.6%) 28(20.1%) 41(28.8%) 33(23.2%) 15(10.4%) 89(62.4%) 36(25.6%) 17(12%) 52(36.8%) 42(29.6%) 48(33.6%) 103(72.5%) 39(27.5%)
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Appiah-Agyekum et al.: Determinants of abortion decisions among students 81
as the removal of unwanted pregnancy based on agreement and decisions of persons involved, others viewed abortion as the process through which females got rid of unwanted or uncalled for pregnancy. Generally, the students explained abortion as the termination of a baby or foetus in the womb before the full term of pregnancy regardless of whether the act was done medically, legally, or deliberately or whether the foetus was unwanted. Results also show that the key determinants of decisions to abort among students were education, religious beliefs, health reasons, financial/economic factors, and family. Other less influential determinants identified were partner’s views, societal pressure/stigma, work/ career, and peer influence. Determinants such as restrictive abortion policies, urban residence, and number of children were not considered by students in their abortion decisions.
Discussion Students’ understanding of abortion Over the past two decades, abortion among students has been a major reproductive health issue in Ghana (13, 14). Consequently, students especially in universities have been the focus of numerous state and non-state interventions on safe abortions, contraception use, and other adolescent and reproductive health practices. It is therefore unsurprising that the students had good knowledge on issues relating to abortions. Explanations provided by the students underscored Modi’s (15) assertion that the central factor with a major proportion of abortions done by university students is that the pregnancy is unwanted. However, the students’ views also confirm that of Silberschmidt and Rasch (16) that forced abortions (abortions done against the wishes of the pregnant mother) are common among students in Sub-Saharan Africa. The students provided several examples of cases where persons (including parents, siblings, or the man responsible for the pregnancy) other than the pregnant mother, through violence, threats, coercion or deceit, facilitated the abortion against the wish of the mother. Furthermore, the students believed that the methods and motives for carrying out the abortion are irrelevant in so far as the pregnancy is not carried to term. This view – that any loss of a foetus whether through deliberate actions or not constituted abortion – challenges the conventional notion (17) that sees abortion as the deliberate expulsion of a foetus. Importantly, it confirms the
findings of other studies (2, 18) that students seeking to abort a pregnancy have little care for whether the process is safe or unsafe, legal or illegal, medical or otherwise, once it results in the abortion. This view may account for the relatively high unsafe abortion rates among students in Ghana and Sub-Saharan Africa. Additionally, several studies have restricted abortion to the loss of a baby within a particular period of pregnancy. Francome (19), for instance, limits abortion to foetal termination that occurs within the first 12 weeks of gestation. In contrast, the students believed that an abortion decision could be made or a procedure performed at any point during the gestation period. Such beliefs may also account for the significant number of late-term abortions among students, most of which are unsafe, and often with disastrous effects on the pregnant mother. ‘… Whether it is a day or 8½ months, once the pregnancy is terminated before the child is born, abortion has taken place. An abortion can therefore be done at any time before the baby is born’
Determinants of abortion decisions Unsafe abortion among students is a major public health problem in Ghana and sub-Saharan Africa, where abortion is restricted by laws that seek to prevent and punish this form of behaviour with the aim of preventing its occurrence (20) and to deter people with like minds from indulging in such a practice. As explained by Ahiadeke (21), Ghanaian authorities have focused so much on the legal and regulatory contexts of abortion services often to the detriment of the determinants of the decision to abort, which more often marks the beginning of the abortion procedure. Moreover, efforts at reducing the incidence of unsafe abortions are also limited by the paucity of information on the factors that influence the decision to abort among students. Evidence from this study suggests that the main factor considered by students in their decision to abort is the likely effect of the pregnancy and the birth of the child on their education. As confirmed by Finer, Frohwirth, Dauphinee, Singh, and Moore (22), Tabberer, Hall, Prendergast, and Webster (23), Crock (24), and Narendra (25), pregnant students, together with their partners or parents, weigh the prospects and the investments and sacrifices that have been made in their education with the impending termination or delay in education as a result of the pregnancy. Specifically, students consider the length of time left to complete school, their desire or prospects for further education, and the adverse effect of the pregnancy and the new born child on their studies in their decisions Brought to you by | University of Exeter Authenticated Download Date | 10/5/16 10:55 PM
