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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 8, Num. 1, 2004, pp. 70-74
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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: nanaoyel@yahoo.co.uk
Code Number: rh04012 Abstract
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[1]:70-74)
Key Words: Abortion, Ghana, law, policy,
community-based approach
Résumé
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[1]: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.
References
- Goffman1963; Parker and Aggleton 2002; Schur1984; Weiss
and Ramakrishna 2001.
- The International Covenant on Economic, Social and
Cultural Rights, the Convention on the Elimination of All Forms of
Discrimination Against Women, The African Charter on Human and People's Rights,
The ICPD
the Beijing Platform of Action, Beijing +5, the Dakar platform, The
UN Millennium Goals.
- Ahiadeke Clement. Incidence of induced abortion in
southern Ghana. Int Fam Perspec 2001; 27(2): 96-101, 108, 101.
- Lassey AT and Wilson JB. Trends in maternal mortality
in Korle-Bu Hospital, 1984-1994. Ghana Med
J 1998; 32a: 910-916.
- Ghana Statistical Service and Macro International Inc.
Ghana Demographic and Health Survey 1998.
- Taylor Joe. Ghana Health Service Workshop, December
2003.
- Deganus-Amorin 1993; Komfo Anokye Hospital, Akosa, 1998;
Korle-Bu Teaching Hospital.
- Alex Afoko. Ghanaian Times 7th May 2004.
- Ghana Youth Reproductive Health Survey Report 2000. GSMF,
PPAG, John Hopkins University, USAID, Focus on Youth Project.
- The Mirror February 21, 2004, 22.
- University of Ghana. Population, environment and development
in Ghana. Pop Impact Project 2000; 4(1).
© Women's Health and Action Research Centre 2004
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