The intersection of stigma, quality of care, and structural barriers: a qualitative study of interactions between abortion seekers and healthcare workers in Australia

doi:10.21203/rs.3.rs-2893909/v1

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Research Article

The intersection of stigma, quality of care, and structural barriers: a qualitative study of interactions between abortion seekers and healthcare workers in Australia

https://doi.org/10.21203/rs.3.rs-2893909/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 07 Sep, 2023

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Background

Abortion is common, safe, and necessary but remains stigmatized. Abortion stigma inhibits quality of care, but stigma and care quality are often examined separately. The aim was to identify the types of enacted stigma in the interactions between abortion seekers and healthcare workers, as well as the characteristics of high-quality non-stigmatizing interactions.

Methods

This phenomenological qualitative study comprised in-depth interviews with people who sought abortion in Australia between March 2020 and November 2022. We recruited through social media and flyers placed in clinics. We examined the interactions between abortion seekers and healthcare workers, and structural barriers influencing interactions, from the perspective of abortion seekers. We conducted thematic analysis and developed typologies by analytically grouping together negative and positive experiences. Negative typologies show categories of stigmatizing interactions. Each positive typology aligns with a negative typology and represents a category of non-stigmatizing and high-quality interactions.

Results

We interviewed 24 abortion seekers and developed five typologies of stigmatizing abortion care: creating barriers to access; judging abortion seekers; ignoring emotional and information needs; making assumptions; and minimizing interactions. The five positive typologies were: overcoming barriers; validating the abortion decision; responding to emotional and information needs; aligning care with preferences and intentions; and providing holistic services that ensure safety. Abortion experiences were influenced by structural factors including abortion regulations, rural health system constraints, and health system adaptations during the COVID-19 pandemic – all of which may influence interpersonal interactions in care.

Conclusions

This study elucidates the interrelationship between stigma, quality of care, and structural barriers, and how these interact to impact abortion experiences. The negative typologies identify stigmatizing healthcare worker behaviors to be avoided, and the positive typologies model high-quality care. These can inform development of stigma-reduction training and approaches for quality improvement, with relevance for other maternal and reproductive health services. Stigma-reduction can incorporate a structural lens through engaging whole-of-service approaches, a focus on power and positionality, and illustrating how providers can reinforce, or overcome, structural stigma. Interventions should address the individual, service-level, and structural forms of stigma that shape the behavior of healthcare workers and contribute to poor experiences for abortion seekers.

abortion

stigma

quality of care

lived experience

qualitative research

Australia

structural stigma

Stigma is “the co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised” (1). It is a well-documented barrier to the delivery of high-quality, equitable care for a range of health conditions and services, with negative health, economic, social, and psychological harms (1, 2). The elimination of stigma and discrimination in healthcare can be described as “a public health imperative” in line with human rights commitments and initiatives (3).

Abortion is a common and necessary part of reproductive healthcare, with an estimated 61% of unintended pregnancies globally ending in abortion, translating to 73.3 million abortions per year (4). Despite this, abortion is stigmatized across the globe, reflecting unequal power relations (5) and gendered social norms that control female sexuality and bodies and idealize motherhood (6).

Abortion stigma has been defined as “a shared understanding that abortion is morally wrong and/or socially unacceptable” (7). It discredits and delegitimizes abortion healthcare and those who seek and provide it, and in doing so limits access to abortion services (8, 9). Across contexts, abortion seekers lack trusted information sources about abortions and keep their decision a secret to limit judgement or rejection (8–10). Healthcare providers too are often stigmatized or marginalized for their involvement in abortion care (8, 11).

Rather than conceptualizing abortion stigma at solely an individual level “as a set of values, beliefs and judgements that flow from stigmatizers to the stigmatized,” we understand enacted stigma as a social process, influenced by structural stigma and broader unequal power relations (5). We define structural stigma as the ways systemic inequalities, laws, and institutional policies and practices constrain and negatively impact quality healthcare and reproductive autonomy. Structural stigma also describes the ways abortion stigma reinforces other systems of oppression, such as racism, ageism, ablism, and sexual orientation and gender discrimination (12). Individual accounts of abortion stigma must be considered in light of the structural factors that shape them, which include health systems, social and economic institutions, and the legal systems (13).

In the context of abortion seeking, stigma can manifest in interactions with providers, pharmacists, medical receptionists, or other personnel encountered on pathways to abortion care (hereafter referred to as ‘healthcare workers'). Abortion seekers around the world commonly anticipate judgement or mistreatment in the health system, and healthcare workers sometimes mistreat abortion seekers or delay their access to services (9, 10, 14–16). As in other sexual and reproductive health services including maternity (17, 18) and HIV care (19), interactions with healthcare providers are among the most important factors influencing quality of care from the perspective of abortion seekers (20–22). Interpersonal interactions on the pathway to abortion care are at the intersection of stigma and quality of care and should be better theorized and understood.

While abortion stigma and abortion quality of care are often examined separately, they are interrelated. A 2022 World Health Organization (WHO) scoping review of 50 studies concluded that stigma is “a significant moderator of quality in abortion care” and identified seven main ways in which abortion stigma inhibits quality of care (9). These are poor treatment of abortion seekers; obstruction of access to care; secrecy on the part of abortion providers and seekers; unnecessary and arduous requirements for those seeking and providing care; poor infrastructure and limited resources; punishment of and threats towards both abortion seekers and providers; and a lack of designated spaces for abortion services to be provided. Sorhaindo and Lavelanet’s (2022) review built on previous efforts by the International Network for the Reduction of Abortion Discrimination and Stigma (Inroads) to integrate an abortion stigma lens to the WHO quality of care framework (23). Our study builds on these efforts by illustrating stigma-related barriers to quality abortion care, and positive manifestations of non-stigmatizing high-quality care, in the permissive legal context of Australia (24).