82 Appiah-Agyekum et al.: Determinants of abortion decisions among students to abort. Consistent with the findings of Hubbard (26), the present study showed that students with good academic grades are more likely to abort to stay in school than poorperforming students who had little academic prospects. Students with scholarships or under sponsorships, as well as those with funding difficulties, are also more likely to abort to avoid the effects the pregnancy may have on the length and completion of their education and their funding opportunities. Additionally, students who have other options of continuing their course, including opportunities to convert to part-time, off-campus distance students, or even deferring the course for the duration of the pregnancy, are also less likely to have an abortion because of their education. Another important determinant of students’ decision to abort is their religious beliefs. The role of religion in reproductive health decisions, especially in developing countries and among females, has been the subject of several studies. These studies have, among other things, emphasised the influence of religion on young women’s autonomy to make reproductive health decisions (27), the nature and scope of clinical practices and reproductive health services made available (28), and patterns and perceptions of sexual and reproductive health decisions among adolescents (29). Specifically, the students in this study believed that their religious beliefs and upbringing, values and doctrines of their religion, likely sanctions and the risk of excommunication from their churches among other religious factors, would be an important determinant of their decision to abort a pregnancy. These findings confirm those of earlier studies by Ellison, Echevarria, and Smith (30) and Adler, Ozer, and Tschann (31). Unmarried students especially are more likely to abort to avoid the religious backlash associated with getting pregnant before marriage, as well as being seen as ‘adulterers’ or ‘fornicators’. Conversely, some students are willing to avoid abortion at all costs because it amounts to murder per their religious teachings. Students also consider the health implications of the impending abortion in deciding whether or not to have an abortion. Often seen as the legal stance of the laws of abortion in Ghana, health factors have become the backbone of the pro-abortion debate in the country [see (21, 32, 33)]. However, rather than focus on the broad implications of health (i.e., complete physical, mental, and social well-being) per World Health Organization (34), health legislations, policies, and decisions on abortion as well as their implementation have been primarily medically based to the detriment of the psychological and sociological well-being of the parties involved in the abortion decision-making [see (20, 35)]. In deciding whether to get
an abortion, the students consider the physical well-being of the pregnant mother and the unborn child, the psychological well-being of the pregnant mother, father and unborn child, and their social well-being. The likelihood of physical and intellectual disabilities or deformities in the unborn child, the death of the mother, and the adverse effects of the abortion on future conception are also prime considerations such that the students were unlikely to have the abortion once the health risks associated with the procedure were certain and unfavourable. Contrary to studies (36–38) that aver that financial/ economic considerations are the sole most prime determinant of decisions to abort among young women, economic considerations appear to be the fourth most important consideration of the students. Interestingly, the availability of financial support from their partner, friends, or family during the term of the pregnancy and after the birth of the baby appears to be of much concern to the students. Additionally, the indirect costs of the pregnancy and childbirth including how the pregnancy and the birth of the baby is going to affect their income and spending levels, sources of income, cost of living, standard of living, economic activities engaged in, as well as other opportunity costs of the pregnancy, have an influence on their decisions. Apart from that, emphasis was also placed on the direct costs of the pregnancy and childbirth, such as the costs of healthcare and medication, feeding, clothing, and housing. In contrast to studies like that of Tunde (39) that suggest that the key economic factors are those that affect the mother, evidence from this study suggests that the economic circumstances of both partners and, to an extent, the families of both partners are key in decisions to abort. Family factors are also an important determinant of decision to abort among the students. The role of family in maternal and reproductive health decisions has been the subject of several studies among several population groups in several contexts. A common element in these studies is the nature of the relationship between the pregnant mother and her family. Although girls with a strong bond with their families or have a supportive family are unlikely to abort a pregnancy (40), the opposite may also be true in certain circumstances. Of importance to the students is the likely reaction of their parents and other family members to the pregnancy; how the pregnancy will affect the social status of their parents and family; how the pregnancy will affect the attention, affection, and social support from their family; and how it will affect their relationship with their family. The students are also likely to abort if they felt that the pregnancy will bring shame, disappointment, or resentment from their family. Although the students are more concerned about their parents and Brought to you by | University of Exeter Authenticated Download Date | 10/5/16 10:55 PM
Appiah-Agyekum et al.: Determinants of abortion decisions among students 83
immediate family members, attitudes and relationships with extended family members are also important in deciding whether or not to abort.
