We found 13,100 papers in our initial search. The search was then narrowed to those studies conducted between 2015-2020 of which six (6) results were obtained from the Advanced Google Scholar search, 18 from PubMed, and one postgraduate thesis from a library in a public university in Ghana. We further focused the search looking at the legal implications of self-managed induced abortion in Ghana and found 22 related studies that were reviewed in this study. We found no study conducted in Ghana on self-induced or self-managed abortion within the period under review. However, self-induced abortion was reported in a number of studies elsewhere 13, 14 including systematic reviews conducted in 2020.21,22
Legal status of self-induced abortion in Ghana
The legal status of self-induced abortion concerns the current law and policy on the practice in the country of self-induced abortion found in recent literature in Ghana. The Criminal Offences Act (Act 29) section 58, sub-section 1 criminalizes self-induced abortion. It states that (a) “a woman who, with intent to cause abortion or miscarriage, administers to herself or consents to be administered to her a poison, drug or any other noxious thing or uses an instrument or any other means, or (b) a person who:(i) administers to a woman a poison, drug or any other noxious thing or uses an instrument or any other means with the intent to cause abortion or miscarriage of that woman, whether or not that woman is pregnant or has given her consent, (ii) induces a woman to cause or consent to causing abortion or miscarriage, (iii) aids and abets a woman to cause abortion or miscarriage, (iv) attempts to cause abortion of miscarriage, or (v) supplies or procures a poison, drug, an instrument or any other thing knowing that it is intended to be used or employed to cause abortion or miscarriage; commits a criminal offense and is liable on conviction to a term of imprisonment not exceeding five years”. 16
Sub-section 2 of the law that indicated circumstances under which abortion is legal is silent on self-induced abortion. It is emphatic in allowing registered medical practitioners to provide in registered health facilities abortion when the pregnancy is the result of rape, defilement, or incest; when a continuation of the pregnancy would involve risk to the life of the pregnant woman or injury to her physical or mental health; or where there is a substantial risk that if the pregnancy were carried to term the child would suffer from or later develop a serious physical abnormality or disease.”16, 17
Self-induced abortion has not been mentioned in the Act. Based on the permissive provisions in sub-section 2 of the law the national Comprehensive Abortion Care (CAC) policy, standards and protocols were developed with the broad operational interpretation of the law to minimize maternal morbidity and mortality associated with complications of induced abortion in the country.17 CAC was made an integral part of the national reproductive health policy and program. Despite the seemingly favourable legal and policy environment, accessing safe abortion care remains a challenge to most service seekers in Ghana”.18 There is no mention of self-managed abortion in the Ghana Health Service reproductive health policy, standards, and protocols. In line with the law, the CAC policy, standards and protocols clearly indicated health care professionals can provide various forms of abortion including medication abortion, under which medical practitioners allow self-managed abortion. For gestations up to 9 weeks, services are extended to a community level by allowing community health officers, nurses, midwives, medical (physician) assistants, and physicians to carry out procedures in health centres, clinics, and hospitals. For gestations more than 9 weeks, only physicians are permitted to perform the procedure in hospitals in addition to manual surgical evaluation which is permitted under similar conditions as medication abortion.23
Methods and extent of self-induced abortion in Ghana
Notwithstanding the guidelines in the revised national CAC policy, standards, and protocols that allow the provision of medication abortion via task sharing,23 the services with the low-level cadres of healthcare providers in the country, self-induced abortion using less safe approaches than expected, continues to be a convenient option to many women in need.24 Although various publications have reported self-induced abortion as criminal or illegal abortion, medication abortion has become a leading approach to resolving unwanted pregnancy in the country.22, 25
Many women in Ghana have previously used over-the-counter medications, herbal concoctions, and other locally known chemical abortifacients, which have been widely reported to be associated with severe maternal complications over the years.26 In line with current evidence there is an increasing shift to the use of misoprostol based medications that may be cheaper alternatives to hospital procured abortion methods.27,28 The evidence was clear in the 2017 maternal health survey that nearly indicated that about 3 in 4 (73%) of the most recent induced abortions were by Misoprostol/+Mifepristone preparations.19 Currently misoprostol only or misoprostol-mifepristone combination is the commonest method of self-induced abortion among educated and other well-informed women in Ghana.28
Forms of self-induced abortion
Both provider-led and in-person self-managed medication abortions are practiced in Ghana and both trained and untrained providers aid the process in varied settings in the country.29,30 Though trained abortion services may be available especially in urban communities, the cost of care is often beyond most women, particularly the youth and other socially disadvantaged ones.18,31 Thus, many women relied on pharmacies and chemists for supply and guidance on how to use the abortion pill, although they are not permitted by the law, policy, standards, and protocols to perform pregnancy terminations. There are also reported disparities between misoprostol provision and demand at pharmacies and chemists.
Despite the wide distribution of the community pharmacies and chemists, and reported high demand for the pill, stocking, and willingness to sell the medication decrease from urban to rural settings. There was little evidence found on the use of telemedicine and digital means of increasing access to self-managed abortion services. Organized national services are non-existent although individual private abortion care providers operate limited mobile services as part of increasing access to underprivileged or vulnerable women at their clinics.
Location of abortion and promoters of self-induced abortion
The publications reviewed reported locations of medication abortions as public or private health facilities, homes, pharmacies, or chemists. The perception that abortion is illegal, negative attitudes of healthcare providers, social stigma, and the need to keep the unwanted pregnancy and the abortion process secret as well as cost, are the main reasons for recourse to self-induced abortion at locations and use of the services of personnel that is not indicated in the national standards and protocols as providers.32,33 Second-trimester abortions for instance are relatively very expensive and are mostly available only in a few private health facilities in urban centres.34
Most providers are aware of the fact that if women had no access to safe abortion services, they would resort to unsafe methods of terminating unwanted pregnancies.35 Yet, many providers have serious dilemmas about care provision. Highly trained providers use the reproductive rights approach to arrive at a decision to provide the procedure whilst less trained providers frequently relied on religious and moral judgment to arrive at a less favourable decision and decline the service provision. Thus provider attitude greatly influences access to safe abortion care in Ghana. The state law criminalizes abortion, society frowns on it and social stigma has been high resulting in inadequate access to provider-based safe services and women still resort to using unsafe self-induced methods or use of the services of the untrained personnel operating in unregistered facilities.
Consequences
The health facility reports and surveys indicated medical complications and social stigma as the most widely reported consequences of induced abortion. Most of the reports were unable to classify and identify those emanating from self-managed abortions partly attributed to poor documentation, the unwillingness of clients to disclose their real experiences for fear of societal stigmatization, shame, and embarrassment as well as criminalization.36,37,38 Consequently, a study has shown that much more is yet to be unearthed about self-managed induced abortion, methods used, safety, effectiveness, client experiences, and reasons for this method of abortion in Ghana.28
Legal Consequences of self-managed abortions in Ghana
There was no evidence of prosecutions of the person(s) found violating the abortion law of Ghana in the literature, although anecdotal shreds of evidence have shown that self-managed abortions using medications have increased and continue to increase particularly during the recent pandemic of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) also known as Coronavirus Disease, 2019 (COVID-19) and its associated restrictions on health care delivery as well as the selective lockdowns of some Ghanaian communities.