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Attitudes toward abortion among students at the University of Cape Coast, Ghana
Sexual & Reproductive Healthcare 11 (2017) 53–59
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Sexual & Reproductive Healthcare j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g
Attitudes toward abortion among students at the University of Cape Coast, Ghana Sarah D. Rominski a,*, Eugene Darteh b, Kwamena Sekyi Dickson b, Michelle Munro-Kramer c a
Global REACH, University of Michigan Medical School, USA Department of Population and Health, University of Cape Coast, Ghana c School of Nursing, University of Michigan, USA b
A R T I C L E
I N F O
Article history: Received 5 May 2016 Revised 10 October 2016 Accepted 13 October 2016 Keywords: Ghana Abortion Abortion attitude Exploratory factor analysis
A B S T R A C T
Objectives: This study aimed to describe the attitudes toward abortion of Ghanaian University students and to determine factors which are associated with supporting a woman’s right to an abortion. Methods: This cross-sectional survey was administered to residential students at the University of Cape Coast. Participants were posed a series of 26 statements to determine to what extent they were supportive of abortion as a woman’s right. An exploratory factor analysis was used to create a scale with the pertinent factors that relate to abortion attitudes and a multivariable linear regression model explored the relationships among significant variables noted during exploratory factor analysis. Results: 1038 students completed the survey and these students had a generally negative view of abortion. Two factors emerged: (1) the Abortion as a Right scale consisted of five questions (α = .755) and (2) the Moral Objection to Abortion scale consisted of three questions (α = .740). In linear regression, being older (β = 1.9), sexually experienced (β = 1.2), having a boyfriend/girlfriend (β = 1.4), and knowing someone who has terminated a pregnancy (β = 1.1) were significantly associated with a more liberal view of a right to an abortion. Discussion: This work supports the idea that students who have personal exposure to an abortion experience hold more liberal views on abortion than those who have not had a similar exposure. © 2016 Elsevier B.V. All rights reserved.
Background Despite having a relatively liberal abortion law [1], complications from unsafe abortion continue to be a major component of Ghana’s maternal mortality [2] and a large burden of disease in the country’s emergency gynecology wards [3,4]. While the law was liberalized in 1985 allowing abortion for a few broad categories [5], and the Ghana Health Service and the Ministry of Health established protocols for the provision of safe abortion services in 2006, nearly half of abortions in the country remain unsafe [5]. The incidence of abortion and associated morbidity and mortality is considered to be highest (25%) among women aged 20– 24 years [6], with a reported rate of 34 per 1000 among women in urban areas [7–9]. The situation in Ghana is further evidence that a liberal law is only effective at reducing mortality and morbidity associated with unsafe abortions if it is accompanied by appropri-
* Corresponding author. Department of Obstetrics and Gynecology, University of Michigan Medical School, USA. E-mail address: [email protected] (S.D. Rominski). http://dx.doi.org/10.1016/j.srhc.2016.10.002 1877-5756/© 2016 Elsevier B.V. All rights reserved.
ate service provision [10] and women’s willingness to seek such services [11–13]. Currently the Ghanaian law allows abortion if at least one of a few broad categories are met: (a) if the pregnancy is the result of rape or incest, (b) if there is gross fetal malformation, or (c) the continuation of the pregnancy endangers the life, or the mental or physical health of the mother [1]. This law is considered one of the most liberal in sub-Saharan Africa. Although a woman may have a right to a safe, clinic-based abortion in Ghana, negative attitudes toward the service from both providers and the general public may be one reason for the high numbers of women who seek services from outside the formal healthcare system [14]. Recent work in Ethiopia, which has a similar abortion law, has demonstrated that healthcare providers justified providing abortions in order to reduce maternal mortality, rather than in terms of a woman’s right to control her body or to have an abortion [15]. Although the framing of the 1985 liberalization of abortion in Ghana has not been well documented, in 2006, the Ghana Health Service published a document, “Prevention and Management of Unsafe Abortion: Comprehensive Abortion Care Services Standards and Protocols” [16]. This document is written from a public health lens, stressing the importance to reduce barriers to unsafe abortion in order to
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prevent unnecessary death and disability. While the “General Principles” section of the document indicates that, among other things, “each client has the right to access the service, as an integral part of comprehensive integrated reproductive health service provision”, this is the only mention of a woman’s right to an abortion. Except for in South Africa, most of the justification for the change in abortion laws, where they have occurred, have been to reduce maternal mortality, rather than based on a woman’s rights [15]. This may undermine the ability of women to insist on this right, and may empower providers to refuse to provide services and stigmatize women who seek these services. The abortion-rights movement in Ghana has been described as a constituency, “less than 10 persons consisting of medical doctors, lawyers and a handful of other interested parties” [17] and it is possible that the views of the nation on a whole are not represented in the liberal law. While it has been reported that Ghanaian society is deeply religious [18], and abortion stigma in Ghana can be linked to religious attitudes [19], general attitudes of University students – a population that falls within the age bracket with the highest incidence of abortion is scant in the country. Work in other settings such as South Africa has shown that cultural attitudes toward abortion correlate with conservative values in general [20]. Importantly, the safe abortion guidelines established in 2006 specifically encourage research and dissemination of information pertaining to abortion to students and other high risk groups [21]. Recent work has explored the determinants of decision-making among Ghanaian university students [21] and students’ knowledge about abortion in Ethiopia [22]. This work has found that students’ decision-making and knowledge are impacted by their education, religion, and relationship status [21]. However, the attitudes and views of sub-Saharan university students toward abortion have been largely unexplored. There is therefore a gap in the literature on Ghanaian University students’ attitudes toward abortion. As attitudes generally underpin laws and policies, it is important to understand the public’s attitudes and views toward an issue, especially one that can be politically charged, such as abortion. This information could provide the framework for future educational endeavors of students and policy changes [23]. The current study therefore sought to examine the attitudes of Ghanaian university students toward abortion. Methods
attitudes. The subset of questions regarding abortion experiences and attitudes are reported here. Sampling A quota was assigned to each hall based on the population of each hall of residence in order to make the sample as representative of the residential students as possible. Due to the exploratory nature of this study there were no a priori hypotheses that necessitated a power analysis. A list of room numbers for each hall was generated, and rooms to include in the survey were randomly selected via a random number generator. Research assistants approached each room and explained the study to the first resident they encountered. Most rooms house two students, although this varies some by hall. If the original student refused participation, the RAs invited a student from the next room. Those students who agreed to participate were handed the tablets hosting the survey. To ensure privacy and confidentiality, the respondents were encouraged to respond to the survey in private. Each survey took about 30 minutes. A total of 1042 residential students were successfully interviewed. Ethical considerations The survey received ethical clearance from the Institutional Review Board of the University of Michigan and was approved by the University of Cape Coast. Five field assistants were trained in the objectives of the survey and were available if any of the respondents had questions while they completed the survey. The field assistants could not view the responses of the participants and no identifying information was collected. Measures Similar to Snegroff [24], Shellenberg et al. [25], and Sorhaindo and colleagues [26], participants were posed a series of 26 declarative statements to determine to what extent they were supportive of abortion as a woman’s right. Participants were asked to respond to these statements on a 5-point Likert scale from Strongly Disagree to Strongly Agree. These statements were developed by the authors based on their experience working in the arena of abortion research in Ghana and based on extant literature.
Setting Analyses Data for the study were collected from a survey of residential students at the University of Cape Coast. The University of Cape Coast is one of the eight public (State-owned) universities in Ghana. It has a total population of about 24,000 pursuing various academic programs. The University has 8 official Halls of residence and hostels, which accommodate more than 6000 residential students. The University operates a residential policy where all freshmen are accommodated in the traditional halls of residence while continuing students make their own arrangements for accommodation.
