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Rosen JG, Mbizvo MT, Chelwa N, Phiri L, Cresswell JA, Filippi V, Kayeyi N. Identifying Profiles of Support for Legal Abortion Services in Zambia: A Latent Class Analysis. Stud Fam Plann 2024; 55:45-59. [PMID: 38351302 PMCID: PMC10960669 DOI: 10.1111/sifp.12257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
Relative to neighboring countries, Zambia has among the most progressive abortion policies, but numerous sociopolitical constraints inhibit knowledge of pregnancy termination rights and access to safe abortion services. Multistage cluster sampling was used to randomly select 1,486 women aged 15-44 years from households in three provinces. We used latent class analysis (LCA) to partition women into discrete groups based on patterns of endorsed support for legalized abortion on six socioeconomic and health conditions. Predictors of probabilistic membership in latent profiles of support for legal abortion services were identified through mixture modeling. A three-class solution of support patterns for legal abortion services emerged from LCA: (1) legal abortion opponents (∼58 percent) opposed legal abortion across scenarios; (2) legal abortion advocates (∼23 percent) universally endorsed legal protections for abortion care; and (3) conditional supporters of legal abortion (∼19 percent) only supported legal abortion in circumstances where the pregnancy threatened the fetus or mother. Advocates and Conditional supporters reported higher exposure to family planning messages compared to opponents. Relative to opponents, advocates were more educated, and Conditional supporters were wealthier. Findings reveal that attitudes towards abortion in Zambia are not monolithic, but women with access to financial/social assets exhibited more receptive attitudes towards legal abortion.
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Affiliation(s)
- Joseph G. Rosen
- Department of International Health, Johns Hopkins Bloomberg
School of Public Health, Baltimore, Maryland, United States
| | | | | | | | - Jenny A. Cresswell
- Centre for Maternal, Adolescent, Reproductive, and Child
Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London
School of Hygiene and Tropical Medicine, London, United Kingdom
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Merner B, Haining CM, Willmott L, Savulescu J, Keogh LA. Health providers' reasons for participating in abortion care: A scoping review. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241233124. [PMID: 38426387 PMCID: PMC10908244 DOI: 10.1177/17455057241233124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/14/2023] [Accepted: 01/25/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND There is a global shortage of health providers in abortion care. Public discourse presents abortion providers as dangerous and greedy and links 'conscience' with refusal to participate. This may discourage provision. A scoping review of empirical evidence is needed to inform public perceptions of the reasons that health providers participate in abortion. OBJECTIVE The study aimed to identify what is known about health providers' reasons for participating in abortion provision. ELIGIBILITY CRITERIA Studies were eligible if they included health providers' reasons for participating in legal abortion provision. Only empirical studies were eligible for inclusion. SOURCES OF EVIDENCE We searched the following databases from January 2000 until January 2022: Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, ScienceDirect and Centre for Agricultural and Biosciences International Abstracts. Grey literature was also searched. METHODS Dual screening was conducted of both title/abstract and full-text articles. Health providers' reasons for provision were extracted and grouped into preliminary categories based on the existing research. These categories were revised by all authors until they sufficiently reflected the extracted data. RESULTS From 3251 records retrieved, 68 studies were included. In descending order, reasons for participating in abortion were as follows: supporting women's choices and advocating for women's rights (76%); being professionally committed to participating in abortion (50%); aligning with personal, religious or moral values (39%); finding provision satisfying and important (33%); being influenced by workplace exposure or support (19%); responding to the community needs for abortion services (14%) and participating for practical and lifestyle reasons (8%). CONCLUSION Abortion providers participated in abortion for a range of reasons. Reasons were mainly focused on supporting women's choices and rights; providing professional health care; and providing services that aligned with the provider's own personal, religious or moral values. The findings provided no evidence to support negative portrayals of abortion providers present in public discourse. Like conscientious objectors, abortion providers can also be motivated by conscience.