Acknowledgments: The authors acknowledge Christabel Nortey, Sonia Oklu, and Yvette Boateng for assisting with the focus group discussions and transcription.
Conclusions
References
The fact that a significant majority of the students were able to explain abortion attests to the success of the awareness campaigns on abortion. However, the findings of this study suggest that student knowledge was limited to the rubrics of abortion and skewed with regard to safety and length of gestations within which safe abortions could be performed. More importantly, their knowledge on abortions had relatively low impact on their attitudes and perceptions towards abortion, with a significant number of the students still showing a likelihood of stigmatising persons involved in abortions. This study further suggests that although a good number of students support the existence of liberal laws, entrenched religious beliefs and doctrines as well as socio-cultural factors may explain the strong anti-abortion sentiments held by some students. While serving as a basis for their support for the banning of abortions, these same factors may account for their refusal to support or undergo abortions even if necessary to preserve their health and/or that of the unborn child, as well as their acceptance and indulgence in abortion stigma. Reproductive health efforts must therefore pay attention to these factors. Apart from the aforementioned results, the findings from this study suggest that factors such as societal pressure and peer influence that, to date, have been the backbone of sexual and reproductive health, anti-abortion stigma, and unsafe abortion education and interventions have minimal influence on abortion decisions among the students. Rather, the principal determinants of abortion decisions among students that need urgent attention are their education, religious beliefs, health, economic situation, and family. Thus, there is the need for a paradigm shift in these campaigns and interventions towards the principal determinants identified in this study to make maximum impact on students. In another breadth, the study also suggests that determinants such as restrictive abortion policies, urban residence, and the number of children that are prime considerations among students and the youth in other developing countries are not considered by Ghanaian students. This result provides the pathway for further research on the differentials in the determinants of abortion among various socio-demographic sections of the youth in developing countries, as well as how these determinants affect their reproductive health choices in life.
1. Organization WH. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 6th ed WHO; Geneva 2011. 2. Grimes DA, Benson J, Singh S, Romero M, Ganatra B, et al. Unsafe abortion: the preventable pandemic. The Lancet 2006;368:1908–19. 3. Pachankis JE. The psychological implications of concealing a stigma: a cognitive-affective-behavioral model. Psychol Bull 2007;133:328–45. 4. Abiodun OM, Balogun OR. Sexual activity and contraceptive use among young female students of tertiary educational institutions in Ilorin, Nigeria. Contraception 2009;79:146–9. 5. Criminal Code, Ghana Publishing corporation § 58–67 (1960). 6. Criminal code (Ammendment Law), 102, Ghana Publishing Corporation (1985). 7. Adanu RM, Tweneboah E. Reasons, fears, and emotions behind induced abortions in Accra, Ghana. Res Rev Inst Afr Stud 2005;20:1–9. 8. Mack JW, Hilden JM, Watterson J, Moore C, Turner B, et al. Parent and physician perspectives on quality of care at the end of life in children with cancer. J Clin Oncol 2005;23:9155–61. 9. Fossey E, Harvey C, McDermott F, Davidson L. Understanding and evaluating qualitative research. Aust NZ J Psychiat 2002;36:717–32. 10. Knoxville Center for Reproductive Health. (2010). Abortion Questionnaire. Knoxville: Knoxville Center for Reproductive Health. 11. Grbich C. Qualitative research in health: an introduction: London: Sage, 1999. 12. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101. 13. Appiah-Agyekum NN, Suapim RH. Knowledge and awareness of HIV/AIDS among high school girls in Ghana. HIV/AIDS (Auckland, NZ) 2013;5:137–44. 14. Aboagye PK, Gebreselassie H, Asare GQ, Mitchell EM, Addy J. An assessment of the readiness to offer contraceptives and comprehensive abortion care in the Greater Accra, Eastern and Ashanti regions of Ghana. Chapel Hill, NC, Ipas, 2007. 15. Modi D. Factors influencing women’s attitudes towards abortion at the University of Pennsylvania. Perspect Psychol 2002;5:42–50. 16. Silberschmidt M, Rasch V. Adolescent girls, illegal abortions and “sugar-daddies” in Dar es Salaam: Vulnerable victims and active social agents. Soc Sci Med 2001;52:1815–26. 17. Mappes TA, DeGrazia D, Brand-Ballard J. Biomedical ethics: McGraw-Hill. Boston, 2001. 18. Shah I, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. J Obstet Gynaecol Can 2009;31:1149–58. 19. Francome C. Abortion in the USA and the UK: Ashgate Publishing, 2004. 20. Morhee R, Morhee E. Overview of the law and availability of abortion services in Ghana. Ghana Med J 2006;40:80–6.
