ABSTRACT

When a woman is faced with an unintended pregnancy the onus lies on her to either carry the pregnancy to term or terminate it, and in the developing world the majority of these are terminated unsafely. The problem of induced abortion can further be exacerbated when they become repeated. Women who have previous records of induced abortion stand a greater risk of resorting to it again when the need arises. It is therefore necessary to note the factors that serve as contributors to the already existing problem of maternal mortality. Therefore, this study sought to identify the various factors associated with a woman obtaining multiple abortions.

The source of data used was the 2007 Ghana Maternal Health Survey. Women between ages 15 and 49 who had ever undergone abortions formed the sample and the total weighted sample size consisted of 1482 women. Univariate, bivariate and binary logistics regression analyses were the various stages of analyses conducted.

The results obtained showed women that who entered into unions when they were less than age 20 were 17.4% less likely to carry out multiple abortions as compared to those who entered into unions when they were thirty years and above. Women who were poor and lived in rural areas were also less likely to seek multiple abortions. In addition, urban dwellers, SHS/higher educated and richer women were more likely to report experiencing multiple abortions. Women who had their first abortion earlier than age 30 and women with an increased number of pregnancies were also susceptible to multiple abortions.

Recommendations therefore include the availability of contraceptives to women, especially those below age 20, as well as reproductive health counselling for the rich and educated women. Also further studies should be conducted to understand why sexually active women not in stable unions are less likely to seek multiple abortions.

CHAPTER ONE

INTRODUCTION

             Background to the Study

The survival of a foetus is often dependent on how the expectant mother safeguards its growth. Its survival in the womb can be terminated consciously or unconsciously. The World Health Organization (WHO) defines abortion as “the expulsion or extraction of a foetus or embryo weighing 500 grams or less from its mother. There are two types of abortion; spontaneous and induced abortion. Spontaneous abortion refers to pregnancy loss at less than 20 weeks of gestation in the absence of elective medical or surgical measures to terminate the pregnancy (Griebel, Halvorsen, Golemon & Day, 2005). On the other hand, induced abortion is the intentional termination of a pregnancy and it may be performed because of two main reasons: medical and elective reasons.

Medical reasons for inducing abortion deal with abortions that are performed because of debilitating medical conditions that confront the mother or the foetus. This pregnancy has to be terminated by a medical practitioner when the life of the female can be protected and the foetus saved from future health problems. Elective reasons (Osler, David, & Morgall, 1997) for terminating a pregnancy, on the other hand, are associated with a woman’s own decision regardless of the fact that she or the foetus suffer no health issues.

Also, induced abortion can either be safe or unsafe. Safe induced abortions are abortions conducted by authorized persons such as a gynaecologist in hospitals and clinics. A safe abortion is a procedure supervised by a medical officer

whilst unsafe abortions are those undertaken by unauthorized persons such as quack doctors in unauthorized places (outside a health unit). WHO defines unsafe abortions as abortions performed by people lacking the necessary skills or in an environment that does not conform to minimum medical standards (World Health Organisation, 2007).

In Ghana, a law on abortion was enacted in 1960 and was further amended in 1985 to make it liberal enough for women. Although this law exists not everybody knows about it (Morhee & Morhee, 2006). The law gives specifications on the reasons that can call for an abortion of a pregnancy. These reasons are the defilement of a female idiot, rape, incest, and health effects the woman or the foetus are likely to face if the pregnancy continues.

Abortion is a public health concern because it poses some dangers to women’s health if not undergone safely. Death is just the most extreme outcome; countless other women and girls suffer from short and long term morbidity ranging from heavy bleeding and infection, pelvic inflammatory disease, infertility and physical disability.

Studies suggest that the frequency of abortion, or how often one procures an abortion, is anchored on various reasons. While some women rely on induced abortion as a form of birth control to delay childbirth, space childbirth or prevent the occurrence of childbirth (Aniteye & Mayhew, 2011), others have different reasons for each of their abortions ranging from financial constraints to the desire to pursue their education. The success of the first induced abortion will

probably lead to successive abortions if the victim goes on being sexually active without using effective contraceptive method.