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Affiliation(s)
- Bronwen Merner
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia
| | - Casey M Haining
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Murdoch Children’s Research Institute, Parkville, VIC, Australia
- University of Melbourne, Parkville, VIC, Australia
| | - Louise A Keogh
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia
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Schaaf M, Lavelanet A, Codjia L, Nihlén Å, Rehnstrom Loi U. A narrative review of challenges related to healthcare worker rights, roles and responsibilities in the provision of sexual and reproductive services in health facilities. BMJ Glob Health 2023; 8:e012421. [PMID: 37918835 PMCID: PMC10626880 DOI: 10.1136/bmjgh-2023-012421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 10/07/2023] [Indexed: 11/04/2023] Open
Abstract
INTRODUCTION This paper identifies and summarises tensions and challenges related to healthcare worker rights and responsibilities and describes how they affect healthcare worker roles in the provision of sexual and reproductive health (SRH) care in health facilities. METHOD The review was undertaken in a two-phase process, namely: (1) development of a list of core constructs and concepts relating to healthcare worker rights, roles and responsibilities to guide the review and (2) literature review. RESULT A total of 110 papers addressing a variety of SRH areas and geographical locations met our inclusion criteria. These papers addressed challenges to healthcare worker rights, roles and responsibilities, including conflicting laws, policies and guidelines; pressure to achieve coverage and quality; violations of the rights and professionalism of healthcare workers, undercutting their ability and motivation to fulfil their responsibilities; inadequate stewardship of the private sector; competing paradigms for decision-making-such as religious beliefs-that are inconsistent with professional responsibilities; donor conditionalities and fragmentation; and, the persistence of embedded practical norms that are at odds with healthcare worker rights and responsibilities. The tensions lead to a host of undesirable outcomes, ranging from professional frustration to the provision of a narrower range of services or of poor-quality services. CONCLUSION Social mores relating to gender and sexuality and other contested domains that relate to social norms, provider religious identity and other deeply held beliefs complicate the terrain for SRH in particular. Despite the particularities of SRH, a whole of systems response may be best suited to address embedded challenges.
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Affiliation(s)
- Marta Schaaf
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Laurence Codjia
- Department of Health Workforce, World Health Organization, Geneva, Switzerland
| | - Åsa Nihlén
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Ulrika Rehnstrom Loi
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
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Self B, Maxwell C, Fleming V. The missing voices in the conscientious objection debate: British service users' experiences of conscientious objection to abortion. BMC Med Ethics 2023; 24:65. [PMID: 37605173 PMCID: PMC10441708 DOI: 10.1186/s12910-023-00934-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/20/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND The fourth section of the 1967 Abortion Act states that individuals (including health care practitioners) do not have to participate in an abortion if they have a conscientious objection. A conscientious objection is a refusal to participate in abortion on the grounds of conscience. This may be informed by religious, moral, philosophical, ethical, or personal beliefs. Currently, there is very little investigation into the impact of conscientious objection on service users in Britain. The perspectives of service users are imperative in understanding the real-world consequences and potential impact of conscientious objection and should be considered when creating and reviewing policies and guidelines. This research provided a platform for women and those who can become pregnant to share their experiences and opinions at a time when these voices are largely excluded in the great tradition of Western political philosophy and law-making processes. METHOD Five service users were interviewed using a narrative interview approach to uncover their abortion journeys and experiences of conscientious objection. FINDINGS The findings were presented as found poems and uncovered that doctors are not always: informing service users that they have a conscientious objection to abortion, giving service users enough information to access abortion (indirect referral), treating them non-judgmentally, and providing medically correct information. Service users did not experience burdens such as long waiting times and were still able to access legal abortion. However, service users did experience negative emotional effects, as they were often left feeling scared, angry, and hopeless when they were not referred and/or were mistreated. CONCLUSIONS Findings indicate that conscientious objection could work in practice. However, it is currently failing some individuals on an emotional level, as not all doctors are adhering to guidelines. Conscientious objection in Britain needs to be addressed, to ensure service users receive fair, impartial, non-judgmental care.
