The impact of gynecologists' conscientious objection on abortion access

Data discrepancies: Italian ministry reports on abortion, contextualised

The Italian Ministry of Health reports annually on activities related to abortion and fertility, providing quantitative data that looks ripe for analysis. Actors ranging from activists to medical providers to European courts have criticised the data as misleading, but the Ministry reports have not changed. In this piece, we bring together different perspectives on this data from inside and outside academia and offer guidance on how it should-and should not-be used in research.In this article, we collect a wide variety of publications ranging from civil society groups' reports to court decisions, academic articles and investigative reporting and harmonise the way they engage with the Italian Ministry of Health's data regarding abortion and particularly conscientious objection.Analyses rooted in the demographic and medical data about abortion seekers, the abortion rates over time, the different methods of abortion, etc are trustworthy and can be used to extrapolate levels of abortion access. This dataset on conscientious objectors systematically undercounts objectors, implying a false equivalence between people who do not object and people who actually work in an abortion service. We recommend that the Ministry report both the number of objectors and the number of medical doctors working in abortion services.The Italian Ministry of Health produces some valuable data about abortion, but conscientious objection is the key feature of abortion access in Italy, and this key datapoint is flawed. The Ministry could improve clarity and increase citizens' trust in government reports by adding data on the number of abortion providers.

Chilean midwives' experiences while providing induced abortion care after the enactment of a law decriminalising abortion

INTRODUCTION

The recent change in Chilean legislation towards abortion enabled midwives to include the care of women having an induced abortion within their scope of practice. However, midwives' identity could be strained by induced abortion care provision as it is contrary to midwives' traditional role. Considering this, the aim of the study was to elucidate how Chilean midwives understand and provide abortion care.

METHODS

A constructivist grounded theory study was conducted using online semi-structured in-depth interviews. Midwives were purposively sampled considering maximum variation criteria and then theoretical sampling occurred. Saturation was achieved with fifteen interviews. Interviews were conducted in Spanish and then translated into English. Constant comparison analysis generated categories. Data were managed using NVivo 12. All interviewees provided their consent to be part of this study.

RESULTS

This article reports on the experiences of nine midwives who had provided lawful induced abortion care in Chile. The experiences of these midwives were grouped into two major categories: 'Defining a position towards abortion' and 'Abortion care is emotional labour'.

CONCLUSION

Midwives can successfully provide abortion care despite being challenged by certain areas of it. Considering the high demand for emotional labour in abortion care, efforts should be made to increase midwives' emotional self-regulation skills. Likewise, organisations should strengthen and implement their offer of well-being and emotional self-care support to midwives.

Conscientious objection and barriers to abortion within a specific regional context - an expert interview study

BACKGROUND

While most countries that allow abortion on women's request also grant physicians a right to conscientious objection (CO), this has proven to constitute a potential barrier to abortion access. Conscientious objection is regarded as an understudied phenomenon the effects of which have not yet been examined in Germany. Based on expert interviews, this study aims to exemplarily reconstruct the processes of abortion in a mid-sized city in Germany, and to identify potential effects of conscientious objection.

METHODS

Five semi-structured interviews with experts from all instances involved have been conducted in April 2020. The experts gave an insight into the medical care structures with regard to abortion procedures, the application and manifestations of conscientious objection in medical practice, and its impact on the care of pregnant women. A content analysis of the transcribed interviews was performed.

RESULTS

Both the procedural processes and the effects of conscientious objection are reported to differ significantly between early abortions performed before the 12th week of pregnancy and late abortions performed at the second and third trimester. Conscientious objection shows structural consequences as it is experienced to further reduce the number of possible providers, especially for early abortions. On the individual level of the doctor-patient relationship, the experts confirmed the neutrality and patient-orientation of the vast majority of doctors. Still, it is especially late abortions that seem to be vulnerable to barriers imposed by conscientious objection in individual medical encounters.

CONCLUSION

Our findings indicate that conscientious objection possibly imposes barriers to both early and late abortion provision and especially in the last procedural steps, which from an ethical point of view is especially problematic. To oblige hospitals to partake in abortion provision in Germany has the potential to prevent negative impacts of conscientious objection on women's rights on an individual as well as on a structural level.

