"Sometimes they used to whisper in our ears": health care workers' perceptions of the effects of abortion legalization in Nepal

Providers' experiences with abortion care: A scoping review

BACKGROUND

Induced abortion is one of the most common gynecological procedures in the world, with as many as three in every ten pregnancies ending in abortion. It, however, remains controversial. The objective of this scoping review was to explore and map existing literature on the experiences of those who provide abortion care.

METHODS AND FINDINGS

This exploratory review followed the Levac et al. guidelines and was reported in accordance with the PRISMA-ScR checklist. CINAHL, Cochrane, EMBASE, PsycInfo, PubMed, and Web of Science were used to identify peer-reviewed, original research articles published on providers' experience of abortion. We identified 106 relevant studies, which include a total sample of 4,250 providers from 28 countries and six continents. Most of the studies were qualitative (n = 83), though quantitative (n = 15) and mixed methods (n = 8) studies were also included. We identified two overarching themes: (1) Providers' experiences with abortion stigma and (2) Providers' reflections on their abortion work. Our findings suggest that providers from around the world experience challenges within society and their communities and workplaces which reinforce the stigmatization and marginalization of abortion and pose questions about the morality of this work. Most, however, are proud of their work, believe abortion care to be socially important and necessary, and remain committed to the provision of care.

CONCLUSIONS

The findings of this review provide a comprehensive overview on the known experiences of providing abortion care. It is a key point of reference for international providers, researchers, and advocates to further this area of research or discussion in their own territories. The findings of this review will inform future work on how to support providers against stigmatization and will offer providers the chance to reflect on their own experiences.

Health care providers attitude towards safe abortion care and its associated factors in Northwest, Ethiopia, 2021: a health facility-based cross-sectional study

BACKGROUND

A negative attitude towards abortion among health care providers providing abortion services could be an obstacle even under a law, which permits abortion on request. Healthcare providers are expected to perform and be change agents of abortion services. However, little information is known about the attitude toward safe abortion among healthcare providers in Ethiopia.

OBJECTIVE

This study aimed to assess health care provider's attitudes towards safe abortion care and its associated factors at the public health facilities of Bahir Dar City, Northwest Ethiopia.

METHODS

A health facility-based cross-sectional study was employed from March 1 to 30/2021 among 416 health-care providers. The data were collected by computer-based generated simple random sampling technique, entered, coded, and cleaned using Epi data version 4.2 and analyzed using Statistical Package of Social Sciences version 25.0. Bivariate and multivariable logistic regression analyses were employed to estimate the crude and adjusted odds ratio with a confidence interval of 95% and a P-value of less than 0.05 considered statistically significant.

RESULTS

The response rate of the study was 99.3%, and 70.2% [95% CI: 65.6-74.6] of health-care providers had a favorable attitude towards safe abortion care. Multivariable analysis indicated that health care providers who are found in the age group of 25-29, 30-34, and ≥ 35 years [AOR = 3.34, 95% CI = 1.03-10.85], [AOR = 4.58, 95% CI = 1.33- 15.83] and [AOR = 5.30, 95% CI = 1.43-19.66] respectively, male health care providers [AOR = 3.20, 95% CI = 1.55-6.60], midwives [AOR = 6.50, 95% CI = 2.40-17.44], working at hospital [AOR = 4.77, 95% CI = 1.53-14.91], ever trained on safe abortion [AOR = 5.09, 95% CI = 2.29-11.32], practicing of an abortion procedure [AOR = 2.52, 95%, CI = 1.13-5.60], knowledge of abortion [AOR = 7.35, 95% CI = 3.23-16.71], awareness on revised abortion law [AOR = 6.44, 95% CI = 3.15-13.17] and need further legalization of abortion law [AOR = 11.78, 95% CI = 5.52-24.26] were associated with a favorable attitude towards safe abortion care.

