Clients' expectations and experiences with providers of menstrual regulation: a qualitative study in Bangladesh

BACKGROUND

Menstrual Regulation (MR) has been legal in Bangladesh since 1979 in an effort to reduce maternal mortality from unsafe abortion care. However, access to high-quality and patient-centered MR care remains a challenge. This analysis aimed to explore what clients know before going into care and the experience itself across a variety of service delivery sites where MR care is available.

METHODS

We conducted 26 qualitative semi-structured interviews with MR clients who were recruited from three different service delivery sites in Dhaka, Bangladesh from January to March 2019. Interviews explored client expectations and beliefs about MR care, the experience of the care they received, and their perception of the quality of that care. We conducted a thematic content analysis using a priori and emergent codes.

RESULTS

Clients overall lacked knowledge about MR care and held fears about the damage to their bodies after receiving care. Despite their fears, roughly half the clients held positive expectations about the care they would receive. Call center clients felt the most prepared by their provider about what to expect during their MR care. During counseling sessions, providers at in-facility locations reinforced the perception of risk of future fertility as a result of MR and commonly questioned clients on their need for MR services. Some even attempted to dissuade nulliparous women from getting the care. Clients received this type of questioning throughout their time at the facilities, not just from their medical providers. The majority of clients perceived their care as good and rationalized these comments from their providers as coming from a caring place. However, a handful of clients did report bad care and negative feelings about their interactions with providers and other clinical staff.

CONCLUSION

Providers and clinical staff can play a key role in shaping the experience of clients accessing MR care. Training on accurate knowledge about the safety and effectiveness of MR, and the importance of client communication could help improve client knowledge and person-centered quality of MR care.

Trust in provider and stigma during second-trimester abortion

OBJECTIVE

To determine whether trust in the provider and sociodemographics are associated with individual-level abortion stigma.

METHODS

We performed a cross sectional and exploratory study design using secondary analysis of a randomized trial that enrolled participants undergoing second trimester abortion. We collected baseline survey data from 70 trial participants to assess stigma (Individual Level of Abortion Stigma scale, ILAS; range 0-4), trust in provider (Trust in Physician scale; range 1-5), anxiety, depression, and sociodemographics. We performed multiple linear regression, for which ILAS score was the outcome of interest. Univariate associations were used to inform the regression model.

RESULTS

The mean abortion stigma score was at the low end of the ILAS at 1.21 (range 0.2-2.8, SD 0.66). Age, race, income, BMI, parity, gestational age at time of abortion, and reasons for ending the pregnancy were not significantly associated with the ILAS score. Higher trust in provider scores were (m 4.0, SD 0.49) and inversely related to the ILAS score, even after adjustment for confounders (β -0.02, CI -0.03 to -0.004, p = 0.013). Screening positive for anxiety or depression was associated with a higher ILAS score ((β 0.48, CI 0.10, 0.90, p = 0.015); (β = 0.27 CI -0.097, 0.643)), while cohabitation was associated with lower ILAS score (β -0.44, CI -0.82 to -0.57, p = 0.025).

CONCLUSIONS

Trust in an abortion provider, anxiety, depression, and cohabitation are associated with abortion stigma among people seeking second trimester abortion care. Interventions that improve trust in a provider may be an area of focus for addressing abortion stigma. Future research should confirm these findings in larger populations and across diverse locations and demographics and to conduct qualitative research to understand what patients perceive as trust-promoting behaviors and words during abortion encounters.

A meta-ethnography on the experience and psychosocial implications of providing abortion care

RATIONALE

Challenges unique to abortion care have negative implications for access to safe abortion and the psychosocial well-being of healthcare providers. A deeper understanding of the experience of providing abortion care can inform responsive interventions toward supporting abortion providers and strengthening health systems.

OBJECTIVE

A meta-ethnography was conducted to describe the experiences of providing abortion care and offer broad conceptual implications of abortion providers' experiences on their psychosocial coping and well-being.

METHODS

International grey and published research reported in English between 2000 and 2020 was identified via Web of Science Core Collection, PsycInfo, PubMed, Science Direct and Africa-Wide. Studies conducted in contexts where elective abortion is legally permitted were included. Study samples included nurses, physicians, counsellors, administrative staff and other healthcare providers involved in abortion care. Qualitative studies and qualitative data from mixed designs were included. The Critical Appraisal Skills Programme tool was used for appraisal and data was analysed using a meta-ethnographic approach.