All data were transferred from the DroidSurvey platform to Excel and then imported into IBM SPSS version 22 (SPSS, Inc., Chicago, IL). First, descriptive statistics were used to explore the data. Then, an exploratory factor analysis was used for data reduction in order to create the outcome variable, a scale with the pertinent factors that relate to abortion attitudes [27]. Finally, a multivariable linear regression was run with variables that were found to be associated with the outcome variable created during exploratory factor analysis.
Instrument Results The questionnaire was developed and pilot tested among similaraged students (n = 20) who studied at the Cape Coast polytechnic, a tertiary-level institution located in the same city. Some slight modifications were made to the survey based on these pilot tests. The survey was self-administered on tablet computers using DroidSurvey software. The instrument had four sections: (a) background, (b) knowledge and attitude of sexual and reproductive health, (c) sexual and reproductive health risk perception, and (d) abortion experience and
Characteristics of the sample Due to the small number of missing responses, it was determined a priori that those participants who had omitted questions would be excluded from data analyses. This resulted in complete data from 1038 (99.6%) students for the regression analyses. Slightly less than half the sample was female (n = 480, 46.2%). A majority (71.9%, n = 746) has ever had a boyfriend or girlfriend. Of those, 476
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Table 2 Full set of statements presented to participants.
Table 1 Participant demographics (n/%). Variable Gender Male Female Romantic relationship history Ever had boyfriend/girlfriend Currently has boyfriend/girlfriend Religion Pentecostal/Charismatic Methodist Catholic Other Christian Presbyterian Muslim Anglican No religion Traditional/Spiritualist Ethnicity Ashanti Fanti Other Ghanaian Ewe Ga/Adangbe Mole-Dagbani Field of study Agriculture Business Computer Science Education Geography Humanities Mathematics Nursing Science Social Science Missing
55
Number (percent) 556 (53.6) 480 (46.2) 746 (71.9) 476 (45.9) 384 (37.0) 170 (16.4) 142 (13.7) 142 (13.7) 118 (11.4) 45 (4.3) 9 (0.9) 4 (0.4) 3 (0.3) 351 (33.8) 294 (28.3) 155 (14.9) 124 (11.9) 84 (8.1) 14 (1.3) 18 (1.7) 212 (20.4) 13 (1.3) 112 (10.8) 20 (1.9) 173 (16.7) 69 (6.6) 65 (6.3) 148 (14.2) 187 (18.0) 22 (2.1)
currently have a boyfriend/girlfriend. For more information about the characteristics of the sample, see Table 1. Preliminary analyses An exploratory factor analysis was utilized to consolidate items based on perceptions of abortion. The full set of statements presented to participants can be seen in Table 2. The suitability of the sample size was examined prior to analyses. As a rule of thumb, Tabachnick and Fidell [28] recommend having at least 300 cases for factor analysis, which our sample greatly surpassed. Sampling adequacy for factor analysis was deemed adequate using the Kaiser– Meyer–Olkin (.74) and the Bartlett test of Sphericity was significant (χ2 (df = 66) = 2095.08, p < .001) indicating that relationships among the items existed [28]. Using principle component analysis with varimax rotation, two factors appeared to load. These factors have been termed Abortion as a Right and Moral Objection to Abortion. The statements for the first factor, Abortion as a Right, were: 1 Access to safe abortion services is every woman’s right. 2 Women need access to safe abortion services. 3 It is a good thing women can obtain legal abortion services in Ghana. 4 A woman should always have a right to have an abortion in the case of an unwanted pregnancy. 5 Women, regardless of the circumstances surrounding their pregnancy, have a right to respectful care for an induced abortion. The questions which composed this factor were summed to create an Abortion as a Right sub-scale. As the initial questions were asked on a 5-point Likert scale, with 1 corresponding to Strongly Dis-
Life begins at conception A woman has a right to control her body Termination of pregnancy is against my religion Termination of pregnancy is against my morals Access to safe abortion services is every woman’s right I believe women have a right to judgment-free abortion care Ghanaian women are suffering from unsafe abortion Unsafe abortion is a preventable cause of death in woman I believe women need access to safe abortion services There are enough abortion care providers in Ghana Women are able to get safe abortion services when they need them I think it’s a good thing that women can obtain legal abortion services in Ghana It’s easier to get abortion services if you are married Abortions among unmarried women are rising in Ghana Unmarried women prefer to have an abortion outside public health clinics Married women prefer to have an abortion outside public health clinics Women prefer to have an abortion in public health clinics Abortions from unregistered providers are more harmful than abortions from registered clinics Abortion is morally wrong A woman should always have a right to have an abortion in case of an unwanted pregnancy A women needs to have her partner/spouse’s approval to have an abortion Abortion care seekers or clients in public health facilities are treated with respect in Ghana Abortion care seekers or clients in private facilities are treated with respect in Ghana Women, regardless of the circumstances surrounding their pregnancy, have a right to respectful care for an induced abortion
agree and 5 corresponding to Strongly Agree, this scale, which ranges from 5 to 25, ranks participants from those who feel that abortion is not a right to those who support abortion rights for all women, regardless of the circumstances surrounding their pregnancy. Participants’ scores on the Abortion as a Right sub-scale ranged from 5 to 25, covering all possible scores, with a mean of 15.6 (SD = 4.9). The Abortion as a Right scale had a Cronbach’s alpha of .755, indicating a high level of internal consistency. The questions for the second factor, Moral Objection to Abortion, were: 1 Termination of pregnancy is against my religion. 2 Termination of pregnancy is against my morals. 3 Abortion is morally wrong. A sub-scale for Moral Objection to Abortion was created, summing the three questions above. This scale ranges from 3 to 15, with a higher score corresponding to a more conservative view of abortion. The participants in this study held generally conservative views of abortion, with 480 (46.2%) scoring 15 on this sub-scale, meaning they strongly agree with all three statements. The mean score was 13.5 (SD = 2.2). Almost 80% of the sample (78.9%) scored 12 or higher on this subscale. The Moral Objection to Abortion sub-scale had a Cronbach alpha of .740. The two sub-scales were negatively associated (Pearson’s correlation = −.108; p = .001), as would be expected. The Abortion as a Right sub-scale was used as the outcome variable in a linear regression. Factors which were significantly associated, p < .05, with this scale in bivariate analysis were entered into a multivariate regression. Table 2 presents the results of participant characteristics tested against the Abortion as a Right sub-scale (Table 3). The distribution of the Abortion as a Right scale can be seen in Fig. 1 and the distribution of the Moral Objection to Abortion scale can be seen in Fig. 2. Factors found to be associated at the p < .1 level in bivariate analysis with the Abortion as a Right scale were being under the age of 20 or over the age of 24, currently having a boyfriend/girlfriend,
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Table 3 Factor loadings of abortion items. Item Factor 1: Abortion as a Right
Factor 2: Moral Objection to Abortion
Loading Access to safe abortion services is every woman’s right Women need access to safe abortion services It is a good thing women can obtain legal abortion services in Ghana A woman should always have a right to have an abortion in a case of an unwanted pregnancy Women, regardless of the circumstances surrounding their pregnancy, have a right to respectful care for an induced abortion Termination of pregnancy is against my religion Termination of pregnancy is against my morals Abortion is morally wrong
.754 .761 .673 .669 .624 .836 .843 .630
having ever had sexual intercourse, having ever terminated a pregnancy (or for males, having a partner who had), and knowing anyone who had terminated a pregnancy. For the Moral Objection to Abortion scale, only ever having sexual intercourse was associated with the sub-scale (Table 4). The majority of the sample (n = 804, 77.6%) were between the ages of 21 and 24, and reported having a boyfriend or girlfriend at the time of the study (n = 476, 63.6%). Fewer students had sexual intercourse (n = 371, 43%), but a majority of those who had used some form of contraception at their last sex (n = 250, 69.8%). While few participants (n = 54, 5.2%) reported they had an abortion, a large minority of the participants (n = 434, 41.8%) knew someone who has had an abortion.
