Introduction

Globally, about 830 women die from pregnancy and childbirth-related complications every day, and abortion accounts for 8 percent of these maternal mortality cases [1]. Abortion is one of the global public health concerns, particularly affecting low- and middle-income countries where there are controversial perspectives as well as varied regulatory regimes [2]. While the developed world has witnessed a significant decline in abortion since the 1990s, same cannot be said for the developing world [3].

In Ghana, abortion is one of the main contributors to the maternal mortality rate [4]. More than one in every ten maternal deaths is attributed to unsafe abortion [5]. The high rate of maternal mortality that results from unsafe abortions can be attributed to social barriers such as provider attitudes [6], conscientious objection, and high stigma [7] attached to abortion in Ghana. These barriers make it difficult to effect appropriate policy reforms and changes that are necessary to address the problems posed by unsafe abortion [7]. Hence, women face many challenges in seeking abortion care [8]. Depending on the frequency, method, and location for seeking an abortion, women tend to have vast experiences motivated by diverse factors [9]. It is, however, worth mentioning that abortion complications do not only result from unsafe abortions, as both safe and unsafe abortions contribute to abortion complications [9].

Studies have indicated that most induced abortions result from unintended pregnancies which could be mistimed pregnancies, unplanned pregnancies or possibly unwanted pregnancies—all these have their associated experiences (see Warriner & Shah [10] and Finer et al. [11]). A woman who seeks a clandestine abortion may try some traditional techniques of varying efficacies and harmfulness, and these clandestine abortions have their own experiences [12]. Some methods of unsafe abortion include drinking toxic fluids such as turpentine and bleach or other drinkable concoctions mixed with livestock manure such as cow dung [12]. Others are a forceful manipulation of the abdomen and insertion of sticks and other objects into the vagina, cervix, or uterus [13]. Many of these techniques pose threats to a woman’s health and, sometimes, even her life [13]. If these methods fail to cause a complete pregnancy termination, the woman may then go to a pharmacist, a nurse, or a doctor known to provide abortion services [13].

According to the 2017 Ghana Maternal Health Survey, 20 percent of women aged 15–49 have ever induced an abortion. However, the percentage of women who have had an induced abortion in the last 5 years preceding the 2007 and 2017 surveys remained relatively unchanged, with 5 percent and 7 percent respectively [14]. A study conducted in Southern Ghana reported 17 abortions per 1,000 women of reproductive age [15] while another found that about 23 percent of women have ever had an induced abortion [16].

Although abortion is a criminal offence in Ghana, it is permitted when the pregnancy is a result of rape or incest, when there is a need to protect the mental or physical health of the mother, and when there is a malformation of the fetus, thus, making the abortion law in Ghana relatively liberal compared to other African countries [7]. Nonetheless, more than two-thirds of women who sought abortion turned to untrained providers or induced an abortion on their own [17, 18]. Concerning common abortion practices, findings from other studies suggest medical abortion through the use of Mifepristone and Misoprostol in Ghana [17, 19, 20]. Data from the Ghana Maternal Health Survey [14] showed 38 percent of the women who induced abortions indicated they used medical abortion, 27 percent used non-medical methods, and 24 percent used dilation and curettage (D&C) or dilation and evacuation (D&E) while 10 percent used other medical methods. Less common methods include: inserting an object, herbs, or other substances into the vagina; and drinking herbal concoctions [17, 20]. The latter methods of abortion are associated with several complications, thus requiring some post-abortion care (PAC).

To help deal with abortion complications and its effects on maternal mortality and morbidity rates, a policy on post-abortion care was introduced in Ghana in 2003 [21]. In 2006, the Ghana Health Service and the Ministry of Health also published protocols for the provision of safe abortion services to help reduce the barriers to safe abortion. This was to help reduce abortion-related mortality and morbidity [22]. However, abortions remain one of the highest contributors to maternal deaths [4]. Though Ghana has made efforts to increase access to post-abortion care, the quality of service is poor, underfunded and has low visibility [23]. It is, therefore, important to promote an equitable and reasonable healthcare seeking environment to improve reproductive and maternal health in Ghana.