FINDINGS

The review included 47 articles. Five themes arose from the data including the emotional challenges of providing clinical and psychological care, organisational and structural challenges, experiences characterised by stigma, pro-choice narratives, and coping with challenges. Outcomes ranged from moral and emotional alignment, resistance to abortion stigma, and job satisfaction to moral distress, emotional suppression, internalised stigma, selective participation and discontinuation of abortion care. Outcomes were dependent on the nature of interpersonal relationships, working conditions, the internalization of positive or negative messages about abortion, personal history and individual coping styles.

CONCLUSIONS

Despite facing significant challenges in their work, the presence of positive outcomes among abortion providers and the moderating role of external and individual-level factors on well-being have encouraging implications for supporting psychosocial wellness among abortion providers.

"They're forcing people to have children that they can't afford": a qualitative study of social support and capital among individuals receiving an abortion in Georgia

Abortion is common but highly stigmatized in the United States, and the overturning of Roe v. Wade severely restricted abortion access in many states across the nation. Data reveal that maternal morbidity and mortality are already increasing, and research suggests existing inequities in abortion access across racial/ethnic and socioeconomic groups will be exacerbated. Research has shown that social support (perceived and received aid from one's social network) and social capital (resources accessed through those social connections) can improve access to health services and decrease barriers to care. Given the escalating barriers to abortion, including longer travel distances, it is imperative to better understand the roles of social support and social capital within abortion access, especially for people living on lower incomes and people of color. Our team conducted in-depth interviews with post-abortion patients (n = 18) from an urban abortion clinic in Georgia in 2019 and 2020, shortly after a six-week gestational age abortion limit had been passed but before it was enacted. We examined how people described their social support and social capital - or lack thereof - when making decisions about their pregnancy and their ability to access abortion. We found that social support and social capital - economic support in particular - were key facilitators of both abortion access and parenting, but participants often experienced barriers to economic support within their social networks due to poverty, unstable partnerships, structural inequality, and abortion stigma. Women experienced constraints to their reproductive autonomy, wherein they had no alternatives but abortion. Our findings suggest that increased economic support and de-stigmatization of abortion are needed to improve reproductive autonomy. Our findings also indicate that restricting and outlawing abortion services is significantly detrimental to the well-being of pregnant people, their families and networks, and their communities by perpetuating cycles of poverty and deepening socioeconomic and racial/ethnic inequities.

Community-based intervention improves abortion knowledge and reduces abortion stigma among women in Oromia, Ethiopia: a quasi-experimental mixed methods evaluation

BACKGROUND

Since liberalization of the Ethiopian abortion law, there have been significant improvements in the availability and utilization of facility-based abortion services in the country. However, nearly half of abortions still take place outside of health facilities, where the quality of procedures remains unknown. Abortion stigma is one reason that unsafe abortion persists. This study aims to evaluate the effect of community interventions conducted from 2016 to 2019 on the level and manifestation of abortion stigma and knowledge in a community in Oromia region, Ethiopia.

METHODS

The study is a quasi-experimental mixed methods evaluation including intervention and comparison communities. Two cross-sectional structured household surveys with independent samples, participatory evaluation wheels, and participatory impact diagrams were conducted with women of reproductive age (15-49) living in the communities. The baseline was conducted in 2016 and the endline in 2019. Difference-in-differences analysis was used to estimate the effect of the intervention on abortion knowledge and Stigmatizing Attitudes, Beliefs, and Actions Scale (SABAS) scores in the intervention community.

RESULTS

One thousand five hundred fifty-five women participated in the household survey and 28 women participated in participatory evaluation meetings. Over one-third (37%) of women surveyed in the intervention community were exposed to the intervention activities. Knowledge of one or more indications of legal abortion increased from 21 to 85% in the intervention community, compared to an increase from 30 to 57% in the comparison. Mean SABAS scores decreased by 9.3 points in the intervention community and increased by 5.3 points in the comparison community. Differences-in-differences models indicate that exposure to the intervention resulted in decreased stigma scores (coefficient = - 9.33, p < 0.001) and increased knowledge (coefficient = 0.26, p < 0.001).

