The termination of pregnancy is one of the major public health concerns, especially in developing countries like Ghana. The termination of pregnancy which is also referred to as abortion can be spontaneous or induced (Nyarko & Potter, 2020). Globally, between 2015 to 2019, it was estimated that 121 million unplanned pregnancies occurred per year. About 60% of the unplanned pregnancies and 29% of all pregnancies were terminated (Hailegebreal, Enyew, Simegn, Seboka, Gilano, Kassa, et al. 2022). From 2010 to 2014, it was estimated that 45% of all pregnancy terminations were unsafe in the world and about 30% of the riskiest unsafe pregnancy terminations were conducted in Africa by nonprofessional personnel using harmful and invasive procedures (World Health Organisation [WHO], 2022). In 2014, pregnancy termination accounted for at least 9% of maternal deaths (approximately 16,000 deaths) in Africa. Thus, women in Africa are disproportionately affected by pregnancy termination-related deaths (WHO, 2018; Baruwa, Amoateng & Biney, 2022). In Ghana, induced abortion is a significant contributor to maternal morbidity and mortality among Ghanaian women aged 15–49 years, accounting for 11% of all maternal deaths in 2007 (GSS et al., 2009; Baruwa, Amoateng & Biney, 2022).
In developing nations, abortion laws are restrictive, thus the decision to terminate a pregnancy is influenced by sociocultural factors such as education, religion, beliefs, values, demographics, sexuality, and attitudes (Boah, Bordotsiah, & Kuurdong, 2019). Pregnancy terminations often occur in secrecy and under unsafe conditions by unskilled individuals (Polis, Castillo, Otupiri, Keogh, Hussain, Nakua, Larsen-Reindorf & Bell, 2020), resulting in a higher risk of complications such as haemorrhaging, infection, uterine perforation, incomplete abortion, maternal deaths, and morbidities. Africa has the highest rate of pregnancy termination-related mortality globally (Baruwa, Amoateng & Biney, 2022).
A significant finding has enabled women to access safe abortion services (Boah, Bordotsiah, & Kuurdong, 2019). Ghana amended its criminal code (Government of Ghana PNDC Law 102) in 1985, decriminalizing abortion under specific circumstances (Polis et al., 2020). Moreover, the Ghanaian government has endeavoured to tackle unintended pregnancies and unsafe abortions by promoting modern contraceptive methods, including abortion services in the Ghana Reproductive Health Strategic Plan, and building the capacity of midwifery trainees in health training institutions on comprehensive abortion care (Boah, Bordotsiah, & Kuurdong, 2019; Nyarko & Potter, 2020; Ba, Zhang, Pasha-Razzak, Khunsriraksakul, Maiga, Chinchilli, & Ssentongo, 2023).
Nevertheless, access to safe termination of pregnancy by Ghanaian women is limited to legal abortion services (Payne, Debbink, Steele, et al., 2013; Ba, Zhang, Pasha-Razzak, Khunsriraksakul, Maiga, Chinchilli, & Ssentongo, 2023). Also, the stigma associated with pregnancy terminations in Ghana and the fact that the laws permit legal pregnancy terminations only under certain conditions (Boah, Bordotsiah, & Kuurdong, 2019; Polis et al, 2020) results in the practice of pregnancy termination in secrecy, even when legitimate and secured services are present and accessible perhaps due to level of education and media exposure among women of reproductive age. Educated women had better access to abortion information which enables them to read and understand issues related to pregnancy termination and health in general. This enhances decision-making relating to the termination of pregnancy (Baruwa, Amoateng & Biney, 2022). It may be assumed that the higher one’s level of education, the less likely the person terminates pregnancy. Similarly, media serves as a channel or communication method used to enhance various health behaviours across populations (Ahinkorah, Seidu, Mensah, Budu 2020). Most often, health campaign messages, including safe abortion and reproductive health education are placed in media such as television, radio, the internet, and newspapers/magazines. Exposure to such messages to some extent influences change in behaviour (Ahinkorah, Seidu, Mensah, Budu, 2020). Some health education and promotion campaigns incorporate new technologies such as the internet, and other digitally assisted devices (Robinson, Tansil, Elder, Soler, Labre, Mercer, 2014) which help women to be aware of certain reproductive health issues such as identification of fertility clinics and locations for safe pregnancy termination. Health information especially on pregnancy termination can also be accessed through the media (Ahinkorah, Seidu, Mensah, Budu, 2020). For instance, “Time to Talk GH” “Smash abortion stigma” media campaigns in Ghana on (radio, television, internet etc.), have upgraded the knowledge of women on termination of pregnancy and their reproductive health in general (Ahinkorah, Seidu, Mensah, Budu, 2020; Sisson, & Kimport, 2017; Baruwa, Amoateng, & Biney, 2022).