Abortion is a legal, common, and safe healthcare service in Australia (24–26). Between 2002 and 2021, all states and territories fully or partially decriminalized abortion (24). Medication and surgical abortions are both available, with varying levels of accessibility depending on location and economic resources (27). Drawing on a patchwork of data sources that potentially include dilation and curettage procedures for miscarriage or other gynecological conditions (28), the most recent estimate finds 17.3 abortion procedures per 1000 women of reproductive age annually (28). This equates to 88,287 abortions per year, or roughly one in three women having an abortion in their lifetime (28). Yet abortion in Australia remains subject to scrutiny, restrictions, and stigma (24). Providers are hesitant to provide abortion care, may keep their abortion provision secret, or are discriminated against for providing abortion care (29–31). Abortion seekers, particularly in rural areas, report secrecy, stigma, and confusion about how to access care (29, 32, 33). In Australia, structural stigma includes the ways abortion stigma intersects with other health system dysfunction, including the overreliance on privatized abortion services and the failure to adequately resource rural healthcare (34–37).

The aim was to identify the types of enacted stigma in the interactions between abortion seekers and healthcare workers, as well as the characteristics of high-quality non-stigmatizing interactions. We examine the interrelationships between abortion stigma and quality of care in the interactions experienced by Australian abortion seekers and consider how these experiences are influenced by structural factors.

Theoretical approach

Our analysis was guided by quality-of-care frameworks relevant to abortion care (9, 23). To conceptualize high-quality abortion care for this analysis, we were informed by the 8 domains of person-centered care for reproductive health equity defined by Sudhinaraset et al. (38), which have been applied to abortion quality of care by Altshuler and Whaley (39): dignity, autonomy, privacy/confidentiality, communication, social support, supportive care, trust, and health facility environment (38, 39). We frame our analysis and discussion in line with the socio-ecological model of abortion stigma, which conceptualizes stigma as operating interconnectedly at different levels, including individual, community, mass media, health system, and legal (6).

Quality of care and stigma research differ in how experiences are framed. The quality-of-care literature describes positive indicators of high quality care (40), whereas stigma research generally reports on negative experiences (8, 9). In this analysis, we seek to connect the negative manifestations of stigma directly with the related positive aspects of stigma-free high-quality care. In doing so, we seek to contribute to the emerging literature (9) that aims to theorize and better understand the link between abortion quality of care and stigma. We base our analysis on the assumption that because stigma and quality of care are interrelated, care-seeking may be more challenging for those seeking stigmatized services than for those seeking non-stigmatized ones. Stigma can not be ignored when considering quality improvement in abortion and is therefore our lens of analysis.

Study design

This was a phenomenological qualitative study (41) using in-depth interviews to learn about experiences of abortion care-seeking in Australia during the COVID-19 pandemic. We examine individual accounts of stigma as they are shaped socially and relationally through interactions with healthcare workers and in the context of structural factors such as regulations and local health system constraints during the pandemic.

Eligibility and recruitment

Inclusion criteria were to be at least 18 years of age, able to give an interview in English, and sought abortion care in Australia between March 2020 and November 2022. Recruitment materials specified “people” rather than “women” to be inclusive of any gender identity. We recruited from December 2020 to November 2022 using social media materials (Twitter, Facebook, and Instagram) posted by sexual and reproductive health organizations in Australia. Flyers were also placed in the waiting rooms of clinics that provided high numbers of abortion services and agreed to support study recruitment. We aimed to recruit a sample of at least 20 participants with diversity in terms of state or territory where they sought an abortion, the type of procedure (medication or surgical), gestational age at time of abortion, as well as intersectional factors including age, rurality, and racial/ethnic background. Potential participants were directed to a Qualtrics survey with screening questions (location, age, date of abortion, type of abortion). We invited eligible respondents to review consent materials and an Explanatory Statement before scheduling an interview.

Data Collection and management

The principal investigator conducted the interviews, which were audio recorded using the Zoom videoconferencing platform. At the beginning of each interview, the investigator reviewed consent information verbally, answered any questions the participant shared, and audio recorded verbal consent. Interviews followed a semi-structured interview guide with questions about participants’ abortion trajectory, from finding out they were pregnant, to information-gathering, to seeking care, as well as their retrospective reflections about the experience. The participant led the discussion based on what was most important for them, with prompts and follow-up questions by the interviewer. Interviews lasted between 30 and 105 minutes, after which participants were given a $40 gift card.

Recordings were automatically transcribed through Zoom. Student research assistants compared all transcripts to the audio file to correct transcription errors. All files were stored on secure Monash University platforms. Ethics approval was obtained from the Monash University Human Research Ethics Committee (Project 30926).

Data Analysis

SM, MB and SW conducted a qualitative thematic analysis of the interview transcripts. We began by creating a loose coding framework based on the existing stigma and quality of care literature and SM and SW’s familiarity with the data. We focused on interactions between abortion seekers and healthcare workers to identify how stigma, as well as high-quality, stigma-free interactions, manifested. We included interactions with all types of healthcare workers, including medical receptionists, security guards, ultrasound operators, general practitioners, nurses, and surgeons. Using the preliminary coding framework, we each coded the same four transcripts. We discussed any discrepancies or lack of clarity in codes, collapsed some codes, expanded others, and updated the codebook. SM and SW then coded the remaining transcripts, meeting with MB periodically to discuss emerging adjustments to the codebook.

The final analysis phase was carried out by the SM and MB who have topical expertise in abortion stigma and typologies. We define typologies as interpretive categories based on the clustering of thematic codes. They are an interpretive lens created through the process of data analysis to allow comparisons and patterns to be drawn across a cohort of diverse experiences (42). In this study, typologies refer to categories of interactions between healthcare workers and abortion seekers. We created the typologies by analytically grouping together positive and negative experiences in an iterative process until we had five negative and five positive typologies.