CONCLUSIONS

This is one of the first studies to measure changes in community-level abortion stigma and knowledge over time in Ethiopia using a mixed method, quasi-experimental design. The results indicate that the community-based intervention improved abortion knowledge and reduced abortion stigma.

Maneuvering in Silence: Abortion Narratives and Reproductive Life Histories from the Faroe Islands

I explore what silence surrounding abortion means to women in their everyday lives and the composition of their selfhood. My analysis is based on one-year of ethnographic fieldwork consisting of 20 interviews with women from the Faroe Islands and participant observation. Building upon theoretical frameworks of belonging and subjectivity studies, I discuss women's silent maneuverings from an understanding of freedom of choice and power as complex entities and expand on the dimensions of belonging and nonbelonging. I find that women's silent maneuverings are a navigational strategy made in a quest for belonging, and propose the concept of performed belonging.

The influence of feminist abortion accompaniment on emotions related to abortion: A longitudinal observational study in Mexico

Emotions can reflect how individuals internalize identities, social roles, and broader power structures, including abortion stigma. Abortion accompaniment, in the form of logistical, informational, and emotional support offered by individuals and organizations, takes a person-centered, feminist, and rights-based approach. We tested the extent to which abortion accompaniment may decrease negative and increase positive feelings an individual holds related to their abortion. Using observational longitudinal data collected between January 2017 and mid-2018, we compared negative and positive emotional responses to a personal abortion experience one month and six months following the abortion to emotions immediately prior to the abortion ("baseline"), among women travelling from outside of Mexico City to abortion clinics in Mexico City with and without support of the accompaniment organization, Fondo MARIA. We used doubly robust longitudinal mixed effects models with inverse probability weighting methods. At baseline, accompanied and unaccompanied participants experienced an average of 4.9 and 4.4 negative emotions out of eight respectively (i.e., anguish, nervousness, scared, anxious, sadness, guilt, anger, shame) and 1.7 and 1.9 positive emotions of out 4 respectively (happiness, calmness, decidedness, and relief). From our model results, women accompanied (n = 77) had larger decreases in negative feelings (p < .05) and larger increases in positive feelings (p < .01) toward their abortion compared to those who were not accompanied (n = 119) at six months. These changes led the majority of accompanied respondents to have primarily positive feelings about their abortion by endline. Abortion accompaniment through Fondo MARIA in Mexico City was associated with a larger decrease in negative feelings, particularly those related to stigma, and a larger increase in positive feelings six months after abortion. Accompaniment's focus on person-centered support, self-determination, and autonomy may enable people seeking abortion to view their decision as one that is valid and legitimate, and resist the predominant stigmatizing narratives framing abortion as something that is transgressive.

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.

Individual abortion providers' experiences with targeted harassment in the United States

OBJECTIVE

To understand individual abortion providers' experiences with targeted harassment.

STUDY DESIGN

We conducted a cross-sectional survey of a convenience sample of US physicians with history of abortion provision, recruited through online groups, and listservs. Respondents completed a Qualtrics survey reporting personal and practice characteristics and experiences with harassment. We calculated descriptive statistics, comparing those who had and hadn't experienced targeted harassment using χ² tests, and we qualitatively analyzed free-text descriptions of harassment experiences to identify themes.

RESULTS

Of 321 respondents, 112 (35%) reported harassment. Targeted harassment was more likely with each decade of increasing age, and was greater for respondents providing outpatient versus only inpatient surgical abortion care (40% vs. 7%, p < 0.001) and care beyond the first trimester compared to only in the first trimester (39% vs. 16%, p = 0.001). Sixty-two respondents (19%) were not currently providing abortions, with 33 (52%) explicitly forbidden from doing so by their employers. Qualitative analysis revealed that most harassment is invasive and intimidating rather than overtly violent, with many providers experiencing intentional public exposure of their abortion work and having their professionalism discredited. Ensuing isolation of providers from their communities both perpetuates and facilitates further abortion provider stigma and harassment.

CONCLUSIONS

Targeted harassment toward abortion providers is widespread and attempts to intimidate providers and isolate them from their communities. More research is needed to explore ways to mitigate isolation of providers, which could improve safety, and have positive effects on the abortion workforce.