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Affiliation(s)
- Becky Self
- Exchange Station, Tithebarn Street, Liverpool, L2 2QP, UK.
| | - Clare Maxwell
- School of Health, 81 Tithebarn St, Liverpool, L2 2ER, UK
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Footman K, Goel K, Rehnström Loi U, Mirelman AJ, Govender V, Ganatra B. Inclusion of abortion-related care in national health benefit packages: results from a WHO global survey. BMJ Glob Health 2023; 8:e012321. [PMID: 37643800 PMCID: PMC10465905 DOI: 10.1136/bmjgh-2023-012321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/13/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Service inclusion in a country's health benefit package (HBP) is an important milestone towards universal health coverage. This study aimed to explore HBP inclusion of abortion interventions globally. METHODS Secondary analysis of the WHO HBP survey, in which officially nominated survey focal points were asked which interventions were included within the HBP of their country or area's largest government health financing scheme. Abortion inclusion was compared by region, income, legal status of abortion and HBP design process variables. Abortion inclusion was compared with other sexual and reproductive health (SRH) services. RESULTS Below half (45%) reported that abortion is included, but treatment of complications from unsafe abortion was more commonly included (63%). Fewer fully included essential abortion medications (22% mifepristone, 42% misoprostol). Abortion was less commonly included than any other SRH service in the survey. Unlike most SRH services, higher cost, higher technology care to treat complications of unsafe abortion was more commonly included than the relatively lower cost, lower technology service of induced abortion. Higher-income contexts and less restrictive legal environments had higher abortion inclusion. Some contexts had additional restrictions, with abortion inclusion dependent on the patient's reason for seeking care. CONCLUSION This global survey finds that abortion services and medications are often not included within HBPs, while treatment of complications from unsafe abortion is more commonly included. There are opportunities to improve HBP abortion inclusion across different legal contexts, which can improve health outcomes and reduce the need for higher cost treatment of complications from unsafe abortion.
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Affiliation(s)
- Katy Footman
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Kratu Goel
- Department of Health Financing and Economics, WHO, Geneva, Switzerland
| | - Ulrika Rehnström Loi
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Andrew J Mirelman
- Department of Health Financing and Economics, WHO, Geneva, Switzerland
| | - Veloshnee Govender
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Bela Ganatra
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
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Jim A, Magwentshu M, Menzel J, Küng SA, August SA, van Rooyen J, Chingwende R, Pearson E. Stigma towards women requesting abortion and association with health facility staff facilitation and obstruction of abortion care in South Africa. Front Glob Womens Health 2023; 4:1142638. [PMID: 37396569 PMCID: PMC10311091 DOI: 10.3389/fgwh.2023.1142638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/03/2023] [Indexed: 07/04/2023] Open
Abstract
Background Abortion stigma has been shown to influence provider attitudes around abortion and may decrease provider willingness to participate in abortion care, or lead some to obstruct care. However, this link remains understudied. Methods The present study uses baseline data collected through a cluster-randomized controlled trial in 16 public sector health facilities in South Africa in 2020. A total of 279 clinical and non-clinical health facility workers were surveyed. Primary outcome measures included: 1) willingness to facilitate abortion care in eight hypothetical scenarios, 2) facilitation of abortion care in the last 30 days, and 3) obstruction of abortion care in the last 30 days. Logistic regression models were used to assess the association between level of stigma as measured through the Stigmatizing Attitudes, Beliefs and Actions Scale (SABAS) and the primary outcomes. Results Overall, 50% of respondents in the sample were willing to facilitate abortion care in each of the eight scenarios, with differences in willingness based on the abortion client's age and personal situation in each scenario. Over 90% reported facilitating abortion care in the last 30 days, but 31% also reported having obstructed abortion care in the last 30 days. Stigma was significantly associated with willingness to facilitate abortion care and actual obstruction of abortion care in the last 30 days. Controlling for covariates, odds of willingness to facilitate abortion care in every scenario decreased with every one-point increase in SABAS score (reflecting more stigmatizing attitudes), and odds of obstructing abortion care increased with every one-point increase in SABAS score. Conclusions Lower abortion stigma on the part of health facility workers was associated with willingness to facilitate abortion access but not actual facilitation of abortion services. Higher abortion stigma was associated with actual obstruction of an abortion service in the last 30 days. Interventions to reduce stigma towards women seeking abortion, and particularly negative stereotyping, among all health facility staff is key to ensuring equitable and non-discriminatory access to abortion. Trial registration Retrospectively registered on clinicaltrials.gov (ID: NCT04290832) on February 27, 2020. Plain english summary The link between stigma against women seeking abortion and decisions around whether to provide, abstain, or obstruct abortion care remains understudied. This paper assesses how stigmatizing beliefs and attitudes towards women seeking abortion in South Africa affects willingness to facilitate abortion care and actual facilitation or obstruction of abortion care in practice. A total of 279 clinical and non-clinical health facility workers were surveyed between February and March 2020. Overall, half of respondents in the sample were willing to facilitate abortion care in each of the eight scenarios, with important differences in willingness by scenario. Almost all respondents reported facilitating an abortion procedure in the last 30 days, but one in three also reported having obstructed abortion care in the last 30 days. More stigmatizing attitudes corresponded to decreased willingness to provide abortion care and increased odds of obstructing abortion care. Results show that stigmatizing attitudes, beliefs, and actions toward women who seek abortion shape how clinical and non-clinical staff in South Africa feel about their participation in abortion services and whether they obstruct this care. Facility staff hold great power in determining whose abortions are facilitated and whose are obstructed, resulting in stigma and discrimination being openly perpetuated. Continuous work to reduce stigma towards women seeking abortion among all health workers is key to ensuring equitable and non-discriminatory access to abortion for all.