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84 Appiah-Agyekum et al.: Determinants of abortion decisions among students 21. Ahiadeke C. Incidence of induced abortion in southern Ghana. Int Fam Plan Perspec 2001;27:96–108. 22. Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Reasons US women have abortions: quantitative and qualitative perspectives. Perspect Sex Repro H 2005;37:110–8. 23. Tabberer S, Hall C, Prendergast S, Webster A. Teenage pregnancy and choice: Joseph Rowntree Foundation York, 2000. 24. Crock RJ. Abortion decision-making attitudes of adolescents attending Roman Catholic schools: ProQuest, 2007. 25. Narendra A. Implications of sex and education on abortion attitudes: a cross-sectional analysis. Research Paper, Oregon State University: 2010. Available at: http://ir.library.oregonstate.edu/ xmlui/handle/1957/16262. 26. Hubbard L. College aspirations among low-income African American high school students: Gendered strategies for success. Anthropol Educ Quart 1999;30:363–83. 27. Jejeebhoy SJ, Sathar ZA. Women’s autonomy in India and Pakistan: the influence of religion and region. Popul Dev Rev 2001;27:687–712. 28. Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med 2007;356:593–600. 29. Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. The Lancet 2007;369:1220–31. 30. Ellison CG, Echevarria S, Smith B. Religion and abortion attitudes among us hispanics: Findings from the 1990 Latino National Political Survey. Soc Sci Quart 2005;86:192–208.
31. Adler NE, Ozer EJ, Tschann J. Abortion among adolescents. Am Psychol 2003;58:211–7. 32. Lassey AT. Complications of induced abortions and their preventions in Ghana. E Afr Med J 1995;72:774–7. 33. Biritwum R. Promoting and monitoring safe motherhood in Ghana. Ghana Med J 2006;40:78–9. 34. Organization, WH. (1948). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. Retrieved Dec. 11, 2004 from. 35. Sedgh G. Abortion in Ghana. Issues in brief (Alan Guttmacher Institute) 2010;(2):1. 36. Elul B. Determinants of induced abortion: an analysis of individual, household and contextual factors in Rajasthan, India. J Biosoc Sci 2011;43:1–17. 37. Blank RM, George CC, London RA. State abortion rates the impact of policies, providers, politics, demographics, and economic environment. J Health Econ 1996;15:513–53. 38. Matthews S, Ribar D, Wilhelm M. The effects of economic conditions and access to reproductive health services on state abortion rates and birthrates. Fam Plann Perspect 1997;29:52–60. 39. Tunde AI. Socio-economical and sociological factors as predictors of illegal abortion among adolescent in akoko west local government area of ondo state, Nigeria. Public H Res 2013;3:33–6. 40. Powell-Griner E, Trent K. Sociodemographic determinants of abortion in the United States. Demography 1987;24:553–61.