"We have to respect that option": The abortion aversion complex in safety-net healthcare organizations

In July 2019, the Trump administration began implementing its domestic gag rule to ban discussion of abortion in pregnancy options counseling and ensure physical separation of contraceptive and abortion services at clinical sites funded by the federal government's Title X Family Planning program. In this paper, we examine how organizational policy utilization correlated with organization-level protocols for discussing abortion in options counseling interactions while the domestic gag rule policy was under legal contest. From April 2018 to July 2019, we conducted in-depth interviews with 50 administrators in charge of setting clinical protocols regarding options counseling after a positive pregnancy test at 20 Title X-covered and 14 non-Title X-covered safety-net healthcare organizations in Ohio. We found that organizational characteristics and Title X policy utilization did not explain the heterogeneity in approaches to abortion referral that administrators reported. Administrators from 2 of 20 organizations covered by Title X policy requirements pre-emptively restricted discussion of abortion in their facilities in advance of policy enactment. Meanwhile, administrators from 10 of 14 non-Title X-covered organizations did not restrict discussion of abortion. Our analysis demonstrates how safety-net healthcare organizations' response to federal policy is shaped by administrators' institutional entrepreneurship within the abortion aversion complex: a pattern of policy miscomprehension and endorsed abortion stigma that facilitates the structural stigmatization of abortion within safety-net healthcare organizations. We conclude that current efforts to reverse the domestic gag rule will fail unless local abortion aversion complexes are targeted with intervention.

Judicial bypass attorneys' experiences with abortion stigma in Texas courts

Texas requires pregnant young people under 18 (i.e., minors) seeking abortion without parental consent to go to court with an attorney to petition a judge for permission to obtain abortion. There is a lack of empirical data on the process through which abortion laws stigmatize abortion and on the actors involved. We use data from in-depth qualitative interviews with 19 attorneys who participated in a collective 800 judicial bypass cases to explore what's at stake for multiple actors within a shared social space and how interactions between those actors reproduce stigma. We extend stigma theory to explain how structural abortion restrictions produce stigma at the individual level. We find that to protect their interests in "keeping pregnant minors in," the Texas court system constrains attorneys' ability to represent minors through politicization and stigmatization; attorneys face logistical and emotional challenges, including navigating hostile or ill-informed courts, witnessing court actors humiliate their clients without means of recourse, and experiencing stigma themselves. Although what's most at stake for their clients becomes most at stake for attorneys- helping young people obtain a judicial bypass so they can access abortion and protecting them from humiliation and trauma- they must reconcile their own violation of norms stigmatizing abortion with their consciences' motivation to represent bypass clients and protect their professional identity and career advancement from being "tainted" by taking judicial bypass cases. In order to protect what is at stake for their clients in the context of the highly stigmatized Texas courts, attorneys rationally make trade-offs that protect some stakes while undermining others. Moreover, attorneys' management of experienced stigma and their violation of norms stigmatizing abortion leads some to reproduce abortion stigma in their interactions with minors.

Experience obtaining legal abortion in Uruguay: knowledge, attitudes, and stigma among abortion clients

BACKGROUND

The abortion law in Uruguay changed in 2012 to allow first trimester abortion on request. Implementation of the law in Uruguay has been lauded, but barriers to care, including abortion stigma, remain. This study aimed to assess women's experiences seeking abortion services and related attitudes and knowledge following implementation of the law in Uruguay.

METHODS

We interviewed 207 eligible women seeking abortion services at a high-volume public hospital in Montevideo in 2014. We generated univariate frequencies to describe women's experiences in care. We conducted regression analysis to examine variations in experiences of stigma by women's age and number of abortions.

RESULTS

Most of the women felt that abortion was a right, were satisfied with the services they received, and agreed with the abortion law. However, 70% found the five-day waiting period unnecessary. Women experienced greater self-judgement than worries about being judged by others. Younger women in the sample (ages 18-21) reported being more worried about judgment than women 22 years or older (1.02 vs. 0.71 on the ILAS sub-scale). One quarter of participants reported feeling judged while obtaining services. Women with more than one abortion had nearly three times the odds of reporting feeling judged.

