Journal name: International Journal of Women’s Health
Article Designation: Original Research
Year: 2018
Volume: 10
International Journal of Women’s Health Dovepress Running head verso: Appiah-Agyekum
Running head recto: Medical abortions among Ghanaian university students
open access to scientific and medical research
DOI: 160297
Open access Full Text article O r I g I n a l  r e s e a r c H
Medical abortions among university students 
in ghana: implications for reproductive health 
education and management
nana nimo appiah- Purpose: In Ghana, unsafe abortion is a major cause of maternal mortality. Even though 
agyekum pharmaceutical drugs seem to be a key means of unsafe abortion, a paucity of evidence exists 
Department of Public administration on the issue among adolescents, students, and other groups at risk. This study therefore explores 
and Health services Management, the abortion experiences of Ghanaian university students with particular reference to pharma-
University of ghana, legon, accra ceutical drugs to fill the knowledge gap and enrich the evidence base for reproductive health 
ghana, ghana
education, policies, and interventions on abortions among students.
Patients and methods: Undergraduate students from the University of Ghana were randomly 
selected and interviewed. The interviews was recorded, transcribed, and analyzed thematically 
using the framework analysis.
Results: Students were aware of safe medical abortion services but were reluctant to use them 
because of cost, stigma, and proximity. Generally, medical abortions were more likely to be 
self-induced among students with misoprostol-based drugs administered orally or vaginally. 
However, students also used various over-the-counter drugs, contraceptives, and prescription 
drugs singly, in series, or in combinations to induce abortion. Yet students had relatively little 
knowledge on the inherent risks and long-term implications of unsafe medical abortions and 
were more likely to have repeat abortions through unsafe medical methods.
Conclusion: Students’ knowledge and awareness of safe medical abortion avenues have not 
influenced their propensity to use them because of stigma, cost, and other factors. Rather, 
several methods of unsafe medical abortions are used increasingly with dire long-term effects 
on students. Serious knowledge gaps exist among students on the methods and risks of medi-
cal abortion. Consequently, there is an urgent need to revise current abortion management 
approaches and redirect attention toward reducing stigma and financial and social costs of safe 
abortion services, and increasing the proactive engagement, counseling, and management of 
medical abortions among students.
Keywords: unsafe abortion, Ghana, medical abortion, university students, misoprostol
Introduction
Medical abortion, also known as chemical or pharmaceutical abortion,1 is a type of 
nonsurgical abortion in which medication or pharmaceutical drugs are used to terminate 
correspondence: nana nimo appiah- a pregnancy usually in the first trimester.
2,3 Of the several means of medical abortions 
agyekum that have been proposed, current evidence supports the use of the antiprogestogen 
Department of Public administration and 
Health services Management, University mifepristone followed by a prostaglandin analog like misoprostol or gemeprost 
of ghana, UgBs, P O Box lg 78, over regimens that use methotrexate followed by misoprostol or misoprostol or 
legon, ghana
Tel +233 24 374 8218 any other alternative alone.
4–6 However, because a combination of mifepristone and 
email nnappiah-agyekum@ug.edu.gh misoprostol is substantially less expensive and does not require special transport 
submit your manuscript | www.dovepress.com International Journal of Women’s Health 2018:10 515–522 515
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or storage arrangements yet still remains as effective, in It also provides the much needed firsthand information 
terms of high complete abortion rates and low continuing on students’ knowledge, awareness, acceptance, methods, 
pregnancy rates, as any published alternative,5 it remains and utilization of unsafe medical abortions practices and 
by far the most commonly used nonsurgical alternative to its implications for reproductive health education and 
surgical termination of early intrauterine pregnancy.7,8 Aside management.
being approved for clinical use for over a decade, it is also This study’s contributions are valuable since it examines 
recommended for use by the World Health Organization the experiences and methods of abortions among students in 
(WHO) and other key global reproductive health bodies.9,10 a nonhospital setting, unlike the majority of studies on unsafe 
In general, although medical abortions are themselves not abortions in Ghana and the subregion that use hospital-based 
unsafe,11 or associated with significant risks, their use becomes data.22 It thus provides firsthand empirical evidence to shape 
unsafe when improperly obtained or administered without contemporary discourse, interventions, and policies on abor-
proper prescription, supervision, and follow-ups or when tions among students by both state and non-state actors.