SM interviewed 24 participants ranging from 20 to 40 years of age (Table 1). All identified as cisgender women. They lived in seven of the eight Australian states and territories, and 10 resided in non-metropolitan areas. Between March 2020 and November 2022, 21 participants had one abortion, two participants had two abortions, and one had a spontaneous miscarriage and so did not obtain an abortion. This leaves 25 completed abortions in the study, of which fifteen were medication, nine surgical, and one feticide and stillbirth. Gestational age at time of abortion ranged from five to 28 weeks.

Table 1

Participant and abortion characteristics
Participant characteristics	n = 24
Age range (mean = 29.6)
20–24	5
25–29	6
30–34	9
35+	4
State/Territory
Victoria	10
Queensland	6
New South Wales	3
South Australia	2
Australian Capital Territory	1
Western Australia	1
Northern Territory	1
Tasmania	0
Rurality
Urban	14
Regional	10
Race/ethnicity
Caucasian	21
Australian Aboriginal	1
Asian	1
Hispanic	1
Abortion characteristics	n = 25
Procedure type
Medication	15
Surgical	9
Feticide and stillbirth	1
Year of abortion
2020	5
2021	11
2022	9

Typologies

We constructed ten typologies of interactions in abortion care (Table 2): five categories of negative interactions that reflect stigmatizing, low-quality care and five categories of positive interactions that reflect non-stigmatizing, high-quality care.

Table 2

Positive and negative typologies of interactions between abortion seekers and healthcare workers
1. Interactions that reflect stigmatizing, low-quality abortion care	2. Interactions that reflect non-stigmatizing, high-quality abortion care
1.1 Creating barriers to abortion access	2.1 Actively helping people access abortion care
1.2 Judging, blaming, questioning, or punishing abortion seekers	2.2 Actively validating abortion decision
1.3 Interactions that do not respond to evolving emotional or information needs of the client	2.3 Interactions responsive to evolving emotional and information needs
1.4 Making assumptions about reproductive intentions and related preferences for care	2.4 Aligning abortion provision/process with client's reproductive intentions
1.5 Minimized interactions that compromise the quality and safety of the service	2.5 Providing holistic and high-quality care to ensure a safe service

Each negative typology demonstrates tangible experiences described by abortion seekers that are explicitly or implicitly influenced by abortion stigma within the healthcare interaction. Each positive typology aligns with a negative typology and represents the nature and type of non-stigmatizing and high-quality interactions that are possible when that form of stigma is absent. The 10 typologies are described below, including codes representing the different manifestations of each typology and illustrative quotes exemplifying the experiences of participants. Interactions that reflect stigmatizing, low-quality abortion care are shown in Table 3, and those that demonstrate non-stigmatizing, high-quality abortion care are shown in Table 4.

Typologies of stigmatizing and low-quality abortion care

Table 3

Typologies of interactions that reflect stigmatizing and low-quality abortion care, with codes representing manifestations of each category and example quotes for each
Typology	Codes (manifestations of the typology)
1.1 Creating barriers to abortion access	Gatekeeping or deliberately delaying care; insufficient information provided when booking/referring; denial of care
1.2 Judging, blaming, questioning, or punishing abortion seekers	Questioned decision; don't do this again; woman bears responsibility; withholding or minimizing pain relief; singled out or treated differently for abortion
1.3 Interactions that do not respond to evolving emotional and information needs of the client	Insufficient attention to emotional needs during and after care; insufficient time and attention to support decisions about abortion care; pushed towards one method; unfriendly and cold
1.4 Making assumptions about reproductive intentions and related preferences for care	Ultrasound wishes not respected; pushing contraception; assume client wants to continue the pregnancy; assume client wants to have the abortion
1.5 Minimized interactions that compromise the quality and safety of the service	Insufficient aftercare information; lack of follow up; recovery rushed, pushed out the door

1.1 Creating barriers to abortion access

Healthcare workers behaved in a range of ways – from subtle to blatant – that created barriers to abortion access. The main behaviors were providing insufficient information to abortion seekers, delaying or gatekeeping access to the service, or denying care altogether. Several participants described hurried and uninformative interactions with their provider. Even when GPs referred onwards, brief interactions left participants confused and unsure how to obtain the service they needed. As one participant described, "I said [to the GP] [...] ‘We'd like to access termination services. [...] I’ve tried to look into it, but I don't know who to access, who to talk to. Is that something that you can help me navigate?’ And he just kind of got a bit uncomfortable and just said, ‘we don't do that here. There's some GPs that do.’ […] I was literally on the phone with him, for I think three minutes in total. […] I left more confused I think than anything. And then they're like, right, here's your bill for $75” (ID18). This cursory care was also experienced in cases when the provider agreed to prescribe medication abortion.

Another form of creating barriers was delaying access, as in the case of one participant who was incorrectly informed (whether intentionally or not) that she could not obtain an abortion until later in pregnancy. “[The receptionist] asked me how far along I was. […] I thought about six weeks. And she said, well, we can't actually do anything till nine weeks.” (ID20). Delaying care also corresponded with providers questioning abortion seekers’ decisions, as with a GP who “was kind of hesitant to give it to me, and he's like, ‘No, I’d rather like you think about it and come back Monday’” (ID15).

Some participants described experiencing denial of care. Two participants said a receptionist denied them access to a GP because they were seeking an abortion. As one said, “[when booking] I said, ‘Oh, by the way this is for a termination of pregnancy. That’s why I need the appointment.’ And the receptionist on the phone just said ‘no, we don't do that.’ But she was very short and very abrupt.” (ID19). Further, some participants had difficulty finding a pharmacy that would fill their prescription for medication abortion.

