New faculties for Comprehensive Abortion Care and family planning will be built at Korle-Bu Teaching Hospital and the University of Legon starting in October this year, the Head of department for Gynecology and Obstetrics at Korle-Bu revealed yesterday.
In an interview with The Statesman Professor E Y Kwawukume said that two buildings will be constructed at the Teaching Hospital specifically for training centres in comprehensive abortion care and family planning.
At present Comprehensive Abortion Care is not including in medical school curriculums but a US based organisation, Buffatt, is working with the Teaching Hospital to make the plans possible.
Prof Kwawukume explained that the facilities will allow teaching of medical students, nurses and doctors on CAC, including practical training in abortion procedures and counseling, building on the elements already included in the syllabus such as post abortion care and family planning.
"This development is good for Ghana and good for the world", he said, "Other countries have adequate abortion care, why can't we give the best to our own people here?" He added that family planning facilities are not currently good enough and because the
Korle-Bu authorities are not willing to help, Buffatt has stepped in to facilitate in bringing Comprehensive Abortion Care to Ghana.
A letter exchanged between Vice President of Buffet and Prof. Kwawukume has set the plans in motion and the professor expressed enthusiasm in the building scheme, adding that ten doctors would be sent to the US organisatation in November to attend a workshop for refresh training in Comprehensive Abortion Care.
"Now women can visit the site for counseling to know exactly what is involved in abortion, they do not need to fall within the criteria of the law for this service whether they are married, unmarried, young or old" the professor said.
These developments in providing women with additional access to safe legal abortions and counselling could be a step in the direction to tackle the crisis of high death rates from unsafe abortions, a figure which doctors estimate to be at 22-30% of all deaths in Ghana.
The World Health Organisation estimates Ghana's maternity mortality rate at 540 deaths per 100,000 live births, but despite one of the most progressive laws on abortion, this figure is one of the highest in West Africa and unsafe abortion is largely responsible for the figure.
The lack of data collected on abortion figures also suggests that many women die without being safely admitted to hospital and their deaths are not recorded as maternal deaths, the difficulties in producing a study lie in the sensitivity of the matter.
Professor Kwawukume said "We are very shy as a society, we do not discuss sex. The issue of abortion needs to be looked at so people know what the law is but in a way that our cultural values can be preserved." Similarly Dr. Patrick Frimpong of La Polyclinic Labadi said on the subject "everything is shrouded by secrecy and myth and it all comes out of religious belief, people should be made to be open, even the Ghana Heath Service is not quite open."
Social perceptions, religious beliefs, moral values and stigma attached to obtaining an abortion play a part in the large amount of women seeking unsafe or 'backstreet abortions in unlicenced practices or attempting to self-induce an abortion, but country director of IPAS, Dr Koma S. Jehu-Appiah believes "a lot of the stigma comes from the medical profession itself".
In an interview with The Statesman, the womens rights activist and doctor of 17 years explained that women are often refused abortions because of personal views of heath personnel on the procedure.
The Patients Charter states that if a doctors religion or moral beliefs prevent them from performing a certain procedure, such as abortion, the doctor must direct the patient to another health professional who can offer the service.
Attitudes to abortion are conflicting with healthcare professionals roles as Dr. Jehu-Appiah noted that referral of patients as stated in the Patients Charter is not always carried out.
Gynecologist Dr. Joe Taylor told The Statesman that opinions on abortion within the medical profession are divided because of religion and personal morals. "We will never have a consensus over the issue, because you cant force anybody to perform an abortion", he said.
Although the Ghana Health Service produces standards and protocol, it is not in the work contract of doctors and nurses to perform abortions, "some people just dont want anything to do with it", he explained.
An assessment carried out in six regions last year concluded that medical personnel are on the whole not comfortable discussing the issue of abortion, Dr Taylor said. As training on the procedure has never been part of the curriculum and will not be until the new faculties are built at Korle-Bu, he said many doctors and nurses have not received training on abortion at all.
Stigma attached to abortion practice, both among the public and the within the medical profession itself, has contributed to high numbers of Ghanaian women risking their lives by undergoing abortions in unlicensed practices or attempting to operate on themselves.
The latter is very widespread and methods include inserting broken glass bottles or cassava sticks into the womb to cause enough bleeding to destroy the fetus.
Dr Jehu- Appiah, explained this method of attempted abortion is attributed to many deaths among pregnant women and he said he has seen cases where women have used coat hangers or had their stomachs massaged in a particular way until they are heavily bleeding.
"If a doctor refuses to give a woman an abortion, she will come into hospital later with an incomplete abortion and post abortion complications, women have lost their wombs as a result and develop septicemia." These, he explained, are everyday occurrences.
