Professionalism, stigma, and willingness to provide patient-centered safe abortion counseling and care: a mixed methods study of Ethiopian midwives

Abstract

Background Midwives are a large proportion of Ethiopia’s health care workforce, and their attitudes and practices shape the quality of reproductive health care, including safe abortion care (SAC) services. This study examines how midwives’ conceptions of their professional roles and views on women who have abortions relate to their willingness to provide respectful SAC. Methods This study uses a cross-sectional, mixed methods design to conduct a regionally representative survey of midwives in Ethiopia’s five largest regions (Oromia; Amhara; Southern Nations, Nationalities, and Peoples [SNNP]; Tigray; and Addis Ababa) with a multistage, cluster sampling design (n = 944). The study reports survey-weighted population estimates and the results of multivariate logistic regression analyzing factors associated with midwives’ willingness to provide SAC. Survey data were triangulated with results from seven focus group discussions (FGDs) held with midwives in the five study regions. Deductive and inductive codes were used to thematically analyze these data. Results The study surveyed 960 respondents. An estimated half of midwives believed that providing SAC was a professional duty. Slightly more than half were willing to provide SAC. A belief in right of refusal was common: two-thirds of respondents said that midwives should be able to refuse SAC provision on moral or religious grounds. Modifiable factors positively associated with willingness to provide SAC were SAC training (AOR 4.02; 95% CI 2.60, 6.20), agreeing that SAC refusal risked women’s lives (AOR 1.69; 95% CI 1.20, 2.37), and viewing SAC provision as a professional duty (AOR 1.72; 95% CI 1.23, 2.39). In line with survey findings, a substantial number of FGD participants stated they had the right to refuse SAC. Responses to client scenarios revealed “directive counseling” to be common: many midwives indicated that they would actively attempt to persuade clients to act as they (the midwives) thought was best, rather than support clients in making their own decisions. Conclusion Findings suggest a need for new guidelines to clarify procedures surrounding conscientious objection and refusal to provide SAC, as well as initiatives to equip midwives to provide rights-based, patient-centered counseling and avoid directive counseling.

A narrative review of challenges related to healthcare worker rights, roles and responsibilities in the provision of sexual and reproductive services in health facilities

“…Studies exploring the provision of abortion services found that providers might judge the patients based on a variety of factors relating to a religious or moral values or stigma, such as on whether or not the person seeking abortion was married,91 92 raped,41 the duration of her pregnancy and whether she was ‘convincing enough’ in articulating her desire for abortion, whether or not the sexual act that resulted in the pregnancy was socially sanctioned, and if contraception was used 41 43 93 94…”

“…Many papers explicitly sought to describe and assess the impact of provider religiosity on SRH care, sometimes as their primary research question. In contexts both with and without a formal conscientious objection regime, there were healthcare workers who explicitly said that they objected to abortion on religious grounds and would not provide it 35 43 65 93–97. A study in Malawi documented how this moral or religious objection extended to the provision of postabortion care, with healthcare workers interviewed describing women seeking post abortion care as ‘sinners’ or ‘criminals’ 98…”

“…Quantitative cross-sectional studies assessing the association of provider religiosity with particular practices found that it was associated with support for conscientious objection,99 HIV stigma,100 negative attitudes towards abortion care101 and pharmacist unwillingness to dispense emergency contraception and medical abortifacients 102. Religiosity and other moral approaches to decision-making that compete with SRH guidelines and ethical guidelines were not static or monolithic; papers reviewed suggested they changed over time and in different contexts, with a diversity of opinions likely held by healthcare workers in the same facility 93 96 103…”

“…Several studies researched directly the question of how competing paradigms for decision-making might be reconciled with public health imperatives and healthcare worker responsibilities as these are enshrined in relevant national guidelines. Many providers included in these studies explained that their own or others’ religious convictions or moral concerns should be overridden by professional obligation to provide care18 93 94 99 104 or by their obligations to their employer or the ‘ethos of the hospital’70 105 by religious values relating to forgiveness106 or by payment to provide services to which they are purportedly religiously or morally opposed, such as abortion or FGM 26 37…”

Sexual and reproductive health in Ethiopia: gains and reflections over the past two decades

“…Finally, social mores and opinions around abortion continue to present barriers to access, even when abortion is legal. Fekadu et al and O’Connell et al address stigma at the provider and community level, exploring barriers that this stigma creates to those seeking abortion care [ 18 , 19 ].…”