Optimizing task‐sharing in abortion care in Ghana: Stakeholder perspectives

Abstract Ghana has made progress in expanding providers in abortion care but access to the service is still a challenge. We explored stakeholder perspectives on task‐sharing in abortion care and the opportunities that exist to optimize this strategy in Ghana. We purposively sampled 12 representatives of agencies that played a key role in expanding abortion care to include midwives for key informant interviews. All interviews were audio recorded, transcribed verbatim, and then coded for thematic analysis. Stakeholders indicated that Ghana was motivated to practice task‐sharing in abortion care because unsafe abortion was contributing significantly to maternal mortality. They noted that the Ghana Health Service utilized the high maternal mortality in the country at the time, advancements in medicine, and the lack of clarity in the definition of the term “health practitioner” to work with partner nongovernmental organizations to successfully task‐share abortion care to include midwives. Access, however, is still poor and provider stigma continues to contribute significantly to conscientious objection. This calls for further task‐sharing in abortion care to include medical or physician assistants, community health officers, and pharmacists to ensure that more women have access to abortion care.


| INTRODUCTION
Inadequate human resources within healthcare systems is common in low-and middle-income countries, especially in hard-to-reach areas where maternal mortality is high. The strategic use of midlevel providers through task-sharing-a process of delegating tasks to less specialized healthcare providers-has been identified as something that increases both productivity and efficiency in health systems. 1 Task-sharing can make more efficient use of the human resources currently available by reallocating tasks among healthcare workers; for example, enabling lay and midlevel healthcare professionals such as nurses, midwives, medical doctors, and community health workers to provide clinical tasks and procedures that would otherwise be restricted to higher-level cadres. 2 Ghana has expanded nurses' roles or, in some cases, has provided nurses with additional training to perform tasks that were previously ascribed to only physicians. These are generally midlevel cadres defined by the Ghana Health Service as: "the person trained to support the highly trained health professionals and can hold the fort in the absence of the professional". 3 In the early 1990s, midwives were trained in manual vacuum aspiration (MVA) to control uterine bleeding. During that period, a training curriculum for health assistants to support nurses was developed and implemented. In 2002, a strategy to train substitutes for doctors (medical assistants) was proposed and continues to be implemented in selected institutions. 4 Medical assistants were traditionally professional nurses with only one additional year of training. However, nurses lost interest in the cadre and so a revised training program that takes secondary school graduates was implemented in October 2006. 5 Physician and medical assistants are still being trained to diagnose and treat various forms of illnesses, from terminal diseases to common colds, to augment the limited number of physicians within the health system. 5 Accumulated evidence suggests that where abortion is legal on broad socioeconomic grounds and on a woman's request, and where safe services are accessible, unsafe abortion and abortion-related mortality and morbidity are reduced. [6][7][8][9][10] The literature further confirms that where there are liberal abortion laws, unsafe abortion and its attendant problems of morbidity and mortality drastically reduce. 10,11 In Ghana, the abortion law was formulated in 1985. The law allowed abortion under a few conditions, including the impregnation of a "female idiot," pregnancy as a result of incest or rape, or a pregnancy that threatens the life of the woman or the unborn child. 12 Since 1985, the law has not witnessed any amendment.
A research study demonstrated the feasibility of using trained midwives at the primary care level to provide postabortion care. It also showed the acceptability of this care by women, healthcare providers, community leaders, and policy makers. 13 Thus, a reproductive health policy reform by the Ghana Health Service in 2003 allowed midlevel providers with midwifery skills to perform postabortion care in Ghana. 14 The reform also allowed for abortion care in Ghana to be provided to the full extent of the law; that is, abortion could be provided to protect the physical and mental health and well-being of a woman on the grounds of rape and where there is fetal malformation.
Over the years, the Ghana Health Service (GHS) has promoted postabortion care within its facilities through the development of guidelines and policies built within the country's reproductive health framework. In 2003, the reproductive health policies and guidelines explicitly included comprehensive abortion care to be provided by trained health professionals with midwifery skills. 14 This included midwives and medical assistants with midwifery skills. To help ensure that legal abortions are provided safely, the GHS and Ministry of Health developed protocols for the provision of safe abortion. These guidelines, which were adopted in 2006, outlined the components of comprehensive abortion care to include counseling and the provision of contraceptives, defined mental health conditions that could qualify a patient for an abortion, and called for expansion of the provider base by authorizing midwives and nurses with midwifery skills to perform first-trimester procedures. 15 To ensure that providers have the necessary skills to offer the service, in 2009 MVA was added to the national curriculum for midwifery education to train additional providers in this lifesaving technique. 16 The standards were revised in 2012 to reflect the addition. 17 The 2012 revision of the comprehensive abortion care services tasksharing policy provided for abortion at various levels of the health system. 17 These levels included the community, subdistrict, district, regional, and teaching hospitals. It also outlined the providers of services at these various levels to include community health officers (CHOs), nurses, midwives, medical assistants or physician assistants, medical practitioners, and obstetricians/gynecologists who are trained in midwifery and have the necessary skills and ability to perform clinical procedures or tasks that are reproductive health-related to provide the service. 17,18 Providers without midwifery skills are limited to referral only. Chemical sellers and pharmacists at all levels are neither permitted to provide abortion services nor manage complications from abortion procedures; however, pharmacists can dispense misoprostol and mifepristone on prescription.
Management of complications at the community level by traditional birth attendants and CHOs is limited to referral to the next level of care. At the subdistrict level, midwives and medical assistants with training in midwifery share tasks such as MVA, medical abortion (<9 weeks' gestation), and management of complications. At the district level, the policy allows task-sharing among midwives, medical practitioners, and obstetricians.  Over the years, the abortion policy has witnessed many reviews and discussions with the goal of making abortion care more accessible, affordable, and of better quality for the average Ghanaian woman. Although Ghana has made significant strides in expanding the cadres of providers for abortion care, access to the service is still a challenge as midwives are not present in most primary care facilities. 19  The aim of the present study was to explore stakeholder perspectives on the process of task-sharing in abortion care in Ghana-including facilitating factors and barriers-and the opportunities that exist to optimize the strategy to improve access to abortion services.