The Association Between Religion and Healthcare Professionals' Attitudes Towards the Conscience Clause. A Preliminary Study From Poland

Objectives: This study was designed to determine the relationship between religion and healthcare practitioners' attitudes towards conscience clauses in Poland. Methods: We developed a survey assessing impact of religion on attitudes healthcare professionals towards the conscience clause. These questions were explored using a sample of 300 Polish healthcare professionals. Results: The results indicate that religiosity was a significant predictor of acceptance of conscience clauses. It also influenced healthcare practitioners' opinions on medical professionals that should be granted the right to conscience clauses and medical services that may be denied on moral grounds. There was also a significant relationship between healthcare practitioners' religiosity and their eagerness to use conscience clauses in a situation of moral conflict. Finally, religious healthcare practitioners were more concerned about the personal consequences of using this right in a medical environment. Conclusion: This study shows that at the same time, both religious and non-religious healthcare professionals believed that the Polish regulations regarding conscience clause are unclear and inaccurate, therefore leading to misinterpretation and abuse regulation of law.

Restrictive points of entry into abortion care in Ireland: a qualitative study of expectations and experiences with the service

This article focuses on access to early medical abortion care under Section 12 of the Health (Regulation of Termination of Pregnancy) Act 2018, in Ireland and identifies existing barriers resulting from gaps in current policy design. The article draws primarily on qualitative interviews with 24 service users, 20 primary healthcare providers in the community and 27 key informants, including from grassroots groups that work with women from different migrant communities, to examine service users' experiences accessing early medical abortions on request up to 12 weeks gestation. The interviews were part of a wider mixed-methods study from 2020-2021 examining the barriers and facilitators to the implementation of abortion policy in Ireland. Our findings highlight care seekers' experiences with the GP-led service provision, including delays, facing non-providers, the mandatory three-day waiting period, and oversubscribed women's health and family planning clinics. Our findings also highlight the compounding challenges for migrants and additional barriers posed by the geographical distribution of the service and the 12-week gestational limit. Finally, it focuses on the remaining challenges for racialised and other marginalised groups. In order to provide a "thick description" of women's lives and the complexity of their experiences with abortion services in Ireland, we also present two narrative vignettes of service users, and their experiences with delays and navigating the healthcare system as migrants. To this effect, this article applies a reproductive justice framework to the results to highlight the compounding effects of these barriers on people located along multiple axes of social inequality.

The Impact of 'conscientious objection' on abortion-related outcomes: A synthesis of legal and health evidence

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.

A Balance of Rights: The Italian Way to the Abortion Controversy

The U.S. Supreme Court's Dobbs ruling triggered a global debate about access to abortion and the legislative models governing it. In the United States, there was a sudden reversal of federal guidance about pregnancy termination that is unprecedented in Western and high-income countries. The strong polarization on the issue of abortion and the difficulty of finding a point of compromise lead one to consider the experiences of countries that have had different paths. Italy stands as a candidate for being a partially alternative model because it allows abortion up to 12 weeks, but without considering it a subjective right. The legislation in place since 1978 aims to balance the interests of the fetus and those of the woman. An issue often raised concerning Italian law is that of conscientious objection granted to doctors. Many gynecologists declare themselves objectors, and this makes access to abortion more difficult in some regions of Italy. After discussing this issue and envisaging different ways to deal with it, the article concludes by highlighting new dilemmas about a possible divorce between the law and medical ethics in different directions and offers some avenues to begin setting up a response.

Attitudes of Polish physicians, nurses and pharmacists towards the ethical and legal aspects of the conscience clause

BACKGROUND

While healthcare professionals' right to invoke the conscience clause has been recognised as a fundamental human right, it continues to provoke a heated debate in Polish society. Although public discourse is filled with ethical and legal considerations on the conscience clause, much less is known about the attitudes of healthcare professionals regarding that matter. The aim of this study was therefore to describe the attitudes of Polish physicians, nurses and pharmacists towards the ethical and legal aspects of the conscience clause.

METHODS

We analysed a group of three hundred healthcare professionals: physicians, nurses and pharmacists in Poznan, Poland, using a standard questionnaire comprising of 29 questions about various ethical and legal aspects of the conscience clause and participants' personal experiences with the conscience clause. The study was conducted between January and March 2020.

RESULTS

This research shows that although most Polish healthcare workers support the right to invoke the conscience clause they differ significantly in their opinions on to whom and to what medical procedures the conscience clause should apply to. It also demonstrated that while the conscience clause is rarely invoked in Poland, most healthcare professionals declare that the current legal regulations in that sphere are unclear and inaccurate.

