Abstract
Background:
Despite liberal abortion laws and wide availability of contraceptives in Ghana, declining Post Abortion Contraception remains a public health challenge due to early unplanned pregnancies and recurrent abortions. The development of this model was therefore to address challenges of low contraception following induced abortion in health facilities within the capital city of Ghana.
Method:
The development of this model was an outcome of a nested study title: ‘decision making for induced abortion in Accra metropolis, Ghana’ in 2014. This model was piloted for four years using Marie Stopes, Ipas and Ghana Health Service trained abortion providers with family planning skills in one hundred purposively selected health facilities comprising 90 private and 10 Non-Governmental Organization mandated by law to provide safe abortion care services in the capital city of Ghana. The model mainly focused on contraceptive products, pricing, placement, promotion and people.
Results:
There was an increase (90% average) in Post Abortion Contraception across the selected facilities following the intervention using the model.
Conclusion:
The study concludes that an integration of products, pricing, placement, promotion and people with options counselling prior to an induced abortion are key considerations for an improved post abortion contraception uptake in developing countries.
Author Contributions
Academic Editor: Alaa Ali Mohamed Elzohry, Lecturer of Anesthesiology & Pain Management South Egypt Cancer Institute Assiut University
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2018 Fred Yao Gbagbo
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests
The authors have declared that no competing interests exist.
Citation:
Background
Global evidence on abortion and contraception have shown that clients treated for abortion related complications leave facilities without adequate access to contraceptive services. Consequently, some of these clients become pregnant early than expected leading to unplanned pregnancy or a repeat abortion. In resent time, Post Abortion Contraception (PAC) for women who have had induced or spontaneous abortion requires various consideration such as medical eligibility, preferences, affordability, availability accessibility and counselling on when to commence a method 1. Because fertility is likely to return within 14days after pregnancy termination, early initiation of contraception following an abortion reduces the risk of recurrent abortions due to an early unintended pregnancy 2.
In Ghana, despite less restrictive laws on induced abortion, unsafe induced abortion account for about 12% of maternal deaths in the country 3. National estimates show that about one in five Ghanaian women aged 15 to 45 years have ever had an abortion, with significant differences by socioeconomic characteristics 4.
A study on decision making for induced abortion in Accra metropolis, Ghana reveled that women of various profiles make different decisions with justifications for abortion based on their peculiar situations during pregnancy. In taking these decision, contraception following an induced abortion is not an immediate concern rather issues about cost, safety and privacy influenced clients’ choice of place and method for abortion. In making abortion decisions, some women collaborated with other people who influenced aspects or the entire decision. Pressure from sexual partners, circumstances surrounding on set of pregnancy and reproductive intentions of women were major push factors for abortion. Although first time pregnancies were mostly aborted, gestational ages, cost of abortion and partner consent did not prevent women from aborting 5.
Materials and Methods
The development of this model was an outcome of a nested study title: ‘decision making for induced abortion in Accra metropolis, Ghana’ in 2014. This was done to solve an identified services delivery challenge of repeat induced abortions due to low contraceptive uptake following induced abortions in Ghana. Prior to developing the model, the study piloted an intervention for Post Abortion Contraception (PAC) uptake on an initial assumption that options counselling prior to an induced abortion that focuses on products, pricing, placement, promotion and people positively influence uptake of PAC services within health facilities in Ghana.
The interventional study followed the principles set out in the WHO handbook for family planning, the Ghana Family Planning standards and protocols. This model was tested for four years using Marie Stopes, Ipas and Ghana Health Service trained abortion providers with family planning skills in one hundred purposively selected health facilities comprising 90 private and 10 Non-Governmental Organization mandated by law to provide safe abortion care services in the capital city of Ghana. The model mainly focused on contraceptive products, pricing, placement, promotion and people. The implementation of the model followed a two weeks training, refresher training and competency certification of services providers in both pregnancy termination (i.e. surgical and medication methods) and family planning services. This is to encourage immediate post abortion contraception following options counselling on methods, client eligibility and reproductive intentions. Providers were then encouraged to capture details of clients served in the monthly client log books over the four year period and collected for analysis.
The study was given ethical approval by the Ghana Health Service Ethics Review Committee. A written consent for data collection and publication was also sought from the Accra Metro Directorate of Health Services, participants and the facilities where the PAC intervention was piloted. To ensure optimal patient privacy and confidentiality, the background characteristics of patients excluded any contact information that could disclose the specific identity of patients.
How the Model Works
The model is a client centered interventional model built to drive voluntary informed consent to contraception that will prevent early unintended pregnancies and multiple induced abortions. The model is driven by two variables a) Post Abortion Contraception (PAC) drivers and b)determinants of PAC uptake in health facilities. The PAC drivers hinges on individual decisions on PAC and commences with Contraception Options Counselling before, during or after an induced abortion. During these period a client is counselled in relation to her reproductive intentions, medical eligibility and preferences for PAC.