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Nana Nimo Appiah-Agyekum*, Constance Sorkpor and Samuel Ofori-Mensah
Determinants of abortion decisions among Ghanaian university students Abstract Background: Unsafe abortion accounts for a significant proportion of maternal and reproductive health related mortalities and complications in developing countries. In Ghana and sub-Saharan Africa in general, abortion remains a significant barrier to achieving the health related MDGs. Yet, there exist a dearth of information on the determinants of abortion decisions among adolescents, students and other populations at risk. Objectives: This study explores the factors that are likely to influence abortion decisions among University students in Ghana. It also explores their knowledge and perceptions on abortion. Methods: Data were collected from 142 randomly sampled students of the University of Ghana through focus group discussions. Questions focused on their knowledge on abortion and the key determinants of their decisions to abort. The results were recorded, transcribed, and analysed qualitatively using the thematic analysis approach. Results: The students were knowledgeable on abortion. In making decisions on abortion, the students considered their education, religious beliefs, health, economic factors, and family. Conclusions: Factors such as societal pressure and peer influence that, to date, have been the backbone of sexual and reproductive health, anti-abortion stigma, and unsafe abortion education and interventions have minimal influence on abortion decisions among the students. Rather, these interventions must focus on their education, religious beliefs, health, economic factors, and family to make maximum impact. *Corresponding author: Nana Nimo Appiah-Agyekum, Department of Public Administration and Health Services Management, University of Ghana Business School PO Box LG 78 Legon, Accra Ghana, Phone: +0023 324 3748 218, E-mail: [email protected]; and Centre for Health Promotion Research, Leeds Metropolitan University, Leeds Constance Sorkpor: Department of Public Administration and Health Services Management, University of Ghana Business School, Accra-Ghana Samuel Ofori-Mensah: Department of Public Administration and Health Services Management, University of Ghana Business School, Accra-Ghana; and Ghana Education Service, Adonten Senior High School, Aburi, Ghana
Keywords: abortion; decisions; determinants; Ghana; students. DOI 10.1515/ijamh-2014-0011 Received February 23, 2014; accepted May 13, 2014; previously published online August 14, 2014
Introduction Each year nearly 42 million women facing an unplanned pregnancy get an abortion, and about 20 million of them resort to unsafe abortion – often self-induced or obtained clandestinely (1). This practice is especially true for women in developing countries who are faced with resource challenges, as well as negative social, religious, and cultural pressure. In fact, Grimes et al. (2) report that nearly all unsafe abortions (97%) are in developing countries with an estimated 68,000 women dying as a result, and millions more having complications, many permanent. Identified by Pachankis (3) as the major vulnerable group, students are most likely to have abortions and suffer abortion stigma in developing countries. In recognition of the aforementioned data and in response to the increasing incidence of unsafe abortions among students and other vulnerable groups (4), the Ghana Health Service and the Ministry of Health (MoH) developed comprehensive protocols and guidelines on abortion. These guidelines, adopted in 2006, aim to complement and address the deficiencies of the Ghanaian criminal code [(5), amended in 1985 (6)] that criminalises abortion in Ghana. The guidelines further outline the components of comprehensive abortion care, including counselling and the provision of contraceptives; define mental health conditions that could qualify a patient for an abortion; and call for expanding the base of abortion providers by authorising midwives and nurses to perform first-trimester procedures. More importantly, the guidelines encourage research into and the dissemination of relevant information on the determinants and effects of abortion, especially to students and other groups at risk. However, a preliminary investigation revealed a paucity of information on the Brought to you by | University of Exeter Authenticated Download Date | 10/5/16 10:55 PM
80 Appiah-Agyekum et al.: Determinants of abortion decisions among students determinants of abortion decisions among students in Ghana, in particular, and Sub-Saharan Africa, in general. Adanu and Tweneboah (7) also recount the incidence of anti-abortion stigma and the imperfect knowledge on the effects and causes of abortions among students attributable to the dearth of empirical research on abortions among higher education students in Ghana and other West African countries. Consequently, this study aims to fill the knowledge gap on the subject and further arm sexual and reproductive health educators, peer counsellors, and other stakeholders with relevant information for evidence-based interventions and policies on abortions among university students. Particular reference is made by the study to the key determinants of decisions to abort among university students.