CONCLUSIONS

While there is an urgent need to raise the awareness regarding the conscience clause among medical students and healthcare professionals and educate them about such issues, it is even more important to improve the legal system in regard to the CC so that it protects both HCPs' right to the CC and safeguards patients' rights to medical services.

Attitudes of Polish physicians, nurses and pharmacists towards the ethical and legal aspects of the conscience clause

Background

While healthcare professionals’ right to invoke the conscience clause has been recognised as a fundamental human right, it continues to provoke a heated debate in Polish society. Although public discourse is filled with ethical and legal considerations on the conscience clause, much less is known about the attitudes of healthcare professionals regarding that matter. The aim of this study was therefore to describe the attitudes of Polish physicians, nurses and pharmacists towards the ethical and legal aspects of the conscience clause.

Methods

We analysed a group of three hundred healthcare professionals: physicians, nurses and pharmacists in Poznan, Poland, using a standard questionnaire comprising of 29 questions about various ethical and legal aspects of the conscience clause and participants’ personal experiences with the conscience clause. The study was conducted between January and March 2020.

Results

This research shows that although most Polish healthcare workers support the right to invoke the conscience clause they differ significantly in their opinions on to whom and to what medical procedures the conscience clause should apply to. It also demonstrated that while the conscience clause is rarely invoked in Poland, most healthcare professionals declare that the current legal regulations in that sphere are unclear and inaccurate.

Conclusions

While there is an urgent need to raise the awareness regarding the conscience clause among medical students and healthcare professionals and educate them about such issues, it is even more important to improve the legal system in regard to the CC so that it protects both HCPs’ right to the CC and safeguards patients’ rights to medical services.

It's about finding a balance…exploring conscientious objection to abortion with UK midwives

BACKGROUND

Despite the right for health professionals to abstain from providing abortion services existing for over 50 years, literature on conscientious objection to abortion scarcely mentions midwives. In addition, little empirical research has been carried out concerning midwives' views surrounding what constitutes participation in abortion and in turn, what areas of care they can withdraw from.

AIM

To explore midwives' beliefs regarding the extent of and limitations to the exercising of their legal right to objection to abortion on conscience grounds.

DESIGN

Qualitative study with 17 midwives in Glasgow and Liverpool, UK.

METHOD

Face to face semi-structured interviews, transcribed verbatim and analysed using a thematic analysis and Human Rights framework for midwifery care.

FINDINGS

The extent of and limitations to CO to abortion-related care was reflected in four themes: respecting and protecting, making informed decisions, providing non-discriminatory care and experience and culture. There was an overriding sense of support for midwives to be able to exercise their right to conscientious objection, how this is operationalised in practice however continues to be fraught with complexity, which in turn poses constant challenges to midwives who object, their colleagues and managers.

CONCLUSIONS

Midwives' beliefs regarding the exercising of their legal right to object to abortion-related care on conscience grounds can be summarized in the challenge of "finding a balance". A national picture of how to accommodate CO to abortion is needed, so that all midwives can continue to give optimal care to women and receive it themselves, within a human rights framework.

A narrative literature review of the impact of conscientious objection by health professionals on women's access to abortion worldwide 2013-2021

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.

Abortion in Countries with Restrictive Abortion Laws-Possible Directions and Solutions from the Perspective of Poland

The tendency towards the radicalization of abortion law is observed in numerous countries, including Poland. The aim of the present paper was to determine the main factors influencing the number of abortions performed worldwide and to indicate the main directions which should be followed to improve the patients’ well-being. The authors conducted their search in the PubMed of the National Library of Medicine and Google Scholar. Databases were extensively searched for all original and review articles/book chapters in English until June 2021. The main problems associated with the contemporary policy of birth regulation include no possibility of undergoing a termination because of the conscience clause invoked by the medical personnel, restrictive abortion law and lack of sexual education. Minimal changes that should be considered are: improved sex education and the availability of contraception, free access to abortion-inducing drugs with adequate information provided by qualified medical personnel in countries with a conscience clause invoked by the personnel, and the development of an international network which would facilitate undergoing a pregnancy termination abroad to provide women with access to legal abortion assisted by professional medical personnel.

