Background
Universal access to safe abortion is fundamental to upholding sexual and reproductive health and rights, and a key part of attaining the United Nations Sustainable Development Goals (SDGs) for good health and well-being (SDG3) and gender equality (SDG5) [
1]. When a woman or pregnant person
1 is unable to access a safe abortion, they may resort to unsafe abortion. It is estimated that 45% of abortions worldwide are performed in unsafe circumstances and represent a major preventable cause of maternal morbidity and mortality [
1].
Abortions at 20 weeks’ gestation and over that are sought for indications other than fetal or maternal medicine (also referred to as ‘non-medicalised’ or ‘psychosocial’ indications in this paper) are highly stigmatised and associated with particular access difficulties due to legal restrictions and a limited availability of services [
1,
2]. Abortions at this gestation are technically more complex than earlier abortions and have a greater risk of complications [
1,
3]. The reasons for seeking an abortion are complex and multifaceted [
4,
5]. Non-medicalised reasons for seeking an abortion at any gestational age may include socioeconomic circumstances, a desire to delay or limit childbearing, partner-related reasons, family violence, sexual assault and/or mental illness [
4,
6]. Abortions may be delayed until 20 weeks’ gestation due to a delay in discovering the pregnancy, difficulty deciding on an abortion and/or finding and accessing an abortion provider, all of which can be influenced by a woman or pregnant person’s personal circumstances and the context in which they are living [
7‐
10].
In Victoria, Australia, abortion was legalised in 2008 and is available on request until 24 weeks’ gestation, after which the approval of two medical practitioners of any kind is needed to proceed [
11]. However, access to abortion at 20 weeks and over in Victoria is complicated by the scarcity of services and providers who perform the procedure and institutional barriers that can delay care [
12]. The Abortion and Contraception Service (ACS) at the Royal Women’s Hospital, a public hospital in metropolitan Melbourne, is the only service in the state that provides abortions at 20 weeks and over for indications other than fetal or maternal medicine.
There is little research exploring the care experiences of abortion providers catering for women and pregnant people choosing abortion at 20 weeks and over for psychosocial reasons, and none in the Australian context. For example, a study undertaken in New Zealand found that midwives providing abortions at 20 weeks and over found their work emotionally burdensome and felt inadequately supported [
13]. There are few other studies addressing this specific area of care. Investigating abortion providers’ care experiences can generate insight into the care that is delivered, identify strengths and areas for improvement in abortion practice, and inform interventions and policies to improve care at the user and health system levels.
The aim of this study was to examine health providers’ perceptions and experiences of providing abortion care at 20 weeks and over for indications other than fetal or maternal medicine, as well as enablers and barriers to this care and how quality of care could be improved in one hospital in Victoria, Australia.
Methods
Study design and setting
A qualitative study design was undertaken to gain an in-depth understanding of the views and experiences of healthcare providers who perform abortions at 20 weeks and over for women’s psychosocial reasons. The study was set at the Abortion and Contraception Service at the Royal Women’s Hospital, a public specialist women’s hospital in metropolitan Melbourne, Victoria catering for more than 9000 births per year [
14]. The ACS is the only service providing abortions at 20 weeks and over for non-medicalised reasons in Victoria. Its workforce consists of a multidisciplinary team of obstetrician-gynaecologists, nurses, midwives, social workers and other healthcare providers. Approximately 12 abortions at 20 weeks and over are conducted each month at the service, and at least one abortion over 24 weeks’ gestation each month, for indications other than fetal or maternal medicine. The ACS provides surgical abortions for any indication up to 24 weeks’ gestation. After 24 weeks an induction of labour is performed, and patients are cared for by multiple units and services that includes the ACS.
Participants and recruitment
Participants were healthcare providers of any discipline aged 18 years and over who are regularly involved in the care of patients having an abortion at 20 weeks and over for indications other than fetal or maternal medicine
2. Participants were initially recruited by convenience sampling, after which initial interviews were conducted with key personnel in the clinic, including doctors, social workers and nurses. Purposive sampling was then employed to ensure that all disciplines and levels of experience within the ACS were adequately captured, including staff members who care for patients having an abortion at 20 weeks and over but do not directly work in the ACS clinic, such as theatre nurses. Participants were contacted for recruitment by email or approached in-person by members of the research team (CMD, CMH) who are also ACS staff members.
Data collection
Semi-structured interviews were conducted by members of the research team who are also experienced ACS providers, including a nurse/midwife and social workers (CMH, CMD). There was a general structure to the interview, but this also enabled participants to explore tangents and personal areas of interest. Interviewers were experienced in reflective listening and trauma-informed care and were able to identify and provide support to participants in distress, guided by a distress protocol. None of the participants became distressed during the interviews. A follow-up call was also undertaken one week after the interview to check on participant health and wellbeing.