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de Londras F, Cleeve A, Rodriguez MI, Farrell A, Furgalska M, Lavelanet AF. The Impact of 'conscientious objection' on abortion-related outcomes: A synthesis of legal and health evidence. Health Policy 2023; 129:104716. [PMID: 36740467 DOI: 10.1016/j.healthpol.2023.104716] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 01/20/2023] [Accepted: 01/31/2023] [Indexed: 02/04/2023]
Abstract
The World Health Organization (WHO) and international human rights bodies have long urged states to take steps to ensure that 'conscientious objection' does not undermine access to abortion in practice. This review uses an established methodology to identify and integrate evidence of the health and human rights impacts of the practice of conscientious objection/refusal. The evidence identified in this review suggests strongly that conscientious objection negatively affects the rights of abortion seekers and has negative implications for the rights of non-objecting health workers. This is exacerbated in situations where an exercise of 'conscience' goes beyond 'opting out' of providing care and extends into seeking to prevent abortion through dissuasion, misinformation, misdirection, delay, and sometimes abuse. The insights from this review suggest that states must take better and further action to centre abortion seekers in the regulation of conscientious objection, and to prevent and ensure accountability for rights-limiting manifestations of conscience that go beyond opting out of direct provision of abortion care in non-emergency settings.
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Affiliation(s)
| | - Amanda Cleeve
- Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, US
| | - Alana Farrell
- Birmingham Law School, University of Birmingham (UK)
| | | | - Antonella F Lavelanet
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Williams CR, Vázquez P, Nigri C, Adanu RM, Bandoh DAB, Berrueta M, Chakraborty S, Gausman J, Kenu E, Khan N, Langer A, Odikro MA, Ramesh S, Saggurti N, Pingray V, Jolivet RR. Improving measures of access to legal abortion: A validation study triangulating multiple data sources to assess a global indicator. PLoS One 2023; 18:e0280411. [PMID: 36638100 PMCID: PMC10045551 DOI: 10.1371/journal.pone.0280411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/22/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Global mechanisms have been established to monitor and facilitate state accountability regarding the legal status of abortion. However, there is little evidence describing whether these mechanisms capture accurate data. Moreover, it is uncertain whether the "legal status of abortion" is a valid proxy measure for access to safe abortion, pursuant to the global goals of reducing preventable maternal mortality and advancing reproductive rights. Therefore, this study sought to assess the accuracy of reported monitoring data, and to determine whether evidence supports the consistent application of domestic law by health care professionals such that legality of abortion functions as a valid indicator of access. METHODS AND FINDINGS We conducted a validation study using three countries as illustrative case examples: Argentina, Ghana, and India. We compared data reported by two global monitoring mechanisms (Countdown to 2030 and the Global Abortion Policies Database) against domestic source documents collected through in-depth policy review. We then surveyed health care professionals authorized to perform abortions about their knowledge of abortion law in their countries and their personal attitudes and practices regarding provision of legal abortion. We compared professionals' responses to the domestic legal frameworks described in the source documents to establish whether professionals consistently applied the law as written. This analysis revealed weaknesses in the criterion validity and construct validity of the "legal status of abortion" indicator. We detected discrepancies between data reported by the global monitoring and accountability mechanisms and the domestic policy reviews, even though all referenced the same source documents. Further, provider surveys unearthed important context-specific barriers to legal abortion not captured by the indicator, including conscientious objection and imposition of restrictions at the provider's discretion. CONCLUSIONS Taken together, these findings denote weaknesses in the indicator "legal status of abortion" as a proxy for access to safe abortion, as well as inaccuracies in data reported to global monitoring mechanisms. This information provides important groundwork for strengthening indicators for monitoring access to abortion and for renewed advocacy to assure abortion rights worldwide.