1.2 Judging, blaming, questioning, or punishing abortion seekers

Participants described direct and implicit communications from healthcare workers that made them feel blamed, judged, or punished for their pregnancy and subsequent abortion. Some participants felt their decision was questioned by providers, for example being told “you'll regret [an abortion] if you're 30” (ID02) or asked, “If I told you [that] you were having twins, would it change your mind?” (ID05). Further, some healthcare providers communicated that abortion should not be repeated. “[The GP said] ‘you're not allowed to do this [abortion] again.’ […] Scolding me like I was some young girl who'd been super irresponsible, not like an adult woman who is aware of, like her decisions” (ID15).

Some participants said they felt that the responsibility for the pregnancy was placed solely on the woman. As one participant told us, “I wish there was more information about male contraception. The fact that the whole situation falls on the person with the uterus is, is really upsetting” (ID04). Other participants felt that the need for pain relief was minimized, or pain relief was withheld from them. “[If] I had adequate information, it would mean I could get better pain medication in advance rather than having to go to the emergency department in the midst of COVID” (ID08). Participants also described being treated differently for abortion, as opposed to other types of health procedures. “I think the GP should have […] had more information and less opinions […], like they would with any other procedure” (ID02).

1.3 Interactions that do not respond to abortion seekers’ emotional and information needs

Participants described interactions with healthcare workers that did not respond to their emotional and information needs at different points in the abortion pathway. These interactions often involved healthcare workers having an unfriendly or cold demeanor. In some cases, participants were not told about the different types of procedures available to them, preventing them from making an informed decision. “[I] would have much preferred surgical but I don't feel like that was like adequately explained to me at the time. […] I remember seeing on my Medicare bill that the doctor had charged me for like $180 for counselling. I don't feel like, you know, I was counselled in any way. In some ways I'm grateful for the fact that she didn't try to talk me out of [an abortion]. But in other ways, I sort of feel like that [appointment] should have involved an exploration of the process of a medical termination versus a surgical termination” (ID08). Others similarly said they would have liked more time with their provider to learn more about what the service would entail.

Many participants also said their providers did not attend to their emotional needs. Some abortion seekers wanted more emotional support during the appointment, while others wanted more structured parallel support like counselling services. One said, “I feel like they definitely could have done more to comfort me and just make the process a little bit easier for me. […] To have a bit more time with the doctor to explain the procedure to me […] I just feel like that would have comforted me” (ID17). Another concurred that emotional support was “really, really lacking. It was very like, very medical focused” (ID21). Further, participants often described the healthcare workers as “disconnected”, “abrupt”, “cold”, “didn't give a crap”, or having “no sympathy”. Particularly impactful was a participant who said, “Everybody in that clinic was cold [...]. It was horrible. From the moment I got there to the moment I left” (ID22).

1.4 Making assumptions about reproductive intentions and related preferences for care

In many interactions, healthcare workers made assumptions about participants’ reproductive intentions. Some providers incorrectly assumed that the person wanted to remain pregnant, or alternatively, that they had already decided they wanted an abortion. Providers also made assumptions about whether the participant wanted to discuss contraception or be shown the ultrasound image.

Diverse providers incorrectly assumed their client wanted to be pregnant, commonly during bloodwork, ultrasound, or when seeking a referral. As one participant said, “[The sonographer] was acting very excited for me, and asking if I wanted images saved, and asking when my due date was, and that sort of thing. Which was really really hard to deal with” (ID25). Another participant told us, “It was horrible. I faked it and I just played along because I didn't want to have that conversation [about abortion]. That felt like taking a bullet” (ID11). In some cases, general practitioners incorrectly assumed the participant wanted to be pregnant, and sometimes failed to provide options for abortion care based on these assumptions. As one participant said, “You think you'd read the room and maybe think, the girl might need some options. […] I wouldn't go back to that GP.” (ID09).

In a few cases, providers incorrectly assumed the client was sure about the decision to have an abortion. One participant who had been coerced to have an abortion by her partner said she would have wanted support from the provider to explore her decision. “Maybe there were assumptions made about me, that I’d been really firm on my decision. […] I wish someone had a dug a little bit deeper” (ID21).

Providers also made assumptions about client preferences for ultrasound and contraception. Multiple participants were shown the ultrasound despite expressing that they did not want to see it. Others requested to see it, but their request was refused. Multiple participants also said they felt the abortion providers overemphasized contraception. As one said, “They also were really pushing an IUD onto me, and I found that really opportunistic” (á). Another noted, “they are reminding [you about contraception] every time, and […] you feel that pressure, feel like you have to do it” (ID23).

1.5 Minimized interactions that compromise the quality and safety of abortion care

Many participants described receiving insufficient procedural or aftercare information, follow up, or time to support the recovery process. This led some to call after hours hotlines or visit the emergency department when they weren’t sure if their symptoms were dangerous. A participant said about her visit to the emergency department, “I just didn't really feel like I should have been there, but I didn't know how else to go about it rather than go to the GP […]. I just don't feel like they prepared me for just how much [bleeding] it would be” (ID21). Further, several participants described being “pushed out the door” (ID17) or rushed through recovery after their surgical abortion. Several were released while still dizzy from anesthesia or without their accompanier being notified, with potential ramifications for their safety. One said, “They hadn’t called [my partner] or anything, and I was still quite, you know, drowsy, [and] stumbling in the car park. […] My partner [happened to] look up in his rear vision mirror and saw me” (ID22). Some were told about aftercare instructions while they were still drowsy, leading them to forget their medication. “I was supposed to have antibiotics that night […] Why didn’t they give [my partner] the information?” (ID22). Further, many participants said they did not receive a follow-up call or the results of their laboratory tests confirming success of the abortion. “I didn't receive any follow-up support. […] I think that they maybe, should have offered me something, or even just a follow-up phone call” (ID17).