CONCLUSIONS

Healthcare providers who had a favorable attitude toward safe abortion care were relatively high compared to the previous studies. Age, sex, profession, workplace, training, knowledge, and practice-related factors were associated with a favorable attitude toward safe abortion. This study indicated that, a need for intervention to help improve the attitude of healthcare providers toward safe abortion care, especially for those working in the maternity care units.

Availability of Safe Second-Trimester Abortion Services in Health Facilities in Accra, Ghana

BACKGROUND

We examined providers, methods employed, cost, and other determinants of availability of second-trimester abortion services in health facilities in Accra, Ghana in 2019 to inform policy and program decisions.

METHODS

A two-stage mixed quantitative and qualitative study designs were employed in the conduct of the study. The first stage was a short interaction of the mystery client with a clinical care provider to identify health facilities that provide second trimester induced abortion, the cost, and referral practices, where the facility did not have the service. The second stage was in-depth interviews of second-trimester abortion care providers and non-providers in various health facilities. For internal validity, it also explored the procedure cost, referral, and other practices at the health facilities included in the study, independent of what was captured in the mystery client survey.

RESULTS

Second-trimester abortion services in Accra, Ghana are widely unavailable even in most facilities that provided abortion services. Referral policies and practices indicated by the service providers at various facility levels were inadequate. Criminalization of the procedure, social stigma, and fear of complications are the main factors that adversely influence the availability of second-trimester abortion in health facilities in Accra.

CONCLUSION

Albeit increasing demand for second-trimester abortion in health facilities in Accra, services are not readily available due to the ambiguity of the law, its interpretation, and limited flow of accurate information on providers. Policies and programs that limit access to Second-trimester abortions in Ghana are amendable to ensure safe services.

Determinants of induced abortion among women of reproductive age: evidence from the 2013 and 2019 Sierra Leone Demographic and Health Survey

BACKGROUND

Worldwide, pregnancy termination due to unintended pregnancy is crucial in maternal health, particularly in settings where abortion laws are restrictive. Presently, there is a paucity of literature on determinants of induced abortion among women of reproductive age in Sierra Leone. The study findings could be used to improve the country's maternal mortality indices and inform health programs and reproductive health policies geared toward tackling induced abortion.

METHODS

We analyzed secondary data from the 2013 and 2019 Sierra Leone Demographic and Health Surveys. The surveys were nationally representative, with weighted samples comprising 16,658 (2013) and 15,574 (2019) women of reproductive age. Descriptive statistics, including frequencies and percentages, were computed, while Chi-square and Binomial Logistics Regression were employed to identify correlates of induced abortion.

RESULTS

The results showed that a minority (9%) of the participants had induced abortion in both surveys. Abortion was significantly associated with age, marital status, employment status, education, parity, and frequency of listening to the radio and watching television (p < 0.05). For instance, women aged 45-49 years (AOR = 7.91; 95% CI: 5.76-10.87), married women (AOR = 2.52; 95% CI: 1.95-3.26), and working women (AOR = 1.65; 95% CI: 1.45-1.87) had a higher likelihood of induced abortion compared to their counterparts. Moreover, women with primary education (AOR = 1.27; 95% CI:1.11-1.46) and those who watch television once a week (AOR = 1.29; 95% CI: 1.11-1.49) were more likely to terminate a pregnancy. Women with six or more children (AOR = 0.40; 95% CI: 0.31-0.52) were less likely to terminate a pregnancy compared to those with no child.

CONCLUSION

The study revealed that a minority of the women had induced abortions. The prevalence of induced abortion did not change over time. Induced abortion was influenced by age, marital status, employment status, education, parity, and exposure to mass media. Therefore, policies and programs to reduce unwanted pregnancies should focus on increasing access to modern contraceptives among women of lower socio-economic status.

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

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.