ally experienced, currently having a boy/girlfriend, and knowing someone who has terminated a pregnancy (Table 5). Holding other variables constant, participants who are over the age of 25 scored almost 2 points higher on the Abortion as a Right sub-scale as their younger colleagues. Likewise, those who currently have a boyfriend/girlfriend or who know anyone who has terminated a pregnancy score over 1 point higher on the scale. Finally, those participants who have ever had sexual intercourse score 1.4 points higher on the scale. Each of these variables remains statistically significant in this multivariate analysis. Due to the lack of significantly associated variables to the Moral Objection to Abortion sub-scale, a multivariate analysis was not conducted with that as the outcome variable.
Modeling
Discussion
When entered into a multivariate linear regression with the Abortion as a Right factor as the outcome, the factors that remained significantly associated are being over the age of 25, being sexu-
In this study of 1042 residential students at the University of Cape Coast, students had a generally conservative view of a woman’s right to an abortion. Many of the students surveyed believed that abor-
Fig. 1. Distribution of Abortion as a Right sub-scale.
S.D. Rominski et al. / Sexual & Reproductive Healthcare 11 (2017) 53–59
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Fig. 2. Distribution of the Moral Objection to Abortion sub-scale.
tion is morally wrong. Results of an exploratory factor analysis suggested two sub-scales: (a) Moral Objection to Abortion and (b) Abortion as a Right. Students held views that abortion is morally wrong, with 480 recording the highest possible score on that subscale. While there has been almost no work done on this topic in Ghana, previous work in South Africa has suggested that university students there hold generally conservative views toward abortion [29]. While young people, including university students, in other settings, including the United States [30], Sweden [31], and Britain [32], generally hold liberal views toward abortion. It seems that in Ghana students are likely to hold conservative views toward the mo-
rality of abortion, even if they have personal experience with having an abortion, or know someone who has had one. On the Abortion as a Right sub-scale, there was a more even distribution, with many students reporting ambivalence when it comes to a woman’s right to an abortion, regardless of the circumstances surrounding her pregnancy. Students who were older (over the age of 25), who currently have a boyfriend/girlfriend, who have ever had sexual intercourse, and who know anyone who has terminated a pregnancy were more likely to be supportive of a woman’s right to an abortion. Similar to Carlton et al. [33], this work did not find a difference in abortion attitude for males versus females, but did
Table 4 Participant characteristics and association with abortion right scale and moral objection scale. Characteristic
Answer
N (%)
p-value – right to abortion
p-value – moral objection
Age
Under 20 21–24 Over 25 No Yes Yes No Yes No Yes No Missing Yes No Missing Yes No Missing
171 (16.5) 804 (77.6) 51 (4.9) 272 (36.4) 476 (63.6) 371 (43.0) 493 (57.1) 250 (69.8) 108 (30.2) 54 (5.2) 974 (93.8) 11 (1.1) 434 (41.8) 594 (57.1) 11 (1.1) 156 (15.0) 866 (83.6) 14 (1.3)
.086 Reference category .004 .097
.353 Reference category .178 .603
Do you currently have a boyfriend/girlfriend?a Have you ever had sexual intercourse?b At last sex, was any contraception used? Have you ever had an abortion/terminated a pregnancy?
Do you know anybody who has ever had an abortion/ terminated a pregnancy before? Ever been forced or coerced into sex
a b
Asked of those participants who answered they had ever had a boyfriend/girlfriend. Asked of those participants who answered they had heard of sexual intercourse.
.000
.074
.984
.222
.050
.500
<.001
.637
.379
.925
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S.D. Rominski et al. / Sexual & Reproductive Healthcare 11 (2017) 53–59
Table 5 Results of the multivariate linear regression with right to abortion scale as the outcome variable. Variable
B (std. error)
Significance
Age > 25 Currently have boyfriend/girlfriend Ever had sexual intercourse Know anyone who has terminated a pregnancy Constant
1.9 (.83) 1.2 (.42) 1.4 (.14) 1.1 (.41) 14.0 (.44)
.022 .004 .001 .006
find that those who have a personal indirect experience with abortion hold more liberal views toward a woman’s right to an abortion. The current study supports the idea that students who have personal exposure to an abortion experience hold more liberal views on abortion than those who have not had a similar exposure [33]. In this case, personal experience with an abortion was not significantly associated with the outcome variable, perhaps because just over 5% of the sample reported they had ever terminated a pregnancy. However, knowing someone who has had a termination was associated with a more liberal view of a woman’s right to an abortion. In a setting where abortion is highly stigmatized, as it appears to be in Ghana, students may not have been completely forthcoming about their own experience with abortion, as other studies in Ghana would suggest a higher proportion of participants of this age group having experienced abortion. It is perhaps not surprising that in a sample where almost every participant reported affiliating with a religion, generally conservative views of abortion predominate. Ghana has been described as a highly religious country [18], and this sample is not different. In settings across the world, religiosity has been associated with generally negative views toward abortion [34]. Previous works in the area of attitudes toward abortion in Ghana have been focused almost exclusively on healthcare providers and their willingness to provide abortion services [35,36] or women seeking care for abortion services [37,38]. This is the first study that we are aware of which aims to assess to what extent Ghanaian university students are supportive of abortion and which finds personal experiences to be associated with students reporting their agreement with a woman’s right to an abortion in the case of an unwanted pregnancy. While attitudes toward abortion have been widely and deeply studied in the United States [39], there has been far less work on this topic in Ghana. This work has important policy implications. Since attitudes form the basis for policies and laws, it is important to understand public attitude. It appears that, while many university students feel that abortion is morally wrong, this does not preclude some of them from also supporting a woman’s right to an abortion. It would be interesting to see what the public support would be for an amendment to the law stating women’s positive rights to an abortion, rather than it being legal only if it is deemed a necessary health intervention. Further work in this area, including determining policy makers’ willingness to sponsor such legislation, would be an important next step. Limitations and future work This study has some limitations which need to be addressed. As this survey asked questions of a sensitive nature, it was developed so it could be taken in a private location on a tablet computer. However, feelings on abortion are undoubtedly complex and might not be best explored through a quantitative survey. Further, the survey did not ask about “hard” or physical reasons [40] for a woman needing an abortion, such as if a pregnancy results from a rape. It would be interesting to include those questions in the future to determine if this population has different levels of acceptability for a variety of circumstances surrounding abortion. Although it is clear
