Professional Pragmatism and Abortion Stigma: Assessing the Performance of the Stigmatizing Attitudes, Beliefs and Actions Scale (SABAS) among Ethiopian Midwives

Stigma towards women requesting abortion and association with health facility staff facilitation and obstruction of abortion care in South Africa

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.

Design and study of psychometric properties of the Community Attitude to Abortion Scale (CAAS) with the Chilean population: Autonomy and Stigma

Introduction

Attitudes toward abortion are related to structural, cultural, and direct gender-based violence. This violence can affect women's mental, physical and reproductive health. Therefore, it is essential to know the nature of community attitudes toward abortion. Since we currently do not have an instrument that measures attitudes towards abortion in Chile, we set the objective of this study to design the Community Attitude to Abortion Scale (CAAS) and analyze its psychometric properties in a Chilean community population.

Methods

This work is an instrumental design study. Using a sampling of panelists by sociodemographic quotas, we obtained a sample of 1,223 participants with a mean age of 36.7 years (SD = 13.56).

Results

As a result, we obtained a scale of 18 items and two correlated factors, Autonomy and Stigma. This structure fits better as an Exploratory Structural Equations Model (ESEM). Both factors have excellent internal consistency. In addition, we obtained evidence of concurrent and discriminant validity: The scores on the factors of the Universal Religious Involvement Scale (I-E12) correlated negatively with Autonomy and positively with Stigma; participants with low levels of identification with a right-wing political orientation, with high levels of identification with a leftwing, pro-feminist, pro-LGBTQ +, and pro-euthanasia political orientation, obtained higher mean scores on Autonomy and lower on Stigma.

Discussion

The CAAS is an adequate tool for use with the Chilean community population, with evidence of consistency and validity. La CAAS is the first tool to measure attitudes to abortion in this country.

Professionalism, stigma, and willingness to provide patient-centered safe abortion counseling and care: a mixed methods study of Ethiopian midwives

Background

Midwives are a large proportion of Ethiopia’s health care workforce, and their attitudes and practices shape the quality of reproductive health care, including safe abortion care (SAC) services. This study examines how midwives’ conceptions of their professional roles and views on women who have abortions relate to their willingness to provide respectful SAC.

Methods

This study uses a cross-sectional, mixed methods design to conduct a regionally representative survey of midwives in Ethiopia’s five largest regions (Oromia; Amhara; Southern Nations, Nationalities, and Peoples [SNNP]; Tigray; and Addis Ababa) with a multistage, cluster sampling design (n = 944). The study reports survey-weighted population estimates and the results of multivariate logistic regression analyzing factors associated with midwives’ willingness to provide SAC. Survey data were triangulated with results from seven focus group discussions (FGDs) held with midwives in the five study regions. Deductive and inductive codes were used to thematically analyze these data.

Results

The study surveyed 960 respondents. An estimated half of midwives believed that providing SAC was a professional duty. Slightly more than half were willing to provide SAC. A belief in right of refusal was common: two-thirds of respondents said that midwives should be able to refuse SAC provision on moral or religious grounds. Modifiable factors positively associated with willingness to provide SAC were SAC training (AOR 4.02; 95% CI 2.60, 6.20), agreeing that SAC refusal risked women’s lives (AOR 1.69; 95% CI 1.20, 2.37), and viewing SAC provision as a professional duty (AOR 1.72; 95% CI 1.23, 2.39). In line with survey findings, a substantial number of FGD participants stated they had the right to refuse SAC. Responses to client scenarios revealed “directive counseling” to be common: many midwives indicated that they would actively attempt to persuade clients to act as they (the midwives) thought was best, rather than support clients in making their own decisions.

Conclusion

Findings suggest a need for new guidelines to clarify procedures surrounding conscientious objection and refusal to provide SAC, as well as initiatives to equip midwives to provide rights-based, patient-centered counseling and avoid directive counseling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01238-0.

When health care workers refuse to provide safe abortion care (SAC) for religious, moral, or personal reasons, they jeopardize their clients’ health and violate the right to care. Scholars believe that health care workers’ professional commitments to patient care and to their profession’s goals can help them prioritize patient care over their personal biases. The Ethiopian government has assigned midwives a central responsibility to provide SAC, but there is no comprehensive understanding of Ethiopian midwives’ willingness to provide SAC and allied rationales, or the relationships between their sense of professional duty and willingness to provide.

To answer these questions, a survey and focus groups with midwives in Ethiopia’s five most populated regions were conducted. Almost half of midwives were unwilling to provide SAC, and half disbelieved that it was midwives’ duty to do so. Most believed that midwives should be able to refuse to provide SAC based on religious or moral objections. Midwives were motivated to provide care by a belief that clients would die without care and by a sense of professional duty. When asked about how they would treat women requesting abortion care and contraceptives, many midwives said that they would encourage the woman to do what the midwife him- or herself thought best, rather than support her in making her own decision.

These regionally representative findings suggest the need for new provider guidelines to clarify practices surrounding conscientious objection and refusal to provide safe abortion care and for programs to better train midwives to provide respectful counseling.