ENSIGN COLLEGE OF PUBLIC HEALTH, KPONG EASTERN REGION, GHANA FACTORS UNDERPINNING COMPREHENSIVE ABORTION CARE AMONG ADULT WOMEN IN REPRODUCTIVE AGE IN THE NEW JUABEN MUNICIPALITY- KOFORIDUA BY ADJEI ELLEN A THESIS SUBMITTED TO THE DEPARTMENT OF COMMUNITY HEALTH, FACULTY OF PUBLIC HEALTH, ENSIGN COLLEGE OF PUBLIC HEALTH IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE APRIL, 2019 i DECLARATION I hereby declare that this submission is my own work towards the MPH, and that, to the best of my knowledge, it contains no material previously published by another person, nor material which has been accepted for the award of any other degree of the institution, except where due acknowledgement has been made in the text. ELLEN ADJEI …………….………. …………………… Student ID: 177100106 Signature Date Certified by: DR. REUBEN K. ESENA ……………………… ……………………… (Supervisor) Signature Date Certified by: DR. STEPHEN MANORTEY ……………………. ……………………… (Head of Department) Signature Date ii ABSTRACT This study investigates the underpinnings of CAC using data from clients and providers of CAC in the New-Juaben Municipality. Knowledge, attitudes and practices (KAP) model is adapted to assess the underpinnings of CAC. Quantitative and qualitative data were solicited from 129 clients and 10 health professionals, respectively, in health facilities that provide CAC in the New- Juaben Municipality. Convenience and purposive sampling techniques aided data collection process in five health facilities, namely, the Regional Hospital, Koforidua, Koforidua Poly Clinic, Magazine Health Centre, Effiduase Reproductive and Child Health Centre, and Asokore Reproductive and Child Health Centre. The findings indicate that knowledge/awareness of the clients on CAC is considerably high at 3.70 on a scale of 1 to 5. Well-known contraceptives include the pill, condom, and injectables. Nonetheless, there was not much awareness of where and how CAC can be obtained. For the health professionals, family planning, counseling, child welfare, anti-natal care, post-natal care, delivery service, maternity, and outpatients’ department (OPD) are health centre services that made up CAC. More than not, clients exhibited accepting attitudes towards CAC. Findings Knowledge/awareness, attitudes and practices significantly explain 71.4% of the variability in CAC usage (p=0.000). When people are aware that safe abortion entails counseling and medication, and midwives and nurses are said to be providing family planning and safe abortion services, they gain enthusiasm to access CAC. Stigma and discrimination, restrictions by religion, time, affordability, accessibility, and negative attitudes of health staff pose challenges for clients to use CAC. The study recommends that CAC should be strengthened in terms of accessibility, finance, training of health staff, and public education. Future studies ought to focus on the quality of comprehensive abortion care. iii DEDICATION This work is dedicated to my husband, Mr. J. A. Allotey. And to our children, Derrick Kpakpo Allotey, Samuel Adotey, and Ernest Adotei Allotey. iv ACKNOWLEDGEMENTS Carrying out this study has taken me through a deliberate commitment to process and academic work, but would have been a little of a success without the support from several individuals. But first, I give thanks to the Almighty, to whom I owe my life in time and eternity, for strengthening me through the full course of this study. I wish to acknowledge, with deep gratitude, my Supervisor, Dr. Reuben K. Esena, for his clear guidance and stimulation of ideas that immensely enabled me to see my way clearer through this research. His time spent with me on this work has given me both humility and expert knowledge about research. I am equally thankful to all the members of the Faculty of Ensign College of Public Health for their intellectual and moral support to me through this research project. God bless you! I also wish to show appreciation to several individuals who, in no small measure, assisted me at different stages of this research. To my research assistant Mr. Tony Kwasi Dwamena, Mr. Francis Tetteh and Mrs. Evelyn Owusu, all of the Koforidua Nursing Training College for your moral support to me and stimulation of ideas through this study. I sincerely appreciate Miss Rose Osei and Mrs. Irene Yeboah at the Family Planning Units, Koforidua, Mrs. Diana Prempeh, Mrs. Esther Mensah and Miss Naomi Ameyigbor at Reproductive and Child Health Centres in Koforidua, for accommodating me and for all your invaluable support through the data collection exercise. Several other individuals played varied roles for the completion of this study. Mentioning your names would produce a long list. You, however, know yourselves. I say God bless you! v LIST OF ABBREVIATIONS AND ACRONYMS CAC - Comprehensive Abortion Care CDC - Centers for Disease Control CHDS - Community-based Health Planning and Services GDHS - Ghana Demography and Health Survey GHS - Ghana Health Services GSSMI - Ghana Statistical Service Macro International MOH - Ministry of Health MVA - Manual Vacuum Aspiration UNDP - United Nations Development Programme WHO - World Health Organization vi TABLE OF CONTENTS DECLARATION.......................................................................................................................................... i ABSTRACT ................................................................................................................................................. ii DEDICATION............................................................................................................................................ iii ACKNOWLEDGEMENTS ...................................................................................................................... iv LIST OF ABBREVIATIONS AND ACRONYMS .................................................................................. v TABLE OF CONTENTS .......................................................................................................................... vi LIST OF TABLES ...................................................................................................................................... x LIST OF FIGURES ................................................................................................................................... xi CHAPTER ONE ......................................................................................................................................... 1 INTRODUCTION ..................................................................................................................... 1 1.1 Background of the Study .................................................................................................. 1 1.2 Problem Statement ............................................................................................................ 4 1.3 Rationale of the Study ....................................................................................................... 5 1.4 Conceptual Framework ..................................................................................................... 6 1.5 Research Questions ........................................................................................................... 9 1.6 General Objective of the Study ......................................................................................... 9 1.6.1 Specific Objectives of the Study .................................................................................... 9 1.7 Profile of the Study Area ................................................................................................ 10 1.7.1 Demography ................................................................................................................. 11 1.7.2 Topography .................................................................................................................. 13 1.7.3 Climate ......................................................................................................................... 13 1.7.4 Infrastructure ................................................................................................................ 14 1.8 Scope of the Study .......................................................................................................... 14 1.9 Organization of the Thesis .............................................................................................. 15 vii CHAPTER TWO ...................................................................................................................................... 16 LITERATURE REVIEW ....................................................................................................... 16 2.1 Introduction ..................................................................................................................... 16 2.2 Knowledge on Comprehensive Abortion Care ............................................................... 16 2.3 Attitudes of People towards Comprehensive Abortion Care .......................................... 20 2.4 Attitudes of Abortion Care Providers towards Abortion ................................................ 21 2.5 Attitude of Women in Reproductive Stage towards Comprehensive Abortion Care ..... 24 2.6 Accessibility of Family Planning Counseling involved in Comprehensive Abortion Care ............................................................................................................................................... 26 2.7 Barriers in seeking Comprehensive Abortion Care ........................................................ 28 2.8 Conclusion ...................................................................................................................... 29 CHAPTER THREE .................................................................................................................................. 31 METHODOLOGY .................................................................................................................. 31 3.1 Introduction ..................................................................................................................... 31 3.2 Research Design ......................................................................................................... 31 3.3 Data Collection Techniques and Tools ........................................................................... 32 3.4 Study Population ............................................................................................................. 34 3.5 Sampling Procedure and Sample Size ............................................................................ 34 3.6 Pre-testing ....................................................................................................................... 37 3.7 Data Handling ................................................................................................................. 38 3.8 Data Analysis Procedure ................................................................................................. 38 3.9 Ethical Considerations .................................................................................................... 39 CHAPTER FOUR ..................................................................................................................................... 41 DATA ANALYSIS .................................................................................................................. 41 4.1 Introduction ..................................................................................................................... 41 viii 4.2 Background Information about Clients ........................................................................... 41 4.2.1 Age ............................................................................................................................... 