that this sample identifies as religious, and religious membership, beliefs, and practices all appear to make independent contributions to the development of attitudes toward legal abortion, we are not able, with these data, to determine which participants are more involved in their religious establishments, and to what extent these beliefs and experiences inform their beliefs on abortion. In future work, it will be important to add a measure of religiosity to investigate this phenomenon. Given how few participants noted personal experiences with an abortion, there was likely under-reporting. This may underestimate the influence of having a personal experience with an abortion and how that shapes the views one takes on this issue. Unless there is more willingness to report this, however, it is not possible to understand the impact that personal experience has. Further, it would be interesting to investigate if the beliefs held by these students are malleable and amenable without necessitating personal experience. For example, is there a way to increase the acceptability of abortion among this population through a modified values clarification workshop where students would be presented with reasons why women might need an abortion? Finally, these data do not attempt to explain behavior differences between members of this population. It would be interesting to determine whether students with more liberal views of a woman’s right for an abortion are more likely to seek care for their own abortion in a safe manner or would be willing to advocate for women’s right to a safe abortion. Conclusion Students at the University of Cape Coast hold generally conservative views of abortion as it relates to their religion and morals. However, many students are supportive of a woman’s right to an abortion, especially if they are older, have a boyfriend/girlfriend, have ever had sexual intercourse, or they know anyone who has had an abortion. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Morhe RAS, Morhe ESK. Overview of the law and availability of abortion services in Ghana. Ghana Med J 2006;40(3):80–6. [2] Ghana Statistical Service, Ghana Health Service and Macro International Inc. Ghana maternal health survey 2007. Calverton (MD): Macro International; 2009. [3] Srofenyoh EK, Lassey AT. Abortion care in a teaching hospital in Ghana. Int J Gynaecol Obstet 2003;82(1):77–8. [4] Yeboah RWN, Kom M. Abortion: the case of Chenard Ward Korle Bu from 200 to 2001. Inst Afr Stud Res Rev 2003;19(1):57–9. [5] Sundaram A, Juarez F, Bankole A, Singh S. Factors associated with abortionseeking and obtaining a safe abortion in Ghana. Stud Fam Plann 2012;43(4):273–86. [6] Baird TL, Billings DL, Demuyakor B. Notes from the field: community education efforts enhance post-abortion care programme in Ghana. Am J Public Health 2000;90(4):631–2. [7] Sedgh G. Abortion in Ghana. In Brief 2010, 2. New York: Guttmacher Institute; 2010. [8] Nyarko P, Adohinzin C, Ramarao S, Tapsoba P, Ajayi A. Profile of abortion seekers in Ghana and their decision-making processes. Accra: Regional Institute for Population Studies: University of Ghana, Legon; 2008. [9] World Health Organisation. Safe abortion: technical and policy guidance for health systems. Geneva (Switzerland): World Health Organisation; 2003. [10] Osman S, Thompson A. Unsafe abortion in South Africa: a preventable pandemic. http://www.ngopulse.org/blogs/unsafe-abortion-south-africa-preventable -pandemic; 2012. [11] Grimes AD, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. Lancet 2006;368(9550):1908–19. [12] Hord C, Wolf M. Breaking the cycle of unsafe abortions in Africa. Afr J Reprod Health 2004;8(1):29–34. [13] Sai F. International commitments and guidance on unsafe abortion. Afr J Reprod Health 2004;8(1):16–18.
S.D. Rominski et al. / Sexual & Reproductive Healthcare 11 (2017) 53–59
[14] Oduro GY, Otsin MNA. “Abortion – it is my own body”: women’s narratives about influences on their abortion decisions in Ghana. Health Care Women Int 2014;35:7–9. [15] Holcombe SJ, Berhe A, Cherie A. Personal beliefs and professional responsibilities: Ethiopian midwives’ attitudes toward providing abortion services after legal reform. Stud Fam Plann 2015;46(1):73–95. [16] Ghana Health Service. Prevention and management of unsafe abortion: comprehensive abortion care services. Standards and protocols. Accra: GHS; 2006. [17] Norman ID, Kweku M, Binka FN. Critical review of the legal framework on abortion in Ghana. Don. J. Law Conflict. Resolut 2015;1(2):10–17. [18] Luginaaha IN, Yiridoeb EK, Taabazuing MM. From mandatory to voluntary testing: balancing human rights, religious and cultural values, and HIV/AIDS prevention in Ghana. Soc Sci Med 2005;61(8):1689–700. [19] Bleek W. Avoiding shame: the ethical context of abortion in Ghana. Anthropol Q 1981;54(4):203. [20] Mahomed F. Examining attitudes towards reproductive rights in the Guateng City – Region of South Africa. Soc Indic Res. 2015. [21] Appiah-Agyekum NN, Sorkpor C, Ofori-Mensah S. Determinants of abortion decisions among Ghanaian university students. Int J Adolesc Med Health 2015;27(1):79–84. [22] Thomas G, Gedif T, Abeshu MA, Geleta B. Assessment of knowledge, attitude and practices regarding medication abortion among regular undergraduate female students in College of Social Sciences Addis Ababa University, Ethiopia. Adv Pharmacoepidemiol Drug Saf 2016;5:1. [23] Adanu RM, Tweneboah E. Reasons, fears, and emotions behind induced abortions in Accra, Ghana. Inst Afr Stud Res Rev 2005;20:1–9. [24] Snegroff S. The development of instruments to measure attitudes toward abortion and knowledge of abortion. J Sch Health 1976;46(5):273–7. [25] Shellenberg KM, Hessini L, Levandowski BA. Developing a scale to measure stigmatizing attitudes and beliefs about women who have abortions: results from Ghana and Zambia. Women Health 2014;54(7):599–616. [26] Sorhaindo AM, Karver TS, Karver JG, Garcia SG. Constructing a validated scale to measure community-level abortion stigma in Mexico. Contraception 2016;93(5):421–31.
59
[27] Floyd FJ, Widaman KF. Factor analysis in the development and refinement of clinical assessment instruments. Psychol Assess 1995;7(3):286–99. [28] Tabachnick BG, Fidell LS. Using multivariate statistics. 5th ed. Boston: Pearson Education; 2007. [29] Patel CJ, Myeni MC. Attitudes toward abortion in a sample of South African female university students. J Appl Soc Psychol 2008;38(3):736–50. [30] Lester D. Attitudes towards abortion. Psychol Rep 2001;89:290. [31] Ekstrand M, Larsson M, Von Essen L, Tydén T. Swedish teenager perceptions of teenage pregnancy, abortion, sexual behavior, and contraceptive habits – a focus group study among 17-year-old female high-school students. Acta Obstet Gynecol Scand 2005;84(10):980–6. [32] Gleeson R, Forde E, Bates E, Powell S, Eadon-Jones E, Draper H. Medical students’ attitudes towards abortion: a UK study. J Med Ethics 2008;34: 783–7. [33] Carlton CL, Nelson ES, Coleman PK. College students’ attitudes towards abortion and commitment to the issue. Soc Sci J 2000;37(4):619–25. [34] Adamczyk A. The effect of personal religiosity on attitudes towards abortion, divorce, and gender equality. EurAmerica 2013;43:213–53. [35] Rominski SD, Lori JR, Nakua E, Dzomeku V, Moyer CA. What makes a likely abortion provider? Evidence from a nation-wide survey of final-year students at Ghana’s public midwifery training colleges. Contraception 2016;93(3):226– 32. [36] Morhe ESK, Morhe RAS, Danso KA. Attitudes of doctors toward establishing safe abortion units in Ghana. Int J Gynaecol Obstet 2007;98(1):70–4. [37] Konney TO, Danso KA, Odoi AT, Opare-Addo HS, Morhe ESK. Attitudes of women with abortion-related complications toward provision of safe abortion services in Ghana. J Womens Health 2009;18(11):1863–6. [38] Aniteye P, Mayhew S. Attitudes and experiences of women admitted to hospital with abortion complications in Ghana. Afr J Reprod Health 2011;15(1):47– 55. [39] Jelen TG, Wilcox C. Causes and consequences of public attitudes toward abortion: a review and research agenda. Polit Res Q 2003;56(4):489– 500. [40] Benin MH. Determinants of opposition to abortion: an analysis of the hard and soft scales. Sociol Perspect 1985;28(2):199–216.