Typologies of non-stigmatizing and high-quality abortion care

Table 4

Typologies of interactions that reflect non-stigmatizing and high-quality abortion care, with codes representing manifestations of each category and example quotes for each
Typology	Codes (manifestations of the typology)
2.1 Actively helping people access abortion care	Proactively supporting access; took time to provide information when booking/referring
2.2 Actively validating abortion decision	No judgement; explicit validation of decision
2.3 Interactions responsive to evolving emotional and information needs	Emotional support and comfort during and beyond service; time and effort to support decisions and tailor abortion care based on preferences
2.4 Aligning abortion provision/process with client's reproductive intentions	Ultrasound- needs met/respected; Contraceptive discussion aligned with client wants/needs; Find out pregnancy preferences/ intentions
2.5 Providing holistic and high-quality care to ensure a safe service	Sufficient aftercare info for safe management; Proactive follow up to ensure safety/wellbeing of client/patient; supportive interactions during recovery

2.1 Actively helping people access abortion care

Participants described proactive support from their providers to ensure they could access abortion care. Some providers, who did not themselves provide abortion care because of health systems constraints, proactively provided abortion information or helped organise the referral and subsequent appointments. For example, one participant described how “[The GP] went through what the process was, and that there were no options available for me in my local area, and that she would have to refer me to somebody else. [...] Yeah, she got me in for the bloods next, all straight away, and then over to the ultrasound, and then she gave me follow-up call. I think she tried to call me four times [...]. And I was amazed that, you know, somebody would take so much time out of their day just to check on me, to make sure that I had [...] got the referral” (ID22). Another participant described receiving assistance from a sonographer. “She was like, ‘you know you have options [...]. You can go to the hospital tonight, if you want to, or I'll call your GP and we can book you in.’ […] She made a call to my GPs office, my GP just happened to be there working late and they got me booked in […]. That was like really efficient and a relief, it meant that I came away from the appointment with a clear plan, and I think that was really important to me at the time. Like yeah again, the sense of agency and some sort of picture of what was about to happen” (ID08).

2.2 Actively validating abortion decision

Participants also experienced interactions that actively validated and supported their decision to have an abortion with different types of healthcare workers along the care pathway. Some providers actively verbalised their support, for example saying, “there's no right or wrong’” (ID18), “we don't judge anybody” (ID24), and “you have every right to be here” (ID08). One abortion seeker said, “[The doctor] just listened and she just said, this is your choice. You know what you need, you know your life, you know what you're capable of, and what you're doing isn't wrong. You're just making a decision. […] She just said all the right things” (ID13). Participants described such support as “affirming”, “empathetic”, “supportive” and “amazing”. Participants sometimes anticipated their decision being questioned when seeking care, and commented favorably when this did not happen. “[The GP] didn't ask, like any questions that would even like imply judgment like ‘How did this happen’. […] She was just incredibly supportive and really like outcome action oriented” (ID01).

2.3 Interactions responsive to evolving emotional and information needs

Many participants described interactions in which healthcare workers offered comfort and emotional support during and after the abortion service, supported an informed decision-making process, or ensured the service aligned with their needs and preferences. Some providers spent ample time to provide options and engaged in a dialectical process with their client to ensure their abortion care was tailored to their preferences. “[The doctor] gave me the options. We weighed them up together and then made the decision together. I sort of already knew what I wanted to go towards, but he was really good […] in talking to me about […] both options in detail” (ID25). Many of these providers went above and beyond the constraints of health systems. For example, one participant told us, “I hope everyone gets access to a GP as lovely as mine was. […] Having access to someone who will take the time to sit with you and go through all the options. Like, we were certainly extending beyond standard appointments. In my time with her we were really going through things and understanding what was going to happen” (ID01).

Participants shared a range of experiences in which their emotional needs were at the center of the interaction. Healthcare workers often comforted participants during the service, for example giving them a hug, stroking their head, and being caring and friendly. One participant who could not have a support person due to COVID-19 restrictions said the “nurse ended up actually coming into the procedure with me and staying with me until I woke up. Incredible” (ID04). These experiences are reflected in the sentiment of one participant who chose a clinic because “they treat you as a person, not a number” (ID06). Some services followed up after the abortion to check on the emotional and physical wellbeing of their client or by offering counseling services.

2.4 Aligning abortion provision/process with client's reproductive intentions

Participants described positive interactions in which the provider sought to understand their reproductive intentions and service-related preferences, and then aimed to provide care accordingly. A few participants said their provider asked them directly about their pregnancy intentions. “I felt like [the GP] was quite kind, you know, and like he asked me what was I wanting to do” (ID21). Providers then tailored the service accordingly. “[My partner and I] were trying to decide what to do, which was very scary because obviously we weren't expecting this [pregnancy]. So, the doctor gave me some time to think. […] Gave me a timeline, if I was to terminate, what sort of termination I would have. And also gave me some vitamins if I was to go ahead with the pregnancy” (ID03).

Ultrasound and contraceptive counseling were areas in which some participants were supported to have an experience that aligned with their preferences. Some were offered a choice of whether to see the ultrasound image. “I really didn't want [to] get an ultrasound at all [...], especially by myself. [...] They were like, ‘someone will come in with you. You don't have to like, look at anything [on the screen].’ And they were just really, really good at calming all the things that I was bringing up” (ID04). Some providers let the client lead any discussion about contraceptives and provided information and support if requested by the client. As one participant told us, “I said, you know I want to have Implanon [the contraceptive implant] put in on my arm. And [we] just sort of talked through that.” (ID09). Another participant who declined an IUD at the time of the abortion appreciated the follow-up a few weeks later. “They contacted me back and we spoke about contraception […] and I said I would like to get it done” (ID24).

