Healthcare Workers Experiences in Providing Comprehensive Abortion Care to Adolescents in the Eastern Region of Ghana: A Qualitative Study

doi:10.21203/rs.3.rs-5027588/v1

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Research Article

Healthcare Workers Experiences in Providing Comprehensive Abortion Care to Adolescents in the Eastern Region of Ghana: A Qualitative Study

https://doi.org/10.21203/rs.3.rs-5027588/v1

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Introduction:

Globally, abortion rates among young women is a public health concern. The Eastern region of Ghana has a high rate of abortions with 17.8% occurring among adolescents in 2021. Adolescents face difficulty accessing comprehensive abortion care (CAC) due to conflict over their decision-making capacity and the requirement for parental consent. This study explored the experiences of healthcare workers in providing CAC to adolescents in the New Juaben Municipality in Eastern Region, Ghana.

Methods

A phenomenological qualitative study was conducted among 12 healthcare providers. Participants who had provided CAC services for at least 6 months were selected through purposive sampling. In-depth interviews were conducted and audio-recorded with permission from the participants. The interviews were transcribed verbatim and inductive thematic analysis was done using ATLAS. it. Results were presented using quotes.

Findings

: Many midwives reportedly felt bad, uncomfortable, and guilty about providing abortion care. Others also felt psychological trauma, which compelled them to stop providing CAC services. Many service providers including physician specialists and some midwives however continuously provided CAC services as part of their professional responsibility to save lives.

Conclusion

The experiences of CAC service providers are diverse. Values clarification workshops are necessary to help healthcare providers balance their religious beliefs and CAC provision. Public education on safe abortion care needs to be strengthened to normalise CAC discussions and reduce the stigma towards CAC service providers.

Comprehensive Abortion Care

Healthcare Workers

Adolescents

New Juaben Municipality

Ghana

Comprehensive abortion care (CAC) includes care for induced abortion, spontaneous abortion, incomplete abortion, or an intrauterine fetal death. It serves as an aid for women seeking respite from unsafe and/ or unwanted pregnancies which could have an impact on their mental or physical health [1, 2, 3]. Recognized as a human right, it enables women to make autonomous decisions regarding reproduction [1]. Despite this, the burden of unsafe abortion in Sub-Saharan Africa is 29%, amounting to 62% of all abortion-related deaths globally [4, 5]. Also, maternal deaths occurring due to unsafe abortions are more prevalent in Africa [6]. This increases the cost of health services and burdens the health system.

Among young Ghanaian women, unplanned pregnancies remain high as their needs for contraception are not fulfilled and they face unique obstacles in accessing sexual and reproductive health services [7]. According to Okyere and colleagues [8], the prevalence of induced abortion among young women and adolescent girls is 26%. Complications from unsafe abortions account for a large number (approximately 43,000 facility-based post-abortion care cases and 38,000 illegal abortion cases) of all maternal mortality and morbidity cases in Ghana [9, 10].

The abortion law in Ghana is relatively lax and is regulated by the Provisional National Defence Council (PNDC) law, section 58 Act 29 of 1960 amended in 1985. It permits abortion if the pregnancy happens as an outcome of rape, defilement or incest; if continuing the pregnancy would pose substantial risks to the woman’s life; if the pregnancy would be detrimental to the mental and physical health and wellbeing of the woman; or it has been established that the child will suffer major physical abnormality or disease and has to be provided by a trained medical professional in a licensed facility [11]. However, enforceability remains a challenge and most healthcare providers are unaware of the circumstances in which abortions are legal [12, 13]. Further, Aniteye and colleagues indicated that healthcare providers experience uncertainties in trying to interpret the abortion law in Ghana coupled with the obvious lack of institutional support [14]. This deters them from providing abortion services for fear of legal threat and stigmatisation [14].

