Providers' Views and Experiences of Abortion Care during Coronavirus Disease Restrictions in Ghana: The Good, Bad and Ugly

  

    
Main    theme
    
Sub-themes
  
  

    
Demand for induced abortion services 
    
The most patronized    abortion services and patrons
  
  

    
Provision of safe induced abortion services
    
Availability, accessibility, and    affordability of abortion services
  
  

    
Cost of abortion services
    
High costs of abortion services in crisis situation
  
  

    
Provider    behaviors
    
Provider basis and judgmental attitudes    towards abortion seekers
  
  

    
Client safety 
    
Technical competency of service providers 
  
  

    
Quality    of abortion services 
    
Public education on safe choices and    regulation of providers
  

Table 2: Respondents opinions on induced abortions during COVID-19 crisis.

“…patronage of abortion pills in our shop has quadrupled between March and April this year. We see increasing numbers of young people daily coming to buy medications for self-induced abortions because of unplanned pregnancy…” (Pharmacy shop attendant, Kasoa).

“………….I don’t know if these young girls were told they should come home and get themselves pregnant when the schools were being closed. Since the closure of the schools, they always come to the shop requesting for pregnancy test strips, emergency contraceptive pills and/or medications for an abortion………...” (Chemical shop attendant, Accra).

“…………….There has been a huge decline in the number of abortion seekers in our clinic since the national directives on social distancing. Before COVID-19, we provide about 20 abortions daily but now we see at most 5 people in day…..As for the young people, they don’t come at all…may be, they are protecting themselves from unwanted pregnancies as they are staying at home………” (Midwife, public hospital)

The COVID-19 crisis with its associated policy directives of restricted movement and social distancing has created an unprecedented increase in the demand for over the counter induced abortion services particularly among young people in Ghana despite the favorable legal environment for safe abortion services in hospitals. Consequently, abortion seekers are not being able to obtain safe induced abortion services as permitted by the Ghanaian law particularly in areas of high COVID-19 cases and subsequent lockdowns. Regardless of these constraints, the demand for abortion services will have to be met in a safe environment by trained providers to prevent complications and fatalities that will put further strain on the already stressed health facilities in Ghana.

Provision of safe induced abortion services

The provision of safe induced abortion services is essential in every pandemic situation that impacts negatively on the life and health of pregnant women. The attendant impacts of COVID-19 have the potential to severely undermine availability, accessibility and affordability of abortion services, as travel restrictions limit transportation options to health facilities providing safe abortion services. Because induced abortion is always a time-sensitive procedure that should not be postponed, many abortion seekers desperately resort to nearby unsafe abortion services or services that endanger their lives and health.

“……the economic insecurity of many people at this time of COVID-19 pandemic is affecting our clients’ ability to pay for induced abortion services since we always see many people pleading for waivers or reductions in the cost of services we provide them…” (Midwife, NGO facility, Kumasi).

“…..it’s a difficult situation at this time, but under the prevailing circumstances, my facility has stopped providing elective abortion services and focusing on managing emergency cases only for now….Although we do refer the elective abortion seekers to other places, our observation is that they end up getting ‘backstreet’ unsafe abortions and return to us with severe complications that become serious emergency to manage……..” (Gynecologist, public hospital, Accra).

“…………sales of abortion pills have increased significantly since the schools were closed, although most clients seem to be concern about, how it works and costs..........’ (Pharmacy shop attendant, Kasoa).

Because access to safe induced abortion services in the midst of the COVID-19 outbreak is becoming challenging to some abortion seekers, some anti-abortion groups and individuals at various health facilities and pharmacy shops are exploiting this situation to deny abortion seekers access to safe induced abortion services. These behaviors undermine public health efforts and progress made so far in increasing women's and girls’ access to safe, legal abortion care in the quest of preventing unsafe abortions and related complications in Ghana. This behavior invariably threatens to increase the strain on already over-burdened health care systems by compelling individuals to seek out unsafe abortion services and increase the need for post-abortion care. 

Cost of abortion services

The costs of induced abortion and related services increased during the COVID-19 crisis in Ghana following the lock down restrictions on movement in the three cities. Some respondents indicated that since the ports were closed they had stopped having regular supply of the abortion pills from their suppliers. The few that they received were expensive hence they had to increase the retail cost accordingly (Pharmacy shop attendants in Accra, Kumasi, Kasoa). Others indicated that:

“…………….my facility has officially suspended providing elective abortions and focusing on only emergency services. Because of sympathy for the clients’ I have decided to unofficially help them using my own resources and of course at a higher price since I have to buy everything myself……………….” (Midwife, public hospital Kasoa).

