Globally, it is estimated annually that approximately 56 million induced abortions occur , of which approximately 55% use unsafe methods. Within the African region, it is estimated that close to 8.2 million women have abortions . For instance, 34 per 1000 women in South, Middle and Eastern Africa and 31 per 1000 women in West Africa are estimated to have undergone abortion . Globally, the use of unsafe abortion methods is more prevalent in settings where access to legal abortion services is highly controlled . Unsafe abortion therefore contributes to 7.9 percent of maternal-related deaths and hence is a major cause of morbidity in women .
Ghana has a liberal abortion law since 1985 . Thus, abortion may be allowed under some circumstances, such as rape, incest, and when the life of the mother or unborn child is at risk . Despite the liberalisation in the law, the use of unsafe abortion methods increased from 45 percent in 2007 to 62 percent in 2017 [7,8]. There have also been efforts by the government of Ghana to reduce the practice of unsafe abortion and as a strategy to reduce maternal mortality. This includes but is not limited to the introduction of the Reducing Maternal Mortality and Morbidity (R3M) program, which aimed at not only improving access to family planning services but also comprehensive abortion care services [7-9]. There has also been a high supply and availability of modern abortion medications, such as mifepristone and misoprostol, on the Ghanaian market [10,11]. These efforts, however, have barely impacted the reduction of the prevalence of unsafe abortion methods in Ghana .
The availability of abortion-related services, programmes and policies and the impact of these interventions may be influenced by some individual, household, community, sociocultural, political, economic and systemic factors [13-16]. Therefore, a vivid comprehension of abortion service provision and abortion safety (safe and unsafe) is paramount, especially in the context of negative perceptions and misconceptions surrounding abortion. Moreover, in recent times, there has been high recognition of the extent to which abortion safety implicates the sexual and reproductive life of women and the health care system .
Empirically, a large body of literature has identified predictors of safe methods [6,9, 18, 19,20]. and unsafe abortion practices [21-25]. Other studies also examine the association between women’s knowledge of abortion law and the practice of induced abortion [26-29]. Furthermore, while some studies use hospital-based data to examine this phenomenon [27,30-32] and community-based surveys [26,28,33,34], others use nationally representative surveys [20, 25, 35, 36]. These previous studies did not fully explore and examine how socio-demographic and economic factors influence women’s knowledge of the legality of abortion under some conditions (rape, incest, risk to mothers and foetus health) and how that interaction determines their safety in having abortion. Again, no study, to the best of our knowledge, has examined how factors affecting abortion safety and knowledge on the legality of abortion change over time using nationally representative data.
The present study seeks to examine how women’s knowledge of the legal status of abortion and socio-demographic and economic factors influence abortion safety in Ghana by comparing the 2007 and 2017 Ghana Maternal Health Survey. Thus, the study explores and examines how women’s socio-demographic and economic characteristics have shaped their knowledge of the legality of abortion under some circumstances and how that affects their abortion safety over a decade (2007-2017).
Brief overview of women’s knowledge of the legality of abortion and abortion practices
Towards the end of the 20th century, the issue of abortion was considered illegal in many countries with moral and religious connotations. It was also highly associated with health complications and deaths, especially when it is unsafely done .
However, in recent times, there has been liberalization of laws on abortion both in the developed and developing world, and Ghana is not an exception. These liberalizations came along with the promotion and advocacy of modern contraceptive use to ensure the reduction in the unsafe abortion rate and its corresponding mortality [37,38].
In 1985, Ghana witnessed the repeal of the 1960 Criminal Code (Act 29), which gave birth to the Provisional National Defense Council (PNDC) Law 102 liberalising law on abortion in Ghana [39,40]. The new law states that induced abortion will only be accepted as legal under the following circumstances:
- If conception results from rape (non-consensual penetrative sexual intercourse)
- Defilement of a female minor (consensual or non-consensual sex with a girl below the age of 16 or mental disability)
- Incest (consensual or non-consensual sex with a female of blood relation)
- Pregnancy that is considered a threat to the health/life of the women or foetus
Studies have argued that these legal amendments and ramifications to Ghana’s abortion law are open to many interpretations because of the wide application of social, mental and physical health used as a basis for practicing induced abortion [8,19]. These studies therefore suggested that there should be more liberalisation and amendments to abortion laws. This will empower women and enhance their right and ability to make an informed choice with regard to the abortion decision process. Meanwhile, the question is ‘How well are women knowledgeable of the legalities surrounding the issue of abortion?’ ‘Even if they are well informed of the legalities of abortion, which factors (internal and external) can affect their safety in having an abortion?
Studies have attempted to provide a possible explanation for the above questions. For instance, a study by Gbagbo  in Ghana found that less than half of women had knowledge of the legality of abortion under some conditions. The study further found that this knowledge on legality of abortion was among women who were highly educated, and it influenced their decision to seek safe abortion services. Again, studies have indicated that women who knew abortion was legal under some circumstances were more likely to choose safe abortion methods [27, 41, 42].
Additionally, some studies argue that in an environment where strict cultural systems, moral and religious laws and conventions prohibit abortion practices, knowledge of the legality of abortion can be influenced by several factors at the individual, household, community, societal and national levels [16, 20, 22,23]. These factors include but are not limited to age , marital status , ethnicity , geographical location  and economic circumstances . The interaction among these multidimensional factors does influence knowledge on the legality of abortion and the decision-making process on the safety of abortion methods .
It is clear from the literature that the relationship between knowledge on legality of abortion under some conditions and abortion is mediated by factors at the micro and macro levels. However, the literature has been silent on how changes in micro- and macrolevel factors might affect the relationship between knowledge of abortion legality and the safety of abortion methods. This is the gap in the literature that this study seeks to fill by examining how the changes in these factors affect legality knowledge of the abortion and abortion decision-making nexus.