Dualities between Tunisian provider beliefs and actions in abortion care

Abstract

Despite Tunisia's historically progressive reproductive health policies, Tunisian women now face significant challenges accessing legal abortion. Through in-depth interviews with providers at six facilities, we explored factors influencing provider attitudes about abortion and provider perspectives about abortion morality, safety, and legality. We found that gatekeepers (counsellors and front office staff) generally believed abortion was immoral, while obstetricians and gynecologists were more likely to support an individual's right to access abortion. However, providers' actions do not necessarily align with their stated beliefs regarding abortion; some providers who said they support abortion access generally held personal beliefs about when and for whom abortion is appropriate which influenced their provision of care. System-level barriers to abortion provision, such as a lack of resources, hinder some providers who may otherwise be willing to provide the service. These system-level barriers may also account for inconsistencies between providers' beliefs and actions related to abortion. Illuminating the complexity in provider beliefs and attitudes about abortion can help us to better understand whether and why abortion care is provided, as well as the factors that ultimately determine whether a woman can obtain an abortion.

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

“…Twenty-six studies ( Aniteye and Mayhew, 2013 ; Cárdenas et al, 2018 ; de Vries et al, 2020 ; Doran and Hornibrook, 2014 ; Esia-Donkoh et al, 2015 ; Fathallah, 2019 ; Freedman et al, 2010 ; Freeman and Coast, 2019 ; Harden and Ogden, 1999 ; Heller et al, 2016 ; Homaifar et al, 2017 ; Hulme-Chambers et al, 2018 ; Izugbara et al, 2015; Izugbara et al, 2017 ; Kimport et al, 2016 ; LaRoche et al, 2020 ; Margo et al, 2016 ; Nandagiri, 2019 ; Marlow et al, 2014 ; Påfs et al, 2020 ; Payne et al, 2013 ; Pheterson and Azize, 2008 ; Raifman et al, 2018 ; Schwandt et al, 2013 ; Ushie et al, 2019 ; Weitz and Cockrill, 2010 ) described instances of providers acting as gatekeepers to abortion care, including actions taken to actively discourage abortion seekers from accessing services. About one-third of these studies ( de Vries et al, 2020 ; Fathallah, 2019 ; Freeman and Coast, 2019 ; Freedman et al, 2010 ; Heller et al, 2016 ; Homaifar et al, 2017 ; Hulme-Chambers et al, 2018 ; Kimport et al, 2016 ; Margo et al, 2016 ; Pheterson and Azize, 2008 ) focused on matters directly related to the delivery of timely services or issues related to geography (i.e.…”

“…Eight of the 26 studies spoke to issues linking gatekeeping and user-centred care ( Doran and Hornibrook, 2014 ; Esia-Donkoh et al, 2015 ; Harden and Ogden, 1999 ; Hulme-Chambers et al, 2018 ; LaRoche et al, 2020 ; Påfs et al, 2020 ; Raifman et al, 2018 ; Weitz and Cockrill, 2010 ). Participants described the unacceptable nature of facing providers who were reluctant or refused to provide care ( Doran and Hornibrook, 2014 ; Påfs et al, 2020 ; Raifman et al, 2018 ; Weitz and Cockrill, 2010 ).…”

“…Eight of the 26 studies spoke to issues linking gatekeeping and user-centred care ( Doran and Hornibrook, 2014 ; Esia-Donkoh et al, 2015 ; Harden and Ogden, 1999 ; Hulme-Chambers et al, 2018 ; LaRoche et al, 2020 ; Påfs et al, 2020 ; Raifman et al, 2018 ; Weitz and Cockrill, 2010 ). Participants described the unacceptable nature of facing providers who were reluctant or refused to provide care ( Doran and Hornibrook, 2014 ; Påfs et al, 2020 ; Raifman et al, 2018 ; Weitz and Cockrill, 2010 ). Even where participants expressed clear desires to proceed with an abortion, providers presented an obstacle to accessing needed information and care ( Harden and Ogden, 1999 ; Hulme-Chambers et al, 2018 ; Påfs et al, 2020 ; Raifman et al, 2018 ).…”

“…Participants described the unacceptable nature of facing providers who were reluctant or refused to provide care ( Doran and Hornibrook, 2014 ; Påfs et al, 2020 ; Raifman et al, 2018 ; Weitz and Cockrill, 2010 ). Even where participants expressed clear desires to proceed with an abortion, providers presented an obstacle to accessing needed information and care ( Harden and Ogden, 1999 ; Hulme-Chambers et al, 2018 ; Påfs et al, 2020 ; Raifman et al, 2018 ). Instead, participants desired staff that were friendly, compassionate, and sympathetic to their needs and individual circumstances ( Esia-Donkoh et al, 2015 ; LaRoche et al, 2020 ; Raifman et al, 2018 ).…”

The role of midwives in first-trimester abortion care: A 40-year experience in Tunisia

“…19 The study also revealed ambivalence, if not opposition, from some ONFP administrative or political staff. 20 These obstacles have never been solved, although the institution itself is the country's main agency in charge of the regulation and institutionalization of these policies.…”