Many published studies in Ghana have examined pregnancy terminations. For instance, Boah, et al. (2019) and Nyarko and Potter (2020) assessed predictors of unsafe induced abortion. Polis, et al. (2017) examined the incidence of induced abortion, Agula et al, (2021) looked at the methods women used for induced abortion, and Ahinkora, et al. (2020) examined mass media exposure and self-efficacy in abortion decision-making. These studies examined aspects of pregnancy termination. There is a dearth of information on educational attainment, media exposure and pregnancy termination. To understand pregnancy termination issues among women of reproductive age, there is a need to investigate educational attainment and media influence together.
To address the issue of unsafe abortions among women of reproductive age in Ghana, it is crucial to comprehensively understand how educational levels and media exposure influence abortion decisions. Such insights can guide intervention strategies to reduce unsafe abortions among the most vulnerable groups and assist healthcare providers and stakeholders in identifying potential reasons behind the high prevalence of abortions. Utilizing data from the 2014 Ghana Demographic and Health Survey (GDHS), we investigated the association between educational attainment, media exposure, and abortion among Ghanaian women aged 19-45. We hypothesized that educational attainment and media exposure are significantly associated with the level at which women between ages 19 and 45 terminate pregnancy.
Theoretical perspective
This study draws from the Social Cognitive Theory (SCT) (Bandura, 1999). SCT is a learning theory based on the premise that people learn through observing the actions and inactions of others. These concepts are fundamental to understanding personality development. The theory highlights the role of observational learning, modelling, expectations, and cognitive processes in facilitating behaviour change (Bandura, 1999). According to SCT, humans can witness and observe the behaviours of others before imitating them, and media can serve as a powerful source of observational learning (Bandura, 1999). “Modelling” behaviour is a common way to demonstrate this concept. Expectation, as one of the constructs of SCT, refers to an individual's anticipation of the consequences resulting from their actions. People evaluate the potential outcomes of their behaviours before engaging in them, and these thought processes can influence the successful execution of the behaviour.
SCT has been applied to a wide range of disciplines, such as personality development and functioning (Schunk & DiBenedetto, 2020; Van Overwalle, 2020), the understanding and treatment of psychological disorders (Schunk & DiBenedetto, 2020; Vollenweider & Preller, 2020), education (Scavarelli et al., 2021; Greenwald & Lai, 2020), and health promotion strategies (Sharma, 2021; Schunk & DiBenedetto, 2020). The SCT provides a framework for understanding how people actively shape and are shaped by their environment.
In this study, SCT is applied to understand how exposure to certain educational content through media channels may influence women’s knowledge, attitudes, and decision-making regarding reproductive health, specifically pregnancy termination. Women in their reproductive age may learn about the consequences and options related to pregnancy termination by observing characters in media who face similar situations. Therefore, the decision to terminate a pregnancy may be influenced by observing others' experiences. A woman who witnesses another woman successfully undergo an abortion procedure may develop a stronger belief in her own ability to undergo the same procedure.
Media portrayals can shape perceptions, attitudes, and behaviours. Also, the media can provide role models who make decisions about pregnancy termination based on their educational background. For instance, characters with higher education may be portrayed as making different choices than those with lower educational attainment. Exposure to educational content in media may enhance the cognitive processes of women, such as critical thinking and decision-making skills. This could affect how women process information related to pregnancy termination, especially concerning their educational background. Therefore, sources of pregnancy termination may include own experiences observed on television, and what a person anticipates to occur as a result of their actions. Knowledge of this may be useful to understanding women’s pregnancy termination behaviours in Ghana.