African Journal of Reproductive Health, Vol. 8, No. 1, April, 2004 pp. 70-74
Destigmatising Abortion: Expanding Community Awareness of Abortion as a Reproductive Health Issue in Ghana
Nana Oye Lithur
Correspondence: Mrs. Nana Oye Lithur, African Women Lawyers Association, House No. C663/3, Crescent Avenue, Asylum Down, Accra, Ghana. Tel: 233-21-251296 (Office), 233-24-704641 (Cellular); Fax: 233-21-228887; E-mail: firstname.lastname@example.org
Code Number: rh04012
Traditional and cultural values, social perceptions, religious teachings and criminalisation have facilitated stigmatisation of abortion in Ghana. Abortion is illegal in Ghana except in three instances. Though the law allows for performance of abortion in three circumstances, the Ghana reproductive health service policy did not have any induced legal abortion services component to cover the three exceptions until it was revised in 2003. The policy only had `unsafe and post-abortion' care components, and abortions performed in health facilities operated by the Ghana Health Service were performed under this component. Though the policy has been revised, women and girls who need abortion services in Ghana more often resort to the backstreet dangerous methods and procedures. Criminalisation of abortion and those who perform abortions has contributed to unsafe abortion, the second leading cause of maternal deaths in Ghana. Most of these are performed outside the formal health service structures. Traditionally, abortion is perceived as a shameful act and the community may shun and give a woman who has caused an abortion derogatory names. Would provision of legal abortion services be culturally acceptable within a Ghanaian community? Yes, if they are made aware of the reproductive health benefits of providing safe abortion services. Three major strategies that would help to destigmatise abortion in the community are (1) the liberal interpretation of the three exceptions to the law on abortion; (2) expanding community awareness of its reproductive health benefits; and (3) improving and increasing access to legal abortion services within the formal health facilities. (Afr J Reprod Health 2004; 8:70-74)
Key Words: Abortion, Ghana, law, policy, community-based approach
Déstigmatisation de l`avortement. Accroissement de la conscience communautaire de l`avortement comme un probléme de la santé de reproduction au Ghana. La stigmatisation de l`avortement au Ghana a été rendu facile par la tradition et les valeurs culturelles, les perceptions sociales, les enseignements religieux et la criminalisation. L`avortement est illégal au Ghana sauf en trios cas. Bien que la loi permet l`avortement en trios cas, la politique du Service de la Santé de Reproduction du Ghana, n`avait aucun service de l`avortement légal provoqué pour couvrir les trios exceptions avant sa revision en l`an 2003. La politique n`avait que des coustituants du soin pour `l' avortement à risque et le post-avortement' et tous les avortements pratiqués dans les institutions de santé gérées par le Service de Santé du Ghana ont été réalises sous ce constituant. Bien que la politique soit revisée, les femmes et les filles qui ont besoin des services d`avortement au Ghana ont recours, le plus souvent, aux procédures et aux méthodes clandestines dangereuses. La criminalisation de l`avortement et ceux qui se font avorter ont contribué à l`avortement à risque, la deuxiéme cause principale des décés maternels au Ghana. La plupart d`entre eux ont lieu en dehors des structures de service de santé formelles. Traditionnellement, l`avortement est perçu comme un acte honteux et la femme qui se fait avorter risque d` être évitée et dénigrée par la communauté. Est.ce que l`assurance des services d`avortemet légal sera culturellement acceptable au sein d`une communauté ghanéenne? Oui, si l'on la sensibilise aux avantages des services d`avortement. Trois stratégies principales qui aideront à déstigmatiser l`avortement dans la communauté sont (1)l`interprétation libérale des trois exceptions à la loi sur l`avortement (2) l`extension de la conscience de la communauté sur les avantages de la santé de reproduction; et (3) l`amélioration et l`augmentation de l`accès aux services d`avortement légal dans le cadre des institutions formelles de santé. (Rev Afr Santé Reprod 2004; 8:70-74)
It is accepted that there is a stigma attached to abortion and those who perform abortions in Ghana. Traditional and cultural values, social perceptions and religious teachings have engendered negative perceptions of abortion. The criminalisation of abortion in Ghana, a colonial legacy, has not helped the situation, and has been a major contributory factor to this stigmatisation.
The concept of `stigmatisation', as used in this text, refers to a situation where a person is discredited for having a marked condition or experience. It involves exclusion, discrimination and ascription of blame.1 This paper addresses `felt' stigma, which a victim perceives and `enacted' stigma, which refers to actions upon the individual or group.1
Generally what is the cultural relativism of reproductive rights in Ghana as an international norm? Ghana is a state party to and has adopted international and regional conventions, charters, treaties and declarations that guarantee the reproductive rights of women.2 Ghana's 1992 constitution guarantees human rights. The paradox is that though a woman's reproductive right is guaranteed by these legal norms, her autonomy and ability to exercise this right is closely linked to the customary laws and traditional practices of her community. These practices may limit the exercise of this right.