42 4.2.2 Gender .......................................................................................................................... 42 4.2.3 Level of Education ....................................................................................................... 42 4.2.4 Occupation ................................................................................................................... 43 4.2.5 Average Monthly Income ............................................................................................ 43 4.2.6 Marital Status ............................................................................................................... 43 4.2.7 Religious Affiliation .................................................................................................... 44 4.3 Description of Health Professionals Interviewed ........................................................... 46 4.4 Clients Experience with Child Birth and Contraception use .......................................... 47 4.5 Knowledge, Attitudes and Practices on Comprehensive Abortion Care ........................ 50 4.5.1 Knowledge on Comprehensive Abortion Care ............................................................ 57 4.5.2 Attitudes and Practices on Comprehensive Abortion Care.......................................... 61 4.6 Underpinnings of Comprehensive Abortion Care .......................................................... 68 4.7 Reasons for Non-patronage of Abortion Care ................................................................ 75 4.7 Conclusion ...................................................................................................................... 78 CHAPTER FIVE ...................................................................................................................................... 79 DISCUSSIONS ........................................................................................................................ 79 5.1 Introduction ..................................................................................................................... 79 5.2 Main Findings ................................................................................................................. 80 5.2.1 Knowledge about Comprehensive Abortion Care ....................................................... 80 5.2.2 Attitudes and Practices on Comprehensive Abortion Care.......................................... 81 5.2.3 Underpinnings of Comprehensive Abortion Care ....................................................... 82 CHAPTER SIX ......................................................................................................................................... 86 CONCLUSIONS AND RECOMMENDATIONS ................................................................ 86 ix 6.1 Introduction ..................................................................................................................... 86 6.2 Conclusion ...................................................................................................................... 86 6.3 Recommendations ........................................................................................................... 88 6.4 Suggestion for Further Studies........................................................................................ 90 REFERENCES .......................................................................................................................................... 91 APPENDICES ........................................................................................................................................... 97 Appendix 1: Questionnaire on Factors Underpinning Comprehensive Abortion Care Among Adults in Reproductive Age in New Juaben Municipality-Koforidua ............................................................. 97 Appendix 2: Interview Guide ............................................................................................... 102 x LIST OF TABLES Table 1.1: Population Distribution ................................................................................................ 12 Table 1.2: Population Distribution by sub-Municipals ................................................................. 13 Table 4.1: Background Data of the Clients ................................................................................... 45 Table 4.2: Time Projection for First Child Birth .......................................................................... 49 Table 4.3: Period of Last Use of Contraception ........................................................................... 50 Table 4.4: Knowledge about Comprehensive Abortion Care (Reliability Analysis) ................... 58 Table 4.5: Level of Knowledge on Comprehensive Abortion Care ............................................. 60 Table 4.6: Initial Reliability Statistics for Attitudes and Practices on Abortion Care .................. 62 Table 4.7: Attitudes and Practices on Comprehensive Abortion Care ......................................... 64 Table 4.8: Variables in the Equation of Comprehensive Abortion Care ...................................... 73 Table 4.9: List of Variables in the Binary Logistic Regression Equation .................................... 74 xi LIST OF FIGURES Figure 1.1: Conceptual Framework on Comprehensive Abortion Care [Modified from Launiala (2009)]........................................................................................................................... 7 Figure 1. 2: Map of New-Juaben Municipality ............................................................................. 11 Figure 4.1: Child Birth and Number of Children associated with the Clients .............................. 48 Figure 4.2: Family Planning and Counseling Seeking in Health Facility..................................... 50 Figure 4.3: Knowledge about Contraception Methods ................................................................. 51 Figure 4.4: Knowledge about Contraception Service in current Health Facilities ....................... 52 Figure 4.5: Source of Information on Contraception Methods ..................................................... 53 Figure 4.6: Reasons for Non-patronage of Abortion Care by the Clients .................................... 76 file:///G:/Abortion/CAC%20Thesis%20Final%20Revised%202.docx%23_Toc7207398 file:///G:/Abortion/CAC%20Thesis%20Final%20Revised%202.docx%23_Toc7207398 1 CHAPTER ONE INTRODUCTION 1.1 Background of the Study There is an increasing global realization that, to reduce child deaths and maternal mortality, women must not go through pain or fatal delivery processes (UNDP, 2016). As concerns about improving reproductive health rages on, the debate on abortion is certainly not an issue that can be swept under carpet. In the midst of these concerns, abortion – termination of pregnancy or fetal development – has attracted debate in Ghana, particularly, because of its prevalence of the safety of its handling. Abortion is, however, considered as a method of family planning and an effective way of preventing dangers from developing. For this reason, the factors underpinning comprehensive abortion care for adult women is the main focus of this study. A key factor is unsafe abortion. Unsafe abortion is a major contributor to maternal morbidity and mortality in developing countries (World Health Organization, 2011). The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating a pregnancy that is performed by an individual lacking the necessary skills, or in an environment that does not conform to minimal medical standards, or both. Unsafe abortion contends to be a major to maternal mortality in developing countries (Murray et al., 2006; Ghana Statistical Service, GHSG and Macro International 2009). About 15% of women in Ghana aged 15-49 years is said to have had at least one abortion (Ghana Statistical Service, GHSG, and Macro International, 2009). Although this percentage gives an indication that abortion is prevalent in the country, there is confusion among experts and researchers that the Ghana’s Abortion Law, the Consolidated Criminal Code, 1980 (Act 29), permits unrestricted access to 2 abortion care. Generally, the law provides limited access to abortion care at best (Norman et al., 2015). The legal provision in Act 29 indicates that abortion is permitted under some circumstances, such as when pregnancy is the result of rape, defilement, or incest; if the continuation would involve risk to the life of the pregnant woman; if the pregnancy will injure the woman’s physical or mental health; or there is a substantial risk that the child may suffer from a serious physical abnormality or disease. The law in another breadth states that “Abortion is unlawful and both the woman and anyone who abets the offence by facilitating the abortion by whatever means, are guilty of an offense of causing abortion” (Morhe et al. 2007). Despite this legal background, it is a known fact that abortion is being done undercover and sometimes under unsafe and clinically unacceptable conditions by a considerable proportion of females, especially the adolescents (Adjei et al. 2015). This exposes many women to the dangers of improperly conducted abortion. Abortion could be spontaneous or induced. Spontaneous abortion occurs without intervention. It is most commonly due to fetal chromosomal defects while, induced abortion results from medical or surgical intervention that can cause abortion. However, induced abortion is a safe medical procedure (Oppong-Darko et al., 2017). Whether spontaneous or induced, abortion demands a complete, well-delivered care to preclude subsequent degeneration of reproductive health of affected women. This has called for efforts from clinicians and health professionals to think about ways to deliver abortion care. In 2006, The Ministry of Health and Ghana Health Service developed standards for the provision of comprehensive abortion care. Since then, midwives and physicians have been handed the authority to perform abortion, yet, in accordance with the law. Safe 3 abortion performed by a qualified healthcare provider has been part of the Reproductive Health Strategy of Ghana since 2003. Also, in Ghana, there is a wide range of services that the Ghana Health Service has brought on board to help reduce the hazards of induced abortion and maternal mortality. This includes family planning services to reduce the incidence of unwanted pregnancies and hence induced abortion; abortion services which are only included in the abortion laws of the country; post abortion complication services (PAC services); and education or the provision of information on abortion issues (Ghana Health Service, 2012). To receive safe abortion, therefore, women who are pregnant must be able to access a comprehensive abortion care. By implication, the World Health Organization (WHO) views a comprehensive abortion care as carrying out the termination of unintended pregnancy by persons professionally trained to do so in an environment that conforms to minimal medical standards. It encompasses practices that eliminate hazardous circumstances before, during and after an abortion (Ahman and Shah, 2008). Ghana’s narrative in terms of delivery of comprehensive abortion care shows that there is more to be done in the face of fact that, there is more to know about the underpinnings of comprehensive abortion care uptake among women adults. The purpose of this study was to investigate the underpinnings of comprehensive abortion care uptake among women adults. A broad-base study dealing with various settlements of Ghana could provide a general understanding of the issue of interest in this study. This, however, does not preclude the possibility of obtaining credible information on comprehensive abortion care from a specified area in Ghana to give, yet, an understanding of what the situation might be in the specified area. This study investigated 4 the underpinnings of comprehensive abortion care among women adults at the New-Juaben municipality in the Eastern Region of Ghana. 