"She is courageous because she does not care what people think about her ": attitudes toward adolescent contraception use among Rwandan family planning providers and adult female modern contraceptive users.

INTRODUCTION: In Rwanda, only 20% of sexually active unmarried young women use family planning as compared to 64% of married women. Adolescence is an important time of growth and development that often includes the initiation of sexual activity. Sexually active adolescents need support in accessing contraceptive services to prevent negative health outcomes. In sub-Saharan Africa, the adolescent population represents a large share of the total population and that proportion is predicted to expand over time. Adolescent contraceptive needs have largely been unmet, and with growing numbers, there is increased potential for negative health sequelae. Due to the low use of contraception by adolescents in Rwanda, and the growing population of adolescents, this study aims to explore the perspectives of family planning providers and adult modern contraceptive users on adolescent contraceptive use. Inclusion of adult community members in the study is a unique contribution, as research on adolescent contraceptive use in sub-Saharan Africa relies primarily on perspectives from adolescents and family planning providers. METHODS: This qualitative study in 2018 utilized 32 in-depth interviews with modern contraceptive users and eight focus group discussions with family planning providers. Respondents were from Musanze and Nyamasheke districts in Rwanda, the districts with the highest and lowest modern contraceptive use among married women, respectively. Coding was conducted in Atlas.ti. RESULTS: Stigma regarding premarital sex results in barriers to adolescent access to contraceptive services. Family planning providers do provide services to adolescents; however, they often recommend secondary abstinence, offer a limited method selection, and accentuate risks associated with sexual activity and contraceptive use. Providers support adolescent clients by emphasizing the need for privacy, confidentiality, and expedient services, particularly through youth corners, which are spaces within health facilities designed to meet youth needs specifically. Modern contraceptive-using adult female community members advocate for youth access to contraception, however mothers have mixed comfort discussing sexual health with their own youth. CONCLUSION: To destigmatize premarital sexual activity, government efforts to initiate communication about this topic must occur at national and community levels with the goal of continued conversation within the family. The government should also train family planning providers and all health personnel interacting with youth on adolescent-friendly health services. Dialogue between community members and family planning providers about adolescent access to contraceptive services could also reduce barriers for adolescents due to community members' generally supportive views on adolescent contraceptive use. Efforts to engage adolescent caregivers in how to talk to youth about sex could also contribute to expanded use.

In Rwanda, youth who are having sex use family planning less than married women. This study involved asking family planning providers and adults what they think about youth using family planning. Data for this study was collected in 2018, and included 32 interviews with adult family planning users and eight group discussions with family planning providers in two areas of Rwanda. The findings show that Rwandans believe youth should not have sex before they are married. Family planning providers do provide youth with services; however, they often push stopping sexual activity, offer a smaller selection of family planning methods, and exaggerate risks associated with sex and family planning use. Family planning providers support youth by honoring their need for privacy, keeping their secrets, and providing fast services so fewer people see them at the clinic. Providers like to help adolescents in youth corners, which are special spaces within health facilities just for youth. Importantly, adult women who use family planning want youth in their community to be able to use family planning, too. In order to respond to the issues raised, the Rwandan government can start conversations in villages and more broadly about the need for youth to have access to family planning. The government should also teach family planning providers and anyone who comes into contact with youth to offer helpful and friendly services. Setting up spaces for adults to talk with family planning providers about youth access to family planning could also contribute to fewer barriers to services for adolescents.

Family planning demand generation in Rwanda: Government efforts at the national and community level impact interpersonal communication and family norms.

Between 2005 and 2020, total contraceptive use among married women in Rwanda increased from 17% to 64%. The aim of this study is to better understand how the Rwandan government's mobilization and demand generation efforts have impacted community norms and interpersonal discourse surrounding family planning. Eight focus group discussions with family planning providers and 32 in-depth interviews with experienced modern contraceptive users were conducted in 2018 in the two Rwandan districts with the highest and the lowest contraceptive prevalence rates. Results suggest that outspoken government support, mass media, and community meetings were valuable sources of information about family planning. Information received through these channels generated interpersonal dialogue about contraceptives through both conversation and observation; however, rumors and misinformation remained a significant barrier to use. A once taboo subject is now normative among married couples. Continuing to address common fears and misinformation through communication channels such as mass media and community meetings may help to further increase contraceptive uptake in Rwanda.

" the availability of contraceptives is everywhere.": coordinated and integrated public family planning service delivery in Rwanda.