Predictors of Pregnancy Termination among Young Women in Ghana: Empirical Evidence from the 2014 Demographic and Health Survey Data

Pregnancy termination remains a delicate and contentious reproductive health issue because of a variety of political, economic, religious, and social reasons. The present study examined the associations between demographic and socio-economic factors and pregnancy termination among young Ghanaian women. This study used data from the 2014 Demographic and Health Survey of Ghana. A sample size of 2114 young women (15-24 years) was considered for the study. Both descriptive (frequency, percentages, and chi-square tests) and inferential (binary logistic regression) analyses were carried out in this study. Statistical significance was pegged at p < 0.05. Young women aged 20-24 were more likely to have a pregnancy terminated compared to those aged 15-19 (AOR = 3.81, CI = 2.62-5.54). The likelihood of having a pregnancy terminated was high among young women who were working compared to those who were not working (AOR = 1.60, CI = 1.19-2.14). Young women who had their first sex at the age of 20-24 (AOR = 0.19, CI = 0.10-0.39) and those whose first sex occurred at first union (AOR = 0.57, CI = 0.34-0.96) had lower odds of having a pregnancy terminated compared to those whose first sex happened when they were less than 15 years. Young women with parity of three or more had the lowest odds of having a pregnancy terminated compared to those with no births (AOR = 0.39, CI = 0.21-0.75). The likelihood of pregnancy termination was lower among young women who lived in rural areas (AOR = 0.65, CI = 0.46-0.92) and those in the Upper East region (AOR = 0.18, CI = 0.08-0.39). The findings indicate the importance of socio-demographic factors in pregnancy termination among young women in Ghana. Government and non-governmental organizations in Ghana should help develop programs (e.g., sexuality education) and strategies (e.g., regular sensitization programs) that reduce unintended pregnancies which often result in pregnancy termination. These programs and strategies should include easy access to contraceptives and comprehensive sexual and reproductive health education. These interventions should be designed considering the socio-demographic characteristics of young women. Such interventions will help to achieve Sustainable Development Goal 3.1 that seeks to reduce the global maternal mortality ratio to fewer than 70 per 100,000 live births by 2030.

Policy, law and post-abortion care services in Kenya

BACKGROUND

Unsafe abortion is still a leading cause of maternal death in most Sub-Saharan African countries. Post-abortion care (PAC) aims to minimize morbidity and mortality following unsafe abortion, addressing incomplete abortion by treating complications, and reducing possible future unwanted pregnancies by providing contraceptive advice. In this article, we draw on data from PAC service providers and patients in Kenya to illustrate how the quality of PAC in healthcare facilities is impacted by law and government policy.

METHODS

A cross-sectional design was used for this study, with in-depth interviews conducted to collect qualitative data from PAC service providers and seekers in healthcare facilities. Data were analyzed both deductively and inductively, with diverse sub-themes related to specific components of PAC quality.

RESULTS

The provision of quality PAC in healthcare facilities in Kenya is still low, with access hindered by restrictions on abortion. Negative attitudes towards abortion result in the continued undirected self-administration of abortifacients. Intermittent service interruptions through industrial strikes and inequitable access to care also drive unsafe terminations. Poor PAC service availability and lack of capacity to manage complications in primary care facilities result in multiple referrals and delays in care following abortion, leading to further complications. Inefficient infection control exposes patients and caregivers to unrelated infections within facilities, and the adequate provision of contraception is a continued challenge.

DISCUSSION

Legal, policy and cultural restrictions to access PAC increase the level of complications. In Kenya, there is limited policy focus on PAC, especially at primary care level, and no guidelines for health providers to provide legal, safe abortion. Discrimination at the point of care discourages women from presenting for care, and discourages providers from freely offering post-abortion contraceptive guidance and services. Poor communication between facilities and communities continues to result in delayed care and access-related discrimination.

CONCLUSION

Greater emphasis should be placed on the prevention of unsafe abortion and improved access to post-abortion care services in healthcare facilities. There is a definite need for service guidelines for this to occur.

