DAKAR, 23 July 2010 (IRIN) - Unsafe abortions account for more than one in 10 women who die in pregnancy in Ghana, according to new research by the US-based Guttmacher Institute, with ignorance of the law and inadequate facilities partly to blame, say health authorities.

Abortion was declared legal in 1985 for women who have been raped, in cases of incest, or where the pregnancy will cause the mother physical or mental harm, but decades on, only 4 percent of women are aware of the law, according to 2009 government health statistics (based on 2007 data).

Over half of healthcare providers at a teaching hospital in Kumasi, south-central Ghana, were unaware that formS of abortion are legal in Ghana, and in localized assessments "many groups working in women's reproductive health did not know either," said senior Guttmacher Institute researcher Gilda Sedgh.

Some 15 percent of women and girls in Ghana have had an abortion, with rates highest for those living in urban areas. Most say they do so because they cannot afford to raise a child, according to studies.
While the majority sought a doctor, 43 percent turned to a pharmacist, friend, or traditional midwives to induce an abortion, with the result that 13 percent experienced a health problem following the procedure, and of them 41 percent received no medical care.

One in 45 women or girls in Ghana risks dying from pregnancy-related causes in their reproductive lifetime, according to the UN Children's Fund (UNICEF).

To raise awareness or not?

While the government has to some degree been clear about its stance on abortion, "making people aware of the law is a slow process," Sedgh told IRIN. "The stigma takes a long time to wane."

But Gloria Quansah Asare, family health director in the Ghana Health Service, told IRIN the government must be cautious in promoting abortion services because there are not enough of them: "We don't go to the public and announce 'come for services'. If you do that and the people come and can't get the services, you will be in trouble."

The health service does not have enough doctors or clinics that can offer comprehensive abortion care, says Asare. By this she means care that includes post-abortion training in family planning, provision of contraception and counselling, on top of the procedure. "But we have doctors who should be able to further train to perform abortions," she told IRIN.

Some NGOs like Marie Stopes International, which is registered to provide abortions in Ghana, help fill the capacity gap.

Instead of promoting abortion services, the health authorities stress the dangers of unsafe abortion and no family planning. "We want to tell our public about the dangers of unsafe abortion... We say don't go to someone who is untrained, but go to a recognized one [doctor]... We want people to practice family planning, so we talk about it."

Family planning

The health service has imposed minimum standards in government hospitals, so that all health workers involved are well-trained, will provide counselling and preserve women's dignity in the care they provide.

This kind of comprehensive care is not yet available in all hospitals or in many private clinics, said Asare. Many doctors still perform abortions with no discussion of family planning or follow-up care: "The next time they [the patient] gets pregnant, she comes again. It is wrong." But take-up is increasing, she and the Guttmacher Institute agree.

The government is running a "life choice" campaign to try to encourage more responsible family planning - billboards across towns, and radio spots, transmit the message. "Everybody talks about family planning... Even the Catholic Church, which doesn't like contraceptives, promotes natural family planning," Asare said.

More contraceptive advice and materials are needed in clinics and hospitals, says the Guttmacher Institute. Some 35 percent of married women in Ghana have an unmet need for contraceptives, according to the 2008 demographic health survey.

"Nobody likes abortion"

Getting the family planning message across should be easier than pushing the availability of safe abortions, as "nobody likes abortion [in Ghana] - society, health professionals, even patients, but people are dying from unsafe abortion," Asare told IRIN. "We did a study and found even health workers are unwilling to perform abortions... so we have to roll it out in such a way that people will accept it," she said.

Many law-enforcers do not agree with the law, and crack down on clinics despite the fact they are providing legal services, Sedgh told IRIN.

Some providers still impose stiff fees because they know the women coming to them are in a bind, says Sedgh. Women in Accra pay anything from $9 to $90 for an abortion in a hospital or private clinic, according to a 2002 study by US doctors.

Asare takes a practical approach. "If a doctor does not want to perform the abortion, he should be able to refer a patient to a place where they can get such a service."

There are signs that views are changing. In one study in the capital Accra, most adolescent females interviewed said though they disapproved of abortion, they could describe situations - such as being in an unstable relationship, or not having enough money to raise a child - where they considered it acceptable.

And 80 percent of doctors at an Accra teaching hospital favoured establishing safe abortion units within hospitals.