2.5 Providing holistic and high-quality care to ensure a safe service

Some participants described receiving sufficient aftercare information, follow up, and supportive care during recovery, which prepared them to manage their abortion safely. In some cases, they received this level of information from just one of the many people they interacted with on their pathway to care. “It was [not the doctor but] the pharmacist that went into detail and said, if this happens, then you gotta go into emergency and […] gave me the […] tools for me to make an informed decision at home, or when to escalate something if something was wrong” (ID16).

Participants also described ways that healthcare workers were supportive and helpful during the recovery process after a surgical abortion. "There was a nurse like right next to me when I woke up […] I think that was very good and comforting to have someone there immediately upon waking up. And I think it was nice, they had like music playing in the recovery" (ID19). High quality care left participants with a sense that seeking an abortion was a legitimate option and they were deserving of good care. One participant said, “I woke up and then had a nice male nurse that was sort of fussing around. I think that [they had] snacks, and they sort of say, have something to eat. So that, that [I] was just feeling as though it was a normal, fine thing to be doing” (ID09).

Some providers also followed up after the procedure to ensure the safety and wellbeing of their client. One participant said, “because it was [about to be] a long weekend, they called me [on] the Friday, to make sure I was all okay” (ID18). Another said their GP called them to proactively organize follow-up care. “She's just going to go through, probably do some blood and stuff again, just to make sure that it was successful” (ID22).

Structural contributors

The abortion seeking experiences described were influenced by structural factors beyond the control of the individual abortion seeker, provider, or clinic. Some of these reflect the timing of this study during the COVID-19 pandemic. Many participants were subject to restrictions prohibiting an accompanying person from entering the abortion service; many had long wait times, interacted with overburdened healthcare workers, or had their appointments cancelled or delayed, reflecting widespread health system pressures during the pandemic. Some encountered scrutiny and regulations placed upon abortion care, as with a participant who needed approval from multiple providers at a hospital to obtain an abortion at 28 weeks gestational age due to a fetal condition. “That really put in perspective, the significance of this medical board. Because even though we had made the decision to terminate the pregnancy, it wasn't our decision. If that makes sense, it was someone else's decision” (ID07). Some lacked a choice in method due to limited provision in their area. “There was no one who did [surgical termination of pregnancy] in north Queensland. If I wanted the surgery, I was going to have to go to Brisbane” (ID15). Others lived in rural areas and had to travel long distances to the nearest provider – sometimes to receive low quality care. In one particularly harrowing experience, the participant described waiting in an abortion clinic for hours, dressed in only a shirt and underwear, in an overcrowded waiting room. Healthcare workers were rude, rushed, uncompassionate, and showed little concern for protecting patient privacy. She said, “if there were more options […] there'd be a bit more competition. But they're the only [abortion provider]. So, they really get to pick and choose as they want. The facilities were terrible, the support was terrible” (ID22). All these structural factors limited the abilities of abortion seekers and providers to ensure an optimal pathway to care.

This study contributes to the evidence base about the interrelationship between abortion stigma, quality of care, and structural factors influencing access – which is only beginning to be understood. It is complex, if not impossible, to disentangle to what extent negative experiences (such as insufficient aftercare, rushed interactions, or unfriendly providers) reflect stigma, or cross-cutting health system limitations, or the poor bedside manner of an individual provider. While we acknowledge that all types of services, including non-stigmatized ones, can have low-quality care, this analysis is based on ample evidence that stigma intersects with and exacerbates other barriers to care and inhibits quality of care (9). As such, we did not seek to fully differentiate between stigma and other system or service limitations, but rather examine them in their interrelatedness.

Based on the experiences and perspectives of abortion seekers in Australia, the findings progress understandings of how different types of interactions with healthcare workers – both stigmatizing and non-stigmatizing – impact abortion experiences. The negative typologies illustrate behaviors that detract from high-quality care, and the positive typologies illustrate patient-centered abortion care and can be used as a benchmark towards which quality improvement efforts can aspire. The positive typologies align with the supportive care, communication, autonomy and dignity domains of Sudhinaraset’s framework for reproductive health equity (38).

Abortion seekers clearly articulated the positive aspects of their pathways through the healthcare system. When their experiences were negative, they explicitly described how they wished it had been different. They discussed the importance of healthcare workers removing barriers to access, actively supporting their abortion decision, and responding to their evolving emotional and information needs. Several participants also described a supportive and dialectical decision-making process in which they were presented with comprehensive information and provided with adequate time and opportunities to ask questions and discuss their options. Both the Australian Commission’s Quality Framework for Health Care (43) and the International Planned Parenthood Federation’s quality of care framework for sexual and reproductive healthcare (44) emphasize shared decision-making about care. The latter recommends strong interpersonal skills and highlights the need to listen patiently to clients’ needs and concerns, answer questions, and use clear, non-judgmental and supportive language (44). Based on the finding in this study that abortion seekers feel isolated and lack support, models outside the health system, such as abortion accompaniment by trained lay-persons and “abortion doula” programs (45, 46), may also have a role in Australia to ensure optimal care experiences.

Our results illustrate the importance of healthcare workers avoiding assumptions about their clients’ abortion decision and reproductive and contraceptive intentions. Depending on circumstances, the same provider behavior may be interpreted in vastly different ways. For example, being congratulated for being pregnant, commonly during bloodwork or ultrasound, was a negative experience for many participants but could be experienced positively for someone who wanted to be pregnant. Relatedly, abortion seekers expressed a desire for tailored care based on an understanding of their circumstances and preferences, particularly when deciding on an abortion method and during contraceptive counselling. A US study found that more than 60% of women accessing abortion in the first trimester did not want to talk about contraception, often because they had already identified their preferred method (47). The authors concluded that providers should not assume that abortion clients needed contraceptive information, but should instead ask whether they wanted to discuss the topic (47). This highlights the importance of preparing providers to communicate in a non-judgmental style with an active listening approach when gathering information about their clients’ preferences and intentions. This aligns with the ‘acceptability/patient-centered’ dimension of the Inroads adaptation (23) of the World Health Organization’s quality of care framework to abortion.