Methods Data were collected through 18 focus group discussions (FGDs) involving 142 students randomly sampled from the main and city campuses of University of Ghana. The discussions were done on weekends to avoid conflicts with the class schedules of the participants, with each session lasting between 65 and 80 min. Appropriate permissions were sought from the relevant university authorities. The study was also reviewed and approved by the research and conference committee of the University of Ghana prior to data collection. The sampling procedure involved inviting voluntary participation from the students through posted notices and lecture room announcements on the nature, content, and use of the study. After 4 weeks, 158 students had volunteered to partake in the study. These students were again briefed on the purpose, the nature of information required, the mode of the FGDs, and the available FGD times. The students were then taken through and given copies of the information sheet and consent forms for the study. After a further two weeks, 142 students gave informed consent and 16 students declined further participation in the study. The 142 students were given the available schedules and venues of the discussions and asked to choose any slot at their convenience. In line with Mack et al. (8) and Fossey, Harvey, McDermott, and Davidson (9), the focus groups were restricted to a maximum of nine participants, thus students who chose groups that had reached the 9-member limit were made to choose another group. A modified version of the Knoxville Centre for Reproductive Health’s (10) abortion questionnaire was used for the study. The questions asked during the discussions were anonymous and focused on gathering information on the participants’ background, perceptions on abortion, and the factors that are likely to influence their decisions to abort. The questionnaire was pretested with a trial group of seven students and further modified before being validated for the study. The FGDs were recorded and transcribed and later shown to participants for signing-off before being analysed. The data were analysed qualitatively on the basis of Grbich’s (11) approach to data analysis. Furthermore, the thematic analysis approach was used because it offers an accessible and theoretically flexible approach to analysing qualitative data (12). Using this
approach, the data gathered were reviewed and sorted out under the relevant themes based on the study objectives. Subsequently, the data were discussed under each theme within the context of relevant literature and with the aim of identifying other subthemes and patterns under each theme. The data were also contrasted with information on abortion provided in the MoH guidelines for abortion, as well as abortion information leaflets distributed to students by the Planned Parenthood Association of Ghana. Particular attention was also paid to comments and answers to follow up questions by the respondents during the discussion.
Results As shown in Table 1, majority (62.4%) of the participants were female with 32.8% being in their teens, 43.2% were between 21 and 30 years, and only 7.2% were above 40 years. Sufficient numbers of participants were drawn from all levels of study on both campuses, with majority of the respondents (62.4%) being Christians, 25.6% were Muslims, and 12% did not indicate their religion. As for marital status, 36.8% of the participants were single, 29.6% were lawfully married, and 33.6% were dating. Also, majority (72.5%) of the respondents were sexually active at the time of the FGDs. Results show that the university students were knowledgeable on abortion. Whereas some viewed abortion Table 1 Details of participants. Gender Male Female Age Under 20 21–30 31–40 41 and above Level of study 100 200 300 400 Post-graduate Religion Christian Muslim Undisclosed Marital status Single Married Dating Sexually active Yes No
53(37.6%) 89(62.4%) 47(32.8%) 61(43.2%) 24(16.8%) 10(7.2%) 25(17.6%) 28(20.1%) 41(28.8%) 33(23.2%) 15(10.4%) 89(62.4%) 36(25.6%) 17(12%) 52(36.8%) 42(29.6%) 48(33.6%) 103(72.5%) 39(27.5%)
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Appiah-Agyekum et al.: Determinants of abortion decisions among students 81
as the removal of unwanted pregnancy based on agreement and decisions of persons involved, others viewed abortion as the process through which females got rid of unwanted or uncalled for pregnancy. Generally, the students explained abortion as the termination of a baby or foetus in the womb before the full term of pregnancy regardless of whether the act was done medically, legally, or deliberately or whether the foetus was unwanted. Results also show that the key determinants of decisions to abort among students were education, religious beliefs, health reasons, financial/economic factors, and family. Other less influential determinants identified were partner’s views, societal pressure/stigma, work/ career, and peer influence. Determinants such as restrictive abortion policies, urban residence, and number of children were not considered by students in their abortion decisions.