BACKGROUND: Contraceptive use in Rwanda tripled since 2005. This study aims to understand the role of coordinated and integrated public family planning service delivery in achieving this increase in contraceptive use in Rwanda. METHODS: This qualitative study in 2018 included eight focus group discussions with family planning providers and 32 in-depth interviews with experienced family planning users. RESULTS: Results indicate a well-coordinated public family planning service delivery system with community health workers and nurses filling different and complementary roles in meeting family planning client needs at the local level. In addition, integration of family planning into other maternal and child health services is the norm. CONCLUSIONS: The coordination and integration of family planning across both providers and services may help explain the rapid increase in Rwanda's contraceptive use and has potential applications for enhancing family planning service delivery in other settings.

Family planning use increased from 17 to 53% in Rwanda in between 2005 and 2015. The purpose of this study is to understand the roles of two types of family planning workers in providing family planning services, how those providers work together to achieve the goal to provide public services, and how the Rwandan health system includes family planning services in a variety of other types of health services. To achieve the study purpose, 32 women with experience using modern methods of contraception were interviewed. In addition, 88 providers participated in eight group discussions to discuss these topics. The results from the interviews and group discussions showed that family planning services are easy to access for Rwandans­due to two types of family planning providers filling different roles to assist Rwandans start and keep using family planning methods. Family planning services are included in services for pregnant, delivering, and postpartum mothers­as well as services for infants and children. These are all times when those adults using the services would also be in need of family planning services. The family planning service delivery team approach­as well as including family planning services in mother's and children's health services likely helps explain the increase in family planning use in Rwanda. Other nations might learn from Rwanda's service delivery approach to family planning to also increase access to family planning for their citizens.

Family planning providers and contraceptive users in Rwanda employ strategies to prevent discontinuation.

BACKGROUND: In Rwanda, nearly a third of contraceptive users discontinue within the first year of use. Family planning programs often focus more on recruitment of new users as opposed to maintaining use among current users. A focus on sustaining users and minimizing discontinuation is imperative for long-term family planning program success. This study explores the efforts providers and contraceptive users in Rwanda employ to prevent one of the greatest challenges to family planning programs: contraceptive discontinuation. METHODS: This was a qualitative study conducted in Rwanda between February and July 2018. It included eight focus group discussions with 88 family planning providers and 32 in-depth interviews with experienced modern contraceptive users. Data were collected in two districts with the highest (Musanze) and lowest (Nyamasheke) rates of contraceptive use. Data were analyzed using thematic content approach. RESULTS: Family planning providers in this study used the following strategies to prevent discontinuation: counseling new users on the potential for side effects and switching, reminding clients about appointments for resupply, as well as supporting dissatisfied users by providing counseling, medicine for side effects, and discussing options for switching methods. Users, on the other hand, employed the following strategies to prevent discontinuation: having an understanding that experiences of side effects vary by individuals, supporting peers to sustain use, persisting with use despite experiences of side effects, and switching methods. CONCLUSIONS: The strategies used by family planning providers and users in Rwanda to prevent discontinuation suggest the possibility of long-term sustained use of contraception in the country. Harnessing and supporting such strategies could contribute to sustaining or improving further contraceptive use in the country.

" the way we welcome them is how we will lead them to love family planning.": family planning providers in Rwanda foster compassionate relationships with clients despite workplace challenges.

BACKGROUND: Rwanda has markedly increased the nation's contraceptive use in a short period of time, tripling contraceptive prevalence in just 5 years between 2005 and 2010. An integral aspect of family planning programs is the interactions between family planning providers and clients. This study aims to understand the client-provider relationship in the Rwandan family planning program and to also examine barriers to those relationships. METHODS: This qualitative study in Rwanda utilized convenience sampling to include eight focus group discussions with family planning providers, both family planning nurses and community health workers, as well as in-depth interviews with 32 experienced modern contraceptive users. Study participants were drawn from the two districts in Rwanda with the highest and lowest modern contraceptive rates, Musanze and Nyamasheke, respectively Data analysis was guided by the thematic content approach, Atlas.ti 8 was utilized for coding the transcripts and collating the coding results, and Microsoft Excel for analyzing the data within code. RESULTS: Data analysis revealed that, despite workplace related challenges - including inadequate staffing, training, and resources, relationships between providers and clients are strong. Family planning providers work hard to understand, learn from, and support clients in their initiation and sustained use of contraceptives. CONCLUSION: Given the existing context of purposeful efforts on the part of family planning providers to build relationships with their clients, if the current level of government support for family planning service provision is enhanced, Rwanda will likely sustain many current users of contraception and engage even more Rwandans in contraceptive services in the future.

