Experiences of women seeking post-abortion care services in a Regional Hospital in Ghana

Introduction Abortions remain one of the highest contributors to maternal deaths in Ghana. In 2003, a policy on post-abortion care was introduced to help reduce abortion-related mortality and morbidity. However, depending on the method of pregnancy termination; women encounter varying experiences. This study examines the experiences of women seeking post-abortion care services in a Regional Hospital in Ghana. Materials and methods In-depth interview technique was used to collect data from 20 purposively selected post-abortion care clients at the Volta Regional Hospital. Data were analysed manually using a qualitative content analysis technique. Results The study found that medical abortion was the main method of pregnancy termination used by women who participated in the study to induce abortion. Spontaneous abortion, however, was attributed mainly to engaging in activities that required the use of excessive energy and travelling on bad roads by pregnant women. The study also revealed that, women do not seek early post-abortion care services due to stigma and poverty. Conclusions We found that severity of pain from complications, stigma and financial constraints were factors that influenced women’s decision to seek post-abortion care services. Our findings also suggest that women who experienced spontaneous abortion mainly received financial and emotional support from partners and other family members. To encourage women to seek early post-abortion care services, the Ministry of Health and the Ghana Health Service should take pragmatic steps to educate women on the dangers associated with delay in seeking post-abortion care services and the factors that expose women to spontaneous abortions.

Qualitative research explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers in health care. Poorly designed studies and inadequate reporting can lead to inappropriate application of qualitative research in decision-making, health care, health policy and future research.
Formal reporting guidelines have been developed for randomized controlled trials (CONSORT) [1], diagnostic test studies (STARD), meta-analysis of RCTs (QUOROM) [2], observational studies (STROBE) [3] and meta-analyses of observational studies (MOOSE) [4]. These aim to improve the quality of reporting these study types and allow readers to better understand the design, conduct, analysis and findings of published studies. This process allows users of published research to be more fuller informed when they critically appraise studies relevant to each checklist and decide upon applicability of research findings to their local settings. Empiric studies have shown that the use of the CONSORT statement is associated with improvements in the quality of reports of randomized controlled trials [5]. Systematic reviews of qualitative research almost always show that key aspects of study design are not reported, and so there is a clear need for a CONSORT-equivalent for qualitative research [6].
The Uniform Requirements for Manuscripts Submitted to Biomedical Journals published by the International Committee of Medical Journal Editors (ICMJE) do not provide reporting guidelines for qualitative studies. Of all the mainstream biomedical journals (Fig. 1), only the British Medical Journal (BMJ) has criteria for reviewing qualitative research. However, the guidelines for authors specifically record that the checklist is not routinely used. In addition, the checklist is not comprehensive and does not provide specific guidance to assess some of the criteria. Although checklists for critical appraisal are available for qualitative research, there is no widely endorsed reporting framework for any type of qualitative research [7].
We have developed a formal reporting checklist for in-depth interviews and focus groups, the most common methods for data collection in qualitative health research.
These two methods are particularly useful for eliciting patient and consumer priorities and needs to improve the quality of health care [8]. The checklist aims to promote complete and transparent reporting among researchers and indirectly improve the rigor, comprehensiveness and credibility of interview and focus-group studies.

Basic definitions
Qualitative studies use non-quantitative methods to contribute new knowledge and to provide new perspectives in health care. Although qualitative research encompasses a broad range of study methods, most qualitative research  [26,27], † References [6, 28 -32], ‡ Author and reviewer guidelines provided by BMJ, JAMA, Lancet, Annals of Internal Medicine, NEJM.
publications in health care describe the use of interviews and focus groups [8].

Interviews
In-depth and semi-structured interviews explore the experiences of participants and the meanings they attribute to them. Researchers encourage participants to talk about issues pertinent to the research question by asking open-ended questions, usually in one-to-one interviews. The interviewer might re-word, re-order or clarify the questions to further investigate topics introduced by the respondent. In qualitative health research, in-depth interviews are often used to study the experiences and meanings of disease, and to explore personal and sensitive themes. They can also help to identify potentially modifiable factors for improving health care [9].

Focus groups
Focus groups are semi-structured discussions with groups of 4-12 people that aim to explore a specific set of issues [10]. Moderators often commence the focus group by asking broad questions about the topic of interest, before asking the focal questions. Although participants individually answer the facilitator's questions, they are encouraged to talk and interact with each other [11]. This technique is built on the notion that the group interaction encourages respondents to explore and clarify individual and shared perspectives [12]. Focus groups are used to explore views on health issues, programs, interventions and research.

Development of a checklist
Search strategy. We performed a comprehensive search for published checklists used to assess or review qualitative studies, and guidelines for reporting qualitative studies in: Medline (1966-Week 1 April 2006), CINAHL (1982-Week 3 April 2006), Cochrane and Campbell protocols, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications. We identified the terms used to index the relevant articles already in our possession and performed a broad search using those search terms. The electronic databases were searched using terms and text words for research (standards), health services research (standards) and qualitative studies (evaluation). Duplicate checklists and detailed instructions for conducting and analysing qualitative studies were excluded.
Data extraction. From each of the included publications, we extracted all criteria for assessing or reporting qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive list. We recorded the frequency of each item across all the publications. Items most frequently included in the checklists related to sampling method, setting for data collection, method of data collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. (see Tables 2 -4) Within each domain we simplified all relevant items by removing duplicates and those that were ambiguous, too broadly defined, not specific to qualitative research, or impractical to assess. Where necessary, the remaining items were rephrased for clarity. Based upon consensus among the authors, two new items that were considered relevant for reporting qualitative research were added. The two new items were identifying the authors who conducted the interview or focus group and reporting the presence of non-participants during the interview or focus group. The COREQ checklist for explicit and comprehensive reporting of qualitative studies consists of 32 criteria, with a descriptor to supplement each item (Table 1).
COREQ: content and rationale (see Tables 1) Domain 1: research team and reflexivity (i) Personal characteristics: Qualitative researchers closely engage with the research process and participants and are therefore unable to completely avoid personal bias. Instead researchers should recognize and clarify for readers their identity, credentials, occupation, gender, experience and training. Subsequently this improves the credibility of the findings by giving readers the ability to assess how these factors might have influenced the researchers' observations and interpretations [13 -15].
(ii) Relationship with participants: The relationship and extent of interaction between the researcher and their participants should be described as it can have an effect on the participants' responses and also on the researchers' understanding of the phenomena [16]. For example, a clinicianresearcher may have a deep understanding of patients' issues but their involvement in patient care may inhibit frank discussion with patient -participants when patients believe that their responses will affect their treatment. For transparency, the investigator should identify and state their assumptions and personal interests in the research topic.