The Ghana Health Service (GHS) in attempts to reduce maternal morbidity and mortality has trained and currently trains midwives to augment medical officers to provide abortion care to reduce the number of unsafe abortions at a faster pace in the country [15]. However, there remain barriers to providing CAC services such as stigma against healthcare workers, discrimination from colleagues, family and friends, and conscientious objection based on religious and moral grounds [3, 15, 16]. Other healthcare providers believe it is best to save the lives of women and reduce maternal morbidity and mortality [15]. As part of SDG 3 (good health and well-being) targets 1 and 7, Ghana is expected to lower the maternal mortality ratio to at least 70 per 100,000 live births and ensure universal access to sexual and reproductive healthcare services respectively [16]. The achievement of the SDGs would be unattainable as long as healthcare workers are stigmatised and discriminated against in their quest to provide CAC services to adolescents.

Data from the District Health Information Management System (DHIMS 2) showed that 17.8% of all abortions in the Eastern Region of Ghana occurred among adolescents in 2021 [18]. Further, of all abortion cases in the New Juaben Municipality, 17.47% were recorded among adolescents in 2021 [18]. Against this backdrop, this study explored healthcare workers’ experiences in providing CAC to adolescents in the New Juaben Municipality in the Eastern Region of Ghana. The findings from this study could be useful in designing interventions to improve the experiences of healthcare workers and adolescents seeking CAC services in the Eastern Region of Ghana and beyond.

Study design

The study employed a phenomenological qualitative design to explore the experiences of healthcare workers in providing CAC services to adolescents in the New Juaben Municipality in the Eastern Region of Ghana. This study design is appropriate since the data was collected from healthcare providers who had experience in providing CAC services. In-depth interviews were used to collect in-depth information on healthcare workers who provide CAC services in the Municipality. This approach was suitable because it helped to explore and describe the experiences of healthcare workers within the area.

Study Setting

The study was conducted in the New Juaben Municipality in the Eastern Region of Ghana. The population of the Municipality stood at 218,457 in 2021 [19, 20]. Females represent 51.03% of the total population of the Municipality. Those aged 15–19 years were 25,412 (11.6%) of the total population with 12,432 (48.9%) being females [19]. The Municipality has 60 Community-based Health Planning and Services (CHPS) compounds, 8 health centres, 13 clinics, 1 maternity home and 4 hospitals [18]. The study was conducted in five public health facilities that provide CAC services (Jumapo Health Centre, Asokore Health Centre, Effiduase Health Centre, Koforidua Polyclinic and the Eastern Regional Hospital).

Study Population

The study involved healthcare workers who provided CAC services in five health facilities in the New Juaben Municipality. Only those who had provided CAC services for at least 6 months, and consented to be part of the study were included. They comprised nine midwives, a physician specialist, a physician assistant and a community health nurse.

Sampling and recruitment

The five health facilities were purposively sampled based on their provision of CAC services. Also, a purposive sampling technique was used to select participants based on their involvement in the provision of CAC services for at least 6 months. Only those who met this pre-defined criterion were recruited for the study. At the health facilities, those who met the pre-defined criteria were identified through the help of the CAC preceptors after permission had been sought from the Municipal Health Directorate, medical superintendents and facility managers. They were then approached and the purpose of the study was thoroughly explained to them in the English language. A convenient time was then scheduled for the interviews after they had agreed to be part of the study.

The actual number of participants was determined when data saturation was reached [21]. According to Polit and Beck, data saturation occurs when themes become repetitive and redundant [22]. Therefore, the sampling procedure was an emergent process in which data was collected until saturation was achieved. Ninety-two percent saturation is usually reached after 12 in-depth interviews have been conducted [23]. In this study, saturation was reached on all major themes after the 12th in-depth interviews.