" we have to think first what we are going to feed our children before we have them ": Rwandan women use family planning to provide a better life for their children.

Use of modern contraception in Rwanda has risen dramatically over a short time period. To better understand contraceptive users' motivations for family planning services in Rwanda, 32 in-depth interviews with contraceptive users and eight focus groups with 88 family planning providers were conducted in Rwanda's Musanze and Nyamasheke districts. Study participants noted how family planning is critical for providing a better life for children. Family planning gives mothers independence from childcare to work in order to provide for their children's wellbeing. Family planning presented an opportunity for generational upward mobility and was perceived as a way to contribute positively to society.

An examination of the barriers to and benefits from collaborative couple contraceptive use in Rwanda.

BACKGROUND: Supportive male involvement is strongly correlated with contraceptive use. In Rwanda, where the contraceptive prevalence rate among married women increased from 17 to 52% from 2005 to 2010, and stagnated at 53% in 2015, understanding the role of male partners in collaborative couple contraceptive use can help inform programs designed to further increase the use of contraception in Rwanda. METHODS: This study utilized qualitative methods in 2018, specifically 32 in-depth interviewers with mostly current users of modern contraceptive methods and eight focus group discussions with family planning providers-both family planning nurses and community health workers (CHWs). Respondents were from Musanze and Nyamasheke Districts, the districts with the highest and lowest modern contraceptive use, respectively, to explore the role of couple collaboration in family planning use in Rwanda. Data were analyzed using the thematic content approach in Atlas.ti (8). RESULTS: Findings demonstrate that some men are opposed to use of male methods of contraception, and some are opposed to any contraceptive use, which can lead to covert use. Women and providers prefer collaborative couple contraceptive use-as a result, providers advocate for and encourage male partner participation in contraceptive use. Women are most often burdened with seeking out information, initiating discussions, and sharing information discovered about contraceptive use with partners. Decision-making about contraceptive use, once discussed, can be collaborative and motivated by financial considerations. When couple contraceptive use is collaborative, benefits range from marital harmony to husband's support of sustained use through reminders about appointments, joint counseling, and support in managing side effects. CONCLUSION: Family planning providers at the community and clinic levels encourage collaborative contraceptive use among couples and some Rwandan couples communicate well about family planning use. Despite the positives, women are expected to source family planning information, share that information with their male partners, seek out family planning services, and use family planning. If more Rwandan male partners accepted use, used male methods of contraception, and participated even more in the work it takes to use family planning, the potential for sustained, and even enhanced, contraceptive use in Rwanda could be realized.

"Family planning in Rwanda is not seen as population control, but rather as a way to empower the people": examining Rwanda's success in family planning from the perspective of public and private stakeholders.

BACKGROUND: Rwanda has made significant strides in improving the health of its people, including increasing access to and use of family planning. Contraceptive use has increased from 17% to 53% in just one decade, from 2005 to 2015. METHODS: The data consist of 13 in-depth interviews conducted with family planning program experts in Rwanda to better understand the mechanisms for success, elucidate remaining challenges, speculate on the future of the program, and discuss potential applicability for translating aspects of the program in other settings. RESULTS: All respondents first noted the positive aspects of government will, leadership, and management of the family planning program when asked to describe the reasons for success. The challenges that loomed the largest for the program were service accessibility for rural Rwandans, adolescent access to and use of contraceptives, opposition from religious institutions, as well as inadequate human resources and funding. These challenges were openly acknowledged and are in the process of being addressed. CONCLUSION: The importance of government leadership and focus in the success of Rwanda's family planning program was prominent. All positive aspects of the program are based upon the strong foundation the government has built and nurtured. Since innovation is welcomed and program evaluation is considered essential, the outlook for Rwanda's family planning program is favorable. The issues that remain are common and persistent challenges for family planning programs. Other nations could learn tangible practices from Rwanda's success and follow Rwanda's efforts to mitigate the remaining challenges.

Ambiguities in Washington State hospital policies, irrespective of Catholic affiliation, regarding abortion and contraception service provision.