“…………most of the clients we see here since the COVID-19 crisis had already attempted abortion on their own and only come with complications that require extra resources to manage at higher cost……..” (Gynecologist, public hospital, Accra).

“……although the cost of induced-abortion here is comparatively cheaper, we have limitations of what we can do hence some of the clients that we refer complain and sometimes weep because of the high cost of services at the referral facilities……….” (Midwife, NGO facility, Kumasi).

“……….it’s sad some of my colleagues are making money out of a crisis situation by charging ghs500-1000 for first trimester termination…….something that we used to do at less than ghs 300 before the COVID-19 crisis” (Gynecologist, public hospital, Kumasi).

Provider behaviors

There were increased provider basis on methods for abortion and judgmental attitudes towards abortion seekers particularly in the hospitals during the pandemic thereby creating additional barrier to accessing safe abortion services in the hospitals.

“……….I sometimes feel very sad when they start crying because they have waited for long hours without services, but I just can’t continue doing abortion when I have to close and go home………..” (Midwife, NGO clinic, Kumasi).

“………..its best to take the abortion pills at this time because it’s client dependent and has less risk for infections from the hospitals……………” (Midwife, Public hospital, Kumasi).

 “…..abortion is not an emergency so this is not the time to be providing abortion services…if young people can’t use contraceptives to prevent unwanted pregnancies, then they should be prepared to give birth and stop disturbing us at the hospital…..” (Gynecologist, public hospital, Accra).

Client safety

The provision of safe abortion is an extremely time-sensitive, essential health service that cannot be procrastinated. It is a crucial element of maternal health care and must be maintained even where non-urgent and elective services are suspended. Because a request for induced abortion care is time-sensitive, delays in receiving abortion care can compel abortion seekers to take desperate actions to overcome gestational limitations, which sometimes compromise client safety and risk complications and death. The safety of abortion seekers in the midst of the current pandemic is a threat to public health efforts of preventing unsafe abortions and related complications in the study area. The cost and financial gain of an abortion service are of much concern to the abortion seekers and some providers respectively. For this reason, ‘who and where’ the abortion is provided is not as important as ‘when and how’ an abortion service is provided

“…….hmmm, these young girls seeking abortion services don’t care about who provides the service and where it is done but desperate to know when it will be completed and how it will be done quickly so that its kept secret…………..” (Midwife, NGO Clinic, Kumasi).

“……I’ve saved the lives of quite a number of young women this month who attempted terminating second trimester pregnancies at home with a combination of drugs and herbal preparations bought from the pharmacy and chemical shops within their communities and bleed profusely when they were rushed into my facility for medical care……..” (Gynecologist, private hospital, Kumasi).

“…….although the prices of abortion pills have increased significantly during the lockdown, abortion seekers continue to buy, despite the complaint of increased cost. We educate people who buy abortion pills from our shop on how it should be taken, danger signs and what to do when they experience any of the danger signs…..we do this because we don’t want our name and reputation in the community to be destroyed by abortion complications………” (Pharmacy shop attendant, Accra).

Quality of abortion services

The quality of health care service delivery is generally of much importance to the Ghana health Service. However, because women and girls will always need contraceptives and safe abortion services even in crisis situations that require some restrictions on human freedoms, the quality of abortion services becomes very much compromise since demand exceeds the supply and there are limited choices to meet clients increasing needs for pregnancies crisis management at this time. Respondents raised the following concerns:

“……….I can’t guarantee the quality of abortion care given to clients in other facilities since counselling is being compromised and clients are not giving informed consent to induced abortion and related services……….” (Midwife, public hospital, Accra).

“Are you serious?…………we are in a crisis situation and you are talking about the quality of abortion care…what is quality about buying and taking an abortion pill?.............” (Chemical Shop attendant, Kasoa).

“……..… we have many options available but your ability to pay for services determines the type of abortion care you get and the quality of services we can provide to you………..” (Midwife, private hospital, Accra).

Discussion

Lessons from Global Health crisis have shown that access to safe abortion care during crisis situations can be challenging [9]. Although many governments are strategizing to contain COVID-19 pandemic at the national level, increasing caseloads on health facilities are negatively affecting access to safe abortion care [10]. In this study, the author examined providers’ views and experiences of induced-abortion services during the COVID-19 pandemic restrictions in Ghana, through an analytical cross-sectional case study design that involved key informants working in Clinics/hospitals, Chemical shops, and Pharmacy shops. The author’s observations in this study could be better discussed as ‘the Good, the Bad and the Ugly.’