Other concoctions women have inserted into themselves include Guinness or Coca-Cola mixed with sugar, strong coffee, sulfuric acid, cooked tobacco leaves herbs or even drinking cement. Dr Joe Taylor specified that he has seen self-induced abortions result in hemorrhage, infections, intoxication, poisoning and infertility.
A family planning nurse at La Polyclinic, Esther Sunkwa-Mills, told The Statesman of a case involving a nineteen year old client who attempted to abort the fetus herself. "It resulted in a gangrenous condition and she had to be taken to theatre, if this patient had easier access to abortion care the complications could have been aborted" she said.
Addressing the issue of stigma in the medical profession, Nurse Sunkwa-Mills explained "you are labeled as the health personnel providing the services" adding "initially it was quite difficult for me to offer these services because of my religious beliefs, now Ive realised a professional should be nonjudgmental- the clients have rights."
In addition Dr Patrick Frimpong of La Polyclinic told The Statesman "because services are not being provided, women often wait until the end of the pregnancy to seek an abortion" adding "we drive them away, its not just about the physical procedure, its about counselling and community participation."
Nurse Sunkwa-Mills explained that many patients have visited unlicensed practices in Nima and Accra Central, "I have been told a lot of women wait in the queue in these places, and they go there because it is cheaper and because of stigma. If they go to some hospitals for an abortion doctors and nurses will frown or shout at them." The procedures are in unhygienic conditions using primitive surgical methods to dislodge the fetus or simply to cause a lot of bleeding.
Dr Frimpong stated that 60-70% of cases for post abortion complications are from backstreet illegal practices and described chronic pelvic pain as a common outcome. Dr Jehu-Appiah explained that unlicensed practices do not use the modern manual vacuum, but an old method which involves painful and inhuman scraping of the womb using a metal rod and the procedure often results in infertility for the woman, a method he believes is "wicked on the side of the physician."
Some patients, Nurse Sunkwa-Mills said, do not want the clinic to call after an abortion procedure at La Polyclinic as it is the post abortion protocol to keep in contact with the clients, "The youth dont want their parents to know and the married dont want their husbands to know, some would only say at the point of death!" Regarding the new plans to teach Comprehensive Abortion Care at medical schools, she said "it should be part of the curriculum at nursing schools, then there would be a better attitude and health personnel would feel more comfortable talking about abortion. Some people cant even talk about sexuality, we need to desensitise them."
Under a law that permits legal termination in the criminal code (29) 1960 (amendment 1985) Sec 58 (2) legal abortions are allowable in the following circumstances; that the pregnancy is caused by rape, incest or defilement by an idiot, or the pregnancy involves a risk to the mothers life or to her physical or mental health, or thirdly that the child may develop a serious physical abnormality or disease.
Dr Joe Taylor explained that some health personnel do not actually know wht the law on abortion is and he attributed this to the fact that Sec 58(2) only offers vague guidelines. For instance there is no specification on the number of weeks up to which pregnancy can be terminated; he said however that many health practitioners are reluctant to perform abortions after 12 weeks because after this time doctors are very conscious about increased complications.
Professor Kwawukume noted "I think the law should be changed, we gynecologists need to sit down and change particular aspects which work in favour of women. The number of weeks a pregnancy can be terminated up to needs to be addressed."
Dr Taylor believes that the law is broad enough in Ghana despite other countries with liberal abortion laws having low maternal mortality rates, Romania he said was the best example of abortion laws amended to result in less death from unsafe abortion.
The fifth Millennium Development goal was to reduce the maternal mortality rate by 75% by the year 2015, and although the law was amended in 2003 to integrate the concept of safe abortion into the national reproductive health policy, Dr Jehu- Appiah believes the only way to reduce this high death rate among pregnant women is to reduce the amount of fatalities due to unsafe abortions.
Despite Ghana having a more progressive law than many African countries, he believes there should be no law on abortion at all, following in the footsteps of countries like Canada where the maternal mortality rate is very low, "if we did not have a law restricting abortions we would be able to reduce this figure to zero." He added "a woman of 15-25 years old does not deserve to die just because she is pregnant"
IPAS work with hospitals to train and equip medical personnel mandated to carry out abortions using the modern manual vacuum. After counselling about motherhood, safe deliveries and the possibility of termination, the patient would have the option to go ahead with an induced abortion, but in safe approved facilities, even if she does not fit the criteria set out by the law.
Failures in family planning account for a large part of the problem, currently only 19% of sexually active Ghanaians use contraceptives. "Schools dont talk about family planning, they talk about abstinence" Nurse Sunkwa-Mills explained. In The Statesmans own investigation, a class of 50 students aged 13 to 20 at a school in Accra all thought that abortion was illegal in Ghana and that it was a very shameful act for a woman.
Looking to Ghanas future in Comprehensive Abortion Care, Dr Frimpong stressed "we are going to hold the bull by the horns, we have had enough of women needlessly dying. The Ghana Health service is poised to stop complications from backstreet abortion."