Data collection

An open-ended interview guide was used for the data collection. In-depth Interviews (IDIs) (face-to-face) were conducted in English Language. Participants were asked about their experiences in providing CAC services to adolescents. Prompts and follow-up questions were also used to elicit more information from the participants. The interview guide was pre-tested among similar healthcare professionals and revised for clarity. Those who took part in the pre-testing were not part of the main study. The interviews were recorded using a digital audio recorder after permission and consent were sought from the study participants. Also, field notes were taken during the interview sessions. The data were collected in a private room in the health facilities to protect the privacy of participants. The interviews were conducted by the first author. An IDI session took about 45 to 60 minutes to complete. All audio-recorded interviews were transcribed verbatim into Microsoft Word. Obvious errors made on the transcripts were corrected before the data analysis.

Data analysis

A thematic analysis approach was used. The process involved critically reading the various transcribed data severally to identify common phrases and expressions that will emerge in each data unit [24]. To identify the main themes, the transcripts were read and re-read to ensure familiarity. A preliminary coding structure and a codebook were created. Only the researchers carried out the coding, categorization and theming of the data. The analysis was data-driven and the themes and the sub-themes were inducted from the transcripts through repeated reading. After a theme was established, the transcript was re-read to make sure that the theme appropriately reflected the data. The themes and the sub-themes were then collectively approved by all authors before the interpretation of the data. Feedback on the preliminary findings was provided to the research participants for validation. The 32-item Consolidated Criteria for Reporting Qualitative Research (COREQ) [25] guidelines were followed in reporting the study’s findings.

Characteristics of participants

Table 1 summarizes essential characteristics of the participants. The ages of the participants ranged from 24 to 56 years. Only one was male and all participants had tertiary education. Only one of the participants belonged to the Islamic religion and one had never married. Four of the participants had provided comprehensive abortion care services for at least 10 years. Six of the participants previously attended annual refresher training.

Table 1

Characteristics of participants
Characteristic	Number of Respondents (N = 12)
Age group
20–29	1
30–39	6
40–49	1
50 and above	4
Sex
Male	1
Female	11
Educational status
Tertiary	12
Religion
Christianity	11
Islam	1
Marital status
Never married	1
Married	11
Occupation
Physician Specialist	1
Physician Assistant	1
Midwife	9
Community Health Nurse	1
Years of CAC experience
Less than 5 years	6
5–9	2
10+	4
Frequency of refresher training
Never	5
Every 6 months	1
Every year	6

Experiences providing comprehensive abortion care to adolescents

The experiences of healthcare workers in the provision of comprehensive abortion care to adolescents were varied. While all participants had provided CAC services to adolescents in their practice, one stopped providing CAC services because of psychological trauma. ‘The babies always come to my dream. When I was providing the services I used to have bad dreams” [Physician Assistant]. The reasons revealed by those who continued to provide CAC services to adolescents included a desire to prevent unsafe abortions, prevent septic incomplete abortions, prevent harm to patients, save lives and take the opportunity to educate adolescents on contraceptive use. One midwife stated that ‘if you don't provide, she will go and take some concoction and then later they will bring her. So you would rather provide the service and then talk to her about contraceptives’. [Midwife 3]. One participant added that;

‘If you don’t provide the service for them and they go and do anything bad and they come with septic incomplete abortion, will you do it for them? That time they are almost dying, they’ve messed up so why won’t you do it for them …There was a patient who used gun powder that’s when I got to know that it's better we give them the service than to make them go and do things like this which might even end up hurting them’ [Physician Specialist]

The specific experiences of the healthcare workers in providing CAC services to adolescents in the New Juaben Municipality in the Eastern Region of Ghana explored in detail below.

Professional responsibility and policy directives

The physician specialist and some midwives in this study felt it was their professional responsibility to provide the service as anyone certain of continuing their pregnancy will not seek CAC services. A midwife stated that ‘it is part of our work. As a midwife, anything concerning reproduction is part of our work. So comprehensive abortion care is part of reproductive health issue’. [Midwife 2].