| Study setting
The study was implemented in Ghana, which has a population of about 25 million. 20 About 20% of women of reproductive age (15-49 years) have ever had an abortion. 21 In 2017, 53 114 abortions occurred and, of these, 13 918 were characterized as unsafe.
Nonmedical methods (e.g. drinking milk/coffee/alcohol/other liquid with sugar, drinking a herbal concoction, drinking other home remedies, using a herbal enema, inserting a substance into the vagina, heavy massage, excessive physical activity, and use of all kinds of unknown tablets) used to induce abortion make up more than 27% of abortions carried out. 21 More than one in 10 pregnancy-related deaths occur as a result of an unsafe abortion and for every woman who dies from an unsafe abortion it is estimated that 15 suffer short-and long-term morbidities. 21 Countrywide estimates may mask regional differences; for example, 14% of pregnancies among women in urban areas end up in an induced abortion compared with 7% among women in rural areas. Women in poor and rural communities in northern Ghana have less access to comprehensive abortion care; for instance, only 3% of women in the northern part of the country have ever had an induced abortion compared with 22% of women in the more urban middle and coastal areas. 21

| Study design
This was an exploratory, descriptive study designed to gain insights into the policy decision to include all cadres of health workers with midwifery skills in the provision of abortion care, and to learn about stakeholder opinions regarding opportunities for further expansion.

| Sampling of respondents
We purposively sampled individuals in the public and private sector who had themselves contributed (or whose agencies had contributed) to the policy on the expansion of abortion care to include midwives.
Selection was based on an individual's or agency's role in advocating for the policy or contributing to the policy framework, implementation, monitoring, or evaluation. Respondents were typically heads of the agencies but, where necessary, members who were more familiar with the agency's role in task-sharing in abortion care were invited for the interview. Identification of the agencies was primarily via snowball sampling.

| Data collection
The lead researcher (RAA) conducted most of the interviews. A research assistant (EK) with more than 2 years' experience in conducting qualitative interviews assisted him. In all, 12 key informant T A B L E 1 Healthcare workers and abortion services in Ghana.