CONCLUSIONS

These findings highlight the need to address abortion stigma even after the law is changed. Some considerations from Uruguay that may be relevant to other jurisdictions reforming abortion laws include: the need for strategies to reduce judgmental behavior from staff and clinicians towards women seeking abortions, including training in counseling skills and empathic communication; addressing stigmatizing attitudes about abortion through community outreach or communications campaigns; mitigating the potential stigma that may be perpetuated through policies to prevent "repeat" abortions; ensuring that younger women and those with more than one abortion feel welcome and are not mistreated during care; and assessing the necessity of a waiting period. The rapid implementation of legal, voluntary abortion services in Uruguay can serve in many ways as an exemplar, and these findings may inform the process of abortion law reform in other countries.

"Like a mother-daughter relationship": Community health intermediaries' knowledge of and attitudes to abortion in Karnataka, India

Community Health Intermediaries (CHIs)- ANMs, ASHAs, and pharmacists- are key to realising task-sharing efforts to increase abortion access in LMICs, but their knowledge of and attitudes to abortion remains underexplored. Evidence on abortion task-sharing has focused primarily on CHIs' technical and clinical abilities, overlooking social contexts and norms that influence attitudes and behaviours. This mixed-methods study describes the abortion knowledge, attitudes, and roles of three cadres of CHIs in rural districts of Karnataka, India. Quantitative data on CHIs' abortion attitudes (n = 118) were collected using the Stigmatising Attitudes, Behaviours, and Actions Scale (SABAS), followed by in-depth interviews (n = 21) with a subset of the population over eight months in 2017. Findings show that CHIs, present at multiple points in women's abortion trajectories, serve as barriers or facilitate access to abortion care. Their abortion attitudes reflect social contexts and environments, drawing on social norms surrounding fertility, woman- and mother-hood. They demonstrate poor knowledge of abortion laws, conflating them with sex-selection laws. CHIs also reflect poor knowledge of abortion methods. They report little to no training on abortion. CHIs contend with entrenched social and structural inequalities in carrying out their tasks, affecting the kind and quality of care they are able to provide. Understanding CHIs' experiences, knowledge and attitudes can advance abortion care-provision, support task-sharing efforts, and potentially improve the quality of women's abortion-seeking experiences.

"It's something that marks you": Abortion stigma after decriminalization in Uruguay

BACKGROUND

Abortion stigma is experienced by women seeking abortion services and by abortion providers in a range of legal contexts, including Uruguay, where abortion was decriminalized up to 12 weeks gestation in 2012. This paper analyzes opinions and attitudes of both abortion clients and health professionals approximately two years following decriminalization and assesses how abortion stigma manifests among these individuals and in institutions that provide care.

METHODS

In 2014, we conducted twenty in-depth, semi-structured interviews with abortion clients (n = 10) and health care professionals (n = 10) in public and private facilities across Uruguay's health system. Interviews were recorded, transcribed, and then coded for thematic analysis.

RESULTS

We find that both clients and health professionals express widespread satisfaction with the implementation of the new law. However, there exist critical points in the service where stigmatizing ideas and attitudes continue to be reproduced, such as the required five-day waiting period and in interactions with hospital staff who do not support access to the service. We also document the prevalence of stigmatizing ideas around abortion that continue to circulate outside the clinical setting.

CONCLUSION

Despite the benefits of decriminalization, abortion clients and health professionals still experience abortion stigma.

Women's experiences of more than one termination of pregnancy within two years: a mixed-methods study

OBJECTIVE

To examine the experiences of women seeking more than one termination of pregnancy (TOP) within 2 years.

DESIGN

Mixed methods study.

SETTING

Six TOP services across Scotland.

SAMPLE

Women presenting for TOP between July and December 2015.

METHODS

Descriptive and inferential analysis of quantitative survey data, thematic analysis of qualitative interview data and integrative analysis. In quantitative analysis, multinomial logistic regression was used to compare three groups: previous TOP within 2 years, previous TOP beyond 2 years and no previous TOP.

MAIN OUTCOME MEASURES

Characteristics and experiences of women seeking TOP.

RESULTS

Of 1662 questionnaire respondents, 14.6% (n = 242) and 19.8% (n = 329) reported previous TOP within and beyond 2 years, respectively. The previous TOP within 2 years group was significantly less likely to own their accommodation than the no previous TOP group (adjusted odds ratio [aOR] 0.34, 95% CI: 0.18-0.62) and previous TOP beyond 2 years group (aOR: 0.44, 95% CI: 0.23-0.85); and more likely to report inconsistent (aOR: 1.63, 95% CI: 1.04-2.57; aOR: 1.95, 95% CI: 1.16-3.28) and consistent (aOR: 2.13, 95% CI: 1.39-3.26; aOR: 1.71, 95% CI: 1.07-2.76) contraceptive use than the no previous TOP and previous TOP within 2 years groups, respectively. Twenty-three women from the previous TOP within 2 years group were interviewed. Qualitative and integrative analyses highlight issues relating to contraceptive challenges, intimate partner violence, life aspirations and socio-economic disadvantage.