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Attitudes toward abortion among students at the University of Cape Coast, Ghana Sarah D. Rominski a,*, Eugene Darteh b, Kwamena Sekyi Dickson b, Michelle Munro-Kramer c a
Global REACH, University of Michigan Medical School, USA Department of Population and Health, University of Cape Coast, Ghana c School of Nursing, University of Michigan, USA b
A R T I C L E
I N F O
Article history: Received 5 May 2016 Revised 10 October 2016 Accepted 13 October 2016 Keywords: Ghana Abortion Abortion attitude Exploratory factor analysis
A B S T R A C T
Objectives: This study aimed to describe the attitudes toward abortion of Ghanaian University students and to determine factors which are associated with supporting a woman’s right to an abortion. Methods: This cross-sectional survey was administered to residential students at the University of Cape Coast. Participants were posed a series of 26 statements to determine to what extent they were supportive of abortion as a woman’s right. An exploratory factor analysis was used to create a scale with the pertinent factors that relate to abortion attitudes and a multivariable linear regression model explored the relationships among significant variables noted during exploratory factor analysis. Results: 1038 students completed the survey and these students had a generally negative view of abortion. Two factors emerged: (1) the Abortion as a Right scale consisted of five questions (α = .755) and (2) the Moral Objection to Abortion scale consisted of three questions (α = .740). In linear regression, being older (β = 1.9), sexually experienced (β = 1.2), having a boyfriend/girlfriend (β = 1.4), and knowing someone who has terminated a pregnancy (β = 1.1) were significantly associated with a more liberal view of a right to an abortion. Discussion: This work supports the idea that students who have personal exposure to an abortion experience hold more liberal views on abortion than those who have not had a similar exposure. © 2016 Elsevier B.V. All rights reserved.
Background Despite having a relatively liberal abortion law [1], complications from unsafe abortion continue to be a major component of Ghana’s maternal mortality [2] and a large burden of disease in the country’s emergency gynecology wards [3,4]. While the law was liberalized in 1985 allowing abortion for a few broad categories [5], and the Ghana Health Service and the Ministry of Health established protocols for the provision of safe abortion services in 2006, nearly half of abortions in the country remain unsafe [5]. The incidence of abortion and associated morbidity and mortality is considered to be highest (25%) among women aged 20– 24 years [6], with a reported rate of 34 per 1000 among women in urban areas [7–9]. The situation in Ghana is further evidence that a liberal law is only effective at reducing mortality and morbidity associated with unsafe abortions if it is accompanied by appropri-
* Corresponding author. Department of Obstetrics and Gynecology, University of Michigan Medical School, USA. E-mail address: [email protected] (S.D. Rominski). http://dx.doi.org/10.1016/j.srhc.2016.10.002 1877-5756/© 2016 Elsevier B.V. All rights reserved.
ate service provision [10] and women’s willingness to seek such services [11–13]. Currently the Ghanaian law allows abortion if at least one of a few broad categories are met: (a) if the pregnancy is the result of rape or incest, (b) if there is gross fetal malformation, or (c) the continuation of the pregnancy endangers the life, or the mental or physical health of the mother [1]. This law is considered one of the most liberal in sub-Saharan Africa. Although a woman may have a right to a safe, clinic-based abortion in Ghana, negative attitudes toward the service from both providers and the general public may be one reason for the high numbers of women who seek services from outside the formal healthcare system [14]. Recent work in Ethiopia, which has a similar abortion law, has demonstrated that healthcare providers justified providing abortions in order to reduce maternal mortality, rather than in terms of a woman’s right to control her body or to have an abortion [15]. Although the framing of the 1985 liberalization of abortion in Ghana has not been well documented, in 2006, the Ghana Health Service published a document, “Prevention and Management of Unsafe Abortion: Comprehensive Abortion Care Services Standards and Protocols” [16]. This document is written from a public health lens, stressing the importance to reduce barriers to unsafe abortion in order to
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prevent unnecessary death and disability. While the “General Principles” section of the document indicates that, among other things, “each client has the right to access the service, as an integral part of comprehensive integrated reproductive health service provision”, this is the only mention of a woman’s right to an abortion. Except for in South Africa, most of the justification for the change in abortion laws, where they have occurred, have been to reduce maternal mortality, rather than based on a woman’s rights [15]. This may undermine the ability of women to insist on this right, and may empower providers to refuse to provide services and stigmatize women who seek these services. The abortion-rights movement in Ghana has been described as a constituency, “less than 10 persons consisting of medical doctors, lawyers and a handful of other interested parties” [17] and it is possible that the views of the nation on a whole are not represented in the liberal law. While it has been reported that Ghanaian society is deeply religious [18], and abortion stigma in Ghana can be linked to religious attitudes [19], general attitudes of University students – a population that falls within the age bracket with the highest incidence of abortion is scant in the country. Work in other settings such as South Africa has shown that cultural attitudes toward abortion correlate with conservative values in general [20]. Importantly, the safe abortion guidelines established in 2006 specifically encourage research and dissemination of information pertaining to abortion to students and other high risk groups [21]. Recent work has explored the determinants of decision-making among Ghanaian university students [21] and students’ knowledge about abortion in Ethiopia [22]. This work has found that students’ decision-making and knowledge are impacted by their education, religion, and relationship status [21]. However, the attitudes and views of sub-Saharan university students toward abortion have been largely unexplored. There is therefore a gap in the literature on Ghanaian University students’ attitudes toward abortion. As attitudes generally underpin laws and policies, it is important to understand the public’s attitudes and views toward an issue, especially one that can be politically charged, such as abortion. This information could provide the framework for future educational endeavors of students and policy changes [23]. The current study therefore sought to examine the attitudes of Ghanaian university students toward abortion. Methods
attitudes. The subset of questions regarding abortion experiences and attitudes are reported here. Sampling A quota was assigned to each hall based on the population of each hall of residence in order to make the sample as representative of the residential students as possible. Due to the exploratory nature of this study there were no a priori hypotheses that necessitated a power analysis. A list of room numbers for each hall was generated, and rooms to include in the survey were randomly selected via a random number generator. Research assistants approached each room and explained the study to the first resident they encountered. Most rooms house two students, although this varies some by hall. If the original student refused participation, the RAs invited a student from the next room. Those students who agreed to participate were handed the tablets hosting the survey. To ensure privacy and confidentiality, the respondents were encouraged to respond to the survey in private. Each survey took about 30 minutes. A total of 1042 residential students were successfully interviewed. Ethical considerations The survey received ethical clearance from the Institutional Review Board of the University of Michigan and was approved by the University of Cape Coast. Five field assistants were trained in the objectives of the survey and were available if any of the respondents had questions while they completed the survey. The field assistants could not view the responses of the participants and no identifying information was collected. Measures Similar to Snegroff [24], Shellenberg et al. [25], and Sorhaindo and colleagues [26], participants were posed a series of 26 declarative statements to determine to what extent they were supportive of abortion as a woman’s right. Participants were asked to respond to these statements on a 5-point Likert scale from Strongly Disagree to Strongly Agree. These statements were developed by the authors based on their experience working in the arena of abortion research in Ghana and based on extant literature.
Setting Analyses Data for the study were collected from a survey of residential students at the University of Cape Coast. The University of Cape Coast is one of the eight public (State-owned) universities in Ghana. It has a total population of about 24,000 pursuing various academic programs. The University has 8 official Halls of residence and hostels, which accommodate more than 6000 residential students. The University operates a residential policy where all freshmen are accommodated in the traditional halls of residence while continuing students make their own arrangements for accommodation.