Various issues concerning abortion have been studied in Ghana. For instance, studies have been conducted on the practice of abortion in Ghana and attitudes towards abortion (see Morhe et al. [24]; Sundaram, et al. [25]; GSS [20]). Others have focused on post-abortion experiences in Ghana (see Esia-Donkoh et al., [26]; Rominski et al., [27]). Esia-Donkoh et al., [26] targeted women who received safe abortion services at a health facility while Rominski et al., [27] focused on post-abortion contraception choices of women. This notwithstanding, there appears to be a paucity in the literature on the health-seeking behavior of women who sought post-abortion care. The current study, therefore, explores the experiences of women who received post-abortion care services in the Volta Regional Hospital. This will enable us to have a clear view of the health-seeking behavior of women who have had unsafe and spontaneous abortions and suggest feasible measures to improve post-abortion care services and maternal health care.

Materials and methods

The study relied on the interpretivist paradigm on the backdrop that it provides a better way of understanding real-life experiences of post-abortion care clients concerning pregnancy termination. The data for the study was collected from post-abortion care clients at a regional level health facility in Ghana. A regional level health facility in Ghana serves as a secondary referral point for all health facilities in a region. The Volta Regional Hospital is one of the state-owned regional referral hospitals. Obstetrics and gynaecology care are some of the critical services available at the facility. The 2017 Ghana Maternal Health Survey indicates that the Volta Region recorded one of the highest incidences of induced abortions and miscarriages. About 16 percent of women in their reproductive age had ever had an abortion.

Clients who were at the facility to seek post-abortion care services were purposefully selected with the help of health professionals. At a point where the PAC clients were about to be discharged, the service providers informed the PAC clients of the study. Clients who were willing to partake in the study were approved by the service provider for their psychological and physical readiness for an interview before they were included. The interview process was carried out by the lead author who had had two years of training and experience in conducting sensitive interviews before this study. A male interviewer was used against the backdrop that Ghanaian women reported more prior sexual activity to male interviewers [28]. Women who were willing to partake in the study were provided with consent forms to sign/thumbprint. They were then allowed to select their place and time of convenience for the interview to be carried out. A psychologist was on standby to be called upon in instances of re-traumatization during the interview process. The interviews were recorded and transcribed. On the average, an interview lasted for about 45 minutes. Informed by data saturation, a total of 20 women, made up of 8 clients who induced abortions and 12 clients who had spontaneous abortions participated in the study. Guest, Bunce, and Johnson [29] theorize that a sample size of six interviews could be enough for the development of meaningful themes and useful interpretations.

The in-depth interviews were conducted with the aid of an interview guide. The guide had two sections (A and B). Section A focused on the background characteristics of the participants, and section B focused on the experiences with pregnancy termination and the support received from family and friends. Respondents were asked to describe their pregnancy termination experiences. Among the key issues were what informed their decisions to seek post-abortion care and the form of support they received while seeking post-abortion care. Ethical clearance for the study was obtained from the Ghana Health Service Ethical Review Committee (GHS-ERC: 14/10/15). Permission to conduct the study was also obtained from the management of the hospital.

Data were analysed manually using a qualitative content analysis technique. A qualitatively-oriented text analysis based on the principles of the consolidated criteria for reporting qualitative research (COREQ) was adopted. To ensure that the findings of the study were credible and unbiased, the recorded interviews were transcribed by an experienced researcher. The transcripts were cross-checked by a member of the research team. The data were coded independently by an expert qualitative data coder and the lead author. To ensure intercoder concordance, the authors and the expert qualitative data coder met afterwards and reviewed the coding outcomes. Two experts in qualitative research cross-checked the codes for consistency. Following the jointly reviewed codes, themes and emerging issues were developed to mirror the narratives. Finally, quotes from the study participants were used to corroborate the issues discussed.

Results

Socio-demographic characteristics of participants

Table 1 presents the socio-demographic characteristics of the participants. Sixteen respondents were in their 20s and three were aged 30–39 years. Those who had attained basic education were seven and six had tertiary education. Nineteen of the participants were Christians and one was a Muslim. Eleven of the participants were never married and nine were married at the time of the study. The participants were mainly dressmakers (5), civil servants (5), and traders (4).