people access incorrect information and medication.6,12,13 In 
Ghana’s case, for instance, Wells et al14 report an increase in Patients and methods
unsafe abortions done through wrongly administered pharma- The study collected data through in-depth interviews held 
ceutical substances often with debilitating effects on parties between April and August 2015 involving 32 randomly 
involved. Though other reasons may be present, Aniteye sampled female students from the main and city campuses of 
et al15 further link the increase in the use of unsafe medical University of Ghana based on Yin’s23 analytical sampling. In 
abortions in Ghana to the high levels of stigma associated line with Leong and Austin,24 three research assistants were 
with safe abortion services in general. recruited and trained to assist in recruiting respondents and 
While majority of women who suffer complications or recording and transcribing interviews.
die from abortions in developing countries are under the age Drawing strength from Appiah-Agyekum,25 the data 
of 30 years,16 teenagers and women in their early 20s are collection procedure was begun by announcing and posting 
more likely to have an unsafe abortion using pharmaceutical notices at strategic locations on the university campuses on 
substances in Ghana than other age groups.17,18 Importantly, the nature, content, inclusion criteria, and use of the study 
the majority of young persons involved in this form of unsafe and asking interested students to contact the research team. 
abortion in Ghana are students.19 This is in spite of compre- The inclusion criterion was that respondents must have ever 
hensive protocols and guidelines on abortions developed by had an abortion. Within 3 weeks of posting the notices, 41 
the Ghanaian Ministry of Health in 2006 targeted at young students had volunteered to partake in the study. They were 
persons and other groups at risk. These protocols and guide- contacted, taken through and given copies of the information 
lines outline the components, qualifying criteria, authorized sheet and consent forms for the study, and given a week to 
facilities and persons, processes, and scope of comprehensive decide and provide informed consent on their further par-
abortion care. In addition, they also address the deficiencies ticipation in the study. After the 1 week period, 32 students 
of the Ghanaian criminal code [(Ghana, 1960), amended in gave written informed consent and nine students declined 
1985 (Ghana, 1985)] that criminalizes abortion and all persons further participation in the study.
involved in the act except in cases of rape, incest, or when the Participation in the study was voluntary and prospec-
health of the mother is medically determined to be at risk. tive respondents regardless of their choice to participate in 
Yet, relatively little evidence exists on the experiences, the study or not were briefed on the purpose, use, and sig-
choices, methods, and availability of pharmaceutical nificance of the study. In addition to seeking consent from 
substances used for self-induced abortions among young respondents, appropriate permissions were sought from the 
females. While a significant number of existing studies have relevant university authorities. All respondent details and 
focused on students’ knowledge, perceptions, and awareness information provided were anonymized. The study was 
on abortion in general20 and other forms of unsafe abortion also reviewed and approved by the research and conference 
methods,19 Appiah-Agyekum et al21 suggest the urgent need committee of the University of Ghana Business School and 
to delve into the experiences and practices of use/abuse of the Ethics Committee for the Humanities of the University 
pharmaceutical substances among students. Thus, this study of Ghana prior to data collection.
aimed to highlight the abortion experiences of university Interviews were held privately at lecture rooms, meeting 
students with particular reference to pharmaceutical drugs. rooms, and faculty offices usually at the close of lectures. 