1.2 Problem Statement Maternal morbidity and mortality is a global public health concern. Unsafe abortions contribute substantially to maternal morbidity and mortality. There is evidence that whether abortion is permitted by law or not, unsafe abortions do occur (WHO, 2011). Abortion is legal and available under a wide scope of certain countries, but many abortions are performed outside legally authorized health services, many of which are unsafe (Dugal and Ramachandran, 2004; Fetters and Samandari, 2009). In sub-Saharan Africa, abortion is liberal in some countries while in other countries abortion is legal only when it preserves life (Sedgh et al., 2012). Even in the advanced worlds like the United States and Europe where abortion is largely legally permitted, there is evidence that some women rely on unsafe abortion (Centres for Disease Control and Prevention (CDC) and ORC Macro, 2005; Grossman et al. 2010; Jones, 2011). There is a seeming limitation of abortion expressed in the legal proposition, “Abortion is unlawful and both the woman and anyone who abets the offence by facilitating the abortion by whatever means, are guilty of an offense of causing abortion”, in Ghana’s Abortion Law (Act 29) (Morhe et al., 2007). Although a section of the law postulates conditions under which abortion is legally permitted, the limitation is, in part, due to lack of knowledge on the abortion law. This exacerbates the socio-cultural perceptions against abortion thereby fueling a high level of stigma for those who need abortion care (Norris et al. 2011). Cultural, religious and traditional stigma against abortion does not only affect women, but also abortion service providers and advocates. Additionally, high cost of safe 5 abortion services greatly challenges safe abortion (Oppong-Darko, 2017; Esantsi et al. 2015). Studies have shown that one other reason that deters women from going in for safe abortion services is the high cost associated with it. Women who are found in the low wealth quintile (poor women) cannot afford legal abortion and may be forced to procure quack services (Sedgh, 2010). Abortion-related deaths contribute significantly to the high rates of maternal mortality and morbidity in Ghana (Adjei et al., 2015). Induced abortion is said to account for 11 percent of maternal deaths behind haemorrhage (Sedge, 2010). A number of studies have focused on the socio-demographics of women who have undergone abortion or barriers to safe abortion services, outcomes of unsafe abortion and methods of unsafe abortion in Ghana (Morhee and Danso 2007; Rominski et al., 2012). However, there is a paucity of studies on the factors that influence comprehensive abortion uptake among adult women although in contemporary times the option for competent abortion care is more available than ever before. This study, therefore, sought to determine the underpinnings of comprehensive abortion care among adult women using data from the New-Juaben municipality. 1.3 Rationale of the Study The subject of abortion is key to women’s as reproductive health. Although there are some studies on abortion, there is a paucity of research on the factors underpinning the choice of comprehensive abortion care to adult women. For example, specific studies on what factors underpin the choice of abortion in the New-Juaben municipality or the Koforidua Township in the Eastern Region of Ghana is palpably difficult to find. This study, therefore, offers the opportunity to understand the peculiar issues regarding to the 6 factors contributing to comprehensive abortion care among adult women in the New- Juaben municipality. The study, therefore, offers information about abortion in the municipality that can be used by the Ghana Health Service and local health facilities for strategic planning to prevent the use of unsafe abortion methods which would otherwise be a preserve for many women who are disposed to such unsafe methods of abortion. The findings of this study would also provide information to policy makers to inform decisions on comprehensive abortion care. This study would also inform other stakeholders such as the government of Ghana, nongovernmental organizations like International Pregnancy Advisory Services (IPAS), Planned Parenthood Association of Ghana (PPAG), Pathfinder International and Marie Stopes International Ghana, to increase their effort in the recast of unsafe-abortion related deaths and morbidities. 1.4 Conceptual Framework The thinking that went into this study gives cognizance, first, to knowledge of abortion care; second, attitudes towards abortion care; and third, practices relative to abortion care. In effect, the Knowledge, Attitude and Practice (KAP) framework was employed in this study as the means by which the underpinnings of comprehensive abortion care can be extrapolated. The KAP framework has been espoused by several public health intervention researchers as a model that is used to critically understand the socio- anthropological and economic aspects of the public health concern in context (Launiala, 2009; World Health Organization, 2008; Wilkinson et al. 2017). Launiala (2009) for instance, argues that context-specific public health information is gathered through knowledge, attitude and practice (KAP) studies. Werner (1977) also adds that the KAP 7 studies often aim to identify indicators that can inform and improve the development and implementation of public health interventions. In this study, knowledge, attitude and practice associated with comprehensive abortion care provides the context in which the underpinning comprehensive abortion care. Figure 1.1 illustrates the diagrammatic structure of the conceptual framework contemplated in this study. As indicated in Figure 1.1, Comprehensive Abortion Care is conceived as a derivative of knowledge, attitudes, and practices in respect of abortion. In other words, the status of comprehensive abortion care would be determined by the KAP. Each of the concepts: Knowledge, Attitudes and Practices, is formed by distinguished but closely interrelated variables. Knowledge simply supplies information of ‘by what means’ and ‘how’ people are made to know about comprehensive abortion care. So, familiarizations, awareness and specific knowledge of people must be tested. Closely related to knowledge Comprehensive Abortion Care Attitudes Knowledge Practices Awareness/familiarity Knowledge General feelings Beliefs Emotions Abortion care seeking behaviours Figure 1.1: Conceptual Framework on Comprehensive Abortion Care [Modified from Launiala (2009)] 8 is ‘Attitudes’, and this reflect how people feel, their beliefs and emotions about abortion. In ideal situations, it is expected that both knowledge and attitudes are capable of resulting in actions or practices about abortion care seeking that correspond with them. Public health professionals usually share the view that knowledge and beliefs are contrasting terms. Knowledge is implicitly viewed to be based on scientific facts and universal truths. This is fundamentally different from beliefs which refer to traditional ideas, which are erroneous from biomedical perspective, and which form obstacles to appropriate behavior and treatment-seeking practices (Good, 1994; Pelto and Pelto, 1997). Petty and Cacioppo (1981) explained that the term ‘attitude’ is often used to mean a person’s general feelings about an issue, object or person. Akin to attitudes are a person’s knowledge, beliefs, emotions, and values, each of which can either be positive or negative. Pelto and Pelto (1997) pointed out that attitude is a derivative of beliefs and/or knowledge. Practices, the third integral part of KAP models, make enquiries into health-related practices of people. These enquiries would normally be on what different treatment and prevention options are people disposed to as far as a health issue such as abortion is concerned. The major criticism of a KAP model is its failure to explain ‘why’ and ‘when’ certain practices are chosen. Hausmann-Muela et al. (2003) have espoused that KAP surveys fail to explain the logic behind people’s behaviour. This view lays claim to the idea that practices or behaviour is explained by multiple factors emanating from socio-cultural, environmental, economic, and structural factors, and so on (Launiala and Honkasalo, 2007; Farmer, 1997). The KAP model has nonetheless been employed in several studies that have 9 produced most credible results and understanding of how people’s knowledge base, beliefs systems and attitudes impact on their action decisions. This study was of the view that, some important factors that underpin people’s choice of comprehensive abortion care can be accounted for through the KAP model. 1.5 Research Questions In order to achieve the objectives of this study, the following research questions were posed: 1. What is the knowledge of adult women on comprehensive abortion care? 2. What are the attitudes and practices of adult women towards comprehensive abortion care? 3. What are the underpinnings of comprehensive abortion care among adult women? 4. What strategies emerge from this study to enhance the reproductive health of adult women? 1.6 General Objective of the Study The general objective of this study was to investigate the underpinnings of comprehensive abortion care among adult women in the New-Juaben municipality. 1.6.1 Specific Objectives of the Study The specific objectives of the study were to: 1. assess the knowledge of adult women on comprehensive abortion care. 2. describe the attitudes and practices of adult women towards comprehensive abortion care. 10 3. determine the underpinnings of comprehensive abortion care among adult women. 4. recommend strategies to enhance reproductive health of adult women based on the findings of the study. 1.7 Profile of the Study Area The study area (Figure 1.2) was the New-Juaben Municipality in the Eastern Region of Ghana, and it accommodates the capital town of that region known as Koforidua. The area is the smallest of the 26 districts in the region. Like all districts in Ghana, New-Juaben has its own health problems, which need to be addressed in the context of Primary Health Care (PHC) and the local environment. New Juaben Municipality is located in the Eastern Region of Ghana. It is the one of the six municipalities and covers a land area of 110 square kilometers with an estimated population of 217,389. It shares boundaries with East Akim Municipality on the north, Akwapim North District on the south, Yilo Krobo District on the east and Suhum Kraboa Coaltar District on the west. 11 Figure 1. 2: Map of New-Juaben Municipality (Source: New Juaben Municipal Health Report, 2017) 1.7.1 Demography The New Juaben Municipality has a land area of 110.0 square kilometers with a total population of 217,389. The population density of the Municipality is 1,976 persons per square kilometer. The distribution of the population of the New-Juaben Municipality is presented in Table 1.1. 