Women of reproductive age seeking unsafe abortion clandestinely are known to be driven by forces of stigmatization, unwanted pregnancy, ignorance of the abortion law, low and failure in contraceptive use [4,8,9,17-19]. However, this study investigated other factors that serve as a medium for these driving forces to thrive. The outcomes of interest in the study were induced abortion alone and all cases of reported abortion (combination of induced and spontaneous abortion). In addition, respondents of the study were women aged 15–49 years but some of them were 13 years of age when they had their pregnancy outcomes in the past.
In this study we found that, women who were not married were more likely to have all cases of abortions (induced or spontaneous) as compared to those who were married. Findings from the 2008 Ghana Demographic and Health Survey indicates that contraceptive use among married women has almost doubled over the past 20 years [20]. This reason may account for the low odds of married women having unsafe abortion. Also, studies carried out by Ahiadeke et al. [10] and Mote et al. [9] in different districts of Ghana and others from sub-Saharan Africa had results that were in line with this finding [9,10,13,21,22]. Stigmatization associated with out-of-wedlock pregnancies in Ghana [23] and perceptions of it being dishonourable in Burkina Faso [13] could be contributing factors to the practice of unsafe abortions. Some unmarried women wanting to postpone childbearing until marriage, others not having adequate financial support to cater for their unborn child and problems associated with informal relationships have been advanced as possible reasons for unsafe induced abortions [17,23,24].
In addition, the findings of this study suggest that the higher the educational level of women, the more likely they are to have abortion (induced or spontaneous). This pattern was observed in the findings of the Mote, Ahiadeke et al. studies and Ghana Maternal Health Survey (GMHS) [3,8-10]. According to Sundaram et al. study (2012), the possible explanation could be that better educated women are more likely to have greater access to information through media and may also have better knowledge of the abortion law [8]. However, this result is in contrast with the finding of a study which was conducted in Ethiopia in which women with higher education were not likely to have induced abortion [25]. The women aged 20–29 years were also found to have lower odds of having abortion as compared to adolescents (13–19 years). Several other studies have reported findings similar to this [13,21,22,26]. The probable explanation for this finding is that women aged 13–19 years are mostly under strict parental (or guardian) control and therefore resort to unsafe abortions for fear of being disowned by their parents [13,23]. A study conducted in Burkina Faso reported that women under parental control were seven-fold as likely to have induced abortion when compared with those not under such control [13]. Moreover, a significant proportion of adolescent may have less access to financial resources to pay for safe induced abortion. Adolescents may also be less likely to know where to get abortion and may be more likely influenced by stigma as compared to older women [23]. According to the Ghana Maternal Health Survey, lack of money to cater for babies is one of the major reasons cited by women who had induced abortion [3]. This suggests that adolescents may use induced abortions as a family planning option for unplanned pregnancy; an indicator of unmet need for contraception.
Wealthiest women in this study were found to have higher likelihood of having all cases of abortions (induced or spontaneous) as compared to the most poor women. This is in line with the fact that odds of having induced abortion in Ghana is 67%-80% higher among women in the top two wealth quintiles than among the those of the lowest quintile [23]. The findings from other studies [27-30] have also shown that poor women suffer more from unsafe induced abortion than wealthiest women. Wealthiest women are financially empowered and can afford to have safe induced abortions in better health facilities as compared to poor women [27,31]. Perhaps these findings explain the increased likelihood of the wealthiest women to have induced abortion.
The marital status of women was found to be significantly associated with induced abortion in this study. This finding is consistent with the influence of marital status on all reported cases of abortion (induced or spontaneous) and findings of several other studies [9,10,13,21,22]. In addition, it was observed in the current study that the higher the educational level of the women, the more likely for them to have induced abortion. This finding is similar to those who had all reported cases of abortions (induced or spontaneous) and findings of other studies [3,8-10] but not statistically significant. Also, the wealthiest women were found in this current study to be more likely to have induced abortion than the most poor women. This finding is in line with the finding of the association of household wealth with all reported cases of abortions (induced or spontaneous) and a study conducted in Ghana [8]. However, the relationship between household wealth and induced abortions was not statistically significant.
According to the 2008 Ghana Demographic and Health Survey (GDHS), Total Fertility Rate (TFR) in rural Ghana declined from 5.6 births per woman to 4.9 births per woman within a period of 5 years. However the change in contraceptive use in rural areas over that same period was not captured by the report(13). That information gap leads to possible inference of induced abortion being a major contributor to the declining TFR in rural Ghana. Concerted efforts should therefore be made to reduce unsafe abortions. Reduction in unsafe abortions could be done by: (a) making contraceptives affordable and easily accessible (b)improving access to induced abortions through intensified educational programs on the current abortion law and its provisions, and (c) improving the rights of persons requiring abortion services in Ghana.
This study however has few limitations. The status of birth outcomes were self-reported and as such it is possible that respondents reported a lot more induced abortions as spontaneous.. The respondents may also find it difficult to accurately recall some of the past pregnancy outcomes. The study could not also ascertain from respondents whether the induced abortions done were perceived to be safe or not. The study also has a limitation of being cross-sectional, as causal relationships could not be established between the identified factors and abortions.