Development of a Conceptual Model and Survey Instrument to Measure Conscientious Objection to Abortion Provision

Abstract

Background and ObjectiveConscientious objection to abortion, clinicians’ refusal to perform legal abortions because of their religious or moral beliefs, has been the subject of increasing debate among bioethicists, policymakers, and public health advocates in recent years. Conscientious objection policies are intended to balance reproductive rights and clinicians’ beliefs. However, in practice, clinician objection can act as a barrier to abortion access–impinging on reproductive rights, and increasing unsafe abortion and related morbidity and mortality. There is little information about conscientious objection from a medical or public health perspective. A quantitative instrument is needed to assess prevalence of conscientious objection and to provide insight on its practice. This paper describes the development of a survey instrument to measure conscientious objection to abortion provision.MethodsA literature review, and in-depth formative interviews with stakeholders in Colombia were used to develop a conceptual model of conscientious objection. This model led to the development of a survey, which was piloted, and then administered, in Ghana.ResultsThe model posits three domains of conscientious objection that form the basis for the survey instrument: 1) beliefs about abortion and conscientious objection; 2) actions related to conscientious objection and abortion; and 3) self-identification as a conscientious objector.ConclusionsThe instrument is intended to be used to assess prevalence among clinicians trained to provide abortions, and to gain insight on how conscientious objection is practiced in a variety of settings. Its results can inform more effective and appropriate strategies to regulate conscientious objection.

Prevalence of conscientious objection to legal abortion among clinicians in northern Ghana

“…The survey assessed provider knowledge, beliefs, practices, and self‐identification as an objector, via both closed and open‐ended questions . Survey design and content were informed by an extensive literature review, formative interviews, and pilot testing in the Kassena–Nankana West District of the Upper East Region, and incorporated validated abortion stigma scales such as the Abortion Provider Stigma Survey and the Stigmatizing Attitudes, Beliefs, and Actions Scale . Findings from the survey's pilot indicated that some providers preferred interviewer‐administered surveys, whereas others found self‐administration more compatible with clinical workflow.…”

Abortion as a human right: The struggle to implement the abortion law in Colombia

“…Another remaining concern is provider resistance to providing abortion services due to conscientious objection. While conscientious objection is well defined in Colombian law, and abortion advocates have made efforts to educate providers and the public, the constraints on it are not enforced . Interview respondents cited many instances when individuals, departments, or institutions illegally claimed conscientious objection.…”

“…While conscientious objection is well defined in Colombian law, and abortion advocates have made efforts to educate providers and the public, the constraints on it are not enforced. 24 The complex nature of the Colombian healthcare system has also affected the implementation of the new law. It is a public-private system with limited continuity of care, as users can seek healthcare services from a number of different providers and facilities that are paid by their insurer.…”

Implementing and expanding safe abortion care: An international comparative case study of six countries

“…Despite wide variation in maternal mortality rates, the proportion attributed to unsafe abortion was disturbingly high across the board and led to active participation from the national health sectors. Religion has been a significant force in all six, and it continues to be associated with antiabortion stigma and refusal of care based on conscience (referred to hereinafter and in all case studies as conscientious objection) . However, while conservative and religious opposition did contribute to prolonging the time to legalization in Uruguay, and did lead to compromises in other countries, such as maintenance of abortion in the criminal code and authorization of conscientious objection, such opposition did not prevent the legal and programmatic changes that ultimately led to expansion of access to safe abortion.…”

“…Religion has been a significant force in all six, and it continues to be associated with antiabortion stigma and refusal of care based on conscience (referred to hereinafter and in all case studies as conscientious objection). [28][29][30][31][32][33] However, while conservative and religious opposition did contribute to prolonging the time to legalization in Uruguay, 4 and did lead to compromises in other countries, such as maintenance of abortion in the criminal code and authorization of conscientious objection, 28,[34][35][36][37][38] such opposition did not prevent the legal and programmatic changes that ultimately led to expansion of access to safe abortion. Another notable similarity is that liberalization of abortion regulations arose in periods following emergence from dictatorship, conflict, or other significant political change, such as the collapse of apartheid.…”