CONCLUSIONS

Women undergoing more than one TOP within 2 years may experience particular challenges and vulnerabilities. Service provision should recognise this and move away from stigmatising discourses of 'repeat abortion'.

FUNDING

Scottish Government.

TWEETABLE ABSTRACT

Women having two or more terminations of pregnancy in 2 years may face key challenges/vulnerabilities including intimate partner violence and socio-economic disadvantage.

"The stakes are so high": interviews with progressive journalists reporting on abortion

OBJECTIVES

Because news frames can influence public and policy agendas, proponents of abortion access should be concerned with how this issue is covered in the news. While previous research has examined the content of news on abortion, this analysis explores the process of newsmaking on abortion, examining how journalists understand their role in and experience of covering abortion.

STUDY DESIGN

We recruited journalists with experience reporting on abortion through listservs for progressive and feminist reporters. Thirty-one participants, with experiences at 75 diverse media outlets, completed in-depth, open-ended interviews. We used grounded theory to code interview transcripts in Dedoose to identity emergent themes.

RESULTS

Journalists described many challenges that applied to reporting generally, but that they perceived to be more difficult around abortion: grappling with the meaning of "neutrality" on this issue, finding new angles for articles, and handling editors with varying knowledge of abortion. Over one-third (n=13) of participants mentioned feeling that the stakes were higher around abortion: this urgency and polarization left journalists frustrated by efforts to find new sources or angles on abortion stories. Finally, over 80% (n=28) of participants reported experiencing anti-abortion harassment as a result of their abortion work.

CONCLUSIONS

The difficulties journalists described when reporting on abortion were often rooted in abortion stigma and the political polarization around the issue. This pattern was true even for reporters who worked to counter abortion stigma through their reporting.

IMPLICATIONS

Advocates interested in accurate, destigmatizing news frames might work pro-actively to educate editors and increase reporters' access to providers, patients, and advocates.

Understanding abortion-related stigma and incidence of unsafe abortion: experiences from community members in Machakos and Trans Nzoia counties Kenya

Introduction

The rate of unsafe abortions in Kenya has increased from 32 per 1000 women of reproductive age in 2002 to 48 per 1000 women in 2012. This is one of the highest in Sub-Saharan Africa. In 2010, Kenya changed its Constitution to include a more enabling provision regarding the provision of abortion services. Abortion-related stigma has been identified as a key driver in silencing women's ability to reproductive choice leading to seeking to unsafe abortion. We sought to explore abortion-related stigma at the community level as a barrier to women realizing their rights to a safe, legal abortion and compare manifestations of abortion stigma at two communities from regions with high and low incidence of unsafe abortion.

Methods

A qualitative study using 26 focus group discussions with general community members in Machakos and Trans Nzoia Counties. We used thematic and content analysis to analyze and compare community member's responses regarding abortion-related stigma.

Results

Although abortion is recognized as being very common within communities, community members expressed various ways that stigmatize women seeking an abortion. This included being labeled as killers and are perceived to be a bad influence for women especially young women. Women reported that they were poorly treated by health providers in health facilities for seeking abortion especially young unmarried women. Institutionalization of stigma especially when Ministry of Health withdrew of standards and guidelines only heightened how stigma presents at the facilities and drives women seeking an abortion to traditional birth attendants who offer unsafe abortions leading to increased morbidity and mortality as a result of abortion-related complications.

Conclusion

Community members located in counties in regions with high incidence of unsafe abortion also reported higher levels of how they would stigmatize a woman seeking an abortion compared to community members from counties in low incidence region. Young unmarried women bore the brunt of being stigmatized. They reported a lack of a supportive environment that provides guidance on correct information on how to prevent unwanted pregnancy and where to get help. Abortion-related stigma plays a major role in women's decision on whether to have a safe or unsafe abortion.