Shaping legal abortion provision in Ghana: using policy theory to understand provider-related obstacles to policy implementation

Health Research Policy and Systems

Susannah H Mayhew¹  Patience Aniteye² 

[1] Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK;Department of Community Health, University of Ghana, Legon, Accra, Ghana

关键词: Qualitative research;    Policy theory;    Policy implementation;    Lipsky;    Health policy;    Ghana;    Abortion;   

Others  :  809748
DOI  :  10.1186/1478-4505-11-23

 received in 2013-01-18, accepted in 2013-06-02,  发布年份 2013

【 摘 要 】

Background

Unsafe abortion is a major public health problem in Ghana; despite its liberal abortion law, access to safe, legal abortion in public health facilities is limited. Theory is often neglected as a tool for providing evidence to inform better practice; in this study we investigated the reasons for poor implementation of the policy in Ghana using Lipsky’s theory of street-level bureaucracy to better understand how providers shape and implement policy and how provider-level barriers might be overcome.

Methods

In-depth interviews were conducted with 43 health professionals of different levels (managers, obstetricians, midwives) at three hospitals in Accra, as well as staff from smaller and private sector facilities. Relevant policy and related documents were also analysed.

Results

Findings confirm that health providers’ views shape provision of safe-abortion services. Most prominently, providers experience conflicts between their religious and moral beliefs about the sanctity of (foetal) life and their duty to provide safe-abortion care. Obstetricians were more exposed to international debates, treaties, and safe-abortion practices and had better awareness of national research on the public health implications of unsafe abortions; these factors tempered their religious views. Midwives were more driven by fundamental religious values condemning abortion as sinful. In addition to personal views and dilemmas, ‘social pressures’ (perceived views of others concerning abortion) and the actions of facility managers affected providers’ decision to (openly) provide abortion services.

In order to achieve a workable balance between these pressures and duties, providers use their ‘discretion’ in deciding if and when to provide abortion services, and develop ‘coping mechanisms’ which impede implementation of abortion policy.

Conclusions

The application of theory confirmed its utility in a lower-middle income setting and expanded its scope by showing that provider values and attitudes (not just resource constraints) modify providers’ implementation of policy; moreover their power of modification is constrained by organisational hierarchies and mid-level managers. We also revealed differing responses of ‘front line workers’ regarding the pressures they face; whilst midwives are seen globally as providers of safe-abortion services, in Ghana the midwife cadre displays more negative attitudes towards them than doctors. These findings allow the identification of recommendations for evidence-based practice.