12 Table 1.1: Population Distribution Source: New-Juaben Municipal Assembly The population distribution according to various sub-districts in the New-Juaben Municipality is as shown in Table 1.2. Population Distribution Number Percent (%) Children (0 - 11 months) 8696 4 Children (12 - 23 months) 4348 2.0 Children (24 - 59 months) 17826 8.2 Children (5 - 14 years) 58695 27 Women (15 - 49 years (WIFA)) 53043 24.4 Men (15 - 49 years) 43478 20 Men and Women (50 - 60 years) 17391 8 Men and Women (60+ years) 13912 6.4 Total 217, 389 100 13 Table 1.2: Population Distribution by sub-Municipals No. Sub-district Number of recognized communities Population % of district population 1. Jumapo 13 15165 7.0 2. Oyoko 9 13650 6.3 3. Effiduase 11 18426 8.5 4. Asokore /Akwadum 20 23641 10.9 5. Koforidua 12 46827 21.5 6. Zongo 9 21552 9.9 7. Adweso 38 51563 23.7 8. Old Estate Densuano 25 26565 12.2 TOTAL 137 217,389 100 Source: New-Juaben Municipal Assembly 1.7.2 Topography The relief of the district is characterized by the continuation of the Kintampo Mampong-Kwahu scarp. The rest of the district is relatively flat with isolated hills dotted across the plains. The district is traversed by a number of rivers and streams. Notable among these is the river Densu and river Nsukwao. The vegetation is characteristically tropical rain forest with many big trees of economic importance 1.7.3 Climate The Municipality falls within the equatorial rain forest zone. Rainfall is therefore abundant throughout the year with the peak between June and August. Temperatures range 14 from 20 – 29o C throughout the year. The hottest months are February and March while the coolest months are July and August. Humidity is high throughout the year. 1.7.4 Infrastructure The New-Juaben Municipality harbours Koforidua, the capital of the Eastern Region of Ghana, but the names are used almost interchangeably. Koforidua, therefore, has all the ministries and regional offices of state institutions expected of a regional capital in Ghana. It must be emphasized that New-Juaben Municipality is larger than the Koforidua Township. About half of the district is made up of the Koforidua Township. A couple of the Sub-districts are within the Koforidua Township. The New-Juaben district is urbanized. 1.8 Scope of the Study This study area was the New-Juaben municipality otherwise popularly known as Koforidua. The choice of this municipality was, first and foremost informed by the researcher since the space of time and resource at disposal for this study was limited to cover more than one locality. Additionally, the choice of the New-Juaben municipality is due to the fact that the municipality is the capital town of the Eastern Region and has not only the Regional Hospital, but also various private health facilities which compliment one’s appreciation of a fair distribution of health services and facilities in the municipality. There is, therefore, a considerable awareness of adult women in this municipality about the reproductive health care choices they are confronted with, and thus, give some useful characterization of women from whom the factors influencing comprehensive abortion care in the municipality can be studied. Adult women from the New-Juaben municipality were, therefore, the target group of interest in this study. 15 1.9 Organization of the Thesis This study is organized into five chapters. Chapter One covers the introduction to the study including the background, statement of problem, objectives of the study, research questions, justification of the study, scope of the study, and the organization of the study. Chapter Two covers review of literature and it presents the conceptual framework of the study followed by an extensive review of the meaning and knowledge of abortion. The review also touches on attitudes and practices associated with abortion without ignoring an empirical review of studies on abortion in Ghana. Chapter Three describes the methods employed in conducting this study. This includes the study area; research philosophy; research design, data and source; study population; sampling procedure; data collection method, research instrument; methods of data analysis; experiences from the fieldwork and ethical consideration. Chapter Four presents the data analysis and the results. The findings are presented under thematic areas, namely, knowledge, attitudes, factors influencing comprehensive abortion care, and emerging strategies for promoting reproductive health. Chapter Five presents the discussion of results obtained relating to their effect of the factors influencing comprehensive abortion care and emerging strategies for promoting reproductive health. Chapter Six presents the summary of the findings, conclusions and recommendations. 16 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter reviews pertinent literature that leads to the understanding of abortion or abortion-related issues. The review attempts to bring out the meaning of abortion and knowledge on comprehensive abortion care. The review also delves into the attitudes towards abortion to understand the acceptability or aversion of people to abortion. Other literature which tries to give relevant outlook on the factors influence uptake of abortion care is also reviewed. 2.2 Knowledge on Comprehensive Abortion Care Abortion, in simple terms, is the expulsion of the foetus before viability. Others also like to see it as the termination of an unwanted pregnancy. The gestational age for viability depends on the country. However, irrespective of this definition, induced abortion is one of the commonest procedures performed throughout the world. It is estimated that about 25% of all pregnancies worldwide end in induced abortion. The proportion of pregnancies ending in abortion fell from 39% to 27% in developed countries, while it increased from 21% to 24% in developing countries between year 2010 and 2014 (Sedgh et al., 2017). Because of the clandestine nature under which abortions are performed (Ahiadeke, 2001), determination of the actual number is next to impossible. In settings including private and government institutions, when they are even performed, the procedure is disguised given the absence of legitimate medical diagnosis to justify the procedure. 17 Nonetheless, it is estimated that 20million abortions out of the 50million abortions are being performed under dangerous conditions, either by untrained providers or unsafe procedures, or both. The difference between levels of maternal mortality in developing and industrialized countries is greater than for any health indicator (Tinker et al., 2000). This finding comes as no surprise because the contributory factors to maternal mortality in developing countries have not been attended to. This logically puts women in developing countries at a higher risk of dying from unsafe abortion as compared to women in developed countries. Experts hold the view that many more women who have not died of unsafe abortion suffer serious long-term injuries and disabilities (Hord, 2004). Although abortion is pervasive, for the reasons that it attracts stigma, and is a taboo in certain cultures or has legal ramifications, it is not often reported. Grimes et al., (2006) found that many women who undergo unsafe abortion are married, with unmarried youth making up a large proportion of women seeking induced abortion in urban areas, however, in developing countries, unsafe abortion rate peak among women aged 20-29 (WHO, 2007). These findings reveal that we are losing women from all the strata of the women population with grave consequences, married women dying and leaving their family behind. Until the second half of the 20th century, abortion law was illegal in most countries and was associated with high illegal and unsafe abortion rate and a correspondingly high maternal morbidity and mortality. World Health Organization (1998) has seen the liberalization of abortion laws in almost every country of the European Union, United State and Canada which helped in promotion of contraception use (Petersen et al., 2016; Rahman et al., 1997). 18 Over the years the reproductive health policy of Ghana on reduction of unsafe abortion only dwelt on promotion of family planning, contraception and post abortion care but not provision of safe abortion within the confines of the law as recommended by World Health Organization (Ghana Demography and Health Survey, 1998) Termination of pregnancy on medico-social grounds as indicated in the current law, is however, not readily available in institutions in the country. Thus, the law criminalizes abortion but gave quite liberal grounds on which legal abortion may be permitted in Ghana as unsafe abortion remains the major cause of maternal morbidity and mortality in the country (Lassey and Wilson, 1994; Aboagye 2000; Adam and Ntumy, 2005). In Ghana, safe abortion is permitted by law under the following situations/conditions: a. If the pregnancy is the result of rape, defilement, or incest; b. If there is substantial risk that the child, if born, may suffer from or later develop a serious physical abnormality or disease; c. If continuance of pregnancy will involve risk to life of the pregnant woman or injury to her physical or mental health [Criminal Code (Amendment) Law, PNDC Law 102, 1985]. The law, meanwhile, has a lot of unanswered questions; how does a victim of rape or incest access safe legal abortion? Is she supposed to go the hospital and request for abortion directly or does she need a police report? The gray area has always been whether the meaning of mental health covers a rape or incest victim? The Ghana Health Service, nonetheless, keeps a documented protocol for comprehensive abortion care in which the condition of the victim is determined in the context of mental health by her ability to engage in productive activities; have fulfilling relationships with other people; adapt to change; 19 cope with adversity; and manage daily life throughout the life cycle. If continuing a pregnancy prevents a woman from performing any of the above-mentioned functions, she is entitled to a legal abortion. Women seeking to terminate early pregnancy now have a choice between medical and surgical procedures. The two major drugs currently used in inducing abortion are mifepristone and methotrexate (Miller et al., 2005; Winikoff and Sheldon, 2012). Acceptability among consumers is particularly important for the success of medical abortion. The success depends on women’s willing to complete the treatment regimen at home and wait for the drugs to take action. Methods of medical procedures for safe abortion care are manual vacuum aspiration (MVA) and dilatation and curettage (DNC). Medically abortion is typically considered a failure when surgical evacuation for any reason including incomplete abortion (Harvey et al, 2001). Although some women may desire the involvement of their partners when obtaining abortion care, male partners are not routinely involved in the abortion care process. Studies on how male involvement relates to women abortion practices may help guide health institutions considering incorporation of male partner in the abortion care. Abortion care may be a significant area for partner inclusion because many seeking and obtaining abortion experience complex emotions and isolation which may desire the involvement of their partners (Lie et al., 2008). Women should be informed about their pregnancy options so that they can make an informed choice about their course of action. All women who require more support in deciding whether to continue the pregnancy or have an abortion should be identified and offered further opportunities to discuss them. 20 Globally, abortion related complication constitutes 13% of all maternal death. It is estimated that there are 28 procedures per 1,000 women in West Africa each year (Guttmacher Institute, 2010). In Ghana where the law restricts elective induced abortion, data to quantify the incidence of abortion are scarce. The existing data on incidence of abortion in Ghana come mainly from hospital records which are unavailable because records keeping is poor and induced abortion often are classified inaccurately. Until 1985 when the criminal code of ethics was amended Ghanaian law prohibited induced abortion except when her life is threatened by the pregnancy. The law now says that abortion is not an offense for midwives and doctors in a government hospital or registered private hospital. Since 1985, the law on abortion in Ghana headed towards liberalization, but there has been a delay in policy formulation and implementation. Hence, safe abortion services on medico-social grounds as permitted by the law are not readily available in government institutions (Marhe, 2006). According to a survey of woman there were at least 15 induced abortions for every 1,000 women of from reproductive ages 15 to 45yrs (Ghana Statistical Service, Ghana Health Service and Macro International, 2009). As at 2007 a more 3% of pregnant woman and only 6% of those seeking an abortion on were aware of the legal status of abortion (Ghana Statistical Service, Ghana Health Service and Macro International, 2009). 