Socio - economic determinants of abortion among women in Mozambique and Ghana: evidence from demographic and health survey

Background

Despite the variances in abortion laws accounting for differences in incidence of abortion among African countries, it appears there is absence of literature on other factors that may also account for the differences in incidence of abortion. Specifically, there is paucity of information on how socio-demographic factors account for the disparities in prevalence of pregnancy termination among women of reproductive age in sub-Saharan Africa. In view of this, this paper examined how socio-demographic factors influence pregnancy termination among women in reproductive age in Mozambique and Ghana.

Methods

The study made use of data from the 2014 Ghana and 2011 Mozambique Demographic and Health Survey for the study. For the purpose of this study a sample of 9375 and 13,660 made up of women in their reproductive ages (15–49) in Ghana and Mozambique respectively was used. The results on the analysis of the association between socio-demographic factors and pregnancy termination are presented as odds ratio (OR) with 95% confidence intervals (CI).

Results

The results revealed that about 25% of the respondents in Ghana and 9% of the respondents in Mozambique reported ever had a pregnancy terminated. In both countries, the odds of pregnancy termination were high among women with primary education, those in the older age groups, women who were Christians and women who were employed. Similarly, higher odds of pregnancy termination were found among ever married women, those who less than four births or more and those who have had access to social media (radio and television).

Conclusion

To reduce unintended pregnancies that could lead to pregnancy termination, there is a need for regular integrated community-based outreach programs targeted at generating community responsiveness of effective contraception and prevention of unintended pregnancy.

Implementation considerations when expanding health worker roles to include safe abortion care: a five-country case study synthesis

Background

Allowing a broader range of trained health workers to deliver services can be an important way of improving access to safe abortion care. However, the expansion of health worker roles may be challenging to implement. This study aimed to explore factors influencing the implementation of role expansion strategies for non-physician providers to include the delivery of abortion care.

Methods

We conducted a multi-country case study synthesis in Bangladesh, Ethiopia, Nepal, South Africa and Uruguay, where the roles of non-physician providers have been formally expanded to include the provision of abortion care. We searched for documentation from each country related to non-physician providers, abortion care services and role expansion through general internet searches, Google Scholar and PubMed, and gathered feedback from 12 key informants. We carried out a thematic analysis of the data, drawing on categories from the SURE Framework of factors affecting the implementation of policy options.

Results

Several factors appeared to affect the successful implementation of including non-physician providers to provide abortion care services. These included health workers’ knowledge about abortion legislation and services; and health workers’ willingness to provide abortion care. Health workers’ willingness appeared to be influenced by their personal views about abortion, the method of abortion and stage of pregnancy and their perceptions of their professional roles. While managers’ and co-workers’ attitudes towards the use of non-physician providers varied, the synthesis suggests that female clients focused less on the type of health worker and more on factors such as trust, privacy, cost, and closeness to home. Health systems factors also played a role, including workloads and incentives, training, supervision and support, supplies, referral systems, and monitoring and evaluation. Strategies used, with varying success, to address some of these issues in the study countries included values clarification workshops, health worker rotation, access to emotional support for health workers, the incorporation of abortion care services into pre-service curricula, and in-service training strategies.

Conclusions

To increase the likelihood of success for role expansion strategies in the area of safe abortion, programme planners must consider how to ensure motivation, support and reasonable working conditions for affected health workers.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4764-z) contains supplementary material, which is available to authorized users.

Abortion and fertility control in Pakistan: the role of misoprostol

OBJECTIVE

To examine how availability of misoprostol has impacted women's abortion-seeking behaviour in Pakistan.

DESIGN

Focused ethnography.

SETTING

A facility providing reproductive health services, including induced abortions in Chakwal, a small town in Northern Punjab, Pakistan.

POPULATION

Women who came to the clinic seeking an abortion or who had had one in the last 6 months (n=23) and all healthcare providers working in the facility (n=14).

METHODS

Semi-structured interviews (n=37), a focus group discussion (n=1) and participant observation (n=41). Latent content analysis was conducted drawing on principles of constant comparison to generate key themes in reported experiences.