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Affiliation(s)
- Caitlin R. Williams
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
- Department of Maternal & Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Paula Vázquez
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
- Department of Health Science, Kinesiology, and Rehabilitation, Universidad Nacional de La Matanza, Buenos Aires, Argentina
| | - Carolina Nigri
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | - Richard M. Adanu
- Department of Population, Family, and Reproductive Health, University of Ghana School of Public Health, Accra, Ghana
| | - Delia A. B. Bandoh
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Greater Accra, Ghana
| | - Mabel Berrueta
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | | | - Jewel Gausman
- Department of Global Health and Population, Women and Health Initiative, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Ernest Kenu
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Greater Accra, Ghana
| | | | - Ana Langer
- Department of Global Health and Population, Women and Health Initiative, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Magdalene A. Odikro
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Greater Accra, Ghana
| | | | | | - Verónica Pingray
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | - R. Rima Jolivet
- Department of Global Health and Population, Women and Health Initiative, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
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Sorhaindo AM, Lavelanet AF. Why does abortion stigma matter? A scoping review and hybrid analysis of qualitative evidence illustrating the role of stigma in the quality of abortion care. Soc Sci Med 2022; 311:115271. [PMID: 36152401 PMCID: PMC9577010 DOI: 10.1016/j.socscimed.2022.115271] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 06/24/2022] [Accepted: 08/04/2022] [Indexed: 12/02/2022]
Abstract
Abortion stigma shapes the environment in which abortion is delivered and received and can have important implications for quality in abortion care. However, this has not previously been clearly articulated and evidenced. We conducted a scoping review of existing qualitative evidence to characterize the relationship between abortion stigma and quality in abortion care. Using a systematic process, we located 50 qualitative studies to include in our analysis. We applied the interface of the WHO quality of care and abortion stigma frameworks to the qualitative evidence to capture manifestations of the interaction between abortion stigma and quality in abortion care in the existing literature. Four overarching themes linked to abortion stigma emerged: A) abortion as a sin and other religious views; B) regulation of abortion; C) judgement, labelling and marking; and D) shame, denial, and secrecy. We further characterized the emerging ways in which abortion stigma operates to inhibit quality in abortion care into seven manifestations of the relationship between abortion stigma and quality in abortion care: 1) poor treatment and the repercussions, 2) gatekeeping and obstruction of access, 3) avoiding disclosure, 4) arduous and unnecessary requirements, 5) poor infrastructure and lack of resources, 6) punishment and threats and 7) lack of a designated place for abortion services. This evidence complements the abortion stigma-adapted WHO quality of care framework suggested by the International Network for the Reduction of Abortion Discrimination and Stigma (inroads) by illustrating specifically how the postulated stigma-related barriers to quality abortion care occur in practice. Further research should assess these manifestations in the quantitative literature and contribute to the development of quality in abortion care indicators that include measures of abortion stigma, and the development of abortion stigma reduction interventions to improve quality in abortion care.
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Affiliation(s)
- Annik Mahalia Sorhaindo
- World Health Organization, Department of Reproductive Health and Research and the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), 20 Avenue Appia, 1211, Geneva, Switzerland.
| | - Antonella Francheska Lavelanet
- World Health Organization, Department of Reproductive Health and Research and the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), 20 Avenue Appia, 1211, Geneva, Switzerland
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Shukla A, Vazquez-Quesada L, Vieitez I, Acharya R, RamaRao S. Quality of care in abortion in the era of technological and medical advancements and self-care. Reprod Health 2022; 19:191. [PMID: 36109756 PMCID: PMC9479303 DOI: 10.1186/s12978-022-01499-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Discussions around quality of abortion care have been focused mainly on service-delivery aspects inside healthcare facilities. More recently, with availability of medical abortion (MA), increase in its self-use, and emergence of other delivery platforms such as telemedicine, the responsibility of quality care has broadened to actors outside of facilities.