Discussion Students’ understanding of abortion Over the past two decades, abortion among students has been a major reproductive health issue in Ghana (13, 14). Consequently, students especially in universities have been the focus of numerous state and non-state interventions on safe abortions, contraception use, and other adolescent and reproductive health practices. It is therefore unsurprising that the students had good knowledge on issues relating to abortions. Explanations provided by the students underscored Modi’s (15) assertion that the central factor with a major proportion of abortions done by university students is that the pregnancy is unwanted. However, the students’ views also confirm that of Silberschmidt and Rasch (16) that forced abortions (abortions done against the wishes of the pregnant mother) are common among students in Sub-Saharan Africa. The students provided several examples of cases where persons (including parents, siblings, or the man responsible for the pregnancy) other than the pregnant mother, through violence, threats, coercion or deceit, facilitated the abortion against the wish of the mother. Furthermore, the students believed that the methods and motives for carrying out the abortion are irrelevant in so far as the pregnancy is not carried to term. This view – that any loss of a foetus whether through deliberate actions or not constituted abortion – challenges the conventional notion (17) that sees abortion as the deliberate expulsion of a foetus. Importantly, it confirms the
findings of other studies (2, 18) that students seeking to abort a pregnancy have little care for whether the process is safe or unsafe, legal or illegal, medical or otherwise, once it results in the abortion. This view may account for the relatively high unsafe abortion rates among students in Ghana and Sub-Saharan Africa. Additionally, several studies have restricted abortion to the loss of a baby within a particular period of pregnancy. Francome (19), for instance, limits abortion to foetal termination that occurs within the first 12 weeks of gestation. In contrast, the students believed that an abortion decision could be made or a procedure performed at any point during the gestation period. Such beliefs may also account for the significant number of late-term abortions among students, most of which are unsafe, and often with disastrous effects on the pregnant mother. ‘… Whether it is a day or 8½ months, once the pregnancy is terminated before the child is born, abortion has taken place. An abortion can therefore be done at any time before the baby is born’
Determinants of abortion decisions Unsafe abortion among students is a major public health problem in Ghana and sub-Saharan Africa, where abortion is restricted by laws that seek to prevent and punish this form of behaviour with the aim of preventing its occurrence (20) and to deter people with like minds from indulging in such a practice. As explained by Ahiadeke (21), Ghanaian authorities have focused so much on the legal and regulatory contexts of abortion services often to the detriment of the determinants of the decision to abort, which more often marks the beginning of the abortion procedure. Moreover, efforts at reducing the incidence of unsafe abortions are also limited by the paucity of information on the factors that influence the decision to abort among students. Evidence from this study suggests that the main factor considered by students in their decision to abort is the likely effect of the pregnancy and the birth of the child on their education. As confirmed by Finer, Frohwirth, Dauphinee, Singh, and Moore (22), Tabberer, Hall, Prendergast, and Webster (23), Crock (24), and Narendra (25), pregnant students, together with their partners or parents, weigh the prospects and the investments and sacrifices that have been made in their education with the impending termination or delay in education as a result of the pregnancy. Specifically, students consider the length of time left to complete school, their desire or prospects for further education, and the adverse effect of the pregnancy and the new born child on their studies in their decisions Brought to you by | University of Exeter Authenticated Download Date | 10/5/16 10:55 PM
82 Appiah-Agyekum et al.: Determinants of abortion decisions among students to abort. Consistent with the findings of Hubbard (26), the present study showed that students with good academic grades are more likely to abort to stay in school than poorperforming students who had little academic prospects. Students with scholarships or under sponsorships, as well as those with funding difficulties, are also more likely to abort to avoid the effects the pregnancy may have on the length and completion of their education and their funding opportunities. Additionally, students who have other options of continuing their course, including opportunities to convert to part-time, off-campus distance students, or even deferring the course for the duration of the pregnancy, are also less likely to have an abortion because of their education. Another important determinant of students’ decision to abort is their religious beliefs. The role of religion in reproductive health decisions, especially in developing countries and among females, has been the subject of several studies. These studies have, among other things, emphasised the influence of religion on young women’s autonomy to make reproductive health decisions (27), the nature and scope of clinical practices and reproductive health services made available (28), and patterns and perceptions of sexual and reproductive health decisions among adolescents (29). Specifically, the students in this study believed that their religious beliefs and upbringing, values and doctrines of their religion, likely sanctions and the risk of excommunication from their churches among other religious factors, would be an important determinant of their decision to abort a pregnancy. These findings confirm those of earlier studies by Ellison, Echevarria, and Smith (30) and Adler, Ozer, and Tschann (31). Unmarried students especially are more likely to abort to avoid the religious backlash associated with getting pregnant before marriage, as well as being seen as ‘adulterers’ or ‘fornicators’. Conversely, some students are willing to avoid abortion at all costs because it amounts to murder per their religious teachings. Students also consider the health implications of the impending abortion in deciding whether or not to have an abortion. Often seen as the legal stance of the laws of abortion in Ghana, health factors have become the backbone of the pro-abortion debate in the country [see (21, 32, 33)]. However, rather than focus on the broad implications of health (i.e., complete physical, mental, and social well-being) per World Health Organization (34), health legislations, policies, and decisions on abortion as well as their implementation have been primarily medically based to the detriment of the psychological and sociological well-being of the parties involved in the abortion decision-making [see (20, 35)]. In deciding whether to get