The physician specialist added ‘I don’t think it is easy for someone to tell you they want to terminate a pregnancy. So if they come and you can help them, you help them… Someone is in need. Yes, they need to plan their lives. Yes, they’ve messed up so if you can give them the service I think it should be given to them’. [Physician Specialist]

A midwife also described that even though she feels uncomfortable providing the services, she does it because of the Ghana Health Service (GHS) policy and regulations on CAC. She noted: ‘We wish it didn’t happen this way but we have no choice and the policy is saying that when they come we shouldn’t sack them … but we are not comfortable because at their age they are coming to do this thing [referring to abortion]’. [Midwife 9]

They further stated that ‘actually we are not comfortable because at their ages they are coming to do this thing but we have no other choice than to do it for them’. [Midwife 9]

Also, ‘it's weird sometimes, you see. Like it's the situation that has come up. If not for the policy, why then would I even do CAC service for an adolescent? … So, it's not something that is really comfortable doing but it is the situation that has come up’. [Midwife 10]

Feeling bad about providing CAC services to adolescents

Some midwives also reported that they felt bad about providing CAC services to adolescents.

‘Yeah at times I feel bad because when they tell their story I think there is a lack of knowledge. They don’t know anything about their menstrual cycle or how to protect themselves during sexual intercourse. So when you hear all these things it makes you sad that we are not preaching family planning very well for them to know that they can even protect themselves from getting pregnant’. [Midwife 7]

Additionally, it was reported that guardians often prevent adolescents from taking contraceptives to prevent further abortions:

‘Hmm, sometimes, I feel bad for them. Sometimes, I feel they have not been guided well because a child under 15 years is getting pregnant and aborting it. But what pains me most is when you want to provide family planning for them and the guardian refuses and says it will make the child promiscuous’. [Midwife 8]

Guilt and sin

The experience of guilt about providing CAC services to adolescents and the belief that providing CAC services is a sin was reported. A midwife recounted that ‘you know as humans as we are, we may feel a bit guilty because we think it is a sin terminating a pregnancy but that’s not the only issue’. [Midwife 9]. Another midwife stated that ‘people were complaining it is a sin, it is murder. But at times you may think the other side that you are saving life ‘. [Midwife 4]

Stigmatization

Socially, CAC providers are often stigmatized by their colleagues, friends, and even family members. This has the tendency to deter providers and widen the gap to service accessibility. In this study, some midwives reported that they were disturbed by the stigma as they are often stigmatized by colleagues and advised to stop providing CAC services. ‘Even in this facility, our colleagues that we work with in other units are calling us abortion midwives, so in fact, it is something else’. [Midwife 9]

‘That one [referring to stigma] it’s disturbing us because I have been here for a long time and people just think I’ve been killing babies and at times my colleagues laugh at me. People just call to tell me to stop providing the CAC services because it’s against my religion and others’. [Midwife 7]

‘With the stigma, for me when I came here earlier, I was feeling bad but later I told myself that I came to work and this is what I’m supposed to do. At the end of the day, I close and go home. …It’s not my wish to be causing abortion for people and I don’t go to call people to come and cause abortion. So it is not my fault’ [Midwife 8]

Also, the perception that CAC service providers were bad as well as the existence of perceived psychological trauma and stigma attached to the provision of CAC services were reported. According to the physician specialist, ‘I know some people see us as bad … Like oh this one does abortions, and babies will be crying on them. No baby has cried on me before and I think maybe it’s a stigma. [Physician Specialist].

Similarly, ‘it's psychological. Nothing came [referring to claims of being haunted by aborted babies]. They just say it to discourage people. They said those things and all of them will say that people said. There's nobody that can say that I was doing it and it happened to me’. [Midwife 2]

Nevertheless, the physician specialist and some other midwives were unperturbed about the stigma as it is their professional responsibility to provide CAC services and do no harm to patients. One stated that ‘as for the stigma it’s there but I don't care. Whatever you say, I won't mind you; I don't care. I know what I'm doing so I don't even think about them’. [Midwife 1]. More so, ‘stigma, it’s there but I don’t have a problem with it because when you come and I save you, you will come back and thank me later’. [Midwife 4].