Body of text
This commentary discusses the meaning of quality of abortion care with the paradigm shift brought by medical and technological advancement in abortions, and raises questions on the role of the state in ensuring quality in abortion management—especially in settings where abortion is decriminalized, but also in countries where abortion is permitted under certain circumstances. It consolidates the experience gained thus far in the provision of safe abortion services and also serves as a forward-thinking tool to keep pace with the uptake of newer health technologies (e.g., availability of medical abortion drugs), service delivery platforms (e.g., telemedicine, online pharmacies), and abortion care providers (e.g., community based pharmacists).
Conclusions
This commentary provides context and rationale, and identifies areas for action that different stakeholders, including health advocates, policymakers, program managers, and women themselves, can adopt to fit into an alternative regime of abortion care.
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Davis JM, Haining CM, Keogh LA. A narrative literature review of the impact of conscientious objection by health professionals on women's access to abortion worldwide 2013-2021. Glob Public Health 2022; 17:2190-2205. [PMID: 35129083 DOI: 10.1080/17441692.2021.2020318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Conscientious objection to provide abortion has been enshrined in laws and policies globally. Insufficient attention has been paid to the direct and indirect ways in which conscientious objection compromises women's access to a lawful abortion. Using a systematic search strategy, this narrative literature review synthesises the literature exploring conscientious objection's impact on women's access to abortion in a range of countries. This narrative literature review builds on an extensive literature review published by Chavkin et al. (2013. Conscientious objection and refusal to provide reproductive healthcare: A white paper examining prevalence, health consequences, and policy responses. International Journal of Gynecology & Obstetrics, 123, S41-S56. https://doi.org/10.1016/S0020-7292(13)60002-8). Searches were undertaken on the Medline (Ovid), Global Health, CINAHL, Scopus and Science Direct databases. Thirty six papers were included for thematic analysis. Conscientious objection to abortion was found to impact women's access to abortion at three main levels: the practitioner level, the healthcare system level and the sociocultural environment level. Conscientious objection was found to impact access directly through attempts by health professionals to restrict access, and indirectly by exacerbating pre-existing barriers to access. Further research is required to better quantify the extent to which this impacts women and whether interventions are effective in reducing the barriers that conscientious objection creates and exacerbates.
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Affiliation(s)
- Jasmine Meredith Davis
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Casey Michelle Haining
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Louise Anne Keogh
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
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Haining CM, Keogh LA. "I haven't had to bare my soul but now I kind of have to": describing how voluntary assisted dying conscientious objectors anticipated approaching conversations with patients in Victoria, Australia. BMC Med Ethics 2021; 22:149. [PMID: 34772412 PMCID: PMC8588572 DOI: 10.1186/s12910-021-00717-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dealing with end of life is challenging for patients and health professionals alike. The situation becomes even more challenging when a patient requests a legally permitted medical service that a health professional is unable to provide due to a conflict of conscience. Such a scenario arises when Victorian health professionals, with a conscientious objection (CO) to voluntary assisted dying (VAD), are presented with patients who request VAD or merely ask about VAD. The Voluntary Assisted Dying Act 2017 (Vic) recognizes the inherent conflict of conscience that may arise for some health professionals when asked to provide VAD and responds by affording broad protection to conscientious objectors who wish to refuse to take part in the VAD process. METHODS Seventeen semi-structured qualitative interviews were conducted with Victorian health professionals with a self-identified CO to VAD in the lead-up to the implementation of VAD in Victoria. Interviews explored how participants anticipated they would manage their CO in practice. Interviews were transcribed verbatim and analyzed thematically. RESULTS Our results reveal that the way in which health professionals claimed they would approach CO conversations is variable and was dependant on the strength of their opposition to VAD. We categorized conscientious objectors according to their approach as either dissuasive non-referrers, passive non-referrers, facilitators or negotiators. Our study also explores the perceived difficulties of exercising one's CO as identified by our participants. CONCLUSION The broad protection offered by the Voluntary Assisted Dying Act 2017 (Vic) encourages a range of behaviors from conscientious objectors, due to the minimal obligations imposed. In order to assist conscientious objectors, more policy, institutional guidance, and education needs to be available to conscientious objectors explicitly addressing how to effectively manage one's CO. Such guidance is imperative to ensuring that their moral integrity is preserved and that they are exercising their CO appropriately.