The interview questions focussed on providers’ care experiences and barriers and facilitators to providing quality abortion care (see Additional file
1). The interview guide was reviewed and revised several times by the research team before being used. Interviews were conducted from April 2022 to December 2022, either in-person in a private and mutually convenient location or via online video conferencing (Zoom software), at a time convenient to both the participant and researcher. A single interview was conducted with each participant. Participants were reimbursed with a $50 Coles/Myer (shopping) voucher for their time. Interviews were recorded using a handheld recording device or the record function on Zoom, depending on the interview format. Field notes were taken by researchers and cross-checked with participants following interviews, there was no further follow up with participants.
Data analysis
Interviews were transcribed verbatim using Otter transcription software [
15]. MM manually edited and reviewed the transcripts for accuracy whilst listening to the audio recordings. A study identification number (i.e., P1, P2, et cetera) was assigned to each interview and all identifying markers were manually removed from the transcripts to maintain confidentiality and privacy. Reflexive thematic analysis was performed using Braun and Clarke’s approach [
16], as it allowed for the inductive development of themes to produce novel insights into this under-researched topic. Data analysis was managed using NVivo software (Version 1.6.1).
Reflexive thematic analysis was primarily conducted by MM using the six recursive steps: familiarisation, coding, generating initial themes, reviewing and developing themes, refining, defining and naming themes, and writing up [
16]. The first stage of the analysis involved familiarisation with the transcripts, which was achieved by listening to audio files, reading transcripts thoroughly and taking preliminary notes on recurring ideas and key concepts in the dataset. MM worked closely with the interviewers to ensure accurate reading and interpretation of transcripts. MM coded the first transcript line-by-line to generate an initial set of codes. Codes were reviewed with AW to ensure all relevant concepts in the interview were captured in full. With this insight, the researcher reviewed the initial coding and subsequently coded the remaining transcripts in the dataset. MM and AW regularly discussed coding development, sharing their interpretations of the data and suggesting different ways of approaching the research question. The coding framework was reviewed by MM, AW and CSEH throughout the coding process to facilitate cross-checking, ensure coding consistency across the transcripts and support theme development. The wider research team (CMD, CMH, PM) was also involved in discussions around sub-theme and theme development, emerging findings and interpretation of the results. Themes, subthemes and codes were then organised and iteratively refined to include new insights.
Throughout the analysis process, researchers considered questions of reflexivity by identifying and reflecting on assumptions and preconceptions regarding abortion care. They acknowledged that being strongly in support of reproductive health and rights and having had professional and personal experiences at the ACS influenced their interpretation of the results. They considered these viewpoints as a useful lens through which to engage with and contextualise the dataset but were also mindful of maintaining a non-judgemental attitude to participants’ views and opinions that differed from their own.
Ethical approvals
Human Research Ethics Approval for the study was obtained from the Royal Women’s Hospital Ethics Committee (Project ID: 79615) and registered with the Monash University Human Research Ethics Committee. Written informed consent was obtained from all participants prior to their interview.
Members of the research team are embedded within the ACS and could potentially be known to participants. To mitigate this, informed written consent was obtained, and participants were assured that participation was voluntary, and that they could withdraw at any time. Participants were given the contact details of a member of the research team for questions and concerns throughout the study.
Supports were made available to researchers in case they experienced any psychological distress while working on the study. The research team had regular fortnightly meetings, providing opportunities for discussion and debriefing, and formal support services (e.g., Employee Assistance Program) at the researchers’ respective institutes were known.
Discussion
We set out to examine health providers’ perceptions and experiences of providing abortion care at 20 weeks and over for indications other than fetal or maternal medicine, as well as enablers and barriers to this care and how quality of care could be improved in one hospital in Victoria, Australia. We found that providers in our study were committed to delivering holistic abortion care that centred women and pregnant people’s needs and autonomy. However, at times they could feel emotionally overwhelmed and challenged by ethical questions that arose in their role. Providers also observed that the lack of abortion services at 20 weeks and over in Victoria compromised equitable access to care and they identified the COVID-19 pandemic as a serious barrier to delivering timely care.
The World Health Organization defines quality abortion care as being effective, efficient, accessible, acceptable (person-centred), equitable and safe [
1]. There should be information provision and counselling, where desired by the patient, and care should be centred around patients’ values and preferences [
1]. Indeed, participants in our study made every effort to prioritise patients’ needs, minimise stigma, and provide a safe and timely service, despite staffing constraints. There is little research that describes what constitutes quality abortion care at 20 weeks and over, which is unique due to the psychosocial and medical complexities at this gestation. Participants in our study felt that consulting patients on their intended arrangements for the pregnancy remains, and providing comprehensive psychosocial care, were particularly important aspects of care at this gestation.