Level Provider
Task-sharing interviews were conducted. On two occasions, the study team had to talk to two individuals from an agency to better understand the agency's contribution to the policy shift. Consent was sought from the respondents to audio record the interviews. The interviews lasted 1-1.5 hours. All interviews were conducted in June 2018.

| Data processing and analysis
All interviews were audio recorded and transcribed verbatim. The transcripts were imported into NVivo version 11 software (QSR International; Melbourne, Vic., Australia) for coding and thematic analysis. We predetermined codes using the interview guide and additional codes were developed for concepts that were not initially captured by the guide but emerged inductively from the data. We segmented the data into similar groups to form preliminary categories of information or themes on the expansion of health worker roles in abortion care. We examined the segments of data related to each theme and where necessary refinements were made.
RAA coded all transcripts and ES coded six of those transcripts separately. The two coding sets were compared to ensure validity.
Discrepancies were discussed and coding was adjusted where necessary. A coding comparison query to determine the inter-rater reliability returned a Kappa coefficient of 0.84.

| RESULTS
Stakeholders were asked to comment on five main thematic areas: (1) the motivation underlying task-sharing for abortion services; (2) their own roles in advocating for task-sharing; (3) factors that facilitated task-sharing in abortion care in Ghana; (4) barriers to tasksharing in abortion care; and (5) opportunities to task-share beyond the midwife.

| Motivation to task-share in abortion care
Stakeholders described the health system's increasing understanding that not every pregnancy is desired and that women in desperation are likely to attempt all manner of procedures to get rid of unwanted pregnancies. In that regard, they commented that the health system Consequently, in the 1990s, the health service revised the reproductive health policy to include the provision of safe abortion ser-

| Facilitating factors for task-sharing in abortion care in Ghana
Stakeholders recounted that, in the past, abortion was performed by doctors because it was done in the theater using curettes.
However, when therapies such as MVA and medications became available, leaders in the health system realized that they could use the absence of a clear definition of "medical practitioner" under the law to include midwives to provide abortion care. According to the stakeholders, Ghana's law on abortion care only permitted medical practitioners to provide the service, which vaguely suggested "medical officers" were the only ones allowed. According to stakeholders, the ratio of medical officers to the population who needed the service was highly disproportionate. In addition, there were reports that medical doctors are not typically frontline providers and they are not accessible, especially in rural areas. This therefore presented an opportunity to expand the providers to include midwives within the community to open the frontiers for more people to have access to safe abortion services. Stakeholders also identified a group of influential Ghanaians who were brought together as champions for the task-sharing policy. They said members of the group were at the frontline, on TV and radio programs, managing the backlash that stemmed from powerful individuals and groups. In addition to explaining the policy to health facility staff, respondents indicated that there were regular mass education campaigns on radio, TV, and other public platforms to sensitize the population to the policy and to inform them about the availability of the service. Stakeholders who were engaged during the process included lawmakers, judges, the police, traditional leaders, women's groups, and religious bodies. The media was also cautiously included as a powerful tool for advocacy.
Interviewees reported that financial access to abortion care was

| Barriers to task-sharing in abortion care in Ghana
According to stakeholders, owing to the stigma around abortion, some women still prefer "quacks" because the health facility environment does not ensure privacy and confidentiality. "Quacks" were defined as all providers both formal and informal who are not trained to provide safe abortion care.
Furthermore, respondents identified conscientious objection as one of the barriers to abortion care. They acknowledged the difficulty in eliminating it from the service because there will always be people with strong opposing views. There were reports that some midwives refuse to provide the service after attending the trainings because relatives, especially their spouses, did not approve of it. Others stopped providing the service because their pastors preached against it. In some communities, providers are stigmatized by both community members and their colleagues as "abortion nurses" and all their properties are tagged as things bought with "abortion money." In addition, community members believe that female abortion providers who have challenges with childbirth are cursed because they provide abortion services. Some of these providers are conscientious objectors because they are undergoing medical procedures to get pregnant while part of their job is to abort pregnancies.