Subsequently, a midwife reported that she has maximum support from her family and friends with regard to providing CAC services as part of her work: ‘my husband is aware but my parents are not. My friends are aware and they don't say anything bad to me. They understand’. [Midwife 2]

An understanding of the experiences of healthcare providers could be advantageous in guiding the development and implementation of interventions to improve CAC services. This study has shown that the experiences of healthcare providers in providing CAC services, especially to adolescents are diverse. The reasons for the provision of CAC services to adolescents as revealed in this study include the prevention of unsafe abortions, prevention of septic incomplete abortions, prevention of harm to patients, saving lives and an avenue for contraceptive education. These findings are consistent with what Oppong-Darko et al. found in Ghana where some midwives viewed abortion as saving lives and are ready to contribute to the reduction of maternal mortalities in the country [15]. This is particularly important as CAC service providers serve as gatekeepers for adolescents seeking abortion services. In a sense, most CAC service providers in the study seem to support a consequentialist argument whereby the provision of CAC services is thought to yield far less negative consequences to adolescents, their families and the healthcare system [26].

Also, some participants reported that even though they feel uncomfortable providing CAC services, they often do it because the GHS policy and regulations on CAC require them to provide the service. In contrast, midwives and nurses in Uganda expressed satisfaction and pride in providing CAC services [27]. There is a need for abortion service providers to be supported after they have been trained to strengthen their performance and output [28]. Results from values clarification and attitude transformation workshops organized in selected countries in Africa, Asia and Latin America revealed that the percentage of healthcare providers supporting unrestricted access to CAC services increased to 90.9% from 35.2% at the beginning of the workshop [29]. This means that with the necessary training, healthcare providers could feel comfortable in providing abortion services to contribute to the reduction of maternal mortality.

In addition, some participants in this current study felt it was their professional responsibility to provide the service because anyone certain of continuing the pregnancy will not seek CAC services. A study conducted in Ethiopia indicated that half of the respondents believed providing abortion services was a professional duty [30]. This is necessary as it encourages patient-centered care free of prejudice. This is also supported by duty-based ethics where following the recommended rules is considered ethical and vice versa [31]. This is because CAC service providers owe adolescents the ethical responsibility to provide safe CAC services.

On the experiences of healthcare providers, some reported experiencing psychological trauma in the provision of CAC services and have since stopped providing the services. This aligns with a qualitative study conducted in Taiwan where nurses felt moral distress when they performed abortions [32]. Similar results were also reported in Canada and in a systematic review where nurses and midwives providing abortion services felt morally distressed and burdened with emotional labor respectively [33, 34]. A physician specialist and some midwives in this current study, however, reported that the psychological trauma was only perceived and not real. This calls for the need to develop psychological counseling programs to provide support for CAC service providers in the health system.

Equally, some midwives viewed providing CAC services as a sin. This agrees with findings in a study conducted in Kenya where healthcare providers considered abortion as a sin and believed women would make it a habit [35]. In Ghana, some midwives reportedly viewed abortion as sinful and against their religious beliefs [15]. Other midwives in this study also felt bad and guilty for providing abortion services. There is a need for values clarification and attitude transformation training to help abortion service providers recognize that their attitudes can change if they allow themselves to have a deeper understanding of the need for CAC services for adolescents and the context in which it is important [29]. This will help improve access to abortion care and other adolescent sexual and reproductive care.