All data were transferred from the DroidSurvey platform to Excel and then imported into IBM SPSS version 22 (SPSS, Inc., Chicago, IL). First, descriptive statistics were used to explore the data. Then, an exploratory factor analysis was used for data reduction in order to create the outcome variable, a scale with the pertinent factors that relate to abortion attitudes [27]. Finally, a multivariable linear regression was run with variables that were found to be associated with the outcome variable created during exploratory factor analysis.
Instrument Results The questionnaire was developed and pilot tested among similaraged students (n = 20) who studied at the Cape Coast polytechnic, a tertiary-level institution located in the same city. Some slight modifications were made to the survey based on these pilot tests. The survey was self-administered on tablet computers using DroidSurvey software. The instrument had four sections: (a) background, (b) knowledge and attitude of sexual and reproductive health, (c) sexual and reproductive health risk perception, and (d) abortion experience and
Characteristics of the sample Due to the small number of missing responses, it was determined a priori that those participants who had omitted questions would be excluded from data analyses. This resulted in complete data from 1038 (99.6%) students for the regression analyses. Slightly less than half the sample was female (n = 480, 46.2%). A majority (71.9%, n = 746) has ever had a boyfriend or girlfriend. Of those, 476
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Table 2 Full set of statements presented to participants.
Table 1 Participant demographics (n/%). Variable Gender Male Female Romantic relationship history Ever had boyfriend/girlfriend Currently has boyfriend/girlfriend Religion Pentecostal/Charismatic Methodist Catholic Other Christian Presbyterian Muslim Anglican No religion Traditional/Spiritualist Ethnicity Ashanti Fanti Other Ghanaian Ewe Ga/Adangbe Mole-Dagbani Field of study Agriculture Business Computer Science Education Geography Humanities Mathematics Nursing Science Social Science Missing
55
Number (percent) 556 (53.6) 480 (46.2) 746 (71.9) 476 (45.9) 384 (37.0) 170 (16.4) 142 (13.7) 142 (13.7) 118 (11.4) 45 (4.3) 9 (0.9) 4 (0.4) 3 (0.3) 351 (33.8) 294 (28.3) 155 (14.9) 124 (11.9) 84 (8.1) 14 (1.3) 18 (1.7) 212 (20.4) 13 (1.3) 112 (10.8) 20 (1.9) 173 (16.7) 69 (6.6) 65 (6.3) 148 (14.2) 187 (18.0) 22 (2.1)
currently have a boyfriend/girlfriend. For more information about the characteristics of the sample, see Table 1. Preliminary analyses An exploratory factor analysis was utilized to consolidate items based on perceptions of abortion. The full set of statements presented to participants can be seen in Table 2. The suitability of the sample size was examined prior to analyses. As a rule of thumb, Tabachnick and Fidell [28] recommend having at least 300 cases for factor analysis, which our sample greatly surpassed. Sampling adequacy for factor analysis was deemed adequate using the Kaiser– Meyer–Olkin (.74) and the Bartlett test of Sphericity was significant (χ2 (df = 66) = 2095.08, p < .001) indicating that relationships among the items existed [28]. Using principle component analysis with varimax rotation, two factors appeared to load. These factors have been termed Abortion as a Right and Moral Objection to Abortion. The statements for the first factor, Abortion as a Right, were: 1 Access to safe abortion services is every woman’s right. 2 Women need access to safe abortion services. 3 It is a good thing women can obtain legal abortion services in Ghana. 4 A woman should always have a right to have an abortion in the case of an unwanted pregnancy. 5 Women, regardless of the circumstances surrounding their pregnancy, have a right to respectful care for an induced abortion. The questions which composed this factor were summed to create an Abortion as a Right sub-scale. As the initial questions were asked on a 5-point Likert scale, with 1 corresponding to Strongly Dis-
Life begins at conception A woman has a right to control her body Termination of pregnancy is against my religion Termination of pregnancy is against my morals Access to safe abortion services is every woman’s right I believe women have a right to judgment-free abortion care Ghanaian women are suffering from unsafe abortion Unsafe abortion is a preventable cause of death in woman I believe women need access to safe abortion services There are enough abortion care providers in Ghana Women are able to get safe abortion services when they need them I think it’s a good thing that women can obtain legal abortion services in Ghana It’s easier to get abortion services if you are married Abortions among unmarried women are rising in Ghana Unmarried women prefer to have an abortion outside public health clinics Married women prefer to have an abortion outside public health clinics Women prefer to have an abortion in public health clinics Abortions from unregistered providers are more harmful than abortions from registered clinics Abortion is morally wrong A woman should always have a right to have an abortion in case of an unwanted pregnancy A women needs to have her partner/spouse’s approval to have an abortion Abortion care seekers or clients in public health facilities are treated with respect in Ghana Abortion care seekers or clients in private facilities are treated with respect in Ghana Women, regardless of the circumstances surrounding their pregnancy, have a right to respectful care for an induced abortion
agree and 5 corresponding to Strongly Agree, this scale, which ranges from 5 to 25, ranks participants from those who feel that abortion is not a right to those who support abortion rights for all women, regardless of the circumstances surrounding their pregnancy. Participants’ scores on the Abortion as a Right sub-scale ranged from 5 to 25, covering all possible scores, with a mean of 15.6 (SD = 4.9). The Abortion as a Right scale had a Cronbach’s alpha of .755, indicating a high level of internal consistency. The questions for the second factor, Moral Objection to Abortion, were: 1 Termination of pregnancy is against my religion. 2 Termination of pregnancy is against my morals. 3 Abortion is morally wrong. A sub-scale for Moral Objection to Abortion was created, summing the three questions above. This scale ranges from 3 to 15, with a higher score corresponding to a more conservative view of abortion. The participants in this study held generally conservative views of abortion, with 480 (46.2%) scoring 15 on this sub-scale, meaning they strongly agree with all three statements. The mean score was 13.5 (SD = 2.2). Almost 80% of the sample (78.9%) scored 12 or higher on this subscale. The Moral Objection to Abortion sub-scale had a Cronbach alpha of .740. The two sub-scales were negatively associated (Pearson’s correlation = −.108; p = .001), as would be expected. The Abortion as a Right sub-scale was used as the outcome variable in a linear regression. Factors which were significantly associated, p < .05, with this scale in bivariate analysis were entered into a multivariate regression. Table 2 presents the results of participant characteristics tested against the Abortion as a Right sub-scale (Table 3). The distribution of the Abortion as a Right scale can be seen in Fig. 1 and the distribution of the Moral Objection to Abortion scale can be seen in Fig. 2. Factors found to be associated at the p < .1 level in bivariate analysis with the Abortion as a Right scale were being under the age of 20 or over the age of 24, currently having a boyfriend/girlfriend,
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Table 3 Factor loadings of abortion items. Item Factor 1: Abortion as a Right
Factor 2: Moral Objection to Abortion
Loading Access to safe abortion services is every woman’s right Women need access to safe abortion services It is a good thing women can obtain legal abortion services in Ghana A woman should always have a right to have an abortion in a case of an unwanted pregnancy Women, regardless of the circumstances surrounding their pregnancy, have a right to respectful care for an induced abortion Termination of pregnancy is against my religion Termination of pregnancy is against my morals Abortion is morally wrong
.754 .761 .673 .669 .624 .836 .843 .630
having ever had sexual intercourse, having ever terminated a pregnancy (or for males, having a partner who had), and knowing anyone who had terminated a pregnancy. For the Moral Objection to Abortion scale, only ever having sexual intercourse was associated with the sub-scale (Table 4). The majority of the sample (n = 804, 77.6%) were between the ages of 21 and 24, and reported having a boyfriend or girlfriend at the time of the study (n = 476, 63.6%). Fewer students had sexual intercourse (n = 371, 43%), but a majority of those who had used some form of contraception at their last sex (n = 250, 69.8%). While few participants (n = 54, 5.2%) reported they had an abortion, a large minority of the participants (n = 434, 41.8%) knew someone who has had an abortion.