This study also demonstrates how interactions with providers can limit abortion seekers’ autonomy. For example, we found that many providers did not ascertain the ultrasound viewing preferences of abortion seekers, and in a few cases ignored the client’s stated preference to see or not see the image. Further, some participants said they felt pressured to take up contraception, like findings from Scotland that abortion seekers may feel coerced to take up contraception (48). A study at a US-based abortion clinic found that autonomy is more important to women in decisions about contraception that it is in their general health care (49). Strategies are urgently needed to ensure that abortion seekers are not pressured to obtain contraception, particularly in light of concerns that contraceptive uptake is not always genuinely voluntary (50).

Our study illustrates how interpersonal interactions can either counteract structural stigma or reinforce it in ways that further restrict reproductive autonomy. For example, one participant received incorrect information that would have delayed their care to nine weeks gestational age; this would have eliminated their option for medication abortion due to regulations across Australia. Another participant was subject to the requirement for medical board approval after 24 weeks gestational age – a form of structural stigma. The participant was ultimately able to obtain an abortion but felt the decision to do so was not truly her own, particularly as one member of the board did not approve the request. As described elsewhere, gestational limits on abortion beyond which exemptions are needed are a way to delegitimize abortion and remove autonomy from pregnant people (51). While not present in this study, other researchers have also described the impact of conscientious objection and other structural barriers placed by hospital authorities (Keogh et al., 2019). Importantly, our study also identified ways in which healthcare workers proactively helped abortion seekers overcome the structural and individual barriers they encountered.

Empathetic interactions and sufficient time with providers were key attributes of positive experiences across multiple typologies that contributed to safe and holistic care. A lack of these was a defining aspect of negative experiences of care. Abortion seekers discussed the importance of attention to their emotional needs during the abortion decision process, throughout the medical service, in recovery from surgery, and in the provision of aftercare and follow-up. While the abortion decision or procedure was not emotionally difficult for some participants, others felt they needed extra support through counselling services. Compassionate care has been articulated as a priority by abortion seekers in various settings (20, 39), and is essential in all contexts, not just formal counselling (23, 52). The Inroads quality of care framework also focuses on the importance of kindness and empathy in abortion care and the necessity of including this in provider training (23).

Some experiences that abortion seekers described as negative could also be considered as normalizing. For example, being told to take over-the-counter pain relief and to expect the discomfort of a period may have made abortion seem like any other service. However, the few participants with high levels of pain in this study said they felt unprepared in terms of pain relief, and several sought after-hours care or went to the emergency department. Two participants said they suspected their pain medication was withheld by a GP or pharmacist because they were having an abortion – perhaps as a form of punishment. As pain is the most common side effect in medication abortion, with severe pain experienced by a substantial minority of those undergoing the procedure (53), strategies are needed to reduce the risk that stigma will influence how providers address the pain management needs of clients.

Some of the barriers experienced by abortion seekers in this study reflected health system challenges during the COVID-19 pandemic (24). Others reveal longstanding structural factors including the systemic staffing and resource limitations of rural health services (36, 37), a lack of options for women and pregnant people in rural and remote areas (36), and the relegation of abortion from public to private service-delivery models (34). We conceptualize these barriers as occurring at the nexus of health system deficiency and structural stigma of abortion. We argue that the low-quality interactions demonstrated in this study reflect the interrelationship between stigmatizing personal beliefs among individual healthcare workers and the various manifestations of structural abortion stigma. A study in the UK similarly found that structural barriers can inhibit patient-centered care, in part reflecting the outsourcing of abortion from the public system to private providers affected by market forces (54). Without a focus on structural as well as other levels of stigma, we are unlikely to make major progress in reducing stigma and its harms (5).

Improving quality of care by addressing abortion stigma

Recent systematic and scoping reviews have identified a need for theory-based and tested stigma reduction interventions (2, 55, 56). This study contributes by identifying specific behaviors – both positive and negative – on which stigma reduction strategies could focus. The findings are of particular relevance in Australia, where national and Victorian state sexual and reproductive health strategies emphasize the need for reduced stigma for sexual and reproductive health services (57, 58) yet stigma remains commonplace. Approximately 15% of healthcare providers in Australia are conscientious objectors, and others may support only some reasons for choosing an abortion (59). There is a clear need for effective interventions to reduce stigmatizing interactions on pathways to abortion care, particularly because stigma exacerbates intersectional inequities in healthcare access (12, 56).

We found that interactions at reception, in ultrasound, during bloodwork, and with referring GPs were common sites of stigmatizing interactions in which abortion seekers’ preferences were not respected. However stigmatizing interactions also occurred in dedicated abortion clinics. These results demonstrate the importance of ongoing and repeated ‘training for all providers and staff including content about non-judgmental and non-directive care’, as emphasized in the Inroads framework for abortion stigma and quality of care (23). Training can help providers develop proactive strategies to overcome the common stigma-related barriers that abortion seekers may encounter, including conscientious objection and gatekeeping. Stigma-reduction strategies are also of relevance to other maternal and reproductive health services, where clients may be disrespected, stigmatized, mistreated, and their preferences not considered (55, 60).

The negative typologies in this study draw attention to the manifestations of abortion stigma that should be avoided in healthcare interactions, from the perspective of abortion seekers. The positive typologies are also important, as constructive feedback and examples that generate positive emotions can be effective for generating behavior change (61, 62). Case studies of the subtle to overt forms of stigma that abortion seekers experience as stigmatizing can help providers identify blind spots in their own practice and consider bystander approaches if they observe these behaviors among colleagues. There is modest or inconclusive evidence, primarily in low- and middle-income contexts, to support using Value Clarification principles when aiming to change knowledge, attitudes, and behaviors of healthcare workers (55, 56, 63). The Value Clarification approach could be refined and refocused to support stigma reduction in the interactions between abortion seekers and healthcare providers.

