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Routine assessment of health facility capacity to provide abortion and post-abortion care can inform policy and programmes to expand access and improve quality. Since 2018, abortion and/or post-abortion care have been integrated into two WHO health facility assessment tools: the Service Availability and Readiness Assessment and the Harmonised Health Facility Assessment. We discuss lessons learnt through experiences integrating abortion into these standardised tools. Our experiences highlight the feasibility of including abortion in health facility assessments across a range of legal contexts. Factors facilitating the integration of abortion include cross-country collaboration and experience sharing, timely inputs into tool adaptations, clear leadership, close relationships among key stakeholders as in assessment coordination groups, use of locally appropriate terminology to refer to abortion and reference to national policies and guidelines. To facilitate high-quality data collection, we identify considerations around question sequencing in tool design, appropriate terminology and the need to balance the normalisation of abortion with adequate sensitisation and education of data collectors. To facilitate appropriate and consistent analysis, future work must ensure adequate disaggregation of recommended and non-recommended abortion methods, alignment with national guidelines and development of a standardised approach for measuring abortion service readiness. Measurement of abortion service availability and readiness should be a routine practice and a standardised component of health facility assessment tools. Evidence generated by health facility assessments that include abortion monitoring can guide efforts to expand access to timely and effective care and help normalise abortion as a core component of sexual and reproductive healthcare., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Abortion in Ghana is legally permissible under certain conditions. Updated in June 2021, the National Comprehensive Abortion Care Services Standards and Protocols included telemedicine as a recognised option for early medical abortion (EMA). Subsequently, Marie Stopes Ghana launched this pilot project to understand the feasibility and acceptability of providing EMA services through telemedicine. The pilot evaluation drew on two research protocols - a process evaluation and a qualitative study. The process evaluation focused on existing routine data sources and additional pilot-specific monitoring, while the qualitative protocol included in-depth interviews with a range of key stakeholders, including telemedicine and in-person patients, healthcare managers, and service providers. Telemedicine for EMA is feasible, acceptable, and has likely expanded access to safe abortion in Ghana. The MSIG telemedicine service package enabled 97% of patients to have a successful EMA at home. Thirty-six per cent of the total 878 patients during the pilot reported that they had no other option for accessing an abortion. Patients described telemedicine EMA services as a highly acceptable and appealing service option. Eighty-four per cent reported they would opt for the telemedicine service again and 83% reported they were very likely to recommend the service. There is potential for telemedicine to expand and improve access to critical SRH services. EMA via telemedicine can be delivered effectively in a low-resource setting. This pilot also showed how telemedicine provides access to patients who feel they do not have other safe service options, meeting specific patient needs in terms of discretion, convenience, and timing.

Objectives: Use of intrauterine balloon tamponades for refractory postpartum haemorrhage (PPH) management has triggered recent debate since effectiveness studies have yielded conflicting results. Implementation research is needed to identify factors influencing successful integration into maternal healthcare packages. The Ellavi uterine balloon tamponade (UBT) (Ellavi) is a new low-cost, preassembled device for treating refractory PPH., Design: A mixed-methods, prospective, implementation research study examining the adoption, sustainability, fidelity, acceptability and feasibility of introducing a newly registered UBT. Cross-sectional surveys were administered post-training and post-use over 10 months., Setting: Three Ghanaian (district, regional) and three Kenyan (levels 4-6) healthcare facilities., Participants: Obstetric staff (n=451) working within participating facilities., Intervention: PPH management training courses were conducted with obstetric staff., Primary and Secondary Outcome Measures: Facility measures of adoption, sustainability and fidelity and individual measures of acceptability and feasibility., Results: All participating hospitals adopted the device during the study period and the majority (52%-62%) of the employed obstetric staff were trained on the Ellavi; sustainability and fidelity to training content were moderate. The Ellavi was suited for this context due to high delivery and PPH burden. Dynamic training curriculums led by local UBT champions and clear instructions on the packaging yielded positive attitudes and perceptions, and high user confidence, resulting in overall high acceptability. Post-training and post-use, ≥79% of the trainees reported that the Ellavi was easy to use. Potential barriers to use included the lack of adjustable drip stands and difficulties calculating bag height according to blood pressure. Overall, the Ellavi can be feasibly integrated into PPH care and was preferred over condom catheters., Conclusions: The training package and time saving Ellavi design facilitated its adoption, acceptability and feasibility. The Ellavi is appropriate and feasible for use among obstetric staff and can be successfully integrated into the Kenyan and Ghanaian maternal healthcare package., Trial Registration Numbers: NCT04502173; NCT05340777., Competing Interests: Competing interests: Over the last decade, MP, JS, PC, PD, RO, AS, MM and EA-H have been directly involved in the development, introduction and scale of the Ellavi uterine balloon tamponade as part of their employment at PATH, which constitutes a non-financial conflict of interest. PATH, an international non-governmental organisation, did not receive any funding from Sinapi Biomedical to conduct this multisite study. The remaining authors have no conflicts of interest to declare., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In this commentary, we distill key messages from a new framework for self-managed medication abortion developed by Global Doctors for Choice. Since Global Doctors for Choice supports doctors working in different contexts around the world, the document also highlights clinical concerns and advocacy opportunities for clinicians in both low- and high-resource settings, and in places with varying legal and administrative restrictions on abortion., (Copyright © 2021. Published by Elsevier Inc.)