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They were also held at the convenience of respondents to Table 1 characteristics of the participants
allow them operate within their comfort zones. Interviews Participant characteristic Frequency (%)
lasted between 45 and 80 minutes and were aided by an age (years)
interview guide. Before analysis, interviews were recorded, 15–19 10 (32)
20–24 18 (56)
transcribed, and later given to respondents to sign-off to 25–29 2 (6)
allow them to review the transcribed data and confirm the $30 2 (6)
accuracy and authenticity of the information attributed to Year of study
them.26 A pre-testing of the interview guide was done prior First 8 (25)
second 10 (31)
to the actual data collection. Third 8 (25)
The data were analyzed qualitatively using the framework Final 6 (19)
analysis approach outlined by Pope et al.27 Analysis began religion
by gaining familiarity with the data. This was done through christian 18 (56)
Muslim 5 (16)
immersion in the raw data by listening to recordings, reading Others 3 (9)
transcripts, and studying interview notes. Second, thematic not stated 6 (19)
frameworks were developed by the researcher by identifying Marital status
and prioritizing key ideas and recurrent themes. The third single 9 (28)
Married 4 (13)
stage was indexing and involved the refinement of broad Dating 19 (59)
themes into simple coherent brief summaries. This was fol- number of abortions
lowed by charting. Charting involved rearranging the data One 17 (53)
More than one 15 (47)
according to the appropriate part of the thematic framework Total 32 (100)
under which they fell. Charts of emerging themes were drawn 
at this point by merging and redefining subthemes. Finally, 
mapping and interpretation were done by using the charts to outside the legal framework of abortions in Ghana. Several 
define concepts, describe the nature of themes, create typolo- participants reported combining different unsafe abortion 
gies, and find associations between themes. methods either in series or simultaneously to enhance 
Discussions of the themes were done within the context effectiveness or because one method did not work at all or 
of relevant literature. Particular attention was also paid to the did not complete the abortion. A common practice among 
comments and answers to follow-up questions by respondents respondents with repeat abortions was the use of methods 
during the discussion. they had used for previous abortion(s) except in cases where 
those methods had not worked or were not immediately avail-
Results able. Another common theme among respondents was the 
Participant characteristics involvement of male partners in the decision to abort, choice 
Participants were drawn from all years of study of the 4-year and timing of abortion methods, financing of abortions, and 
degree programs run by the University of Ghana. All respon- provision of abortifacients.
dents were aged .18 years. Majority of the participants 
were Christian (56%) and were currently dating (59%). Pharmaceutical abortifacients/methods
Other characteristics of the participants are shown in Table 1. Pharmaceutical abortifacients especially misoprostol-based 
brands evolved as the most common means of abortion 
general results experienced by students who participated in the study. In 
About half of the respondents (48%) had undergone an abor- addition, safe medical abortion services provided by blue star 
tion more than once with majority (59%) of them having facilities (a network of private safe abortion and reproductive 
undergone an abortion before their 20th birthday and in their health care providers) were more popular among students 
first trimester of pregnancy (90%). A significant majority than those provided by public health facilities in Ghana. 
of participants (87%) had also considered safe abortion Although participants showed high knowledge of the avail-
services even though relatively few (53%) had actually ever ability of safe medical abortion outlets, the utilization of the 
used them. services provided by these outlets was not prominent in the 
Generally, students described several unsafe abortion experiences shared by the participants. Instead, experiences 
methods performed by unqualified and unskilled providers shared by students suggest that they were more content and 
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comfortable obtaining and using pharmaceutical substances combinations of OTC drugs, or prescription drugs. Several 
themselves instead of going to a safe medical abortion service combinations of OTC drugs, prescription drugs, and/or con-
provider as they believed that to be a cheaper and more traceptives had also been used to induce abortions by students 
discreet option. even though overdosing combinations of emergency contra-
ceptive pills with painkillers were popular. Some participants 
…they will give you the same medabon which I can buy 
had also induced abortions through the therapeutic effect of 
in town for less than a third of their price without having 
other pharmaceuticals meant for other health conditions. 
to fill any forms or be embarrassed in front of people. 
Arthotec (Searle Industrie, Evreux, France) and Oxaprost 
[19 years, level 200]
(Beta Laboratories, La Rioja – Argentina), which though 
Furthermore, students who had used the services of blue contain misoprostol and diclofenac, are originally meant to 
star facilities in Ghana did not patronize them for subsequent treat arthritis and rheumatism, respectively, were common 
abortions nor recommend their use to their peers because of in this regard among students.
the unfavorable proximity, stigma attached to persons seen 
...my friend told me that Arthrotec, even though is used for 
entering or leaving the premises of safe abortion providers, 
arthritis would suffice for the abortion, I went to a pharmacy 
acquired knowledge on administering the drugs, over-
and simply told them I had been sent by my mother to buy 
bureaucratic administrative processes, waiting time, and 
it for her joint pains. [20 year old, level 200]
cost of services.