ally experienced, currently having a boy/girlfriend, and knowing someone who has terminated a pregnancy (Table 5). Holding other variables constant, participants who are over the age of 25 scored almost 2 points higher on the Abortion as a Right sub-scale as their younger colleagues. Likewise, those who currently have a boyfriend/girlfriend or who know anyone who has terminated a pregnancy score over 1 point higher on the scale. Finally, those participants who have ever had sexual intercourse score 1.4 points higher on the scale. Each of these variables remains statistically significant in this multivariate analysis. Due to the lack of significantly associated variables to the Moral Objection to Abortion sub-scale, a multivariate analysis was not conducted with that as the outcome variable.
Modeling
Discussion
When entered into a multivariate linear regression with the Abortion as a Right factor as the outcome, the factors that remained significantly associated are being over the age of 25, being sexu-
In this study of 1042 residential students at the University of Cape Coast, students had a generally conservative view of a woman’s right to an abortion. Many of the students surveyed believed that abor-
Fig. 1. Distribution of Abortion as a Right sub-scale.
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Fig. 2. Distribution of the Moral Objection to Abortion sub-scale.
tion is morally wrong. Results of an exploratory factor analysis suggested two sub-scales: (a) Moral Objection to Abortion and (b) Abortion as a Right. Students held views that abortion is morally wrong, with 480 recording the highest possible score on that subscale. While there has been almost no work done on this topic in Ghana, previous work in South Africa has suggested that university students there hold generally conservative views toward abortion [29]. While young people, including university students, in other settings, including the United States [30], Sweden [31], and Britain [32], generally hold liberal views toward abortion. It seems that in Ghana students are likely to hold conservative views toward the mo-
rality of abortion, even if they have personal experience with having an abortion, or know someone who has had one. On the Abortion as a Right sub-scale, there was a more even distribution, with many students reporting ambivalence when it comes to a woman’s right to an abortion, regardless of the circumstances surrounding her pregnancy. Students who were older (over the age of 25), who currently have a boyfriend/girlfriend, who have ever had sexual intercourse, and who know anyone who has terminated a pregnancy were more likely to be supportive of a woman’s right to an abortion. Similar to Carlton et al. [33], this work did not find a difference in abortion attitude for males versus females, but did
Table 4 Participant characteristics and association with abortion right scale and moral objection scale. Characteristic
Answer
N (%)
p-value – right to abortion
p-value – moral objection
Age
Under 20 21–24 Over 25 No Yes Yes No Yes No Yes No Missing Yes No Missing Yes No Missing
171 (16.5) 804 (77.6) 51 (4.9) 272 (36.4) 476 (63.6) 371 (43.0) 493 (57.1) 250 (69.8) 108 (30.2) 54 (5.2) 974 (93.8) 11 (1.1) 434 (41.8) 594 (57.1) 11 (1.1) 156 (15.0) 866 (83.6) 14 (1.3)
.086 Reference category .004 .097
.353 Reference category .178 .603
Do you currently have a boyfriend/girlfriend?a Have you ever had sexual intercourse?b At last sex, was any contraception used? Have you ever had an abortion/terminated a pregnancy?
Do you know anybody who has ever had an abortion/ terminated a pregnancy before? Ever been forced or coerced into sex
a b
Asked of those participants who answered they had ever had a boyfriend/girlfriend. Asked of those participants who answered they had heard of sexual intercourse.
.000
.074
.984
.222
.050
.500
<.001
.637
.379
.925
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Table 5 Results of the multivariate linear regression with right to abortion scale as the outcome variable. Variable
B (std. error)
Significance
Age > 25 Currently have boyfriend/girlfriend Ever had sexual intercourse Know anyone who has terminated a pregnancy Constant
1.9 (.83) 1.2 (.42) 1.4 (.14) 1.1 (.41) 14.0 (.44)
.022 .004 .001 .006
find that those who have a personal indirect experience with abortion hold more liberal views toward a woman’s right to an abortion. The current study supports the idea that students who have personal exposure to an abortion experience hold more liberal views on abortion than those who have not had a similar exposure [33]. In this case, personal experience with an abortion was not significantly associated with the outcome variable, perhaps because just over 5% of the sample reported they had ever terminated a pregnancy. However, knowing someone who has had a termination was associated with a more liberal view of a woman’s right to an abortion. In a setting where abortion is highly stigmatized, as it appears to be in Ghana, students may not have been completely forthcoming about their own experience with abortion, as other studies in Ghana would suggest a higher proportion of participants of this age group having experienced abortion. It is perhaps not surprising that in a sample where almost every participant reported affiliating with a religion, generally conservative views of abortion predominate. Ghana has been described as a highly religious country [18], and this sample is not different. In settings across the world, religiosity has been associated with generally negative views toward abortion [34]. Previous works in the area of attitudes toward abortion in Ghana have been focused almost exclusively on healthcare providers and their willingness to provide abortion services [35,36] or women seeking care for abortion services [37,38]. This is the first study that we are aware of which aims to assess to what extent Ghanaian university students are supportive of abortion and which finds personal experiences to be associated with students reporting their agreement with a woman’s right to an abortion in the case of an unwanted pregnancy. While attitudes toward abortion have been widely and deeply studied in the United States [39], there has been far less work on this topic in Ghana. This work has important policy implications. Since attitudes form the basis for policies and laws, it is important to understand public attitude. It appears that, while many university students feel that abortion is morally wrong, this does not preclude some of them from also supporting a woman’s right to an abortion. It would be interesting to see what the public support would be for an amendment to the law stating women’s positive rights to an abortion, rather than it being legal only if it is deemed a necessary health intervention. Further work in this area, including determining policy makers’ willingness to sponsor such legislation, would be an important next step. Limitations and future work This study has some limitations which need to be addressed. As this survey asked questions of a sensitive nature, it was developed so it could be taken in a private location on a tablet computer. However, feelings on abortion are undoubtedly complex and might not be best explored through a quantitative survey. Further, the survey did not ask about “hard” or physical reasons [40] for a woman needing an abortion, such as if a pregnancy results from a rape. It would be interesting to include those questions in the future to determine if this population has different levels of acceptability for a variety of circumstances surrounding abortion. Although it is clear