Following a successful counselling then leads to determinants of PAC uptake in health facilities which goes beyond successful counselling in a health facility to involve determinates of PAC (i.e products, pricing, placement, promotions and people) as key factors that have to be well balanced to ensure access to the desired PAC services of choice (Figure 1).
Figure 1: Post Abortion Contraception uptake Model [F.Y. Gbagbo (2017)]![Y. Gbagbo (2017)]](/article/757/images/image1.jpg)
Results
This model during the pilot phase was found useful as there was a significant increase in PAC services and decrease in repeat induced abortions in the participating health facilities.Figure 2 shows results of PAC during the pilot phase of the model. There was an increase (90% average) in PAC across the selected facilities following the intervention using the model.(figure 2)
Figure 2.Results of Post Abortion Contraception uptake using Gbagbo’s Model.
Discussion of Model
Public health estimation from the World Health Organization (WHO) indicates that, globally, close to 20 million unsafe abortions occur each year, with about 95% of these abortions being done in developing countries. This accounts for almost 80,000 abortion related complications annually leading to about 13% of all maternal deaths in the world, 6. Although these deaths are preventable by contraceptive use, about 123 million people, particularly in developing countries, are not using contraceptives, for various reasons 7.
Although many countries have incorporated Post abortion counseling into post abortion care services to decrease unwanted pregnancies and induced abortions 8 the low uptake of contraception following an induced abortion and its associated consequences remains a public health challenge in Ghana and other developing countries hence the development of an innovative client provide centered model to address the challenge.
Post Abortion Contraception uptake Model (The Gbagbo’s Model) was developed as an interventional model to enhance uptake of contraception following an induced abortion (medical or surgical) in Ghana. The model was based on three identified drivers of post abortion contraception (i.e. Reproductive intentions, Medical Eligibility and contraceptive Preferences of clients). These variables were predominantly driven by clients because they were specific to clients’ needs at the time of Post Abortion Contraception decision making. Because abortion services in Ghana are only legally permissible in registered health facilities 9, the study looked at key determinants of Post Abortion Contraception uptake in health facilities and found that issues relating to products, pricing, placement, promotion and people/service providers contributed significantly to arriving at a decision for Post Abortion Contraception. With regards to product issues, it was observed that most young people have misconceptions about family planning hence there was a need to rebranded post abortion ‘family planning’ as post abortion ‘contraception’ to demystify young people’s perceptions of family planning to increase their acceptance to contraception. Following this was clients’ concerns about cost of abortion services of which an additional cost of contraception was deemed high.
To address this challenge, the cost of Post Abortion Contraception following an abortion was integrated into the costs of induced abortion services to ensure a one stop shop service, thus it becomes a package hence a client would not have to pay extra for contraception after paying for an abortion. The issue of client follow up visits and missing up on clients review appointments after 14days were also considered hence the concept of placement evolved there by making voluntary and immediate Post Abortion Contraception services a key quality indicator of percentage of abortions provided in all health facilities. To avoid the risk of forcing or cohesion of clients to meet this quality indicator lead to the concept of promotion where options counseling on Post Abortion Contraception and informed consenting before the abortion services is encouraged. A comprehensive abortion care service requires skilled, knowledgeable and competent service providers hence the model considered people who will provide the required Post Abortion Contraception services as required. To achieve this, the model considered capacity building and technical update on Post Abortion Contraception to all service providers as very important activity to enable quality and safe services that meets clients’ satisfaction.
The model identifies itself with the statement: “If the woman we treat for…abortion…is there because she could not get contraception, we have failed her. If she leaves without family planning we have failed her twice.” [1994, Post abortion Care (PAC) Consortium, International Conference on Population and Development (ICPD), Cairo]. In relation to this, the study observed that performance management processes and rewards that emphasize the importance of PAC in facilities encourage actions that improve uptake of PAC. Additionally, rebranding PAC, integrating PAC as a package for abortion care, making PAC a major quality indicator of safe abortion and capacity building of service providers on contraceptive updates is key for PAC uptake.
Conclusion
The study concludes that an integration of products, pricing, placement, promotion and people with options counselling prior to an induced abortion are key considerations for an improved post abortion contraception uptake in Ghana. The study recommends the use of the Post Abortion Contraception uptake Model as an integral package of comprehensive safe abortion care in all health facilities providing abortion services in developing countries.
Acknowledgments
The author is grateful to all the participants in this study that lead to developing this model.
Ethics Approval and Consent to Participate
Ethical approval for the study was sought from the Ghana Health Service Ethical Review Committee. A written consent for data collection and publication was also sought from the Accra Metro Directorate of Health Services and participants.
Consent to Publish
To ensure optimal client privacy and confidentiality, the background characteristics of respondents excluded any contact information that could disclose their specific identity hence written consent for publication was “Not applicable” in this case. However all clients involved in the study were verbally informed that their records will be used for studies of which they verbally consented. A written consent for publication was also sought from the various facilities involved in the study.