RESULTS

All the respondents had sought an abortion to limit their fertility. Although some reported contraceptive use, improper use, undesirable side effects and restrictions on use had led to the unwanted pregnancy. All the women specifically requested misoprostol within days of their pregnancy, suggesting that they not only had knowledge of misoprostol as a backup in case of contraceptive failure, but may have pre-planned its use of in place of using contraception. Women reconciled their decision to undergo an abortion by describing it as a mistake, miscarriage or menstrual cycle issue.

CONCLUSIONS

Misoprostol's availability, ease of use and effectiveness have increased the role of abortion in fertility control.

Challenges encountered in providing integrated HIV, antenatal and postnatal care services: a case study of Katakwi and Mubende districts in Uganda

Background

Integration of sexual and reproductive health (SRH), HIV/AIDS and maternal health (MH) services is a critical strategy to confront the HIV/AIDS epidemic, high maternal mortality and the unmet need for contraception. In 2011 the AIDS Information Centre (AIC) in partnership with the Ministry of Health implemented SRH, HIV/AIDS and MH integration services in the districts of Katakwi and Mubende in Uganda. This paper documents challenges encountered in providing these integrated services in the two districts.

Methods

This was a cross-sectional qualitative study conducted in Mubende and Katakwi districts in Uganda. Data were collected using 10 focus group discussions with 89 women attending ANC and postnatal care and 21 key informant interviews with district managers and health workers who were involved in the integrated service delivery. Content thematic approach was used for data analysis.

Results

The study findings indicate that various challenges were encountered in integrating HIV, ANC and PNC services. Major challenges included inadequate staff, gaps in knowledge of service providers especially with regard to provision of long-term family planning, limited space, shortage of critical supplies such as HIV test kits, drugs and gloves.

Conclusion

These findings indicate that the delivery of integrated HIV, SRH and MH services is hampered greatly by health system challenges and depict the need for additional staffing in health facilities, capacity building of health workers and health managers as well as ensuring sufficient supplies to health facilities for smooth implementation of integrated SRH, HIV and MH services.

Service provider perspectives on post-abortion contraception in Nepal

The government of Nepal has articulated a commitment to the provision of post-abortion contraception since the implementation of a legal safe abortion policy in 2004. Despite this, gaps in services remain. This study examined the perspectives of abortion service providers and administrators regarding strengths and shortcomings of post-abortion contraceptive service provision. In-depth interviews were conducted with 24 abortion providers and administrators at four major health facilities that provide legal abortion in Nepal. Facility factors perceived to impact post-abortion contraceptive services included on-site availability of contraceptive supplies, dedicated and well-trained staff and adequate infrastructure. Cultural norms emerged as influencing contraceptive demand by patients, including method use being unacceptable for women whose husbands migrate and limited decision-making power among women. Service providers described their personal views on appropriate childbearing and the use of specific contraceptive methods that influenced counselling. Findings suggest that improvements to a facility's infrastructure and training to address provider biases and misinformation may improve post-abortion family planning uptake. Adapting services to be sensitive to cultural expectations and norms may help address some barriers to contraceptive use. More research is needed to determine how to best meet the contraceptive needs of women who have infrequent sexual activity or who may face stigma for using family planning, including adolescents, unmarried women and women whose husbands migrate.

Marital status and abortion among young women in Rupandehi, Nepal

BACKGROUND

Despite liberalization of the Nepal abortion law, young women continue to experience barriers to safe abortion services. We hypothesize that marital status may differentially impact such barriers, given the societal context of Nepal.

METHODS

We evaluated differences in reproductive knowledge and attitudes by marital status with a probability-based, cross-sectional survey of young women in Rupandehi district, Nepal. Participants (N = 600) were surveyed in 2012 on demographics, romantic experiences, media habits, reproductive information, and abortion knowledge and attitudes. We used logistic regression to assess differences by marital status, controlling for age.