Is the Right to Abortion at Risk in Times of COVID-19? The Italian State of Affairs within the European Context

The COVID-19 health emergency has thrown the health systems of most European countries into a deep crisis, forcing them to call off and postpone all interventions deemed not essential or life-saving in order to focus most resources on the treatment of COVID-19 patients. To facilitate women who are experiencing difficulties in terminating their pregnancies in Italy, the Ministry of Health has adapted to the regulations in force in most European countries and issued new guidelines that allow medical abortion up to 63 days, i.e., 9 weeks of gestational age, without mandatory hospitalization. This decision was met with some controversy, based on the assumption that the abortion pill could "incentivize" women to resort to abortion more easily. In fact, statistical data show that in countries that have been using medical abortion for some time, the number of abortions has not increased. The authors expect that even in Italy, as is the case in other European countries, the use of telemedicine is likely to gradually increase as a safe and valuable option in the third phase of the health emergency. The authors argue that there is a need to favor pharmacological abortion by setting up adequately equipped counseling centers, as is the case in other European countries, limiting hospitalization to only a few particularly complex cases.

The highly complex issue of conscientious objection to abortion: can the recent European Court of Human Rights ruling Grimmark v. Sweden redefine the notions of care before freedom of conscience?

PURPOSE

The article aims to elaborate on two recent European Court of Human Rights (ECtHR) decisions which have rejected, on grounds of non-admissibility, the appeals by two Swedish midwives who refused to carry out abortion-related services, basing their refusal on conscientious objection, and to expound upon the legal and ethical underpinnings and core standards applied to the framing process of such a ECtHR decision.

MATERIALS AND METHODS

By drawing upon relevant recommendations from international institutions, the authors have aimed to assess how the ECtHR rationale could affect the balance between CO and patient rights; searches have been conducted up until December 2020.

RESULTS

In both decisions the European Court has asserted that the right to exercise conscientious objection must give way to the protection of the right to health of women seeking to have an abortion.

CONCLUSIONS

ECtHR judges concluded that the failure to provide for a right to conscientious objection does not constitute, in fact, a violation of the more general right to freedom of thought, conscience and religion, if provided for by a state law to protect the right to health. The legal ethical and social ramifications of such a decision are of enormous magnitude.

Quotas: Enabling Conscientious Objection to Coexist with Abortion Access

The debate regarding the role of conscientious objection in healthcare has been protracted, with increasing demands for curbs on conscientious objection. There is a growing body of evidence that indicates that in some cases, high rates of conscientious objection can affect access to legal medical services such as abortion—a major concern of critics of conscientious objection. Moreover, few solutions have been put forward that aim to satisfy both this concern and that of defenders of conscientious objection—being expected to participate in the provision of services that compromise their moral integrity. Here we attempt to bring some resolution to the debate by proposing a pragmatic, long-term solution offering what we believe to be an acceptable compromise—a quota system for medical trainees in specialties where a conscientious objection can be exercised, and is known to cause conflict. We envisage two main objectives of the quota system we propose. First, as a means to introduce conscientious objection into countries where this is not presently permitted. Second, to minimise or eliminate the effects of high rates of conscientious objection in countries such as Italy, where access to legal abortion provision can be negatively affected.

Gestational age limits for abortion and cross-border reproductive care in Europe: a mixed-methods study

Objectives

Little is known about the experiences of women who travel within Europe for abortion care from countries with relatively liberal laws. This paper aims to assess the primary reasons for travel among a sample of women who travelled from European countries with relatively liberal abortion laws to obtain abortion care mainly in the UK and the Netherlands.

Design

Multi‐country, 5‐year mixed methods study on barriers to legal abortion and travel for abortion.

Setting

UK, the Netherlands and Spain.

Population or Sample

We present quantitative data from 204 surveys, and qualitative data from 30 in‐depth interviews with pregnant people who travelled to the UK, the Netherlands and Spain from countries where abortion is legal on broad grounds within specific gestational age (GA) limits.

Methods

Mixed‐methods.

Main outcome measures

GA when presenting at abortion clinic, primary reason for abortion‐related travel.

Results

Study participants overwhelmingly reported travelling for abortion because they had exceeded GA limits in their country of residence. Participants also reported numerous delays and barriers to receiving care.

Conclusions

Our findings highlight the need for policies that support access to abortion throughout pregnancy and illustrate that early access to it is necessary but not sufficient to meet people’s reproductive health needs.

Funding

This study is funded by the European Research Council (ERC).

Tweetable abstract

This study shows that GA limits drive women from EU countries where abortion is legal to seek abortions abroad.

This study shows that GA limits drive women from EU countries where abortion is legal to seek abortions abroad.