2.3 Attitudes of People towards Comprehensive Abortion Care In order to put the attitudes towards comprehensive abortion care into perspective, it is important to state an example from Colombia where the Ministry of Health of 21 Colombia establishment a pilot site for safe abortion and post abortion care service in the year 2000. The abortion care service was set-up at the mother-child health government clinics in Sihanoukville upon the acceptance of all women of reproductive age women from the generality of the population (Prada et al., 2013). Thus, the service attracted awareness of many people in the country. Discernibly, the aim of the establishment was to test how safe abortion and post abortion care service can be implemented pursuit to liberal abortion laws. Yet, in Columbia, many abortions continue to occur despite the fairly liberalized abortion environment in that country (Prada et al., 2013). This is just a microcosm of the situation on the large global scene. Even in the countries with well liberalized abortion environment, there is a remnant that uses unsafe abortion methods outside of the mainstream, legal abortion care let alone in countries with less liberalized abortion environment or in developing countries. This stands to reason that, there is an important component of the provision of safe abortion beside creation of service centres and even creation of awareness. This component is the attitudes of people towards abortion care. There is expansive literature on the attitudes or response of people to abortion which can be studied in two related perspectives – attitudes of abortion service providers and attitudes of abortion care seekers. 2.4 Attitudes of Abortion Care Providers towards Abortion A number of studies have shown that nurses and midwives disliked being involved in abortion services, and they commonly reported hesitance in providing these services (Harries et al., 2009; Klingberg-Allvin et al., 2007; Mokgethi et al., 2006; Warenius et al., 2006; Mayers et al., 2005; Botes, 2000). For instance, Klingberg-Allvin et al., (2007) found that among midwifery students in Vietnam the main reason for choosing midwifery as a 22 profession was to care for women in labour and delivery, and hardly any of the students wanted to work in the area of abortion services. Similar attitudes were reported among physicians (Harries et. al., 2009). Furthermore, health facility managers in South Africa expressed difficulties when recruiting, retaining and scheduling health care providers for induced abortion procedures (Mayers et al., 2005; Harries et al., 2009). Studies have also found that nurses’ resistance to providing abortion services was a powerful barrier against access to safe abortion services, with nurses’ and midwives’ strong opposition to abortion affecting rural women in particular (Cooper et al., 2005; Botes, 2000; Harrison et al., 2000). Additionally, nurses and midwives have judgmental attitudes towards abortion patients (Mokgethi et al., 2006; Gmeiner et al., 2000; Harrison et al., 2000). In general, nurses seem to withdraw from the patients and ignored their responsibilities as caregivers (Payne et al., 2013; Mngadi et al., 2008; Mokgethi et al., 2006; Botes, 2000). Furthermore, participants from both Sub-Saharan Africa and Southeast Asia alleged they could not provide holistic nursing care to women undergoing an induced abortion because they had negative feelings about the women’s decision (Klingberg-Allvin et al., 2007; Harrison et al., 2000). The nurses and midwives also acknowledged that these women received inadequate care due to the poor relationship between the nurse and the patient (Mngadi et al., 2008; Klingberg-Allvin et al., 2007). On the other hand, a study by Cooper et al., (2005) gave a positive view on nurses’ and midwives’ attitudes towards abortion. In this study, the nurses expressed a strong interest in medical abortions. In a recent study, health care providers, in general, preferred medical abortions, as this required minimal involvement on their part in the abortion process (Harries et al. 2012). Furthermore, early termination of pregnancy, that is, 23 menstrual regulation, was more accepted among health care providers than second- trimester abortions (Harries et al. 2012; Djohan et al., 1993). Other constraints identified in literature in relation to quality abortion care were lack of training, lack of staff accountability (Nguyen et al, 2007), poor supervision and regulation (Dovlo, 2004) as well as some individual level barriers and organization constraints (Say and Foy, 2005). The attitude of health care providers for comprehensive abortion care services is a matter of great importance which forms an integral part of the whole process of abortion care it affects the interaction with the women before, during and after the process of rendering the comprehensive abortion care services. Some providers exude the judgmental attitude through some gestures and comments being passed. Oppong-Darko et al. (2017) observed that some midwives in Ghana expressed abortion as being sinful and against their religion to assist in abortion care, albeit others felt it was good to save the lives of women. Supportive attitude, on the other hand, are also displayed by some providers as they try hard to understand the situation if the client, do not easily judge the client opting for abortion, and encourage and advise the client (IPAS, 2014; IPAS 2013). Some health care providers support the idea of training more nurses and midwives to carry out legal, safe and comprehensive abortion care services. Religious beliefs played a role for some providers in deciding not to be involved in abortion services, as most health care providers contemplate on the decision to carry out comprehensive abortion care services based on religious and moral grounds. Despite personal or religious beliefs inhibiting the involvement, some providers are able to put aside their personal values from emotional and religious opinions and described themselves 24 favour response to abortion, viewing abortion care as part of their professional conduct (Mustapha, 2013; Oppong-Darko, 2017). Health care providers sometimes also act as advocates. Some health service providers, sometimes, have views concerning who is to handle the abortion process based on experience. To this end, they request for ways and means to help amend some laws and policies that restricts women. Also they assist lawmakers in making of current laws and policies that affect abortion care (IPAS, 2013) 2.5 Attitude of Women in Reproductive Stage towards Comprehensive Abortion Care The beliefs and concerns of clients receiving comprehensive abortion care services also carry a considerable influence on the procedures and their implementation. A study carried out in Ethiopia demonstrated that, 57% of a sampled population of reproductive women supported the fact that comprehensive abortion care is a safe practice while 43% had a negative view on it (Addis et al, 2015). In a study conducted on rural Ghana, it was observed that unmarried women were more likely to have abortion compared to married women. It is, therefore, Women with low level of education of up to secondary education were more likely to have induced abortion compared to women without education. This implies that there is accepting attitudes are exhibited by unmarried women and moderately educated women towards abortion more than married women and uneducated women (Adjei, et al., 2015). In another study at the Northern Region of Ghana, it was found out that reproductive health services were available in the community but received low utilization because of perceived negative attitude of health workers, including breach of confidentiality and social norms (Kyilleh, et al., 2018). 25 The subject of attitude of abortion care seekers in Ghana cannot go without mentioning that in matters of sexual reproductive health, perceived barriers to accessibility by service users comprise embarrassment or shyness, fear of safety, fear of family finding out, and cost of service (Thatte, et al., 2016). Thatte et al. (2016) also maintained that these barriers to seeking of sexual reproductive health service equally affect abortion care as it does to HIV/STI testing and contraception. It is important to note that, fear of safety and cost of service in respect of abortion directly reflects on the attitude of people to abortion care seeking. Especially in the absence of quality information about professional abortion care, then where people are introduced to fear of safety, this could distort their perception on comprehensive abortion care, thereby, exposing them to other methods of abortion which are offered as simple to use outside the care of abortion care providers. The move away from abortion care providers or professional abortion care facilities is further exacerbated by the idea of high cost of acquiring that professional service. Although many women may receive the involvement of their partners when obtaining abortion care, male partners are not routinely involved in the abortion care process. Studies on how male involvement relate to women abortion practice may help guide health institutions considering incorporating of male partner in abortion care. Abortion care may be a significant area for inclusion because many seeking and obtaining abortion experience complex emotions and feelings of solution and may desire the involvement of their partners (Lie et al.,2008). Additionally, to potential benefit for women at individual level, the inclusion of male partners may improve women’s access to safe abortion care globally (World Health Organization, 2015). 26 There is a lot of literature on professional abortion service providers’ attitude to abortion. A larger part of this literature highlights the discriminating attitudes of these professionals. However, there is not as much research on the factors that affect women in their reproductive ages in seeking comprehensive abortion care. This study, therefore, provides an important opportunity not only to augment existing information about the factors that affect women in their reproductive ages in connection with abortion care, but also to provide empirical information about comprehensive abortion care in the New- Juaben municipality. 