Providers of abortion at all gestations have been found to face many challenges in their role, including grappling with the ethical considerations of their work, and at times experiencing negative emotional impacts, such as anxiety, sadness and grief [
17‐
20]. Many have described having inadequate supports in place to manage these challenges [
17,
20,
21]. Though providers in this study similarly found their work difficult at times, they highlighted that the supportive team environment enabled them to successfully navigate emotional and ethical challenges. Participants felt that they could rely on colleagues and managers for support, with whom they had good relationships, and found structured supportive supervision such as team meetings and clinical supervision to be a helpful tool for navigating difficulties that could arise. Our study suggests that these may be vital elements to supporting abortion providers’ wellbeing and promoting satisfaction in their role. Many studies have found that providers engage in abortion work due to personal beliefs and values around supporting reproductive autonomy and therefore find their work rewarding [
17,
18,
22], which was mirrored in our study. This may be a protective factor in sustaining providers in their challenging role.
Workforce shortages exist at all levels of abortion provision in Victoria, limiting the availability of services and impacting equitable access to care [
12,
23]. This has been attributed to difficulty attracting providers to work in abortion services due to stigma, conscientious objection, and limited training opportunities for medical students and obstetrician-gynaecologist trainees and other staff [
24]. Our research highlights workforce limitations as a significant barrier to being able to provide the service. People living in rural and regional areas are particularly impacted, as they face additional challenges to abortion access such as a limited availability of GP appointments, poor information provision and conscientious objection by GPs, stigma, cost and transport barriers, and concerns about confidentiality [
24‐
27]. A decline in private services providing abortion at 20 weeks and over has been observed in recent years, although the reasons for this are unclear [
12]. The reproductive health and rights of women and pregnant people are threatened as a result. Leadership and culture have been identified by the WHO as key components of an enabling environment for abortion care [
1]. Healthcare leadership can contribute to legislation and institutional policies and environments that are supportive of abortion provision, such as commitments to building a sustainable workforce and enhancing public provision [
28‐
30]. Participants in our study spoke of supportive leadership from managers and a strong commitment to reproductive rights as key enablers of quality abortion provision at their service. Fostering leadership and a culture that support and enable abortion provision is critical in building capacity for abortion provision at 20 weeks and over in the healthcare system.
The COVID-19 pandemic emergency caused significant disruptions to the delivery of sexual and reproductive healthcare worldwide [
31,
32]. The interviews in this study were conducted in 2022 with thousands of COVID-19 cases in the Victorian community, but disease control measures had eased significantly compared to 2020 and 2021, which saw strict lockdowns and movement restrictions [
33]. Participants described barriers to delivering abortion care during the pandemic including visitor restrictions, increased administrative requirements, and understaffing, similarly reported to have impacted abortion services globally [
34,
35]. While the COVID-19 pandemic prompted innovations to maintain abortion accessibility in some contexts, such as the provision of early medical abortion via telehealth [
32], participants in our study did not observe these changes at their service. Instead, they thought that the pandemic delayed access to their service and saw more patients presenting at 20 weeks and over, necessitating a more complex and difficult procedure than at earlier gestations.
Strengths and limitations
A major strength of our study was that it explored the novel perspectives of abortion providers at 20 weeks and over for psychosocial reasons in Victoria, Australia, the first study of its kind in the Australian context. Additionally, a diverse range of professions and levels of experience were captured in the sample. Our study was limited by participants being mostly non-Indigenous, Australian-born, English-speaking females, meaning that perspectives outside of these demographic parameters may not have been captured. The ACS also has strong institutional support for its work, a significant enabler to abortion provision, and findings may differ in settings where this is not the case. Our study may have been impacted by social desirability bias, whereby participants give responses that they believe the interviewers want to hear, rather than their true opinions or experiences, due to interviewers also being ACS staff members. However, the study was led by ACS staff together with an independent medical research institute to mitigate these issues. Whilst this paper did not report on service user experiences of abortion care, this work is part of a larger study including exploring user experiences of abortions at 20 weeks and over, which will complement this work and give unique and important insight into user experiences of quality of care.
Implications for policy and practice
The findings point to an urgent need for more services providing abortion at 20 weeks and over for non-medicalised reasons in Victoria, to secure access to safe and equitable care. A state-wide abortion strategy that outlines adequate service provision, particularly in public hospitals, supports training and workforce development and addresses stigma would be an important step in this process. More research investigating the care experiences of abortion at 20 weeks and over for psychosocial reasons from provider and user perspectives throughout Australia and worldwide is needed to compare findings between contexts. Furthermore, research that evaluates strategies to strengthen the abortion workforce, investigates stigma-reduction measures and engages and encourages hospitals to provide affordable, accessible and acceptable care, is urgently needed.
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