Majority of students reported a successful abortion on the 
…once they taught me how to use the drug, I didn’t see the 
first attempt using pharmaceutical abortifacients while some 
need to go there again to join the same queue and go through 
participants who were unsuccessful with the first attempt used a 
the same processes…. [21 years, level 400]
higher dosage of the same medicine, substituted the medicine, 
In addition to Medabon (Sun Pharmaceutical Industries or combined it with other medicines in subsequent attempts 
Europe B.V., the Netherlands) (one pill of mifepristone and which were successful. With the exception of severe abdominal 
four pills of misoprostol) that had been approved by the pain, prolonged nausea, hemorrhage (excessive/copious bleed-
Ghana Health Service for first trimester abortions, the use ing), fatigue, and fever, no immediate or short-term adverse 
of misoprostol-only drugs, mainly Cytotec (Pharmacia Ltd, effects of using medications for abortion were reported.
Morpeth, Northumberland, UK) for abortions was also com-
mon among students. Also, over-the-counter (OTC) drugs Discussion
like Aspirin (Zydus Cadila, Gujarat, India) and Diclofenac Findings by Shah and Ahman,28 Ahiadeke,29 and Sedgh30 
(Blue Cross Laboratories Ltd, Mumbai, India) were used confirm that unsafe abortions involved incorrect administra-
solely or in combination with alcoholic beverages, herbs, tion of medications and were performed by unqualified and 
and roots while prescription drugs like metformin (Macleods unskilled providers outside the legal framework of abortions. 
Pharmaceuticals Ltd, Himachal Pradesh, India), Faverin Especially among students, Ankomah et al31 confirm the 
(Mylan Laboratories SAS, Châtillon-sur-Chalaronne, likelihood of repeat abortions that may be attributable to 
France), or Paxil (GlaxoSmithKline plc, London, UK) were the low contraceptive usage among students.25,32 In contrast 
easily available and obtained illegally from both private and to Banerjee et al33 who report the use of multiple sources of 
public health care facilities, pharmacies, and drug outlets for the same unsafe abortion method after previous unsuccess-
abortions. In general, price, recommendation from peers, ful attempts, findings suggest that students were unlikely to 
success from prior use, length of gestation, and availability repeat an unsafe abortion method that had not provided the 
were the key factors influencing their use. desired results within the expected time. In addition, findings 
draw attention to the combination of unsafe abortion methods 
…these drugs are everywhere and once you are willing 
either in series or simultaneously with significant potential 
to pay what they ask, you will get it without any hassle or 
risks. While similar high-risk unsafe abortion practices have 
funny questions. [19 years, level 100]
been associated with young people,34 the prevalence of these 
Experiences shared by participants also show that phar- practices among students, based on this study, seems to be 
maceutical abortifacients were primarily administered orally associated more with the desire to catalyze or improve the 
or as suppositories or through both the means. Findings also efficacy of the abortion method rather than other factors like 
show that pharmaceutical abortions were often self-induced ignorance,35 poverty,36 and mitigation of perceived risks of 
through wrong administration and wrong dosages and complications.37
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In general, there has been a gradual shift from surgical Consistent with Patel and Desai,52 pharmaceutical abor-
abortions to pharmaceutical abortifacients38 attributable to tifacients were mainly administered orally or vaginally or 
advances in technology, market shifts, and related increased both. While findings of Paluku et al53 support that educa-
levels of access to pharmaceutical abortifacients.39,40 tion and literacy levels have a significant influence on the 
This seems to be the case in Ghana where findings from choice and use of pharmaceutical abortifacients, other factors 
earlier studies by Appiah-Agyekum et al21 confirm that like price,54 success from prior use,55 length and timing of 
pharmaceutical abortifacients are the most preferred abortion pregnancy,56 and availability57 were also key factors that 
methods among university students. This may however not be influenced students’ choice of pharmaceuticals. Safety and 
the case for all categories of the population as surgical abor- potential side effects,58 legal restrictions,59 and available 
tions have been identified as the preferred abortion method information and support systems12 were however not sup-
for working women and married women in Ghana.29,41 ported by findings as factors influencing students’ choice 
Consistent with El-Adas,42 misoprostol-based brands and utilization of pharmaceutical abortifacients even though 
are very popular among students who appeared relatively these factors were found to be key determinants of choice of 
knowledgeable on how to access and use them for abortions. medical abortions in other studies.