2.6 Accessibility of Family Planning Counseling involved in Comprehensive Abortion Care To provide a service environment that protects the dignity of women seeking post- abortion care, necessary measures must be taken. Measures such as provider-training and values clarification exercises need to properly constitute the care to ensure that women are treated with respect in a manner that consequently prevents stigmatization and negligence. One must also ensure equitable access to family planning services, regardless of the uterine evacuation method used. The contraceptives which can be used after surgical or medical uterine evacuation treatment are the same, and most can be initiated on the day of treatment of an incomplete abortion with a few exceptions. Some evidence suggests that post- abortion clients are either more or less likely to be offered family planning counseling and services depending on which method of uterine evacuation they receive (Nielsen et al., 2009). It is important that all providers and facilities treating women for incomplete abortion offer immediate and on-site family planning counseling and services as an integral 27 part of post-abortion care (Rasch et al., 2004), regardless of the uterine evacuation method. Post-abortion family planning uptake is high when quality services are offered before discharge (Ceylan, 2009).The structure and administration of services affect post-abortion clients' choice and access to family planning services. Service programs that are integrated under one administrative authority enhance access to family planning services post abortion, while vertical programs may result in fragmented service-delivery systems that are more difficult for clients to negotiate. Studies in Cambodia and Tanzania found that post-abortion care clients served in facilities with on-site family planning services were significantly more likely to accept a contraception method than clients served in facilities that refer for family planning services (McDougall et al., 2009; Wanjiru et al., 2007). Family planning guidance indicates that helping a woman to initiate an effective method of contraception is an essential task in providing post abortion care, and it should not be deferred to a follow-up visit (Hatcher et al., 2009). Other studies have shown that women are most likely to begin using a family planning method if they can immediately obtain it at the time of their post-abortion care treatment, instead of returning for another visit or being referred elsewhere to obtain it. In accordance with the policies and guidelines of the comprehensive abortion care process, the client is entitled to receiving family planning counseling services as part of pre-abortion care and post-abortion care. It helps to reduce issues of unintended pregnancies which go a long way to reduce the need for abortion (Jumbo, 2013). It was obtained from a study carried out in La General Hospital, Accra, that, 16 out of 21 clients received family planning counseling during the pre-abortion care. During this period, it was proven that clients received family planning counseling on whether to keep abortion 28 or not, the various family planning methods and their side effects, and types of contraception available (Kyere-Darkwah, 2016). Family planning empowers women and can save their lives. It can also help reduce poverty, slow population growth and ease pressures on the environment. Yet, family planning services often fail to reach those with the greatest need; the poor, those living in remote areas and urban slums and people with little education. Sometimes also, social costs and increased financial and time burdens on the health systems and providers limit the accessibility of clients to family planning counseling services (Salvelevia et al, 2003). Some studies demonstrated that, certain clients are offered family planning services based on the type of uterine evacuation method used. It was advised thereof that, health care providers must have immediate and on-site family planning counseling as an integral part of the post-abortion care (HIP, 2012). 2.7 Barriers in seeking Comprehensive Abortion Care There is increasing recognition by the international community of how unsafe abortion is contributing maternal mortality. Shah and Ahman (2010) observed that the total number of unsafe abortion globally has increased to 21.6 million in 2008. The narrative is not any better in contemporary times as unsafe abortion is still a challenge yet to be addressed convincingly. However, there are so many barriers to safe abortion delivery. In about 26% of the world’s population, abortion is prohibited and is done only to safe the woman’s life, that is, therapeutic abortion (Grimes et al., 2006). Even in those counties with more liberal abortion legal frameworks, there are other social economic and health systems barriers, such as stigma and discrimination, surrounding abortion that prevent adequate access to safe abortion and post-abortion care. 29 Studies have shown that, religion is the most important factor influencing the attitude and practices of health care providers toward induces abortions (Boötes 2000, Belton et al. 2009; Aniteye and Mayhew, 2013; Abeli and Gaber Mariam, 2011). Furthermore, abortion is perceived to be a sinful act according to various moral and religious views. These views, in different, ways prevent women from taking up comprehensive abortion care. However, some opinions explained the fact that abortion care is very salient reproductive right of women (Kyere-Darkwah, 2016; Helena, 2012; Addiset al, 2015). Some other factors that inhibit the provision of comprehensive abortion care include narrow interpretation of laws, technological limitations, and conscientious refusal of care and provider attitudes (IPAS, 2014). According to a study carried out in Zambia by Jumbo (2013), barriers affecting comprehensive abortion care services were grouped into two which are supply barriers and demand barriers. Supply barriers included availability – where are no facilities available to render comprehensive abortion care services; and affordability, being the major demand barrier, affected the patronage of the comprehensive abortion care, since women are most times disadvantaged in wealth and resources both in time and monetary aspects. Weak health systems also contribute to problems of provider shortages together with lack of access to consistent supply of medications and contraception cares (Amplify Change, 2018). 2.8 Conclusion This chapter has elucidated the state of knowledge on abortion. From the review, it emerged that the rate of abortion is not decreasing significantly. Rather, there is an increased trend in the number of women who resort to abortion. Nonetheless, there is a 30 major problem where many of the women who take to abortion are using unsafe methods of abortion and, unfortunately, increasing morbidity and mortality rate consequent to abortion. This necessitates the need for comprehensive abortion care. The study is conceptualized that knowledge, attitudes, and practices of people concerned with abortion are the main pillars by which the influence of comprehensive abortion care can be explained. The next chapter presents the methodology of the study. 31 CHAPTER THREE METHODOLOGY 3.1 Introduction This chapter presents the methodology which gives the systematic approach to this study. This section is organized to describe the research design, study population, sampling procedure and sample size, data collection instrument, data collection, validity and reliability, data analysis procedure, and ethical consideration. 3.2 Research Design The study adopts a survey design. This was meant to allow the health facilities in the geographical field of study to be surveyed and be conversant with the characteristics of health facilities and people that were going to be engaged in the study. The survey design paved the way for subjects with relevant characteristics to receive maximum attention. Mixed methods constituted the approach to data collection and analysis. Therefore, both quantitative and qualitative data were utilized. This offered opportunity for the study to quantify phenomena with rich insight and be able to make generalizations, as well as be able to obtain in-depth information to explain phenomena or give insight into issues under study. Quantitative and qualitative approaches have criticisms of their own. A major critique of the quantitative approach is that it falls within the positivist school of thought, thereby paying crucial attention to knowledge based on facts. As such, the quantitative method is strong in generating ideas for the purpose of generalization, but is weak in explaining human behavior (Saunders et al., 2009). The qualitative method lies within interpretative paradigm of explanations to reality and is strong in providing explanations 32 to human behaviour, beliefs, values and experiences. However, it is weak in finding cause for generalization (Patton, 2015). Combining the two methods is good for scientific research (Teye, 2012). The advantage of using mixed methods for this study is that it provides an opportunity for the strength of the two methods to be harnessed for data collection and analysis. By the mixed method, this study is able to obtain the insight and explanations to questions from comprehensive abortion care practitioners and users in a way that enriches the discussion on the factors underpinning comprehensive abortion care. Furthermore, to overcome other weaknesses arising from the use of both quantitative and qualitative methods, their strengths were built upon by means of triangulation as recommended by Tashakkori and Teddlie (2003). This approach was important because it helps in corroboration, complementarity, initiation and expansion (Onwuegbuzie et al., 2010). To meet the objectives of this study, knowledge concerning comprehensive abortion care in the New-Juaben Municipality will be interrogated. This incorporates data from adult women visiting health facilities that provide comprehensive abortion care in the municipality, as well as views from selected reproductive health professionals from those facilities. Attitudes and practices of these people towards comprehensive abortion care will also be interrogated, whence the underpinnings of comprehensive abortion care will be determined. 3.3 Data Collection Techniques and Tools Data collection was undertaken through administration of questionnaires and conducting of Key Informant/Expert Interviews (KIEI). The administration of questionnaires aimed to obtain quantitative data from adult women visiting the health 33 facilities at the instance of data collection. To achieve this, data enumerators were stationed at each of the health facilities of interest in this study over a period of five clear days during which they interacted with clients and administered the questionnaires to them. During the same period, a day was schedule for the interview of key informants who are health professionals in the line of providing comprehensive abortion care at the various health facilities. A structured questionnaire was, therefore, the instrument of data collection from the adult women at the health facilities. The questionnaire was designed to solicit background data of the participants or clients. The background data indicated the age, sex, religion, level of education, occupation, income levels, marital status, and number of children alive. In addition to that, there were three sections; the first was an assessment of awareness and knowledge about comprehensive abortion care. This section incorporated questions that concern pre-abortion, actual abortion, and post-abortion issues. It comprised family planning, counseling, post-abortion care follow-ups, and other relevant issues. The next section provided data relating to the attitudes and practices of people towards comprehensive abortion care. This section attempted to identify accepting attitudes of people or their aversive attitudes to comprehensive abortion care and the practices thereof. The last section solicited reasons for non-patronage of comprehensive abortion care, as well as recommendations for enhanced patronage of comprehensive abortion care by adult women. The assessments were drawn by means of approval ratings anchored on a Likert scale response format which ranged from 1 to 5 where “1” represents the lowest approval level of the respondent and “5” indicates the highest approval level of the respondent (See Appendix 1). 