RESULTS

Participants, who comprised never-married (54%) and ever-married women (45%), reported good access to basic reproductive health and abortion information. Social desirability bias might have prevented reporting of premarital romantic and sexual activity given that participants reported more premarital activities for their friends than for themselves. Only 45% knew that abortion was legal, and fewer ever-married women were aware of abortion legality. Never-married women expected more negative responses from having an abortion than ever-married women.

CONCLUSIONS

Findings highlight the need for providing sexual and reproductive health care information and services to young women regardless of marital status.

Shaping legal abortion provision in Ghana: using policy theory to understand provider-related obstacles to policy implementation

Background

Unsafe abortion is a major public health problem in Ghana; despite its liberal abortion law, access to safe, legal abortion in public health facilities is limited. Theory is often neglected as a tool for providing evidence to inform better practice; in this study we investigated the reasons for poor implementation of the policy in Ghana using Lipsky’s theory of street-level bureaucracy to better understand how providers shape and implement policy and how provider-level barriers might be overcome.

Methods

In-depth interviews were conducted with 43 health professionals of different levels (managers, obstetricians, midwives) at three hospitals in Accra, as well as staff from smaller and private sector facilities. Relevant policy and related documents were also analysed.

Results

Findings confirm that health providers’ views shape provision of safe-abortion services. Most prominently, providers experience conflicts between their religious and moral beliefs about the sanctity of (foetal) life and their duty to provide safe-abortion care. Obstetricians were more exposed to international debates, treaties, and safe-abortion practices and had better awareness of national research on the public health implications of unsafe abortions; these factors tempered their religious views. Midwives were more driven by fundamental religious values condemning abortion as sinful. In addition to personal views and dilemmas, ‘social pressures’ (perceived views of others concerning abortion) and the actions of facility managers affected providers’ decision to (openly) provide abortion services.

In order to achieve a workable balance between these pressures and duties, providers use their ‘discretion’ in deciding if and when to provide abortion services, and develop ‘coping mechanisms’ which impede implementation of abortion policy.

Conclusions

The application of theory confirmed its utility in a lower-middle income setting and expanded its scope by showing that provider values and attitudes (not just resource constraints) modify providers’ implementation of policy; moreover their power of modification is constrained by organisational hierarchies and mid-level managers. We also revealed differing responses of ‘front line workers’ regarding the pressures they face; whilst midwives are seen globally as providers of safe-abortion services, in Ghana the midwife cadre displays more negative attitudes towards them than doctors. These findings allow the identification of recommendations for evidence-based practice.

Effects of abortion legalization in Nepal, 2001-2010

Background

Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion.

Methods

We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001–2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001–2003), early implementation (2004–2006), and later implementation (2007–2010).

Results

23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75).

Conclusion

Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women’s health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.

Proud, not yet satisfied: the experiences of abortion service providers in the Kathmandu Valley, Nepal

OBJECTIVES

In Nepal, the change of the abortion law in 2002 extended the staff duties at family planning clinics to include performing induced abortions. This study investigated the experiences, opinions and attitudes of the staff about their work at safe abortion service centres in the Kathmandu Valley and identified areas in which the health care staff stated the need for improvement.

STUDY DESIGN

Fifteen qualitative semi-structured interviews were conducted with doctors and nurses working with induced abortion at one hospital and five clinics in the Kathmandu Valley. The interviews were transcribed verbatim and analysed using the constant comparative method.

RESULTS

The core category 'Proud, not yet satisfied' comprised a strong perception of providing an important service that is beneficial for women's health and a feeling of pride in providing quality service. Four related categories were identified: 'Beneficial legal framework', 'A will to reach out to all women', 'Frustration about misuse' and 'Dilemma of sex-selective abortion'. The respondents emphasised that improvements are necessary to (1) ensure that all women have access to safe abortion services; (2) prevent abortions from being used instead of contraceptives; (3) stop illegal medical abortions; and (4) deal with the dilemma of sex-selective abortions.

CONCLUSIONS

Respondents were proud of and had positive experiences from their work. They stated they have the opportunity to secure women's rights and health; however, changes are needed to bring the quality of abortion care to a satisfactory level.