that this sample identifies as religious, and religious membership, beliefs, and practices all appear to make independent contributions to the development of attitudes toward legal abortion, we are not able, with these data, to determine which participants are more involved in their religious establishments, and to what extent these beliefs and experiences inform their beliefs on abortion. In future work, it will be important to add a measure of religiosity to investigate this phenomenon. Given how few participants noted personal experiences with an abortion, there was likely under-reporting. This may underestimate the influence of having a personal experience with an abortion and how that shapes the views one takes on this issue. Unless there is more willingness to report this, however, it is not possible to understand the impact that personal experience has. Further, it would be interesting to investigate if the beliefs held by these students are malleable and amenable without necessitating personal experience. For example, is there a way to increase the acceptability of abortion among this population through a modified values clarification workshop where students would be presented with reasons why women might need an abortion? Finally, these data do not attempt to explain behavior differences between members of this population. It would be interesting to determine whether students with more liberal views of a woman’s right for an abortion are more likely to seek care for their own abortion in a safe manner or would be willing to advocate for women’s right to a safe abortion. Conclusion Students at the University of Cape Coast hold generally conservative views of abortion as it relates to their religion and morals. However, many students are supportive of a woman’s right to an abortion, especially if they are older, have a boyfriend/girlfriend, have ever had sexual intercourse, or they know anyone who has had an abortion. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Morhe RAS, Morhe ESK. Overview of the law and availability of abortion services in Ghana. Ghana Med J 2006;40(3):80–6. [2] Ghana Statistical Service, Ghana Health Service and Macro International Inc. Ghana maternal health survey 2007. Calverton (MD): Macro International; 2009. [3] Srofenyoh EK, Lassey AT. Abortion care in a teaching hospital in Ghana. Int J Gynaecol Obstet 2003;82(1):77–8. [4] Yeboah RWN, Kom M. Abortion: the case of Chenard Ward Korle Bu from 200 to 2001. Inst Afr Stud Res Rev 2003;19(1):57–9. [5] Sundaram A, Juarez F, Bankole A, Singh S. Factors associated with abortionseeking and obtaining a safe abortion in Ghana. Stud Fam Plann 2012;43(4):273–86. [6] Baird TL, Billings DL, Demuyakor B. Notes from the field: community education efforts enhance post-abortion care programme in Ghana. Am J Public Health 2000;90(4):631–2. [7] Sedgh G. Abortion in Ghana. In Brief 2010, 2. New York: Guttmacher Institute; 2010. [8] Nyarko P, Adohinzin C, Ramarao S, Tapsoba P, Ajayi A. Profile of abortion seekers in Ghana and their decision-making processes. Accra: Regional Institute for Population Studies: University of Ghana, Legon; 2008. [9] World Health Organisation. Safe abortion: technical and policy guidance for health systems. Geneva (Switzerland): World Health Organisation; 2003. [10] Osman S, Thompson A. Unsafe abortion in South Africa: a preventable pandemic. http://www.ngopulse.org/blogs/unsafe-abortion-south-africa-preventable -pandemic; 2012. [11] Grimes AD, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. Lancet 2006;368(9550):1908–19. [12] Hord C, Wolf M. Breaking the cycle of unsafe abortions in Africa. Afr J Reprod Health 2004;8(1):29–34. [13] Sai F. International commitments and guidance on unsafe abortion. Afr J Reprod Health 2004;8(1):16–18.
S.D. Rominski et al. / Sexual & Reproductive Healthcare 11 (2017) 53–59
[14] Oduro GY, Otsin MNA. “Abortion – it is my own body”: women’s narratives about influences on their abortion decisions in Ghana. Health Care Women Int 2014;35:7–9. [15] Holcombe SJ, Berhe A, Cherie A. Personal beliefs and professional responsibilities: Ethiopian midwives’ attitudes toward providing abortion services after legal reform. Stud Fam Plann 2015;46(1):73–95. [16] Ghana Health Service. Prevention and management of unsafe abortion: comprehensive abortion care services. Standards and protocols. Accra: GHS; 2006. [17] Norman ID, Kweku M, Binka FN. Critical review of the legal framework on abortion in Ghana. Don. J. Law Conflict. Resolut 2015;1(2):10–17. [18] Luginaaha IN, Yiridoeb EK, Taabazuing MM. From mandatory to voluntary testing: balancing human rights, religious and cultural values, and HIV/AIDS prevention in Ghana. Soc Sci Med 2005;61(8):1689–700. [19] Bleek W. Avoiding shame: the ethical context of abortion in Ghana. Anthropol Q 1981;54(4):203. [20] Mahomed F. Examining attitudes towards reproductive rights in the Guateng City – Region of South Africa. Soc Indic Res. 2015. [21] Appiah-Agyekum NN, Sorkpor C, Ofori-Mensah S. Determinants of abortion decisions among Ghanaian university students. Int J Adolesc Med Health 2015;27(1):79–84. [22] Thomas G, Gedif T, Abeshu MA, Geleta B. Assessment of knowledge, attitude and practices regarding medication abortion among regular undergraduate female students in College of Social Sciences Addis Ababa University, Ethiopia. Adv Pharmacoepidemiol Drug Saf 2016;5:1. [23] Adanu RM, Tweneboah E. Reasons, fears, and emotions behind induced abortions in Accra, Ghana. Inst Afr Stud Res Rev 2005;20:1–9. [24] Snegroff S. The development of instruments to measure attitudes toward abortion and knowledge of abortion. J Sch Health 1976;46(5):273–7. [25] Shellenberg KM, Hessini L, Levandowski BA. Developing a scale to measure stigmatizing attitudes and beliefs about women who have abortions: results from Ghana and Zambia. Women Health 2014;54(7):599–616. [26] Sorhaindo AM, Karver TS, Karver JG, Garcia SG. Constructing a validated scale to measure community-level abortion stigma in Mexico. Contraception 2016;93(5):421–31.
59
[27] Floyd FJ, Widaman KF. Factor analysis in the development and refinement of clinical assessment instruments. Psychol Assess 1995;7(3):286–99. [28] Tabachnick BG, Fidell LS. Using multivariate statistics. 5th ed. Boston: Pearson Education; 2007. [29] Patel CJ, Myeni MC. Attitudes toward abortion in a sample of South African female university students. J Appl Soc Psychol 2008;38(3):736–50. [30] Lester D. Attitudes towards abortion. Psychol Rep 2001;89:290. [31] Ekstrand M, Larsson M, Von Essen L, Tydén T. Swedish teenager perceptions of teenage pregnancy, abortion, sexual behavior, and contraceptive habits – a focus group study among 17-year-old female high-school students. Acta Obstet Gynecol Scand 2005;84(10):980–6. [32] Gleeson R, Forde E, Bates E, Powell S, Eadon-Jones E, Draper H. Medical students’ attitudes towards abortion: a UK study. J Med Ethics 2008;34: 783–7. [33] Carlton CL, Nelson ES, Coleman PK. College students’ attitudes towards abortion and commitment to the issue. Soc Sci J 2000;37(4):619–25. [34] Adamczyk A. The effect of personal religiosity on attitudes towards abortion, divorce, and gender equality. EurAmerica 2013;43:213–53. [35] Rominski SD, Lori JR, Nakua E, Dzomeku V, Moyer CA. What makes a likely abortion provider? Evidence from a nation-wide survey of final-year students at Ghana’s public midwifery training colleges. Contraception 2016;93(3):226– 32. [36] Morhe ESK, Morhe RAS, Danso KA. Attitudes of doctors toward establishing safe abortion units in Ghana. Int J Gynaecol Obstet 2007;98(1):70–4. [37] Konney TO, Danso KA, Odoi AT, Opare-Addo HS, Morhe ESK. Attitudes of women with abortion-related complications toward provision of safe abortion services in Ghana. J Womens Health 2009;18(11):1863–6. [38] Aniteye P, Mayhew S. Attitudes and experiences of women admitted to hospital with abortion complications in Ghana. Afr J Reprod Health 2011;15(1):47– 55. [39] Jelen TG, Wilcox C. Causes and consequences of public attitudes toward abortion: a review and research agenda. Polit Res Q 2003;56(4):489– 500. [40] Benin MH. Determinants of opposition to abortion: an analysis of the hard and soft scales. Sociol Perspect 1985;28(2):199–216.