34 The KIEI was conducted by the assistance of an interview guide which was the other instrument of data collection in this study. The interview guide contained key questions pursuant to the objectives of the study which aimed to direct the questions to the objectives of the study. Particularly, the interview guide was to provide keys that help to further explore opinions of health professionals on their knowledge about comprehensive abortion care, including attitudes and practices of parties to the provision of comprehensive abortion care, and ideas on how to increase patronage of comprehensive abortion care. 3.4 Study Population The population of the study refers to the whole people or unit of interest in the study for the purpose of obtaining data (Patton, 2015). The population of this study was on two levels: first, any adult woman on visit to any of the health facilities providing comprehensive abortion care in the New-Juaben Municipality forms part of the population. Second, comprehensive abortion care professionals in the health facilities within the municipality were also members of the study population. For this reason, comprehensive abortion care practitioners and users of that care constituted the study population. This population comprised family planning service providers, abortion care providers, counseling providers, and all such practitioners whose work facilitates the provision of comprehensive abortion care. Comprehensive abortion care users is defined as women above age eighteen (18), which is the constitutionally accepted age by which one is an adult and no more than 49 years. 3.5 Sampling Procedure and Sample Size Sampling is crucial in research because resources such as time, money, distance, and workload would not permit experimenting with a whole population (Leech, 2004). In 35 determining the sample size for the study, the key issue was to obtain women in their reproductive years. According to the Ghana Statistical Service (2014) out of 95,040 women of all ages in the New-Juaben Municipality, 61,193 are in their reproductive years. The proportion of women within the reproductive age bracket is, therefore, 64.4% in the New- Juaben Municipality. Based on this information the target sample size in this study was calculated using Cochran’s (1963) sample size calculation formula: 𝑛 = 1.962𝑝𝑞 𝑒2 Where n is the sample size, e is the desired margin of error = 0.05, p is the estimated proportion of the population which has the attribute in question = 64.4% = 0.644, and q is derived from 1 – p. Effectively, the sample size is given by: 𝑛 = 1.962(0.644)(0.356) 0.052 = 142.2 The targeted sample size was, therefore, 142 women in their reproductive ages. This study employed a multi-stage sampling procedure in collecting data. Multi-stage sampling saves time and provides clearly defined steps through which participants in the study should be selected without bias. The first stage of the sampling procedure resulted in the specification of relevant health centres and key informants. At this stage, the purposive sampling method is used to identify health centres on the basis of their accreditation to provide comprehensive abortion care. Consequently, it emerged that, at least ten (10) health centres within the New-Juaben Municipality have the authority to provide comprehensive abortion care. The comprehensive abortion care professionals in these health facilities were then purposively 36 sampled as key informants. Meanwhile, not all of the health facilities have been actively involved in providing that care for different reasons. For example, the Oyoko Health Centre, albeit authorized to provide comprehensive abortion care, is not doing so because since the transfer of the health professional who was in charge, there has not been a replacement. The existing health staffs are also not trained to provide abortion care. The case is not different with the Akwadum Health Centre since there has been no replacement after the retirement of the staff in charge of provision of comprehensive abortion care. At the Jumapo Health Centre as well, the personnel have not been trained to provide comprehensive abortion care. The outcome for all such health facilities has been that the personnel are not empowered or emboldened to render comprehensive abortion care. On the basis of these considerations, five (5) health facilities that were actively rendering comprehensive abortion care were purposively retained as the health facilities from which users of comprehensive abortion care were recruited for the study. These health facilities include the Regional Hospital, Asokore Reproductive and Child Health Centre, Magazine Health Centre, Effiduase Reproductive and Child Health Centre, and Koforidua Poly Clinic. Again, by the purposive sampling method, the leaders of the health professionals at the five health centres known to be actively providing comprehensive abortion care also provided insight in aid of the study. Senior nurses and/or midwives who preside over comprehensive abortion care delivery in their health centres. Two of these health professionals were contacted in each of the five health facilities. Thus, 10 health professionals were engaged in in-depth interview. 37 The second stage of sampling resulted in the recruitment of adult women; potential or active users of comprehensive abortion care. Convenience sampling method was employed to establish contact with adult women and to seek their participation in the study across the five health facilities that were actively rendering comprehensive abortion care. This sampling method was chosen because of the imprecision involved in knowing the actual number of adult women who would be visit the health facilities. However, the convenience method provided the space and time within which any adult woman visiting the health facility that was ready and willing to participate in the study at the instance of data collection could be part of the study. The participation of the adult women in the study was by means of questionnaire administration to obtain the views of the women on stated issues of comprehensive abortion care. 3.6 Pre-testing Pre-test, according to Creswell and Clark (2006), is critical for quality assurance and inclusiveness in research. Pre-test provides the researcher a prior picture of what is to be anticipated in the actual period of data collection and offers the opportunity for corrections to be made to instruments and methods for data collection (Bryman, 2012). A pre-test was carried out prior to the data collection exercise using the instruments that were developed at the New Tafo Government Hospital in the Eastern Region of Ghana. This hospital is a health facility with clinical staff and midwives who offer family planning and abortion care. Twenty (20) adult women and four (4) health professionals participated in the pretesting exercise. Generally, the instruments proved to be material to achieve the objectives of the study and participants understood the questions that were posed without 38 ambiguity. A few corrections which surfaced in the pretesting exercise were used to further improve upon the data collection instruments. 3.7 Data Handling Data collected from respondents was handled with confidentiality. Privacy was ensured during the period of interview and filling of questionnaire. Assistance was given to respondents who were illiterates by interpreting the questions to them, and recording their responses. There was periodic compilation of completed data. 3.8 Data Analysis Procedure Findings from this study were synthesized from both quantitative and qualitative methods of data analysis. Data analysis helps to answer research questions and to establish patterns of knowledge out of available data (Creswell, 2013). The qualitative data was analyzed by, first and foremost, transcribing, and afterward, organizing or structuring them thematically (Patton, 2015). Data analysis through the qualitative method provided understanding of what informs respondents’ behaviour, opinion, knowledge, and perceptions (Castro et al., 2010). The thematic analysis helped to tease out themes from the qualitative data consequent to rigorous reading of textual recordings. Similar views were grouped under themes to which they must adhere in order to form patterns of thought. Verbatim quotes were used to emphasize significant points. In line with the ethical consideration of anonymity, respondents whose views were quoted were kept anonymous to protect their real identity. The quantitative data was analyzed using STATA version 14. First, however, data from the questionnaires were entered in the Statistical Package for Social Sciences (SPSS) 39 to speed up the process of checking for errors and cleaning of data. The background data of the respondents was analyzed using descriptive statistics, particularly, frequencies and percentages. Binary Logistic Regression that treated contraception use (and by extension comprehensive abortion care) as a dependent variable and independent variables emerging out of demographic data, elements of knowledge on comprehensive abortion care as well as attitudes and practices on comprehensive abortion care formed the procedure of determining the underpinnings of comprehensive abortion care. Incidentally, Chi Square test was used to determine the dependence of comprehensive abortion care on other demographic factors. 3.9 Ethical Considerations The success of every research depends on the consideration of key ethical issues (Burnham, 2008). This research was conducted bearing in mind high level of integrity. This was demonstrated by, first, submitting an introductory letter seeking permission of the management of the health facilities involved to undertake a study of this nature. The acceptance of the permission by management warranted that the study could engage health professionals at convenient time during the period of the study, and so it happened. The object of the study was communicated to the health professionals, notably, involved in the delivery of comprehensive abortion care. Second, the study deployed informed consent forms for the data collection exercise to take place smoothly. Before interviews were conducted and questionnaires were completed by respondents, the purpose of the research was discussed and explained to participants. At all stages, permission was sought from the participants in the study before any exercise, either data collection or clarification of issues, was undertaken. Where 40 respondents were unable to read and/or write, research assistants provided assistance and explained issues to the appreciation of such respondents. Finally, confidentiality, anonymity and privacy were assured the participants of the study. The object here was to prevent disclosure of data or identity of participants to any other party. The assurance to this effect was given to the participants in demonstrating that the study is not to expose any individual to harm. 41 CHAPTER FOUR DATA ANALYSIS 4.1 Introduction This chapter presents the analyses of data obtained from the field work undertaken in the study. The results have been discussed in light of the objectives of the study, specifically, to come to terms with the levels of knowledge about comprehensive abortion care, attitudes and practices towards comprehensive abortion care, and to determine that underpinnings of comprehensive abortion care. Subsequently, strategies for enhancing reproductive health of adult women is gleaned out of the data obtained in the study. A total of 139 respondents participated in the study. This comprised 129 clients to the selected health facilities and 10 health professionals of health facilities that provide comprehensive abortion care in the New-Juaben Municipality. Effectively, the Regional Hospital, Asokore Reproductive and Child Health Centre, Magazine Health Centre, Effiduase Reproductive and Child Health Centre, and Koforidua Poly Clinic were the areas where the field work took place. The analysis here made use of both quantitative from the clients and visitors and qualitative data in the form of interviews granted by the health professionals. 4.2 Background Information about Clients The background data obtained from the clients include their distribution by age, gender, level of education, occupation, average monthly income, marital status, religious affiliation, attempts at birth, number of children, contraception use, and patronage of family planning service. The statistics from these points came, notably, from the clients of the health facilities who participated in the study. 