BACKGROUND: In 2014, the governor of Washington State mandated that all hospitals publically post a reproductive health policy amidst concerns about the lack of clarity among the public how hospitals handled various aspects of reproductive health care. METHODS: The objective of this study is to assess the clarity of abortion and contraception service provision in the hospital reproductive health policies for the public in Washington State. All Washington State hospital reproductive health policies (n = 88) were analyzed in 2016 using content analysis. Results were stratified by Catholic religious affiliation of the hospital. RESULTS: There were more similarities than differences between the non-Catholic and Catholic hospital reproductive health policies; however, there were a few differences. Non-Catholic hospitals were more likely than Catholic hospitals to use legal language (except for emergency contraception), include conscientious clause for providers (44% vs. 0%), and were less likely to specify that emergency contraception use was available for sexual assault victims only (16% vs 54%). Most hospital reproductive health policies, regardless of Catholic affiliation, provided more confusion than clarity in terms of abortion and contraception service provision. CONCLUSIONS: The impact of Catholic, and non-Catholic, affiliated hospital care on patients who need abortion and contraceptive services is concerning. Given the difficulties in meeting the goals of increased transparency for the public through hospital policy language, the government should instead mandate hospitals use a standardized checklist. Additionally, patients are in dire need of positive rights to information about and services to avoid the potential gap in care that the negative rights afforded to providers and facilities to opt-out of providing abortion and contraceptive services have created.

Inadequate birth spacing is perceived as riskier than all family planning methods, except sterilization and abortion, in a qualitative study among urban Nigerians.

BACKGROUND: Fertility is high in Nigeria and contraceptive use is low. Little is known about how urban Nigerians perceive the risk of contraceptive use in relation to pregnancy and birth. This study examines and compares the risk perception of family planning methods and pregnancy related scenarios among urban Nigerians. METHODS: A total of 26 focus group discussions with 243 participants were conducted in September and October 2010 in Ibadan and Kaduna. The groups were stratified by sex, age, family planning use, and city. Study participants were asked to identify the risk associated with six different family planning methods and four pregnancy related risks. The data were coded in ATLAS.ti 6 and analyzed using the thematic content analysis approach. RESULTS: The ten family planning and pregnancy related items ranked as follows from most to least risky: sterilization, abortion, getting pregnant soon after having a baby (no birth spacing), pill, IUD, injectable, having a birth under 18 years of age (teenage motherhood), condom use, having six children, and fertility awareness methods. Risk of family planning methods was often categorized in terms of side effects and complications. Positive perceptions of teenage motherhood and having many children influenced the low ranking of these items. CONCLUSION: Inadequate birth spacing was rated as more risky than all contraceptive methods and pregnancy related events except for sterilization and abortion. Some of the participants' risk perceptions of contraceptives and pregnancy related scenarios does not correspond to actual risk of methods and practices. Instead, the items' perceived riskiness largely correspond with prevailing social norms. However, there was a high level of understanding of the risks of inadequate birth spacing. TRIAL REGISTRATION NUMBER: This study is not a randomized control trial so the study has not been registered as such.

Contraceptive service provider imposed restrictions to contraceptive access in urban Nigeria.

BACKGROUND: Health service providers can restrict access to contraceptives through their own imposed biases about method appropriateness. In this study, provider biases toward contraceptive service provision among urban Nigerian providers was assessed. METHODS: Health providers working in health facilities, as well as pharmacists and patent medical vendors (PMV), in Abuja, Benin City, Ibadan, Ilorin, Kaduna, and Zaria, were surveyed in 2011 concerning their self-reported biases in service provision based on age, parity, and marital status. RESULTS: Minimum age bias was the most common bias while minimum parity was the least common bias reported by providers. Condoms were consistently provided with the least amount of bias, followed by provision of emergency contraception (EC), pills, injectables, and IUDs. Experience of in-service training for health facility providers was associated with decreased prevalence of marital status bias for the pill, injectable, and IUD; however, training experience did not, or had the opposite effect on, pharmacists and PMV operator's reports of service provision bias. CONCLUSIONS: Provider imposed eligibility barriers in urban study sites in Nigeria were pervasive - the most prevalent restriction across method and provider type was minimum age. Given the large and growing adolescent population - interventions aimed at increasing supportive provision of contraceptives to youth in this context are urgently needed. The results show that the effect of in-service training on provider biases was limited. Future efforts to address provider biases in contraceptive service provision, among all provider types, must find creative ways to address this critical barrier to increased contraceptive use.

"Doctors are in the best position to know ": The perceived medicalization of contraceptive method choice in Ibadan and Kaduna, Nigeria.