【 授权许可】

   
2013 Aniteye and Mayhew; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Aniteye P, Mayhew S: Attitudes and Experiences of Women Admitted to Hospital with Abortion Complications in Ghana. Afr J Reprod Health 2011, 15(1):47-55.
• [2]Aboagye PK, Gebreselassie H, Quansah Asare G, Mitchell EMH, Addy J: An Assessment of the Readiness to Offer Contraceptives and Comprehensive Abortion Care in the Greater Accra, Eastern and Ashanti regions of Ghana. Chapel Hill, NC: Ipas; 2007.
• [3]Ghana Health Service 2004–2008: Strategic Plan for the Implementation of Comprehensive Abortion Care Services in Ghana. Accra: GHS; 2004.
• [4]The Criminal Code (Amendment) Law: PNDC L 102. The Gazette. Accra and Tema: Ghana Publishing Corporation; 1985.
• [5]Brookman-Amissah E, Moyo JB: Abortion law reform in sub-Saharan Africa: no turning back. Reprod Health Matters 2004, 12(24):227-234.
• [6]Ghana Health Service: Prevention and management of unsafe abortion: comprehensive abortion care services. Accra: GHS; 2006. [Standards and Protocols]
• [7]Ghana Health Service: A Strategic Assessment of Comprehensive Abortion Care in Ghana;: Report. GHS: Accra; 2005.
• [8]Sabatier PA, Mazmanian DA: The conditions for effective implementations: a guide to accomplishing policy objectives. Pol Anal 1979, 5:481-504.
• [9]Lipsky M: Street Level Bureaucracy: Dilemmas of the Individual in Public Services. New York: Russell Sage Foundation; 1980.
• [10]Hogwood B, Gunn L: Policy Analysis for the Real World. Oxford: Oxford University Press; 1984.
• [11]Sabatier PA: Top-down and bottom-up approaches to implementation research: a critical analysis and suggested synthesis. J Public Pol 1986, 6:21-48.
• [12]Sabatier PA: Theories of the Policy Process. Boulder, CO: Westview; 1999.
• [13]Goggin ML, Bowman AOM, Lester JP, O’Toole LJ Jr: Implementation Theory and Practice: Toward a Third Generation. Glenview, IL: Scott Foresman/Little, Brown and Company; 1990.
• [14]Matland RE: Synthesizing the implementation literature: the ambiguity conflict model of policy implementation. J-PART 1995, 5(2):145-174.
• [15]Saetren H: Facts and myths about research on public policy implementation: out of fashion, allegedly dead, but still very much alive and relevant. Policy Studies J 2005, 33:559-582.
• [16]Hill M, Hupe P: Implementing Public Policy. 2nd edition. London: SAGE Publications; 2009.
• [17]Buse K: Addressing the theoretical, practical and ethical challenges inherent in prospective health policy analysis. Health Policy Plan 2008, 23:351-360.
• [18]Surjadjaja C, Mayhew SH: Can policy analysis theories predict and inform policy change? Reflections on a case study of the battle for legal abortion in Indonesia. Health Policy Plan 2011, 26(5):373-384.
• [19]Walt G, Gilson L: Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan 1994, 9(4):353-370.
• [20]Walker L, Gilson L: We are bitter but we are satisfied: nurses as street-level bureaucrats in South Africa. Social Sci Med 2004, 59:1251-1261.
• [21]Penn-Kekana L, Blaauw D, Schneider H: “It makes me want to run away to Saudi Arabia”: management and implementation challenges for public financing reforms from a maternity ward perspective. Health Policy Plan 2004, 19(Suppl 1):171-177.
• [22]Witter S, Arhinful DK, Kusi A, Zakariah-Akoto S: The experience of Ghana in implementing a user fee exemption policy to provide free delivery care. Reprod Health Matters 2007, 15(30):61-71.
• [23]Armar-Klemesu M, Graham W, Arhinful D, Hussein J: An Evaluation of Ghana’s Policy of Universal Fee Exemption for Delivery Care: Preliminary Findings. Aberdeen: IMMPACT; 2006.
• [24]Voetagbe G, Yellu N, Mills J, Mitchell E, Adu-Amankwah A, Jehu-Appiah K, Nyante F: Midwifery tutors’ capacity and willingness to teach contraception, post-abortion care and legal pregnancy termination in Ghana. Human Res Health 2010, 8:2. BioMed Central Full Text
• [25]Harries J, Stinson K, Orner P: Health care providers’ attitudes towards termination of pregnancy: a qualitative study in South Africa. BMC Public Health 2009, 9:296. BioMed Central Full Text
