New studies explore the role of Ghanaian midwives in the provision of abortion care

13.05.2010 In Ghana, unsafe abortion is the second leading cause of maternal death, despite the country’s relatively liberal abortion laws. Indications for legal abortion include rape, incest, risk to the woman’s life or to her physical or mental health, fetal malformation, or if the woman is mentally challenged. However, thousands of women each year continue to suffer from the consequences of unsafe abortion. In a country where more than 60 percent of the country’s population lives in rural areas where midwives are the main service providers, comprehensive abortion care by midwives is critical to the reduction of death and injury from unsafe abortion in the country.

Two recent studies cite the importance of the provision of abortion care by midwives in Ghana and explore some of the challenges related to midwifery training and practice that have thus far limited full expansion of midwifery for abortion care:

Some midwives don’t understand Ghana abortion law

A study recently published in Human Resources for Health, found that the majority of midwifery tutors in Ghana do not know all the legal indications for abortion. A joint project among the Ghana Ministry of Health, the Ghana Registered Midwives Association, Population Council, JHPIEGO and Ipas, the study aimed to identify the ability and knowledge gaps existing in comprehensive abortion care services and to explore the willingness of midwifery tutors to offer clinical training in contraception, postabortion care and legal pregnancy termination. Only 18.9 percent of the 74 midwifery tutors from the country’s 14 schools of midwifery who were interviewed knew all the legal indications for abortion. The researchers also found that pre-service training of tutors of midwifery schools did not include all the methods of abortion. In fact, 77 percent of tutors did not learn about uterine evacuation with manual vacuum aspiration (MVA). Seventy-three percent said their training did not include medical abortion.

The majority of midwifery tutors interviewed seemed willing to teach comprehensive abortion care, citing their desire to help reduce maternal death and disabilities in Ghana by training students to provide comprehensive abortion care, including the management of injuries from unsafe abortion. The study suggests that comprehensive abortion care training, including information on legal indications, should be greatly expanded for midwifery tutors.

Postabortion care remains limited

Another study, this one based on nationally representative health facility data and published in the Journal of Midwifery and Women’s Health, found that although the provision of postabortion care by midwives is an efficient and cost-effective strategy for reducing maternal morbidity and mortality, clinical training of midwives leads to a lower yield of postabortion care providers when compared to physicians, especially in the public sector.

Researchers found that several key characteristics lead to provision of postabortion care services by midwives:

Midwifery students who receive in-service, stand-alone training on postabortion care are more likely to provide those services in their communities;
Midwives who practice in private facilities are more likely to provide postabortion care, most likely because the private sector in Ghana has been traditionally more willing to offer a broad range of reproductive health services to a broader range of women;
Awareness of Ghana’s supportive policy—evidenced by having a copy of the National Reproductive Health Policy and Standards at a facility—leads to greater provision of postabortion care by midwives.

Overall, 28 percent of providers interviewed offer postabortion care services, with 80 percent of physicians and 20 percent of midwives offering postabortion care.

“Further work should consider what policy and practice support can be offered to maximize the return on in-service training investments and tap into the underutilized and cost-effective resource of trained midwives. Midwives are community leaders with unparalleled access to rural women, so their role in reducing deaths and injuries from unsafe abortion can’t be overlooked,” says Kathryn Andersen Clark, Ipas senior research and evaluation associate and one of the study’s authors.