an abortion, the students consider the physical well-being of the pregnant mother and the unborn child, the psychological well-being of the pregnant mother, father and unborn child, and their social well-being. The likelihood of physical and intellectual disabilities or deformities in the unborn child, the death of the mother, and the adverse effects of the abortion on future conception are also prime considerations such that the students were unlikely to have the abortion once the health risks associated with the procedure were certain and unfavourable. Contrary to studies (36–38) that aver that financial/ economic considerations are the sole most prime determinant of decisions to abort among young women, economic considerations appear to be the fourth most important consideration of the students. Interestingly, the availability of financial support from their partner, friends, or family during the term of the pregnancy and after the birth of the baby appears to be of much concern to the students. Additionally, the indirect costs of the pregnancy and childbirth including how the pregnancy and the birth of the baby is going to affect their income and spending levels, sources of income, cost of living, standard of living, economic activities engaged in, as well as other opportunity costs of the pregnancy, have an influence on their decisions. Apart from that, emphasis was also placed on the direct costs of the pregnancy and childbirth, such as the costs of healthcare and medication, feeding, clothing, and housing. In contrast to studies like that of Tunde (39) that suggest that the key economic factors are those that affect the mother, evidence from this study suggests that the economic circumstances of both partners and, to an extent, the families of both partners are key in decisions to abort. Family factors are also an important determinant of decision to abort among the students. The role of family in maternal and reproductive health decisions has been the subject of several studies among several population groups in several contexts. A common element in these studies is the nature of the relationship between the pregnant mother and her family. Although girls with a strong bond with their families or have a supportive family are unlikely to abort a pregnancy (40), the opposite may also be true in certain circumstances. Of importance to the students is the likely reaction of their parents and other family members to the pregnancy; how the pregnancy will affect the social status of their parents and family; how the pregnancy will affect the attention, affection, and social support from their family; and how it will affect their relationship with their family. The students are also likely to abort if they felt that the pregnancy will bring shame, disappointment, or resentment from their family. Although the students are more concerned about their parents and Brought to you by | University of Exeter Authenticated Download Date | 10/5/16 10:55 PM
Appiah-Agyekum et al.: Determinants of abortion decisions among students 83
immediate family members, attitudes and relationships with extended family members are also important in deciding whether or not to abort.
Acknowledgments: The authors acknowledge Christabel Nortey, Sonia Oklu, and Yvette Boateng for assisting with the focus group discussions and transcription.
Conclusions
References
The fact that a significant majority of the students were able to explain abortion attests to the success of the awareness campaigns on abortion. However, the findings of this study suggest that student knowledge was limited to the rubrics of abortion and skewed with regard to safety and length of gestations within which safe abortions could be performed. More importantly, their knowledge on abortions had relatively low impact on their attitudes and perceptions towards abortion, with a significant number of the students still showing a likelihood of stigmatising persons involved in abortions. This study further suggests that although a good number of students support the existence of liberal laws, entrenched religious beliefs and doctrines as well as socio-cultural factors may explain the strong anti-abortion sentiments held by some students. While serving as a basis for their support for the banning of abortions, these same factors may account for their refusal to support or undergo abortions even if necessary to preserve their health and/or that of the unborn child, as well as their acceptance and indulgence in abortion stigma. Reproductive health efforts must therefore pay attention to these factors. Apart from the aforementioned results, the findings from this study suggest that factors such as societal pressure and peer influence that, to date, have been the backbone of sexual and reproductive health, anti-abortion stigma, and unsafe abortion education and interventions have minimal influence on abortion decisions among the students. Rather, the principal determinants of abortion decisions among students that need urgent attention are their education, religious beliefs, health, economic situation, and family. Thus, there is the need for a paradigm shift in these campaigns and interventions towards the principal determinants identified in this study to make maximum impact on students. In another breadth, the study also suggests that determinants such as restrictive abortion policies, urban residence, and the number of children that are prime considerations among students and the youth in other developing countries are not considered by Ghanaian students. This result provides the pathway for further research on the differentials in the determinants of abortion among various socio-demographic sections of the youth in developing countries, as well as how these determinants affect their reproductive health choices in life.
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