• [26]Mokgethi NE, Ehlers VJ, van der Merwe MM: Professional nurses’ attitudes towards providing termination of pregnancy services in a tertiary hospital in North West province of South Africa. Curationis Mar 2006, 29(1):32-39.
• [27]Jewkes RK, Gumede T, Westaway MS, Dickson K, Brown H, Rees H: Why are women still aborting outside designated facilities in metropolitan South Africa? BJOG 2005, 112:1236-1242.
• [28]Sibuyi MC: Provision of abortion services by midwives in Limpopo province of South Africa. Afr J Reprod Health 2004, 8(1):75-78.
• [29]Mhlanga RE: Abortion: developments and impact in South Africa. Br Med Bull 2003, 67(1):115-126.
• [30]Varkey SJ, Fonn S, Ketlhapile M: Health Workers for Choice. Johannesburg: Women’s Project; 2001.
• [31]Hill ZE, Tawiah-Agyemang C, Kirkwood B: The context of informal abortions in rural Ghana. J Womens Health 2009, 18(12):2017-2022.
• [32]Henry R, Fayorsey C: Coping with Pregnancy: Experiences with Adolescents in Ga Mashi, Accra. Calverton, MD: ORC Macro; 2002.
• [33]Sai F: An overview of unsafe abortion in Africa. Foreword. Afr J Fertil Sexual Reprod Heal 1996, 1(1):2-3.
• [34]Schuster S: Abortion in the moral world of the Cameroon grassfields. Reprod Health Matters 2005, 13(26):130-138.
• [35]Lazarus ES: Politicizing abortion: personal morality and professional responsibility of residents training in the United States. Soc Sci Med 1997, 44:1417-1425.
• [36]Garel M, Gosme-Seguret S, Kaminski M, Cuttini M: Ethical decision-making in prenatal diagnosis and termination of pregnancy: a qualitative survey among physicians and midwives. Prenat Diagn 2002, 22(9):811-817.
• [37]Onah HE, Ogbuokiri CM, Obi SN, Oguanuo TC: Knowledge, attitude and practice of private medical practitioners towards abortion and post abortion care in Enugu, south-eastern Nigeria. J Obstet Gynaecol 2009, 29(5):415-418.
• [38]Gilson L, Palmer N, Schneider H: Trust and health worker performance: exploring a conceptual framework using South African evidence. Social Sci Med 2005, 61(7):1418-1429.
• [39]Hessini L: Global progress in abortion advocacy and policy: an assessment of the decade since ICPD. Reprod Health Matters 2005, 13(25):88-100.
• [40]Berer M: Provision of abortion by mid-level providers: international policy, practice and perspectives. Bull World Health Organ 2009, 87(1):58-63.
• [41]Lupton D: Medicine as Culture. Illness, Disease and the Body in Western Societies. London: Sage Publications; 1994.
• [42]Luker K: Abortion and the Politics of Motherhood. Los Angeles: University of California Press Ltd.; 1984.
• [43]Joffe CE, Weitz TA, Stacey CL: Uneasy allies: pro-choice physicians, feminist health activists and the struggle for abortion rights. Sociol Health Illness 2004, 26(6):775-796.
• [44]Puri M, Lamichhane P, Harken T, Blum M, Harper CC, Darney PD, Henderson JT: “Sometimes they used to whisper in our ears”: health care workers’ perceptions of the effects of abortion legalization in Nepal. BMC Public Health 2012, 12:297. BioMed Central Full Text
• [45]Lee E: Abortion, Motherhood and Mental Health: Medicalising Reproduction in the United States and Great Britain. Social Problems and Social Issues. Hawthorne, NY: Aldine de Gruyter; 2003.
• [46]Turner KL, Hyman AG, Gabriel MC: Clarifying values and transforming attitudes to improve access to second trimester abortion. Reprod Health Matters 2008, 16(31 Supplement):108-116.
• [47]Turner KL, Gabriel MC: Clarifying Values to Transform Attitudes about Abortion: Practical Applications of a New Theoretical Framework and Toolkit. London, UK: Global Safe Abortion Conference; 2007.
• [48]Klugman B, Hlatshwayo Z: Strategy and action for abortion access: a comparative analysis. In Advocating for Abortion Access: Eleven Country Studies. Edited by Klugman B, Budlender D. Witwatersrand: School of Public Health, University of the Witwatersrand; 2000:7-40.
• [49]Samandari G, Wolf M, Basnett I, Hyman A, Andersen K: Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care. BMC Reprod Health 2012, 9:7. BioMed Central Full Text