Objective: To assess the prevalence of conscientious objection (CO), motivations, knowledge of Ghana's abortion law, attitudes, and behaviors toward abortion provision among medical providers in northern Ghana, and measures to regulate CO., Methods: Between June and November 2015, the present cross-sectional survey-based descriptive study measured prevalence, knowledge, and attitudes about CO among 213 eligible health practitioners who were trained in abortion provision and working in hospital facilities in northern Ghana. Results were stratified by facility ownership and provider type., Results: Approximately half (94/213, 44.1%) of trained providers reported that they were currently providing abortions. The overall prevalence of self-identified and hypothetical objection was 37.9% and 33.8%, respectively. Among 87 physicians, 37 (42.5%) and 39 (44.8%) were categorized as self-identified and hypothetical objectors, respectively. Among 126 midwives, nurses, and physician assistants, 43 (34.7%) and 33 (26.2%) were coded as self-identified and hypothetical objectors, respectively. A high proportion of providers reported familiarity with Ghana's abortion law and supported regulation of CO., Conclusion: CO based on moral and religious grounds is prevalent in northern Ghana. Providers indicated an acceptance of policies and guidelines that would regulate its application to reduce the burden that CO poses for women seeking abortion services., (© 2017 International Federation of Gynecology and Obstetrics.)

Background: Brucellosis is a zoonotic pathogen responsible for great economic losses in most sub-Saharan nations. Although Ghana has successfully implemented the "One Health" initiative for the control of some emerging infectious zoonotic diseases with pandemic potential like Avian Influenza, there is very limited data available on brucellosis especially human brucellosis prevalence. He objective of his study is to determine the seroprevalence of human and bovine brucellosis as well as the predisposing factors at the community level in the North Tongu District of Ghana., Materials and Methods: Rose Bengal Plate test (RBPT) was used to analyze blood samples from 178 cattle farmers, and 315 cattle. The positive samples were further confirmed with cELISA. Predisposing factors were determined by questionnaires administered to cattle farmers. All sample sites were geo-referenced., Results: Human and bovine brucellosis seroprevalence using RBPT were 10.1% and 22.9% respectively. Eighty six percent (62/72) of bovine cases were confirmed with ELISA. Delivery assistants were more likely to be infected (p=0.043) with odds ratio of 2.7. Out of the human cases (18), males constituted 88.9%. Ages 11-20 years recorded 77.7% seropositivity whilst cattle drovers represented 44.5% (8/18) of positives. Significant risk factors in cattle were herd size (p=0.037), history of retained placenta (0.000) and abortion (0.005)., Conclusion: Bovine and human brucellosis is prevalent in North Tongu district, Ghana. Close contact with parturient cows was a major predisposing factor for human infection. Early referral of positive persons to the Hospital for confirmation and treatment is required to comply with the "One Health" initiative on brucellosis and other zoonoses.

Background: Uterine rupture causes high maternal and neonatal mortality in many rural setting in the world. Further studies might provide specific interventions to reduce the high prevalence., Objective: To determine the frequency, causes, clinical presentation, management and outcome of uterine rupture, Setting: Department of Obstetrics and Gynaecology, Upper West Regional Hospital, Wa, Ghana., Design: Retrospective descriptive study., Method: A descriptive study of cases of ruptured uterus in the Regional Hospital from 1st January, 2007 to 31st December 2008 was done. A structured questionnaire was developed to collate data from various registers for analysis., Results: Total deliveries were 5085 with 4172(82%) spontaneous vaginal delivery and 911(17.9%) caesarean sections. Uterine rupture occurred in 41 cases for a ratio of 1:124 Grand multipara with five or more deliveries represented 41.5% while those with two prior successful deliveries represented 31.7%. The mean parity was 3.8 (SD 2.3) under antenatal care, 85.4% had at least four visits. Severe anaemia 28(68.3%) and abdominal tenderness 27(65.8%) were the most frequent clinical presentation while the use of local herbal concoction with suspected uterotonic activity 24(58.5%), fetopelvic disproportion 4 (9.8%) and malpresentation 5(12.1%) were the most significant causes. Major complications were: neonatal deaths 34(82.9%), maternal mortality 4(9.8%) and wound infections 15 (36.6%). Subtotal hysterectomy 10(24.4%) and total hysterectomy 18(43.8%) were preferred to uterine repair 12(23.3%) and 87.8% required at least two units of blood transfusion., Conclusion: skilled attendance with accessible emergency obstetric care and focused antenatal care are key elements for the prevention and management of uterine rupture.

Non-puerperal uterine inversion is rare. A 42-year old woman presented with lower abdominal pain, offensive vaginal discharge and a huge protruding mass per vaginum. A clinical diagnosis of non-puerperal uterine inversion was made and she successfully underwent vaginal hysterectomy. A high index of suspicion is required to make a prompt diagnosis.