The Ghanaian individual is completely merged within his/her community and does not have an identity distinct from his/her family or clan (abusua). He/she adheres to the community value systems. Rites of passage including birth, initiation, puberty, marriage, inheritance and burial ceremonies are determined by ethnic lineage. The community is therefore a fulcrum for the Ghanaian and an important consideration in discussing ways of destigmatising abortion. This community, by its practices, stigmatises abortion. Formal institutions of governments additionally stigmatise abortion by failing to integrate legal abortion services as provided by the law.
Abortion is illegal in Ghana, with three exceptions to the rule. Section 58 of the Consolidated Criminal Code of 1960 (Act 29) was amended in 1985. It defines abortion as the premature expulsion of conception from the uterus or womb before the period of gestation is completed. It is a crime for any woman to administer or cause to be administered on her any poison, drug or other noxious thing, or to use an instrument to cause an abortion. Any person who administers the drug is also guilty. The maximum term is five years imprisonment.
The three exceptions are applicable if the pregnancy was as a result of rape, defilement or incest; would pose a risk to the life of the pregnant woman or injury to her physical or mental health; or where there is substantial risk that if the child were born may suffer from a serious abnormality or disease. Prior to the amendment, abortion was criminal in all circumstances and the maximum sentence was ten years imprisonment.
Ghana adopted a national reproductive health policy in 1997. Though Ghanaian law allows for the performance of abortion in three circumstances, the policy does not make provision for health services for legal abortions. One of the components of the policy is the management of unsafe abortion and post-abortion care. Following the Ghana reproductive health policy, therefore, health services will only be provided for women who have gone through an unsafe abortion or need post-abortion care. The Ministry of Health reviewed the policy in 2003 and has included a section on provision of legal abortion services in its revised policy. The reviewed policy is in the process of implementation.
Abortion stigmatisation permeates officialdom and is a silent and ignored contributor to statistics on maternal mortality in Ghana. It has been noted that Ghana's high levels of maternal mortality could be an effect of the legal restrictions on abortions for some subgroups in Ghana.3
Abortion is one of the leading causes of maternal mortality in Ghana.4 There is however limited data on abortion in the country. The Ghana demographic and health survey of 1998 had as its primary objective `provision of current and reliable data on fertility and family planning behaviour5; it however lacks basic information about the prevalence of abortion in Ghana. In the section entitled `pregnancy outcome', the survey explains that 9.7% of all pregnancies would be lost through spontaneous or induced abortion. It does not desegregate the data to show how many early pregnancies occurred because of induced abortion, both legal and illegal.
Enacted stigmatisation has contributed to unsafe abortions in Ghana. Abortion services for the three exceptions, as prescribed by law, are not readily available at health centres across the country. Even where they are, there is ignorance about the law and the three legal exceptions. Some health personnel are not aware that abortion is legal in certain circumstances and do not provide abortion services to cover them. There is a false perception that all abortions are criminal.
The law criminalises activities of those who assist women to procure abortions. To avoid prosecution and a custodial sentence, some health workers are wary of providing legal abortion services even where it is available. This is because they would not risk being identified with a criminal record for providing abortion services. Some women and girls need the services at all costs because of unwanted pregnancies and would resort to dangerous methods and procedures like insertion of objects, taking dangerous doses of over-the-counter drugs, douching with poisonous and caustic substances, enema with potent herbal preparations, instead of seeking professional health services.6
Despite the prevalence of abortion in Ghana and the fact that it is criminalised in certain instances, women are rarely prosecuted for abortion under section 58 of the criminal code. This fact can be ascertained by comparing statistics on police reports on abortion and statistics on reported cases from the two largest hospitals in Ghana.
Hospital-based studies7 indicate that 22% and 30% respectively of maternal deaths in Komfo Anokye Hospital, Kumasi, and Korle-Bu Teaching Hospital are due to unsafe abortion. A newspaper report8 indicated that complications from abortions are the leading causes of admissions in the Asikuma District of Ghana; more than a thousand cases are reported annually at the hospital. A study in Ghana9 that explored people's perception and behaviour related to abortion found that 11.2% and 16% of males and females respectively, who were sexually active, reported that they caused or assisted a woman to procure an abortion.
On the other hand, 70 cases of abortion were heard by the High Court in Accra between 1965 and 1969 and only three resulted in convictions. From 1999 to 2002, the total number of abortion cases reported to the police in Ghana rose from 172 in 1999 to 256 in 2002, and 177 in 2002.
Analysing statistics from the studies at Korle-Bu and Komfo Anokye and reports from the Asikuma District, it is obvious that the incidence of unsafe abortion is high. It is the second leading cause of maternal mortality in Ghana. In Asikuma District alone, over 1,000 cases were reported and yet cumulative national statistics from the Criminal and Investigation Unit of the Ghana Police Service over a three-year period - from 1999 to 2002 - (775 cases) account for less than the 1,000 abortions performed in only one of the 110 districts in Ghana over a period of one year.