However, because the efficacy of misoprostol is associ-
ated with first trimester abortions, performed under skilled Implications for reproductive health 
supervision, in combination with mifepristone or to aid other education and management
means of abortion,43,44 its unmonitored use and abuse by Generally, students seem to be knowledgeable and aware of 
students especially outside the conditions above may expose pharmaceutical abortion services, abortifacients, processes, 
them to significant risks. These may include uterine rupture,45 inherent risks, and associated effects. Yet, high stigma and 
incomplete abortions,46 and other high-risk contraindications social unacceptance of using abortion services, whether safe 
that may lead to long-term reproductive health challenges or not, implied that self-induced abortion methods were more 
with its attendant effects.47 acceptable to students than those that required assistance from 
Findings of unsafe use of common analgesics and other skilled personnel. This by implication therefore suggests that 
OTC drugs, either alone or in combination with emergency the conventional practice of increasing the availability of safe 
contraceptive pills or other substances to induce abortions abortion services may not necessarily translate into increased 
by participants, are causing distress considering the ease utilization of these services in the absence of a vibrant effort 
with which these drugs could be obtained and abused. While aimed at destigmatizing abortion services. Again, the legal 
generally the use of mild analgesics does not cause spontane- restrictions that criminalize abortion and parties engaged 
ous abortion or pose any significant risk when used to reduce in it seem to be having an unintended effect of increasing 
pain in induced abortions,48 they may, when overdosed or clandestine abortions especially as students strive to have 
wrongly administered for the main purpose of inducing undetected abortions.
abortions, increase the risk of preeclampsia and preterm In addition, this study draws the attention of reproduc-
birth in subsequent pregnancies.49 In the case of prescrip- tive health educators and practitioners that female decisions 
tion drugs, even limited uncontrolled use may be addictive to abort are almost always carried out regardless of how it 
and may have serious physical and psychological effects50 is performed, how much it costs, and how many times the 
on the students. abortion may be performed. Repeated attempts to terminate a 
Pharmaceutical drugs in general may have severe con- pregnancy through one method or varying the preparation and 
sequences even to a toxic or lethal extent when improperly administration of abortifacients to enhance efficacy show the 
combined or used concurrently with other pharmacological desire and will of students to abort irrespective of repercus-
substances or items with chemical properties.51 Consequently, sions; some of which may be long-term and immediately not 
unsafe abortion performed through a combination of drugs manifested. This raises several important questions on the 
exposes students to significant health risks. Findings from approaches and emphasis on the management of unsafe abor-
this study on the common use of arthritis medication by par- tion practices among the youth and students especially.