While training necessarily engages individual healthcare workers, there are ways to bring a structural lens. First, whole-of-institution or whole-of-service approaches can support change at multiple levels, for example by sensitizing management, developing protocols and policies to institutionalize de-stigmatization, and shifting culture around abortion at the hospital or service levels. Whole-school approaches to violence prevention, for example, have shown promising results (64, 65). Another way to bring structural factors into provider training is by focusing on positionality and the power differentials between abortion consumers and healthcare workers. This draws on conceptions of stigma as incorporating power dynamics (5). Discussions of ‘abortion exceptionalism’ – “the idea that abortion is regulated both differently and more stringently than other medical procedures that are comparable to abortion in complexity and safety” (66), can help illustrate the legal and regulatory structures that reinforce stigma. This is relevant in Australia (67, 68), where a 2023 proposal to the Therapeutic Goods Administration in Australia aims to remove ‘exceptional’ regulations (69). A focus on structural stigma, which operates within organizations, government, institutions, laws, and public discourse (13), is important for future intervention development – particularly as reviews of stigma-reduction efforts have found no have found no interventions that focus on the structural and societal drivers of stigma (13, 55, 56).

Our choice of qualitative methods provided rich empirical data from the perspective of abortion seekers, but means the study is not generalizable to the broader population. Participants self-selected into the study, so the sample may reflect those with particularly strong positive or negative experiences or with strong opinions about abortion. Another limitation of the analysis is the attempt to create discrete typologies when the manifestations of stigma are interrelated. Further, while the sample included a range of experiences in rurality, type of abortion, and gestational age at time of abortion, abortion seekers in Victoria were overrepresented, and we did not recruit anyone who tried to obtain an abortion but failed to access it. Further, the sample was predominantly white and entirely cis-gendered. This limits our analysis of intersectional experiences of abortion stigma. Challenges recruiting diverse samples remain in health research (70), and stigma-reduction intervention development should ensure that a range of experiences are reflected. Finally, many aspects of stigma raised in the interviews (internalized, anticipated, and how these relate to low expectations of care) are not examined in this analysis due to the focus on healthcare interactions. Consideration of these stigma experiences and how they interrelate with the typologies would paint a more comprehensive picture of the role of stigma in abortion experiences in Australia.

Individual experiences of abortion stigma, the structural factors shaping these, and abortion quality of care are interrelated and cannot be examined in isolation. The results highlight the need for strategies to reduce stigma, avoid assumptions, and support the autonomy of abortion seekers, particularly during ultrasound, bloodwork, and contraceptive counseling. The typologies presented in this paper can help structure training for the range of healthcare workers who interact with abortion seekers. The negative typologies show behaviors that should be avoided, and the positive typologies model stigma-free and high-quality care and are useful for quality improvement. The findings also illustrate structural forms of stigma at clinic, service, institution, and health system levels that contribute to poor experiences for abortion seekers. These too must be addressed in stigma reduction strategies, alongside consideration of how they shape the behavior of healthcare workers. Theory-based and tested stigma-reduction approaches that identify and intervene on harmful interactions between healthcare consumers and providers will have broad applicability to other maternal and reproductive health services around the world.

Ethics approval and consent to participate

Ethics approval was obtained from the Monash University Human Research Ethics Committee (ID 30926). All methods were performed in accordance with the Declaration of Helsinki. All participants provided audio-recorded verbal informed consent after reviewing an explanatory statement, as approved by the Monash University Human Research Ethics Committee.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available for privacy reasons but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This analysis was funded by a Seeding Grant from the NHMRC-funded SPHERE Centre for Research Excellence in Sexual and Reproductive Health for Women in Primary Care. The network of researchers affiliated with SPHERE has influenced the conception of the study, and five co-authors (SM, SW, JF, DB, KIB) are affiliated with SPHERE.

Authors’ contributions

SM led conception and design of the study with input from JF, DB and KIB. SM and MB developed the analysis strategy, SM, MB and SW conducted analysis and interpretation. SM drafted the paper with substantive contributions from MB. All authors reviewed subsequent drafts, provided substantive revisions, and approved the submitted version.

Acknowledgements

We acknowledge Anisa Assifi, Sarah Baum, Anna Noonan, Sarah Ratcliffe, Mridula Shankar, Angela Taft, Kari Vallury, and the SPHERE CRE community for conceptual input that influenced the development this study. We thank the amazing organizations and clinics across Australia that supported recruitment of participants. And most importantly, we appreciate the participants in this study who shared their experiences with us and supported this research.

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No competing interests reported.

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The intersection of stigma, quality of care, and structural barriers: a qualitative study of interactions between abortion seekers and healthcare workers in Australia

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Journal Publication

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Abstract

Background

Methods

Theoretical approach

Study design

Eligibility and recruitment

Data Collection and management

Data Analysis

Results

Typologies

Typologies of stigmatizing and low-quality abortion care

1.1 Creating barriers to abortion access

1.2 Judging, blaming, questioning, or punishing abortion seekers

1.3 Interactions that do not respond to abortion seekers’ emotional and information needs

1.4 Making assumptions about reproductive intentions and related preferences for care

1.5 Minimized interactions that compromise the quality and safety of abortion care

Typologies of non-stigmatizing and high-quality abortion care

2.1 Actively helping people access abortion care

2.2 Actively validating abortion decision

2.3 Interactions responsive to evolving emotional and information needs

2.4 Aligning abortion provision/process with client's reproductive intentions

2.5 Providing holistic and high-quality care to ensure a safe service

Structural contributors

Discussion

Improving quality of care by addressing abortion stigma

Conclusions

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1