Unsafe abortion is silently being performed underground within the communities in Ghana and outside the formal health service structures. This is as a result of stigmatisation coupled with the lack of health services for abortion. It is perceived that those who perform abortions are criminals breaking the law.
Traditionally, abortion is perceived as a shameful act. In the Ga tradition, families where women are known to have performed abortions are branded as `the family where its womenfolk remove pregnancies'. A derogatory tag is attached to the family and it may adversely affect the chances of getting married for girls in such family. This is because a big premium is placed on fertility and ability to have children; the performance of an abortion is perceived as limiting a woman's chances of childbirth. Traditionally, the community may give a woman who has caused an abortion derogatory names, which sometimes connotes immorality.
Certain Ghanaian customary practises facilitate recourse to abortion. A marriage ceremony cannot be performed for a pregnant woman. In certain tribes in Ghana, it is a taboo for a woman to get pregnant before puberty rites are performed for her. The dipo custom is a puberty rite performed for Krobo girls. They have to be virgins to undergo the puberty rite. A girl who gets pregnant before performance of these rites may decide to abort the pregnancy to pave way for performance of the custom. This is because great shame would be brought upon the family if it becomes public knowledge that she was pregnant and could not go through the ceremony. To avoid disclosure, abortion is carried out secretly. Unorthodox methods are used, resulting in needless deaths and reproductive health consequences for women.
Religion also plays a major role in stigmatisation of abortion in Ghana. The Catholic doctrine, for instance, is against abortion. It is perceived by some religious leaders as being against biblical teachings; they therefore preach against it. There isn't yet an organised religious anti-abortion pressure group in Ghana.
Theresa Azigli is a 22-year-old petty hawker from Krobo-Odumase district in Ghana. She has three children who are not being maintained by their fathers. She got pregnant with a fourth child when her third child was five months old and decided to abort the pregnancy. A health inspector discovered the fetus and she was arrested and prosecuted. She pleaded guilty and was wrongly sentenced to a maximum sentence of ten years.
The judge applied a repealed law in passing the sentence. Section 58, as amended, stipulates that the maximum sentence for abortion is five years. The judge did not consider whether her case fell within the three stipulated exceptions. The case was extensively discussed in the media. An appeal was filed on her behalf by a team of lawyers offering pro-bono services.10 The judgement was quashed and she was discharged. It is interesting that the trial judge, after convicting, gave her the maximum sentence. After her release from prison, Theresa left her community because of the taunts, stigma and derogatory names she was given by some members of her community. She has had to resettle in another community and start a new life there.
The issue is whether legal abortion services would be culturally acceptable and patronised if set up in health facilities by government in the communities. Expanding awareness of the reproductive health benefits of providing and accessing safe abortion services in health facilities would be key to destigmatising abortion.
Another significant intervention that would facilitate destigmatisation of abortion is a more liberal interpretation of the law on abortion. The three exceptions ought to be interpreted as liberally as possible to allay the fears of health workers who would have to provide the service to women. They would readily provide the said service if they were assured that it would not lead to prosecution by the police.
Strategic stakeholders would have to be identified and an advocacy plan implemented to improve access to safe abortion services. They should be made to understand the consequences of stigmatising abortion, its link to the high rates of unsafe abortion and maternal mortality, and the justification for advocating and improving access to safe abortion services at health facilities.
Traditional leaders have to be provided with information on the implications of unsafe abortion and its contribution to maternal mortality, encouraged to incorporate information on consequences of unsafe abortion in puberty and initiation rites. Political leaders should be encouraged to make safe abortion less controversial. Religious leaders should be made to understand that providing sexuality education on abortion would not promote promiscuity.
There are risks and challenges in destigmatising abortion. The following two examples illustrate how criminalising a cultural, religious or traditional practice that has community support without creating awareness or seeking community legitimacy will not ultimately protect the reproductive rights of women. The promulgation of legislation to criminalise the harmful traditional practise of trokosi, for instance, has not led to a significant reduction in the number of girls being held in bondage by shrine owners. Female circumcision was criminalised in Ghana in 1994. Nine years after the law was passed it still remains prevalent in remote parts of the Upper East and Upper West Regions of Ghana, where it affects an estimated 86% of the rural female population.11 Strategies for destigmatising abortion should be multi-faceted and should involve the community.
Notwithstanding these challenges, we can learn from some best practices. Domestic violence that was hitherto perceived as a private matter is now discussed within the public domain and considered a violation of women's rights after sustained advocacy and sensitisation of the community.
Abortion is a controversial issue touching on religious, cultural, moral and traditional values. Unfortunately, these considerations currently outweigh its health implications in Ghana. The need for destigmatising abortion by expanding community awareness, adopting a liberal interpretation of the law, and improving access to legal abortion services, can therefore not be overemphasised.
© Women's Health and Action Research Centre 2004