ticipants to gain the therapeutic benefit of abortions seem to As evidenced by this study, because majority of phar-
be consistent with Watzer et al46 and show a growing trend maceutical abortions are performed in the first trimester 
in the use of pharmaceutical substances which may cause where students may not show visible signs of pregnancy 
abortion as a side effect or contraindication among abortion- and may thus not be noted by reproductive health stakehold-
seeking students. ers, reactive measures at targeting pregnant mothers and 
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appiah-agyekum Dovepress
abortion-seeking females may yield little returns. Meanwhile, The ease and freedom with which unsafe abortion ser-
stigma, embarrassment, and discomfort also restrict students vices and medical abortifacients seem to be readily available 
from seeking assistance with their pregnancies or counseling for sale from peddlers, chemical shops, and unauthorized 
on decisions to abort. Therefore, as an effective management facilities has a positive impact on their acceptance, use, 
strategy, focus must be shifted to proactive measures of and referrals. Poor monitoring and regulation of the health 
providing open yet more private avenues for students using sector as well as lax application of policies on safe abor-
peer networks, private social media communication, anony- tion services seem to provide illegal abortion providers a 
mous counseling, and abortion information set-ups. Other field day to market and operate with dire consequences on 
mechanisms like 24 hour hotlines and web-based support their subjects. Mass education, provision of safe abortion 
services that have been successful in other countries may hubs, and subsidizing safe abortion services around student 
also be considered. campuses and settlements may well increase their access 
Also findings of repeat abortions especially done in teen and propensity to use safe abortion services. Reproductive 
years by students also raises key questions on the efficacy of health policies and education must also throw more light on 
interventions and the significant funding and attention that reducing abortion stigma and creating greater opportunities 
have consistently been placed on preventing teenage preg- for dialog and interaction with students and other populations 
nancies among girls in school. Considering evidence from at risk on their decisions to abort as well as the available 
other studies suggesting teenage girls as a key group at risk safe options.
of unsafe abortions and the increasing numbers of recorded Finally, experiences shared by participants also indicate 
abortions among students, equal if not more emphasis must a high level of involvement and support by their male part-
rather be channeled to managing teenage abortions and ners in the decision to abort, choosing a method of abortion, 
developing specific informational material aimed at students funding the procedure as well as support throughout the 
than on the prevention of pregnancy. process. Yet, reproductive health policies and education seem 
Furthermore, the increased use of pharmaceutical abor- to overly focus on females without appropriately involving 
tions generally seems to be linked to the perception that it is their partners. Targeting male partners in safe abortion ini-
a risk-free, convenient, and cheaper abortion method. While tiatives may thus provide a lasting key to prevent abortion 
it may be less risky and carry less complications than other in the first place and swaying choices toward safe abortion 
crude abortion methods, reproductive health stakeholders services if that fails.
must drive home the point that it nonetheless has its own 
risks and associated complications. Particularly, by varying Conclusion
drugs, over-dosing, wrongly mixing or combining medica- Even though there may be similarities in abortion decisions 
tions, and other unsafe practices, students seem to increase and experiences among the youth in general, this study sup-
their risks of suffering reproductive health complications and ports Appiah-Agyekum et al21 that some striking differences 
infections and further reduce their chances of safe pregnancy exist in outcomes between youths of varying literacy and 
and delivery later in life. These risks are exacerbated by the educational levels. Consequently, experiences of students 
unregulated use of medications, lack of follow-ups, and prior on abortions in terms of their decisions, choice of method, 
pregnancy testing to determine the length of gestation and and level of knowledge on abortions differ in illiterate and 
the self-induced nature of pharmaceutical abortions. uneducated youths. For instance, while some studies42,60 
Considering the above, reproductive health policymakers report a high use of herbal abortifacients and quack doctor 
and educators must generally enhance counseling and advi- services among students, this study suggests that students 
sory services for populations at risk in addition to increasing are less likely to use those methods but are more likely to 
initiatives to prevent abortions. While stiff punishments and use misoprostol-based pills.
legislations that criminalize abortions may achieve short-term In addition, students seem to be knowledgeable of safe 
success in preventing abortions, they have the long-run effect medical abortion services and likely effects of abortions 
of forcing students to clandestinely opt for unsafe abortion even though choice of abortion methods was influenced 
practices. Practically, attention and educational efforts on by prior use, ease of access, cost, and referral from peers. 
managing unsafe abortions must shift immediately toward While multiple abortions were common among participants, 
promoting safe sexual habits and contraceptive use among the use of multiple methods was also likely especially based 
students rather than the usual emphasis on abstinence, which on relative success and effects of previously used methods. 
seems not to have had much influence on students. In general, unsafe abortion services seemed to be more 
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Dovepress Medical abortions among ghanaian university students
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