OBJECTIVES: The medicalization and clinic-based distribution of contraceptive methods have been criticized as barriers to increasing levels of contraceptive use in Nigeria and other settings; however, our understanding of how clients themselves perceive the contraceptive method decision-making process is very limited. METHODS: Focus group discussions among men and women in Ibadan and Kaduna, Nigeria, were used to examine attitudes and norms surrounding contraceptive method decision-making in September and October of 2010. RESULTS: Choosing a family planning method was presented as a medical decision: best done by a doctor who conducts clinical tests on the client to determine the best, side effect free, contraceptive method for each client. An absolute trust in health professionals, hospitals, and governments to provide safe contraception was evident. CONCLUSION: The level of medicalization placed on contraceptive method choice by urban Nigerians is problematic, especially since a test that can determine what contraceptive methods will cause side effects in an individual does not exist, and side effects often do occur with contraceptive method use. PRACTICE IMPLICATIONS: Provider and client education approaches would help to improve client involvement in contraceptive decision-making and method choice.

Assessing girls' HIV vulnerability: evidence from Botswana, Malawi and Mozambique.

Past research documents multiple factors associated with girls' susceptibility to human immunodeficiency virus transmission; yet a literature review found no systematic approach to measure vulnerability. This study characterized, developed and tested a set of indicators to measure girls' vulnerability, resulting in the vulnerable girls index (VGI). A quasi- experimental, separate-sample pre-/post-test design was used to test the index. Adolescent girls were randomly drawn for the pre-test (2277 respondents) and post-test (1418 respondents) from 16 purposively selected communities in Botswana, Malawi and Mozambique. The higher the VGI score-or the more vulnerable the girl-the more likely she was to report premarital sexual experience across the three countries and the more likely she was to report low agency to insist upon condom use in Botswana and Mozambique. The VGI can be used to assess girls' vulnerability levels across time and space for policy and programme planning purposes, and as part of programme evaluations.

Community Support and Adolescent Girls' Vulnerability to HIV/AIDS: Evidence From Botswana, Malawi, and Mozambique.

Girls are vulnerable to HIV in part because the social systems in which they live have failed to support and protect them. The goal of this research was to develop a viable supportive community index and test its association with intermediate variables associated with HIV risk across 16 communities in Botswana, Malawi, and Mozambique. This cross-sectional survey with separate samples randomly drawn in each country (2010) yielded a total sample of 1,418 adolescent girls (aged 11-18). Multilevel, multivariate logistic regression, while controlling for vulnerability, age, religion, and residence, found that an increase in supportive community index is positively associated with the odds of indicating improved community support for girls and with the confidence to refuse unwanted sex with a boyfriend across the three countries, as well as with self-efficacy to insist on condom use in Botswana and Mozambique. Program implementers and decision makers alike can use the supportive community index to identify and measure structural factors associated with girls' vulnerability to HIV/AIDS; this will potentially contribute to judicious decision making regarding resource allocation to enhance community-level, protective factors for adolescent girls.

Couple years protection lost, a new tool for family planning programs to prioritize stockout interventions.

OBJECTIVE: To develop and evaluate a new measure--couple years protection lost (CYPL)--to identify facilities with the most damaging contraceptive stockouts and therefore direct program response. METHODS: As part of a prospective descriptive study, data were gathered on stocks of contraceptives (oral contraceptive pill, intrauterine device, and two types of implant) at 10 family planning facilities in Abuja, Nigeria, between January and August 2012. CYPL values-a summation of average client volume across contraceptive methods multiplied by the number of stockouts and the USAID couple years of protection value for each method-were calculated for each facility. RESULTS: Over the 8-month study period, the 10 facilities had CYPL values ranging from 15.7 to 588.7. Two facilities had a similarly high number of stockouts (9 vs 8), but completely different CYPL values (462.1 vs 15.7). CONCLUSION: By utilizing the CYPL measure, health programs can target family planning facilities with the most damaging stockouts first and thus strategically reduce the negative impact of contraceptive stockouts.

The Integrated Gateway Model: a catalytic approach to behavior change.