Domain 2: study design
(i) Theoretical framework: Researchers should clarify the theoretical frameworks underpinning their study so readers can understand how the researchers explored their research questions and aims. Theoretical frameworks in qualitative research include: grounded theory, to build theories from the data; ethnography, to understand the culture of groups with shared characteristics; phenomenology, to describe the meaning and significance of experiences; discourse analysis, to analyse linguistic expression; and content analysis, to systematically organize data into a structured format [10].
(ii) Participant selection: Researchers should report how participants were selected. Usually purposive sampling is used which involves selecting participants who share particular characteristics and have the potential to provide rich, relevant and diverse data pertinent to the research question [13,17]. Convenience sampling is less optimal because it may fail to capture important perspectives from difficultto-reach people [16]. Rigorous attempts to recruit participants and reasons for non-participation should be stated to reduce the likelihood of making unsupported statements [18].    Researchers should report the sample size of their study to enable readers to assess the diversity of perspectives included. (iii) Setting: Researchers should describe the context in which the data were collected because it illuminates why participants responded in a particular way. For instance, participants might be more reserved and feel disempowered talking in a hospital setting. The presence of non-participants during interviews or focus groups should be reported as this can also affect the opinions expressed by participants. For example, parent interviewees might be reluctant to talk on sensitive topics if their children are present. Participant characteristics, such as basic demographic data, should be reported so readers can consider the relevance of the findings and interpretations to their own situation. This also allows readers to assess whether perspectives from different groups were explored and compared, such as patients and health care providers [13,19].
(iv) Data collection: The questions and prompts used in data collection should be provided to enhance the readers' understanding of the researcher's focus and to give readers the ability to assess whether participants were encouraged to openly convey their viewpoints. Researchers should also report whether repeat interviews were conducted as this can influence the rapport developed between the researcher and participants and affect the richness of data obtained. The method of recording the participants' words should be reported. Generally, audio recording and transcription more accurately reflect the participants' views than contemporaneous researcher notes, more so if participants checked their own transcript for accuracy [19][20][21]. Reasons for not audio recording should be provided. In addition, field notes maintain contextual details and non-verbal expressions for data analysis and interpretation [19,22]. Duration of the interview or focus group should be reported as this affects the amount of data obtained. Researchers should also clarify whether participants were recruited until no new relevant knowledge was being obtained from new participants (data saturation) [23,24].

Domain 3: analysis and findings
(i) Data analysis: Specifying the use of multiple coders or other methods of researcher triangulation can indicate a broader and more complex understanding of the phenomenon. The credibility of the findings can be assessed if the process of coding (selecting significant sections from participant statements), and the derivation and identification of themes are made explicit. Descriptions of coding and memoing demonstrate how the researchers perceived, examined and developed their understanding of the data [17,19]. Researchers sometimes use software packages to assist with storage, searching and coding of qualitative data. In addition, obtaining feedback from participants on the research findings adds validity to the researcher's interpretations by ensuring that the participants' own meanings and perspectives are represented and not curtailed by the researchers' own agenda and knowledge [23].
(ii) Reporting: If supporting quotations are provided, researchers should include quotations from different participants to add transparency and trustworthiness to their findings and interpretations of the data [17]. Readers should be able to assess the consistency between the data presented and the study findings, including the both major and minor themes. Summary findings, interpretations and theories generated should be clearly presented in qualitative research publications.

Discussion
The COREQ checklist was developed to promote explicit and comprehensive reporting of qualitative studies (interviews and focus groups). The checklist consists of items specific to reporting qualitative studies and precludes generic criteria that are applicable to all types of research reports. COREQ is a comprehensive checklist that covers necessary components of study design, which should be reported. The criteria included in the checklist can help researchers to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.
At present, we acknowledge there is no empiric basis that shows that the introduction of COREQ will improve the quality of reporting of qualitative research. However this is no different than when CONSORT, QUOROM and other reporting checklists were introduced. Subsequent research has shown that these checklists have improved the quality of reporting of study types relevant to each checklist [5,25], and we believe that the effect of COREQ is likely to be similar. Despite differences in the objectives and methods of quantitative and qualitative methods, the underlying aim of transparency in research methods and, at the least, the theoretical possibility of the reader being able to duplicate the study methods should be the aims of both methodological approaches. There is a perception among research funding agencies, clinicians and policy makers, that qualitative research is 'second class' research. Initiatives like COREQ are designed to encourage improvement in the quality of reporting of qualitative studies, which will indirectly lead to improved conduct, and greater recognition of qualitative research as inherently equal scientific endeavor compared with quantitative research that is used to assess the quality and safety of health care. We invite readers to comment on COREQ to improve the checklist.