| DISCUSSION
The global initiative on task-sharing has helped countries make more efficient use of their human resources for health by reallocating tasks among healthcare workers to allow lay and midlevel healthcare professionals to provide clinical tasks and procedures safely that would otherwise be restricted to higher-level cadres. Ghana has been successful in sharing clinical responsibilities between medical doctors and midwives partly because the global initiative on task-sharing supported it. The policy to expand health workers in abortion care to include midwives was also within the remit of the law. The GHS and partners leveraged the liberal law on abortion and the lack of clarity on terminologies such as "medical practitioner" to include midwives in abortion care.
Several studies on task-sharing have made recommendations that healthcare providers should be trained in services close to their job descriptions to make task-sharing more efficient. 23 In Ghana, midwives had comprehensive training that supported the organization of tasksharing in abortion care. The additional 2 weeks' training certified by the GHS was to hone the skills of the midwives. Provision of additional training for midlevel providers in abortion care before they provide the service has been recommended in other settings. 24 Thus, their inclusion in abortion care did not raise concerns about lowering standards of care or lowering the distinction of doctors who have dedicated many years to earn their professions. Studies in sub-Saharan Africa have shown safe outcomes for midlevel providers such as nurses, physician assistants, and midwives trained in medical abortion services. 25,26 Opportunities still exist within the GHS for further expansion of health worker roles in abortion care. Current advocacy efforts focus on the inclusion of medical or physician assistants, pharmacists, and community health nurses in abortion care to improve access and further reduce the contribution of unsafe abortion to maternal morbidity and mortality. With the evolution of medical therapies, women do not necessarily need a medical doctor to have a safe abortion, although good dating of a pregnancy should remain a priority. Indeed, some studies have suggested that women can self-administer medical abortion medicines safely and effectively via telemedicine. 26 In view of that, midlevel providers such as nurse practitioners and physician assistants should be included in the health workforce that provides abortion care. If trained, these midlevel providers can provide first-trimester MVA and medical abortion as safely and effectively as physicians and midwives. 26,27 Because CHOs work in remote communities, it might not always be practical to refer women in need of abortion care to other facilitiesmost may have difficulty traveling the long distances or meeting the costs of travel. Under these circumstances, CHOs may be forced to provide the service outside of their defined tasks owing to the absence of a midwife or doctor. A study in central Uganda reported similar findings for midwives before their role in abortion care was formalized. 24 Furthermore, even though the abortion policy does not permit pharmacists to provide abortion, they still do. According to the 2017 maternal health survey, doctors, nurses, or community health officers/nurses are the most common abortion providers (41%) followed by pharmacists, who provide 33% of abortions. 21 Further task-sharing to include CHOs and physician assistants, as well as pharmacists for medical abortion, is therefore feasible and should be pursued by the health system.
In conclusion, task-sharing in abortion care has been embraced by the health service in Ghana to improve access to safe abortion services. Factors such as availability of data on the contribution of unsafe abortions to maternal deaths contributed to the rapid inclusion of midwives in abortion care. Provider stigma still contributes to conscientious objection but strategies such as values clarification are helping to get more health workers to provide the service. Considering that midwives and doctors are in limited supply, coupled with the high prevalence of conscientious objection, 28 not all midwives and doctors will offer the service. Therefore, there is a need to continue to expand health worker roles in abortion care to include providers such as medical or physician assistants, CHOs, as well as pharmacists, to ensure that more women-especially those in rural areas-have access to safe abortion care.