The good

Globally, countries that have been affected by the COVID-19 have devised strategies with the aim of treating the sick and preventing further spread. In Ghana, all Academic institutions and public recreational facilities have been closed down indefinitely with some presidential directives on human restrictions thereby making most young people now at home. Anecdotal evidence has however shown that whilst these young people remain at home, they will have sexual and reproductive health needs, including decisions on contraception and induce abortion services that have to be met.

Following the agreements reached by governments in the 1994 International Conference on Population and Development (ICPD) in Cairo, which was reaffirmed at three global conferences such as the 1995 Fourth World Conference on Women (FWCW) in Beijing, the five-year review of ICPD in 1999 (ICPD+5) and the five-year review of FWCW in 2000, governments reiterated that in circumstances where abortion is not against national laws, health systems have an obligation to train and equip health-service providers to ensure that adequate decisions are made for accessibility of safe induced abortion services by women [11]. The Government of Ghana has since then formulated and/or revised various national policies, standards and protocols to guide the provision of safe abortions services [4]. As the COVID-19 pandemic spreads around the world, the Ghana Health service and its development partners in sexual and reproductive health and rights have prioritized service delivery to women and girls who need sexual and reproductive health services, while protecting the health and safety of all clients and staff.

Following the increasing cases of COVID-19 and its future uncertainties to meet the reproductive health needs of women and girls there have been many adaptations and innovations within the health sector to delivering induced abortion services to all people who need them. One of such innovations is promoting uptake of Long Acting and Reversible Contraceptives (LARCs) to prevent unplanned pregnancies, whilst respecting national policy directives of lockdowns and restricted movements. Some health facilities in the study areas have also adopted the key recommendations of the International Federation of Gynecology and Obstetrics [12]. for providing safe abortion services and have started using telemedicine, providing easy access to mifepristone and misoprostol for self-administered medical abortion, removal of unnecessary waiting periods to include digital client education initiatives that highlights the safety of abortion and in exceptional cases where a client must visit the hospital, arrangements have been made to ensure the availability of abortion and related services as permitted by law. The arrangements as recommended are good, practical and easily implemented solutions that are expected to release the pressure on the health system, free up providers and ensure access to safe induced abortion and related services for all at all times.

The bad

The rapid spread of the coronavirus and the increasing numbers of cases and fatalities, have dominated the international and local news headlines as well as social media cycles all around the world including Ghana. This unbalanced media rapportage has drown other equally important public health issues such as induced abortion and access to safe services. As the Ghana Health Service prepares to provide the required care to the sick in anticipated increases in demand for the care of people with COVID-19, some health facilities in the study areas have become solely designated as treatment centers for COVID-19 whilst others are implementing plans to cancel elective and non-urgent clinical procedures to expand hospitals’ capacity to provide critical care.

In relation to this, facilities that hitherto COVID-19 were noted for providing sexual and reproductive health services including safe abortion care have become either reluctant or unreceptive to providing elective abortion services because elective induced abortion is not perceived as an essential component of comprehensive health care. This situation sometimes delays access to safe abortion or denies clients from having safe abortion care.

Globally, COVID-19 pandemic has exposed the flaws in the ways in which existing legal frameworks for induced abortion works even in countries with unrestrictive abortion laws continue to undermine access to this essential health service by failing to recognize the safety of medical abortion and permitting women to undertake safe self-managed abortion with telemedicine counselling [8]. Whilst empirical evidence abound on the efficacy and safety of self-managed medical abortion [13-15], the Ghanaian abortion law at this crucial time is still fully being enforced with all the restrictions. Because pregnancy termination is a time-sensitive service, a delay or denial to safe termination may increase the risks to seeking unsafe alternatives which can negatively impact a person’s life, health, and well-being. It is therefore imperative for abortion laws at this time to be relaxed to expand access. If legalized, prescriptions for medication to be taken at home that would terminate pregnancies up to 10 weeks will ease the burden on service providers to focus on other emergencies.