Considering the social context, CAC providers are not free from the stigma emanating from their colleagues, friends, and even family members. In this study, some midwives reported that they were stigmatized by their colleagues who are not involved in CAC provision. Similar results were reported in Ethiopia where abortion service providers faced stigma from their colleagues who do not provide abortion services and are often forced to keep their jobs a secret from families and friends [16]. Also, Rehnström Loi et al. [36] stated that healthcare providers in Southeast Asia and sub-Saharan Africa had reservations about providing safe abortion services because of associated stigma and victimization. Mamabolo and Tjallinks [37] in a study conducted in South Africa also revealed that nurses and midwives providing abortion care had insufficient emotional support from their colleagues, families and friends. Other midwives in South Africa also exhibited a need for emotional support to reduce their negative feelings toward abortion care [38]. Social support is thus important for healthcare providers involved in CAC as it reassures them and relegates any negative emotions they might have. There is also a need for intensive values clarification training for healthcare workers to help reduce the stigma towards CAC providers. The public should also be sensitized on the abortion laws in Ghana to increase acceptability.

The findings of this study should be interpreted with certain limitations in mind. The study was conducted in only five health facilities and among 12 CAC service providers. While the study has shed important light on the experiences and perspectives of these CAC service providers, the findings of this study may not be generalized. This said, the study has provided an in-depth and contextualized understanding of the experiences of CAC service providers.

The study revealed some negative experiences of healthcare providers such as stigma, discomfort, guilt and sin and psychological trauma. The positive experiences revolve around the motivation to reduce maternal morbidity and mortality and perform their professional duties. Values clarification and attitude transformation training interventions are critical to helping CAC service providers find a balance between their personal values, religious beliefs and CAC service provision. Education on safe abortion care should also be strengthened to normalize CAC discussions and reduce the stigma towards CAC service providers. These are important in contributing directly to the achievement of sustainable development goal 3 and promoting gender equality.

CAC Comprehensive Abortion Care

DHIMS District Health Information Management System

GHS Ghana Health Service

IDIs In-depth Interviews

PNDC Provisional National Defence Council

SDGs Sustainable Development Goals

UN United Nations

WHO World Health Organization

Ethical issues and consent to participate

Ethical clearance for the study was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC) with the number GHS-ERC: 039/11/22. Administrative approval was, however, sought from the New Juaben North Municipal Health Directorate, New Juaben South Municipal Health Directorate, medical superintendents of the Eastern Regional Hospital and the Koforidua Polyclinic. Copies of the ethical clearance letter and consent form were made available for those concerned.

Participation in the study was completely voluntary. The participants had the right to refuse participation or withdraw at any time they felt uncomfortable. If they wished to opt out of the study after they had provided consent, they were free to do so and their interviews would have been discarded and not included in the study. Written consent was obtained from the study participants after they had understood the purpose of the study and agreed to participate. They were asked to sign the informed consent forms. This research was conducted in accordance with the requirements of this ethics approval.

Consent for publication

All participants gave consent for the study’s findings to be published. All authors also consented to the publication of this manuscript.

Availability of data

The data generated and analyzed in this study are not publicly available due to confidentiality undertakings given to research participants as required by the study’s ethics approval. Requests to discuss this should be directed to the corresponding author.

Competing interest

The authors declare no competing interests.

Funding

The study was self-funded.

Author contributions

Study conception and design was done by both authors; Debuo Der Amanda did recruitment of participants and data collection; data analysis and interpretation were done by both authors. Both authors reviewed the results, drafted, reviewed and approved the final version of the manuscript.

Acknowledgments

The authors are grateful for the support of the New Juaben North Municipal Health Directorate, Koforidua Polyclinic, and the Regional Hospital, Koforidua, during the data collection. The authors are entirely indebted to the participants who supported this research.

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No competing interests reported.

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Healthcare Workers Experiences in Providing Comprehensive Abortion Care to Adolescents in the Eastern Region of Ghana: A Qualitative Study

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Abstract

Introduction:

Methods

Findings

Conclusion

Introduction

Methods

Study design

Study Setting

Study Population

Sampling and recruitment

Data collection

Data analysis

Results

Characteristics of participants

Experiences providing comprehensive abortion care to adolescents

Professional responsibility and policy directives

Feeling bad about providing CAC services to adolescents

Guilt and sin

Stigmatization

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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