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Table 1. Socio-demographic characteristics of participants.

https://doi.org/10.1371/journal.pone.0248478.t001

Discussion

We explored the experiences of women seeking PAC services. The results showed that women who induced their abortions relied on medications to terminate their pregnancies. This could be as a result of the fact that medical abortion offers women the privacy to terminate their pregnancies without having to consult others in health facilities. This also helps to reduce stigma, as when done successfully, no one might even know of it. This is in line with a study conducted by Sedgh [17], which revealed that most women who had an abortion, induced abortion on their own. Other studies also observed that women generally preferred medical abortions to other pregnancy termination techniques [19, 20]. Given the high usage of medical abortion, it is important to strengthen public education for women and pharmacists on the right medication for medical abortion to reduce the risk of women using illegal methods of abortions. The findings are, therefore, suggestive of urgent need for the government of Ghana to acknowledge that safe abortion care should constitute a critical part of the interventions to reduce maternal morbidity and mortality.

The study also found that the spontaneous termination of pregnancies among women was mostly perceived as a result of engaging in strenuous physical activities. This is, however, not medically proven, as it is from the respondents’ lay point of view. This corroborates the findings of Wong et al. [30] that there is an elevated risk for women working in jobs that required the use of strenuous physical energy. It would, therefore, be imperative for women to know their health conditions before indulging in certain activities while pregnant.

It was observed that, whereas various factors influenced the time a woman decided to seek professional healthcare for post-abortion complications, the main factor was the severity of the pain resulting from the complications. Stigma and poverty, nonetheless, also played a vital role in influencing the decision-making process. The delay by women seeking PAC services could be attributed to the fact that women would like to suffer in silence to protect their privacy rather than suffer the stigma attached to abortion since in most developing countries, abortion is a religious, moral, and political issue instead of a medical or public health issue [3]. This corroborates the findings of Finer and Henshaw [31], who argued that most women allow a longer time to elapse between abortion and the time for seeking care. This could be attributed to the stigma associated with induced abortion in developing countries, coupled with the laws that render an abortion legal only under certain conditions [7]. Consequently, more advocacy has to be done to encourage women to seek early PAC services to reduce the rate of late reporting for PAC services when complications arise.

The study has revealed that women who presented with spontaneous abortion received both emotional and financial support from family and friends while their counterparts who presented with induced abortion mainly received only financial support. A possible explanation is that spontaneous abortion could result in post-traumatic disorder [32] hence the need for emotional support for this group of women. There is therefore the need for well-targeted and responsive post-abortion counselling services for PAC clients.

Despite the important findings made from this study, it is imperative to indicate its possible limitations. For instance, the study was delimited to clients from only one health facility and a small sample size which limited the study from being generalized to the general Ghanaian society. This, however, did not limit the validity and trustworthiness of the study, since the necessary steps were followed to make the instrument valid and trustworthy.

Conclusions

The study established that women who induced their abortions preferred to do so through medical abortion. However, the women who participated in the study are of the view that their spontaneous abortions were mostly as a result of carrying out activities that required the use of excessive energy, and travelling on bumpy roads. The study also concluded that stigma served as a barrier that hindered women from seeking PAC services. Furthermore, the study has shown that women who experienced spontaneous abortion for PAC services mainly received financial and emotional support from their partners and other family members. To encourage women to seek early treatment, the Ministry of Health and the Ghana Health Service should take pragmatic steps to educate women on the dangers associated with delayed post-abortion care and the factors that expose women to spontaneous abortions.

Supporting information

Acknowledgments

We acknowledge the immense assistance from the Volta Regional Hospital, Ho and the post-abortion care clients who participated in this research. We are also grateful to Mr. Ebenezer Agbaglo of the Department of English, University of Cape Coast, who proofread this document before publication. Our appreciation also goes to Mr. Abdul-Aziz Seidu of the Department of Population and Health, University of Cape Coast, for assisting in proofreading and copyediting the manuscript.