42 4.2.1 Age The ages of the clients from whom quantitative data was gathered ranged from 18 years to 49 years. The largest percentage (34.9%) of the clients represented those in 18-24 age-group. The percentage generally reduced in older age groupings indicating that a lot more of the participants in the study were younger. In the age group 30-34, the percentage of the participants was 24.0%. The percentage dropped sharply to 9.3% for those in the 35- 39 age-group, and further to 4.7% and 3.9% in the 40-44 and 45-49 age-groups respectively. This implies that, it is not only people in their most sexually reproductive years that have participated in this study, but also people in their sexually active years. Their views were material to the discussions on comprehensive abortion care. 4.2.2 Gender The majority (87.6%) of the clients were females with only 12.4% of males participating in the study. Rightly so, the study is predisposed to the knowledge, attitude, behavior and practices of adult women towards comprehensive abortion care. The large participation of females enhances the representation of the views women on the pertinent issues in the study. 4.2.3 Level of Education A few clients, representing 7.8 percent, had no formal education. Nonetheless, 24.4% of the clients had Primary/Junior High School or Secondary/Senior High School level of education. A slightly higher percentage (27.1%) of the clients had tertiary level of education. Meanwhile, 12.4 percent of the clients also had technical education. Effectively, level of education was, generally, high among the clients. 43 4.2.4 Occupation About two out of every five (41.1%) of the clients were traders. About half of that proportion (20.2%) represented the clients who were unemployed. Although there were civil/public servants (13.2%), artisans (12.4%), students (8.5%) and a very few others such as nurses, farmers and decorators, these are not comparable to the proportion that was unemployed. This means that considerable proportion of the clients had limited sources of economic livelihood apart from trading. 4.2.5 Average Monthly Income A little less than half (49.1%) of the clients earned an average income of 100 to 500 Ghana Cedis per month. As income levels increased beyond 500 Ghana Cedis, the percentage of the clients became smaller. For example, 21.1 percent of the clients earned from 501 to 1,000 Ghana Cedis per month. Beyond 1,000 through 1,500 Ghana Cedis per month, the percentage of clients further reduced to 14.0 percent. At 2,000 Ghana Cedis per month, the percentage of the clients reduced to 1.8. About one out of every ten (9.6%) clients, however, earned less than 100 Ghana Cedis per month. It means, therefore, that 100 to 500 Ghana Cedis per month is the most probable range of income earned by the clients. 4.2.6 Marital Status A little more than half (51.2%) of the clients represented those who were single. The clients who were married made up 38 percent of the participants in this study. For both of these categories, abortion and family planning services will be an important issue. Beside this, 6.1 percent of the clients were cohabiting with sexual partner (cohabitation). There existed 3.1 percent made up of clients who were separated with their sexual partners, 44 and 1.6 percent representing clients who had divorced their partners. Obviously, issues relating unwanted pregnancy will be important for most of these clients. 4.2.7 Religious Affiliation The majority (78.4%) of the clients represented Christians, whiles about one out of every five (21.6%) was in the Islamic faith. It is very likely that the tenets of these religions will inform the views of the clients on abortion and family planning questions. For example, both religions principally frown vehemently on abortion and this might play an important role in the disposition of clients to abortion-related issues. Table 4.1 presents the composite results of the background data obtained from the field work in the various health facilities contacted. Other information relating to the clients’ experience with birth and contraception use is presented hereafter. 45 Table 4.1: Background Data of the Clients Variables Frequency Percent Total 129 100 Age Groups 18-24 45 34.9 25-29 30 23.3 30-34 31 24.0 35-39 12 9.3 40-44 6 4.7 45-49 5 3.9 Gender Male 16 12.4 Female 113 87.6 Level of education No formal education 10 7.8 Primary/JHS/JSS/ Secondary/SHS/SSS 35 27.2 Commercial/Vocational/Technical 16 12.4 Tertiary 34 26.4 Occupation Unemployed 26 20.2 Artisan 16 12.4 Trader 53 41.1 Civil/Public Servant 17 13.2 Student 11 8.5 Decorator 2 1.6 Farmer 2 1.6 Nurse 2 1.6 Average monthly income (GHC) Less than 100 11 9.6 100 to 500 56 49.1 501 to 1,000 24 21.1 1,001 to 1,500 16 14 1,501 to 2,000 5 4.4 More than 2,000 2 1.8 Marital status Single 66 51.2 Married 49 38.0 Cohabitation 8 6.2 Separated 4 3.1 Divorced 2 1.6 Religious affiliation Christian 98 78.4 Islam 27 21.6 Source: Field Work, 2019 46 4.3 Description of Health Professionals Interviewed The other group of respondents in this study were the 10 health professionals, two from each of the five health facilities that were the focal point of this study. To put the interviews into proper perspective, a description of the health professionals is presented. In each of the health facilities, the two health professionals engaged were in the capacity of senior nurse and/or midwife. Overall, they have served in the professional health sector for no less than 19 years. The midwife engaged in interview at the Koforidua Regional Hospital, for example, had served in as a midwife in the health sector for 25 years. It is from this perspective that their insights have been used in the study. The qualitative data was used to corroborate the quantitative data in order to produce synthesized information that gives account of relevant angles on the issues raised in the study. Exemplary quotes that give insight into issues under discussion were presented verbatim. In order to preserve confidentiality and privacy, pseudonyms have been used to identify the respondents whose responses present the rich context in which various emerging themes can be explained. The pseudonyms are given as follows: Koforidua Regional Hospital Senior midwife Respondent 1 Nurse Respondent 2 Koforidua Polyclinic Midwife Respondent 3 Nurse Respondent 4 Effiduase Reproductive and Child Health Centre Midwife Respondent 5 Senior nurse Respondent 6 47 Asokore Reproductive and Child Health Centre Senior nurse Respondent 7 Midwife Respondent 8 Magazine Health Centre Midwife Respondent 9 Nurse Respondent 10 4.4 Clients Experience with Child Birth and Contraception use This part of the analysis is on information about birth experience and contraception use. The information throws light on the position of the participants in the study regarding child birth, and their readiness or preparedness for children. It also attempts to provide results on predisposition of the participants to contraception use. At the first instance, the results show that a little less than seven out of every ten (68.2%) clients have ever given birth. Following this, it emerged that the largest percentage (37.1%) of the clients who had ever given birth had one live child. About a quarter (25.8%) of the clients who had ever given birth had two children alive. With further increments in the number of children, the percentage of clients decreased. This gives the indication that the participants were wary or unable to host increasing numbers of children. Figure 4.1 explains the results. 48 Figure 4.1: Child Birth and Number of Children associated with the Clients Source: Field Work, 2019 On the part of the clients who had never given birth, it appears that they have a reduced clamor over haste to give birth to their first child. In fact, the largest proportion constituting about a quarter (25.8%) of them could not tell the period in which they would like to give birth to their first child. Although this reflects a certain level of indecision on exactly when they want to give birth, it increases their likelihood of sustaining an unplanned pregnancy. However, the data shows an increasing tendency of the clients to delay their first child birth. As 24.2 percent of the clients wanted to give birth to their first child in no less a time than three years, a lower percentage (21.2%) of the clients wanted to give birth to their first child in two years’ time. There is further a drop to 19.7 percent of the clients who wanted to give birth to their first child as close as a year’s time. From these inclinations of the clients, there is a measure of restraint or caution at play in their bid to give birth to their first child. Table 4.2 shows the results. Have you ever given birth? One Two Three Four Five More than five Number of children alive Yes 68.2% 37.5% 26.1% 18.2% 9.1% 4.5% 4.5% No 31.8% 68.2% 37.5% 26.1% 18.2% 9.1% 4.5% 4.5% 31.8% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% Child Birth and Number of Children associated with the Respondents 49 Table 4.2: Time Projection for First Child Birth Variables Frequency Percent Total 66 100.0 In a year's time 13 19.7 In two years’ time 14 21.2 In three years’ time 16 24.2 More than three years’ time 6 9.1 Don't know 17 25.8 Source: Field Work, 2019 Another instance in the analysis revealed how the clients have patronized contraception methods or family planning services. The results show that, 66.7% of the clients in this study have ever used a contraception method. Further, the last time these clients, amounting to 86 people, used a contraception method was any other period even as far as beyond two years. The largest percentage (48.8%) of these clients used a contraception method most recently in less than six months ago. The clients whose last time of using a contraception method ranged from six-months to one-year made up 14 percent, whiles 12.8 percent used contraception the last time in between one-year and two- years. It is interested to note, however, that the latest use of contraception method by as much as 24.4% of the clients occurred in more than two-years ago. It is observable that, depending on the type of contraception method used, the effectiveness of the method may decline with passage of time when a review is not carried out. Therefore, a long last-time- use of contraceptive may predispose the clients to unplanned pregnancy subject to the type of contraception method applied over the period. The results obtained are as shown in Table 4.3. 50 Table 4.3: Period of Last Use of Contraception Variables Frequency Percent Total 86 100.0 Less than 6 months ago 42 48.8 6 months to 1 year ago 12 14.0 Between 1 year to 2 years ago 11 12.8 More than 2 years ago 21 24.4 Source: Field Work, 2019 About three out of every five (63%) clients have sought family planning and counseling service in health facility at a point in time. This is illustrated in Figure 4.2. Figure 4.2: Family Planning and Counseling Seeking in Health Facility Source: Field Work, 2019 4.5 Knowledge, Attitudes and Practices on Comprehensive Abortion Care This section zooms into knowledge/awareness, attitudes, and practices (KAP) of the respondents on family planning and comprehensive abortion service. To begin, the respondents’ knowledge on contraception was examined. The clients were posed with the question: “What types of contraception methods do you know?” Yes 63% No 37% Have you ever sought family planning and counseling with any health facility? 51 The responses to the question indicated that, majority (above 60%) of the clients have knowledge about contraception methods namely: pill, condom, and injectables. Specifically, more of the clients (76.7%) knew about condom than pill and inj