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Affiliation(s)
- Casey Michelle Haining
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Victoria, 3010 Australia
| | - Louise Anne Keogh
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Victoria, 3010 Australia
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Footman K, Chelwa N, Douthwaite M, Mdala J, Mulenga D, Brander C, Church K. Treading the Thin Line: Pharmacy Workers' Perspectives on Medication Abortion Provision in Lusaka, Zambia. Stud Fam Plann 2021; 52:179-194. [PMID: 33826147 DOI: 10.1111/sifp.12151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies. METHODS We conducted 16 in-depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka. RESULTS We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers' motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion, and level of desperation. CONCLUSION These findings highlight how pharmacy staff informally determine women's abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion.
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Affiliation(s)
- Katharine Footman
- MSI Reproductive Choices, London, W1T 6LP, UK.,Department of Social Policy, London School of Economics and Political Science
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14
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Kolodziejczyk I, Kuzma J. Knowledge and Attitudes Towards Abortion and Euthanasia Among Health Students in Papua New Guinea. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2020; 11:977-987. [PMID: 33363426 PMCID: PMC7753174 DOI: 10.2147/amep.s281199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/23/2020] [Indexed: 06/12/2023]
Abstract
PURPOSE The purpose of this study was to explore knowledge and attitudes of health program students towards ethical issues pertaining to the beginning and the end of human life, and associations between these attitudes and demographic variables. PARTICIPANTS AND METHODS The study took a mixed-method approach with self-administered survey questionnaires and in-depth interviews. A total of 88 students participated in the survey, and 10 students participated in interviews. The study was conducted among students in the Health Extension Program at a Christian university in Papua New Guinea. RESULTS Students showed a higher acceptance of abortion than euthanasia. More year-4 students presented significantly deeper knowledge of euthanasia and abortion compared to year-1 students. There were no gender differences regarding knowledge and attitude towards these two bioethical issues. The majority of students opposed the idea of women's right to abortion, which is attributed mainly to socio-cultural reasons. The qualitative analysis indicated a very strong perception that having children 'defines' womanhood and also revealed general disapproval of any form of euthanasia. A low level of acceptance of various forms of euthanasia is associated with a respect for older people in Melanesian society and beliefs that ancestors' support is required for achieving prosperity in life. CONCLUSION The study offered a comprehensive description and analysis of students' knowledge and attitudes towards ethical issues pertaining to the beginning and the end of human life. Presented a low level of knowledge towards bioethical issues, together with a small proportion of the knowledge gained from lectures and tutorials, indicated inadequate teaching of bioethics and calls for further improvement. In the perspective of rapid social and cultural changes in the Papua New Guinea society, further studies on changing attitudes towards bioethics issues would be valuable.
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Affiliation(s)
- Iwona Kolodziejczyk
- Centre for Learning and Teaching, Divine Word University, Madang, Papua New Guinea
| | - Jerzy Kuzma
- Medical Department, Divine Word University, Madang, Papua New Guinea
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Haaland MES, Mumba Zulu J, Moland KM, Haukanes H. When abortion becomes public - Everyday politics of reproduction in rural Zambia. Soc Sci Med 2020; 265:113502. [PMID: 33183861 DOI: 10.1016/j.socscimed.2020.113502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/15/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
Abstract
This article takes the public reaction to the discovery of an aborted foetus in a rural Zambian community as the empirical starting point for exploring the everyday politics of reproduction. It builds on eleven months of ethnographic fieldwork on abortion and abortion policy in Zambia in 2017 and 2018, including participant observation in the community where the episode took place and interviews with clinic staff and neighbours. The article explores local dynamics of abortion opposition in a country where abortion is legally permitted on broad grounds. By analysing this case as an anthropological event, it discusses how opposition to abortion is dynamic and changes depending on the situation at hand. While abortions that avoid public attention may be silently tolerated, abortions that become openly known are harshly condemned. Through scrutiny of a specific case of collective moral judgement of abortion, the article examines how values like responsible motherhood, sexual virtue and protection of life emerge and are shared, allowing participants to protect and accumulate their own integrity in a moral economy that forges stronger social ties within the community. The article argues that even the harshest expressions of opposition to abortion may not be as categorical as they first appear. It calls for increased attention to dynamics of moral and political opposition to abortion to understand what is socially at stake for those who engage in it.