Prata et al. (2013, pg 1) state that “repeat abortion or having more than one pregnancy termination is bound in a vicious cycle with unintended pregnancy” (Prata, Martina, Ashyley, & Yilma, 2013, pg 1). Also, complications of induced abortions are often exacerbated when the procedure becomes repeated. Multiple induced abortions increase a woman’s chances of severe health effects (Prata et al., 2013). Understanding the factors associated with multiple induced abortions is of great interest in this study. The study seeks to identify factors that are related to multiple induced abortions among women in Ghana. The major factors associated with induced abortion may be socio-demographic, socio-economic and socio-cultural. It is expedient that such factors are considered by researchers in our bid to help curb maternal mortality.

             Problem Statement

Women in developing countries have a higher likelihood of having induced abortions than women in developed countries. The abortion rate from 2010 to 2014 stood at 27 abortions per 1,000 women in developed countries, while in developing countries the rate was higher at 37 abortions per 1,000 women. In Western Africa, the figure was 31 abortions per 1000 women between 2010 and 2014 (Guttmacher Institute, 2016).

Furthermore, obtaining safe abortions come at a cost. The high cost of safe abortions makes it unattractive to some women, especially for women in sub

Saharan Africa where the economic situation often makes life burdensome. In 2015, some public and private health facilities in Ghana were charging between GHC500 (approximately USD 130) and GHC700 (approximately USD 185) as against GHC120 (approximately USD 38) and GHC130 (approximately USD

• in 2014 to perform abortions for pregnancies that were one to four months old (Awlesu, 2015). Women in the top two wealth quintiles are known to be those who can readily access it (Adjei et al., 2015); however, unsafe means become the next possible option for those who cannot.

Every year, close to 20 million women risk their lives and health by undergoing unsafe abortions (Grimes, Benson, Singh, Romero, Okonofua, et al., 2006).

Some suffer permanent complications and even death as a result of these unsafe abortions. On average, every woman in a developing country is expected to have at least one unsafe abortion before the end of her reproductive age (Shah & Åhman, 2004). The disability adjusted life year’s (DALYs) combined burden of morbidity and mortality per 1000 unsafe abortions in sub Saharan Africa is exceptionally high (World Health Organisation, 2007). In Ghana, unsafe abortion is the second cause of maternal mortality among women (GSS, GHS, & Macro, 2009).

Although there is an existing law in Ghana on induced abortions, most women and healthcare providers may be oblivious of this existing law (Morhee & Morhee, 2006). Stigmatisation of abortion seekers and abortion service providers makes it difficult for prospective abortion seekers to use health facilities in Ghana (Payne et al., 2008). These women eventually seek abortions from quack doctors,

pharmacists and nurses who operate outside approved healthcare facilities (Ahiadeke, 2001; Appiah-Agyekum, 2014). Harsh substances like laundry bleach, tea made of livestock manure, and other concoctions are used by women in Africa, and for that matter Ghana, to abort pregnancies (Bleek, 1978). Other substances are inserted into the uterus through the cervix like rubber catheters, lump of sugar and knitting needles (Grimes, Benson, Singh, Romero, Ganatra, et al., 2006). Grimes et al. (2006) succinctly state that “irrespective of the research methodologies used, the public health message is clear: unsafe abortion kills large numbers of women” (Grimes et al., 2006 pg 3).

According to Lithur (2004), in Ghana, “unsafe abortion is silently being performed underground within the communities in Ghana and outside the formal health service structures. This is as a result of stigmatisation coupled with the lack of health services for abortion” (Lithur, 2004, pg 4). Some family planning nurses and even some doctors are judgmental about those seeking induced abortion and they tend to be harsh towards them (Payne et al., 2013). Women who want to acquire these services are likely to avoid the health personnel or health unit because of what they may have heard about the treatment given by health professionals to those seeking abortions (Schwandt et al., 2013).

Although an abortion may be safe, the adverse health challenges faced by repeat abortion seekers cannot be ignored. Multiple abortions exacerbate the challenges that arise from induced abortions; however, little is known about women who seek repeat abortions in Africa (Prata et al., 2013). Prata et al. (2013, pg 57) also

state that the available information is not enough for generalizing. Health problems like ectopic pregnancies, placenta previa, foetal loss, preterm delivery, potential low fertility are the resultant factors of repeat abortion (Thorpe et al 2003; as cited in Prata et al., 2013). In a study by Aniteye & Mayhew (2011), conducted in two major hospitals in Ghana where women were seeking treatment for incomplete abortions, twenty-two percent of the respondents had a second abortion experience whilst 14% had a higher number of abortions.