The ugly

Despite having a safe and effective means of terminating an early pregnancy without any need to physically go to a hospital fits well within the ‘stay at home’ mantra for containing COVID-19 globally, some anti-abortionist are using lockdowns and restrictions to call for converting some health facilities into COVID-19 isolation and treatment centers so as to close as many abortion clinics as possible in some countries like the United States of America [15]. In Ghana, hospitals and health workers that were hitherto known for providing induced abortion services have now reclined and are focusing on emergency cases only. These actions will invariably lead to another public health crisis of increasing maternal deaths and illnesses emanating from unsafe abortions even if COVID-19 is contained. Resource constraints in crisis situations are often a source of human rights violations in maternal health settings, such as mistreatment and abuse of abortion seekers and violations of the right to information, informed consent, professionalism and quality of care. Such violations disproportionately impact marginalized populations, such as racial and ethnic minorities, poor women and rural women. Governments must take steps to guarantee women and girls’ rights in these settings. Furthermore, as information continues to evolve about the risk of COVID-19 to pregnant women, it is paramount that governments and health care providers continue ensuring women’s rights to make decisions about pregnancy outcomes including induced abortions. As resources are reallocated to respond to the pandemic, it remains critical that all people have access to high quality and nonjudgmental safe abortion care services, free from discrimination, stigmatization and coercion.

While the global response has rightly focused on containing the virus and treating the infected [16], it has also illustrated gaps in our existing approach to sexual and reproductive health care and articulated the need to embrace a comprehensive approach to health care long after the crisis ends. Consequently, the Marie Stopes Ghana, was reported in a TV3, 7 pm news bulletin on Friday April 24, 2020, about some projections for women with unwanted pregnancies that will seek early abortion whilst in lockdown and staying at home in Ghana. Although there is a clear need to consider the impact of COVID-19 self-isolation on all reproductive health services [7,17], not only can remote provision of healthcare ease the growing pressure on the Ghana Health Service, but without this option, women who find themselves with an unwanted pregnancy will be forced to choose between exposing themselves or healthcare workers to the risk of infection with COVID-19 in clinic waiting rooms, or to continue with an unwanted pregnancy.

As all academic institutions have been closed in Ghana and most young people are currently at home with restricted movement, there has not been any media education on contraception or a national consideration of access to contraception, and whether this might be affected through the supply chain disruptions for health commodities. Every woman or girl has the right to sexual and reproductive health choices including access to safe abortion_. ^[8,18] Because seeking and/or provision of induced abortion services is generally stigmatized in Ghana [19], the situation is even heightened in crisis situations like COVID-19 where there have been some restrictions of health care delivery to emergency services in the lockdown areas. This development is further deepening the culture of silence around induced abortion [20], as health care providers are not giving abortion seekers the essential information on the alternative ways to access safe abortions when required. Others may resort to using other unsafe methods for abortion such as counterfeit drugs, quack doctors, knitting needles, pesticides, small bottles filled with improvised explosives inserted into the uterus [21] or choose to access abortion medications from pharmacy and chemical shops illegally which are just some of the things abortion seekers resort to in desperate attempts to end their pregnancy if safe and affordable services are unavailable.

Conclusion

Findings of this study is evident that the unfolding COVID-19 crisis is restricting access to high-quality safe abortion services as permitted by the Ghanaian abortion law (Act 29 sections 58 a,b,c). Ghana has another opportunity to do things right in ensuring the removal of all the barriers to accessing safe abortion services as permitted by law. The COVID-19 crises situation cannot be used as an excuse to deny people access to sexual and reproductive health services including induced abortion although they may not be classified under emergency care which may increase the vulnerabilities of those women and girls who are already hard hit by the pandemic. Induced abortion services, should therefore be prioritized in health care delivery in the midst of containing COVID-19 pandemic in Ghana, to minimize risk of women and girls resorting to unsafe abortions. As much as possible the Ghana Health Service and its partners in Sexual and Reproductive Health and Rights should device new innovations and technologies to prevent unwanted pregnancies from occurring in the first place. Moreover, it is important for policy makers to do wider consultations during the decision-making processes for health care in crisis situations, so that people’s sexual and reproductive health needs and barriers are understood and incorporated into a comprehensive response plan that works for everyone.

There will however be challenges in policy decisions, programs implementation and reproductive health choices including induced abortion even in a country like Ghana where abortion is ‘liberal’ thereby leaving abortion seekers, health facilities and service providers with some biases on choice and dilemma of ‘the Good, the Bad and the Ugly’ decisions in making abortion services accessible and affordable in the midst of restrictions for containing COVID-19 in Ghana. Every challenge however, presents new opportunities to change ways, adapt and lead others to the new way. This is the best time empirical evidence is required to advocate for regulatory and institutional reforms for relaxing abortion laws and removing restrictions on the cadre of providers, how abortion should be done and where services can be provided safely.

Acknowledgment

The author is grateful to all individuals, institutions and facilities for their excellent support in conducting this study and writing the manuscript.

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