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Affiliation(s)
- Marte E S Haaland
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Norway; Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Norway.
| | | | - Karen Marie Moland
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Norway; Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Norway
| | - Haldis Haukanes
- Department of Health Promotion and Development, University of Bergen, Bergen, Norway
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Ngwako K, Banke-Thomas A. 'I guess we have to treat them, but … ': health care provider perspectives on management of women presenting with unsafe abortion in Botswana. Glob Public Health 2020; 15:1308-1321. [PMID: 32290777 DOI: 10.1080/17441692.2020.1751863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Maternal mortality due to unsafe abortion and its complications stands among the three leading causes of maternal death in Botswana. Health care providers (HCPs) including doctors and nurses are at the frontline of providing care to women who have had an unsafe abortion. This qualitative study explored the knowledge, attitudes and perceptions of HCPs towards unsafe abortion in Botswana. We purposively sampled 18 HCPs and used a semi-structured topic guide to engage them in in-depth interviews, which were audio-recorded. These interviews were transcribed and analysed to identify emerging themes. We found that HCPs were knowledgeable about unsafe abortion, local inducers, and its management. However, their religious and moral biases as well as concern for the safety of women biased their view on the subject-matter and of the women themselves. These biases also affected their willingness to provide care, including provision of analgesics. Notwithstanding these biases and the reported lack of clarity on their legal role in managing unsafe abortion, many HCPs recognised their duty-of-care to patients. The continued strengthening of post-abortion services should be implemented in conjunction with engagements with providers to clarify their values and the roles they would be willing to play in abortion and post-abortion care services.
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Affiliation(s)
- Karabo Ngwako
- Department of Obstetrics and Gynaecology, Kanye Seventh-Day Adventist Hospital, Kanye, Botswana.,Department of Health Sciences, University of Roehampton Online, London, United Kingdom
| | - Aduragbemi Banke-Thomas
- Department of Health Sciences, University of Roehampton Online, London, United Kingdom.,Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
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Silent politics and unknown numbers: Rural health bureaucrats and Zambian abortion policy. Soc Sci Med 2020; 251:112909. [DOI: 10.1016/j.socscimed.2020.112909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 11/23/2022]
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Zulu JM, Haaland MES. Situating the Mexico City Policy: what shapes contraceptive access and abortion? LANCET GLOBAL HEALTH 2019; 7:e984-e985. [DOI: 10.1016/s2214-109x(19)30278-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
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Harries J, Constant D. Providing safe abortion services: Experiences and perspectives of providers in South Africa. Best Pract Res Clin Obstet Gynaecol 2019; 62:79-89. [PMID: 31279763 DOI: 10.1016/j.bpobgyn.2019.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/05/2019] [Accepted: 05/14/2019] [Indexed: 10/26/2022]
Abstract
Despite abortion being legally available on request up to and including the gestational age of 12 weeks in South Africa, barriers to access remain. Barriers include provider opposition to abortion and a shortage of trained and willing providers, which has implications for access to safe abortion services. Exploring the factors that determine providers' levels of involvement in abortion services can facilitate improvements in service provision. Providers' conceptualizations of abortion are influenced by numerous factors, including moral and religious views, in which abortion is perceived by some as a sin, whereas others view access to safe abortions as an important component of a woman's right to reproductive autonomy and choice. Barriers to service provision include limited abortion and values clarification training and misinterpretation of conscientious objection. Providers have difficulties with the emotional and visual impact of second trimester abortions. There is an urgent need to address provider shortage, and abortion education and training need to be included in medical and nursing curricula to ensure sustaining abortion services.
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Affiliation(s)
- Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa.
| | - Deborah Constant
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa.
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