OBJECTIVES: To develop and test an Integrated Gateway Model of behaviors and factors leading to subsequent positive reproductive, maternal, and child health behaviors. METHODS: A secondary analysis was conducted using previously published household survey data collected from men (n=5551; 2011) and women (n=16144; 2011) in Nigeria and women in Egypt (n=2240; 2004-2007). The number of health behaviors each potential gateway behavior predicted was assessed by multivariate regression, adjusting for potential confounders. The influence of gateway factors on gateway behaviors was tested via interaction terms. Gateway behaviors and factors were ranked by the number of health outcomes predicted, both separately and synergistically. RESULTS: The key gateway behavior identified in both datasets was spousal communication about family planning, whereas the key gateway factor was exposure to family planning messages. CONCLUSIONS: The model could facilitate innovative research and programming that in turn might promote cascades of positive behaviors in reproductive, maternal, and child health.

Perceived Risks Associated with Contraceptive Method Use among Men and Women in Ibadan and Kaduna, Nigeria.

Research shows that side effects are often the most common reason for contraceptive non-use in Nigeria; however, research to date has not explored the underlying factors that influence risk and benefit perceptions associated with specific contraceptive methods in Nigeria. A qualitative study design using focus group discussions was used to explore social attitudes and beliefs about family planning methods in Ibadan and Kaduna, Nigeria. A total of 26 focus group discussions were held in 2010 with men and women of reproductive age, disaggregated by city, sex, age, marital status, neighborhood socioeconomic status, and--for women only--family planning experience. A discussion guide was used that included specific questions about the perceived risks and benefits associated with the use of six different family planning methods. A thematic content analytic approach guided the analysis. Participants identified a spectrum of risks encompassing perceived threats to health (both real and fictitious) and social concerns, as well as benefits associated with each method. By exploring Nigerian perspectives on the risks and benefits associated with specific family planning methods, programs aiming to increase contraceptive use in Nigeria can be better equipped to highlight recognized benefits, address specific concerns, and work to dispel misperceptions associated with each family planning method.

Making a difference in adult-child relationships: evidence from an adult-child communication intervention in Botswana, Malawi, and Mozambique.

Girls are vulnerable to HIV in part because the social systems in which they live have failed to protect them. This study evaluates a program aimed at strengthening adult-child relationships to reduce girls' vulnerability to HIV in Botswana, Malawi, and Mozambique. In addition to an extensive process evaluation, a cross-sectional post-intervention survey was conducted in the three countries. The total sample size was 1418 adolescent girls (ages 11-18). Bivariate and multilevel, multivariate analyses were conducted to assess the association between adult program exposure and adult-child relationship improvement. In Botswana, Malawi, and Mozambique, girls whose mothers and fathers participated in the program, as compared to those whose parents did not participate in the program, were significantly more likely to report that their relationships with their parents had improved. Research has shown the important role that adults can play in the mitigation of youth risk taking behavior.

Group versus individual family planning counseling in Ghana: a randomized, noninferiority trial.

BACKGROUND: Group, rather than individual, family planning counseling has the potential to increase family planning knowledge and use through more efficient use of limited human resources. STUDY DESIGN: A randomized, noninferiority study design was utilized to identify whether group family planning counseling is as effective as individual family planning counseling in Ghana. Female gynecology patients were enrolled from two teaching hospitals in Ghana in June and July 2008. Patients were randomized to receive either group or individual family planning counseling. The primary outcome in this study was change in modern contraceptive method knowledge. Changes in family planning use intention before and after the intervention and intended method type were also explored. RESULTS: Comparisons between the two study arms suggest that randomization was successful. The difference in change in modern contraceptive methods known from baseline to follow-up between the two study arms (group-individual), adjusted for study site, was -0.21, (95% confidence interval: -0.53 to 0.12) suggesting no difference between the two arms. CONCLUSIONS: Group family planning counseling was as effective as individual family planning counseling in increasing modern contraceptive knowledge among female gynecology patients in Ghana.

Pathways to unsafe abortion in Ghana: the role of male partners, women and health care providers.

BACKGROUND: Despite abortion being legal, complications from induced abortion are the second leading cause of maternal mortality in Ghana. The objective of this study was to understand the decision-making process associated with induced abortion in Ghana. STUDY DESIGN: Data were collected from female postabortion patients, male partners, family planning nurses and obstetricians/gynecologists at two teaching hospitals in Ghana using in-depth interviews and focus group discussions. RESULTS: While experiences differ for married and single women, men are involved in abortion decision making directly, through "orders" to abort, or indirectly, through denying responsibility for the pregnancy. Health care providers can be barriers to seeking safe abortions in this setting. CONCLUSIONS: Women who choose to terminate a pregnancy without their male partners' knowledge should have the means (both financial and social) to do so safely. Interventions with health care providers should discourage judgemental attitudes and emphasize individually focused patient care.