Availability of Data and Material
The data sets used and/or analyzed during the current study are available on reasonable request.
Funding
Not applicable. (This study was funded by the author).
Questionnaire
Data Processing Particulars
Place where respondent had the last abortion_____________________________
Code for respondent:________________________________________________
Code for Interviewer:_ ______________________________________________
Medium of communication during the interview__________________________
Interview Date:_____________________________________________________
A). Background Characteristics of Respondents After Abortion
I would like to ask you a few questions regarding your background. Please feel free to answer the following:
| No. | QUESTIONS AND FILTERS | CODING CATEGORIES | SKIP TO | |
|---|---|---|---|---|
| 1 | How old are you? (Record in completed years) | Age in years ( ) | ||
| 2 | To which ethnic group do you belong? | |||
| 3 | In which town do you usually live? (Specify exact location) | |||
| 4 | What is your religious affiliation? | Christian…………………………..1 | ||
| Islam………………………………2 | ||||
| Atheist…………………………….4 | ||||
| Other specify………………………5 | ||||
| 5 | What work do you currently do? | Not working----------------------------1 | ||
| Self employed--------------------------2 | ||||
| Student/Apprentice--------------------3 | ||||
| House wife-----------------------------4 | ||||
| Other specify---------------------------5 | ||||
| 6 | What is the highest level of school you have completed? | None................................................1 | ||
| Primary............................................2 | ||||
| JSS/MSLC.......................................3 | ||||
| Secondary…………........................4 | ||||
| Post Secondary................................5 | ||||
| Tertiary………………....................6 | ||||
| 7 | What is your marital status? | Never Married..................................1 | ||
| Married……….................................2 | ||||
| Divorced..........................................3 | ||||
| Separated.........................................4 | ||||
| Living in union.................................5 | ||||
| Widowed..........................................6 | ||||
| 8 | How many children do you have? How many are sons and how many are daughters?(Record ‘00’ if none). | Sons.................. | ||
| Daughters............. | ||||
| Total................. | ||||
B). Background Characteristics of Respondents at Last Abortion
I would like to ask you a few questions regarding your background at the time of having your immediate past abortion. Please feel free to answer the following:
| No. | QUESTIONS AND FILTERS | CODING CATEGORIES | SKIP TO |
|---|---|---|---|
| 9 | How old were you when you aborted the immediate past pregnancy?(Record in completed years) | Age in years ( ) | |
| 10 | Who was responsible for the pregnancy you last aborted? | ||
| 11 | Where were you living at the time you aborted the immediate past pregnancy? (Specify exact location) | ||
| 12 | Where were you working (employed) at the time you aborted the immediate past pregnancy? | Not working----------------------------1 | |
| Self employed--------------------------2 | |||
| Student/Apprentice--------------------3 | |||
| House wife-----------------------------4 | |||
| Other specify---------------------------5 | |||
| 13 | What was the highest level of school you have completed at the time you aborted the immediate past pregnancy? | None................................................1 | |
| Primary............................................2 | |||
| JSS/MSLC.......................................3 | |||
| Secondary…………........................4 | |||
| Post Secondary................................5 | |||
| Tertiary………………....................6 | |||
| 14 | What was your marital status at the time you aborted the immediate past pregnancy? | Married............................................1 | |
| Living in union.................................2 | |||
| Divorced..........................................3 | |||
| Separated.........................................4 | |||
| Widowed.........................................5 | |||
| Single...............................................6 | |||
| 15 | How many children did you have at the time you aborted the immediate past pregnancy? How many are sons and how many are daughters?(Record ‘00’ if none). | Sons.................. | |
| Daughters............. | |||
| Total................. | |||
References
- 2.Stoddard A, D L Eisenberg. (2011) Controversies in family planning: timing of ovulation after abortion and the conundrum of post abortion intrauterine device insertion. Contraception. 84-119.
- 3. (2009) Ghana Statistical Service, Ghana Health Service. ICF International. Ghana Demographic and Health Survey 2014.Rockville,Maryland USA:GSS,GHS,andICFInternational..
- 4. (2015) Ghana Statistical Service, Ghana Health Service. ICF International. Ghana Demographic and Health Survey 2014.Rockville,Maryland,USA:GSS,GHS,and ICF International .
- 5.F Y Gbagbo. (2014) Decision-making for induced abortion in Accra metropolis. PhD thesis,UniversityofCapeCoast , Ghana
- 6. (1998) World Health Organization/Division of Reproductive Health : Unsafe abortion: global and regional estimates of incidence and mortality due to unsafe abortion, with a listing of available country data (WHO/RHT/MSM/97.16). Geneva: World Health Organization.
- 7. (2004) UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction : Family planning. Research on Reproductive Health at WHO-pushing the frontiers of knowledge. Biennial Report 2002–2003 Geneva, WHO
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