Globally, there has been a slight reduction in abortion rates. Between 1990–1994 and 2015–2019, global abortion rates declined from 40 abortions per 1000 women aged 15–49 years to 39 abortions per 1000 women aged 15–49 years, respectively. However, abortion rates have increased in Oceania (51%), sub-Saharan Africa (24%), Central and South Asia (15%), and East and Southeast Asia (13%) regions (Bearak et al., 2020). Also, abortion rates declined in countries where abortion is broadly legal (−8%), while it increased in countries where abortion is restrictive (12%) (Bearak et al., 2020). In Ghana, abortion is relatively liberal and is permitted when there is incest, rape, or the life of the mother or unborn child is at risk (Sundaram et al., 2012) and can be conducted only by a registered medical practitioner at a government hospital, registered private hospital or a place approved by the Minister of Health (Finlay and Fox, 2013; Malhotra and Devi, 1979). According to the Ghana Maternal Health Survey, the proportion of women in Ghana aged 15–49 who have ever had an induced abortion increased from 14.5% in 2007 to 19.6% in 2017 (GSS et al., 2009, 2018).
Abortion is deemed induced if a pregnancy is terminated intentionally (Rigterink et al., 2023) or by artificial means (Atrash and Saftlas, 2000). Induced abortion can be safe or unsafe, depending on whether a qualified person performs it or is done in a standard environment (Atuhaire, 2019). Hence, induced abortion is unsafe if it is not performed by an unqualified person or done in a sub-standard environment or both. In contrast, induced abortion is safe when performed by a qualified person who adheres to WHO guidelines on performing abortions (Atuhaire, 2019).
Debates on induced abortion as a public health issue are shaped by two perspectives; pro-life and pro-choice proponents. Proponents of pro-life argue that the human embryo is an individual with a right to life. They express moral and political opposition to induced abortion and advocate for legal restrictions on abortions (Duduc and Coleman, 2007). On the other hand, proponents of pro-choice argue that the decision to terminate a pregnancy is the personal, reproductive and human right of the woman since it relates to her body, health and future (Schonhardt-Bailey, 2008), asserting that the embryo’s rights should not supersede hers until viability (Hewson, 2001).
These perspectives have influenced abortion legislation and its associated outcomes. While liberalization of abortion laws is associated with positive outcomes, criminalization of abortion laws is associated with negative outcomes (Ishola et al., 2021; De Londras et al., 2022). Ishola et al. (2021) suggest that relatively liberal legislation is associated with reductions in fertility and maternal mortality. Following the liberalization of the abortion law in Ghana, Finlay and Fox (2013) in their study using the Ghana Demographic and Health Survey (GDHS), reported lower odds of having a child. In Africa and Latin America, where abortion is illegal in most of those countries, the abortion rate is 29 per 1000 women of reproductive age and 32 per 1000 women, respectively. In contrast, in Western Europe, where abortion is allowed, there are 12 per 1000 women (Sedgh et al., 2012).
In sub-Saharan Africa (SSA) and Latin America and the Caribbean (LAC) countries with restrictive abortion laws, women’s choice to terminate pregnancies reflects empowerment. Empowered women have the right to make choices, access opportunities and resources, and control their lives (Alsop and Heinsohn, 2005). Making independent healthcare decisions signifies empowered women exercising their reproductive rights (Castro Lopes et al., 2024).
Contrary to the views of pro-life proponents are international human rights perspectives. International human rights standards regarding abortion have progressed from abolishing punitive measures against women to broadening the criteria for lawful abortion and implementing procedural safeguards to ensure access (Erdman and Cook, 2020).
There is a favorable legal and policy environment regarding the provision of abortion services in Ghana. The Ghana Health Service Comprehensive Abortion Care Policy Standards and Protocols integrated into the national reproductive health policy allow healthcare professionals to provide both surgical and medication abortions (Ghana Health Service, 2021). Nevertheless, there is an unduly high criminal connotation of induced abortion in Ghana. This criminalization has not reduced the practice but rather promoted social stigma, shame, embarrassment and negative provider attitudes (Boah et al., 2019; Adjei et al., 2015; Hu et al., 2010; Aniteye and Mayhew, 2019; Payne et al., 2013). Morhe et al. (2020) recommend multilevel stakeholder engagement to decriminalize and consider abortion as an effective medicolegal intervention, thereby improving access to safe abortion in Ghana.
In the literature, geographic areas (geography) are measured as either region of residence, ecological zones (cluster of regions) or place of residence (rural/urban). Studies have established that geographic differences affect sexual and reproductive health services utilization (Baruwa et al., 2022; Lentiro et al., 2019; Tesema et al., 2020; Yao et al., 2012). For instance, Kumi-Kyereme’s study (2021) among in-school young people with disabilities in Ghana found that young people in the coastal and forest zones are less likely to use sexual and reproductive health services than those in the Savannah zone. In South Africa, a study by Makola et al. (2019) found that adolescent girls and young women aged 15–24 residing in rural areas are more likely to use contraceptives than those in urban areas.
Our study hinges on the ecological theory, on the premise that individual behavior is shaped by the interaction of individual, community, and environmental factors (Cockrill et al., 2013). Instead of solely focusing on individual characteristics, the social–ecological framework explores how personal characteristics are shaped by broader factors such as legal and institutional policies and community norms, all interact to influence individual behavior. The social–ecological framework is relevant for examining induced abortion because the different levels of the social–ecological environment can affect the experience of induced abortion among AGYW. These factors (individual factors, community factors, and environment) form the three nested levels of the model. In this study, all three level factors are used to examine their effects on induced abortion among adolescents and young women.
Studies on induced abortion have identified individual (such as age, religion, educational level, marital status, and number of children, among others) and household (household income) level factors as predictors (Yeboah et al., 2024; Chae et al., 2017; Danso et al., 2022; Ranji, 2012; Sedgh et al., 2015). However, there are some limitations in studies on induced abortion. First, studies have found that induced abortion varies by ecological zone (Danso et al., 2022; Keogh et al., 2015; Polis et al., 2020) and by place of residence, with induced abortion more prevalent in urban areas than rural areas (Chae et al., 2017; Danso et al., 2022). However, studies on induced abortion have examined ecological zones and place of residence as independent variables predicting induced abortion. Second, studies on induced abortion have primarily focused on women in their reproductive ages (15–49 years) (Chae et al., 2017; Danso et al., 2022; Keogh et al., 2015; Boah et al., 2019). However, studies have reported that unsafe and induced abortions are prevalent among women aged 15–24, especially in sub-Saharan Africa (Chae et al., 2017; Shah and Åhman, 2012).
To the best of our knowledge, after an extensive literature search, there is currently no study in Ghana that has examined the nuances pertaining to induced abortion in ecological zones by place of residence. Therefore, this study examined the predictors of induced abortion in ecological zones by place of residence among women aged 15–24. The study sample was restricted to only women who had ever been pregnant, as they were the ones likely to have experienced either a live birth, miscarriage or induced abortion. Understanding the predictors of induced abortion within each ecological zone can facilitate the development of targeted interventions and policies that address the specific needs and challenges faced by young women in different regions. This study had two hypotheses: (a) AGYW in the Savannah zone are less likely to have an induced abortion than those in the forest zone, and (b) AGYW residing in urban areas are more likely to have an induced abortion than those in the rural areas.
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