The role of healthcare providers in expanding legal abortion: Qualitative insights from Argentina, Ireland, and South Korea.

Abortion laws are key in creating an enabling environment that facilitates the advancement of people's sexual and reproductive health and rights. Around 50 countries have liberalized their abortion laws in the last decades by adding new grounds allowing abortion. The road toward the expansion of legal abortion is a long, highly sensitive, and difficult process. The specific role of healthcare providers in influencing abortion law reforms has been scarcely studied. With the objective to better understand their (potential) roles, a qualitative study was conducted in 2021 focusing on three countries that had recently liberalized their abortion regulations: Argentina, South Korea, and Ireland. For each country, key informant interviews were conducted with actors in advocacy for legal change, the majority with healthcare providers. The study results indicate that healthcare providers can contribute to the expansion of legal abortion through their influence on public and legal debates. Healthcare providers were found to be scientifically credible and trustworthy. Their voice and argumentation counteracted anti-rights arguments and addressed information gaps, by providing specific clinical experiences and medical information. Healthcare providers amplified women's experiences through their testimonies and had entry points within governmental bodies, which facilitated their advocacy. These healthcare providers often functioned as individual operating obstetrician/gynecologists or general practitioners who were engaged in networks of health professionals or had previous advocacy experience. In a global context of social and political contention around abortion, extending the engagement of healthcare providers in law and policy deliberation on abortion appears to be useful. This requires recognizing the diversity of roles that healthcare providers can take up, creating a safe environment in which they can operate, equipping them with skills that go beyond the medical expert role and facilitating strategic partnerships that seek complementarity between multiple stakeholders, building on the uniqueness of each stakeholder's expertise.

Restrictive points of entry into abortion care in Ireland: a qualitative study of expectations and experiences with the service.

This article focuses on access to early medical abortion care under Section 12 of the Health (Regulation of Termination of Pregnancy) Act 2018, in Ireland and identifies existing barriers resulting from gaps in current policy design. The article draws primarily on qualitative interviews with 24 service users, 20 primary healthcare providers in the community and 27 key informants, including from grassroots groups that work with women from different migrant communities, to examine service users' experiences accessing early medical abortions on request up to 12 weeks gestation. The interviews were part of a wider mixed-methods study from 2020-2021 examining the barriers and facilitators to the implementation of abortion policy in Ireland. Our findings highlight care seekers' experiences with the GP-led service provision, including delays, facing non-providers, the mandatory three-day waiting period, and oversubscribed women's health and family planning clinics. Our findings also highlight the compounding challenges for migrants and additional barriers posed by the geographical distribution of the service and the 12-week gestational limit. Finally, it focuses on the remaining challenges for racialised and other marginalised groups. In order to provide a "thick description" of women's lives and the complexity of their experiences with abortion services in Ireland, we also present two narrative vignettes of service users, and their experiences with delays and navigating the healthcare system as migrants. To this effect, this article applies a reproductive justice framework to the results to highlight the compounding effects of these barriers on people located along multiple axes of social inequality.

Abortion policy implementation in Ireland: successes and challenges in the establishment of hospital-based services.

Objective: To describe successes and highlight remaining challenges in the establishment of hospital-based abortion services after legal change in the Republic of Ireland. Methods: We conducted a mixed-methods study on the implementation of abortion policy in Ireland. In this manuscript, we present the results from a qualitative analysis of in-depth interviews conducted with hospital-based providers, service users, and key informants. We used Dedoose software to conduct a thematic analysis of the data. Results: We report findings from interviews with 28 obstetrician gynecologists, midwives, psychiatrists, anesthesiologists, and nurses; a subset of 7 service users who sought care in hospitals; and 27 key informants. In this analysis, we describe how key themes that pertain to information, capacity and power, facilitated and hindered the implementation of hospital-based abortion services. We found that individual champions are key to establishing the service, but their motivation is not always sufficient to integrate abortion into existing clinical services, and conscientious objection is a persistent barrier to expanding abortion services. The main challenges highlighted here are lack of abortion provision at some hospitals and limited access to surgical abortion at most hospitals due to provider-level, logistical, and infrastructure barriers. Conclusions: This study presents new information on how abortion policy is implemented on the ground in hospital settings. Its findings can inform public health officials and providers in Ireland and other countries wishing to establish abortion services.

Information flow as reproductive governance. Patient journey analysis of information barriers and facilitators to abortion care in the republic of Ireland.

Background: Information flow - information communication and transmission pathways and practices within healthcare systems - impacts patient journeys. Historically, regulating information flow was a key technology of reproductive governance in the Republic of Ireland. Pre-2018, law and the State sustained informational barriers to and through abortion care in Ireland. An expanded abortion service was implemented in January 2019. Method: Patient Journey Analysis (PJA) interrogates informational facilitators and barriers to/through post-2019 abortion care in Ireland. We focus on information flow at the interfaces between the 'public' sphere and 'point of entry', 'point of entry' and primary care, and primary and secondary care. Materials: The paper uses data from a mixed-method study. A tool for assessing online abortion service information (ASIAT), desktop research, and qualitative data from 108 in-depth interviews with providers, policy-makers, advocacy groups, and service users informed the analysis. Results: Abortion patient journeys vary. Information flow issues, e.g. communication of how to access services, referral systems, and information handover, act as barriers and facilitators. Barriers increase where movement from primary to secondary is needed. Applications: The article identifies good practice in information flow strategy, as well as areas for development. It illustrates the significance of information flow in accomplishing reproductive governance.

Abortion policy implementation in Ireland: Lessons from the community model of care.

BACKGROUND: In 2018, the right to lawful abortion in the Republic of Ireland significantly expanded, and service provision commenced on 1 January, 2019. Community provision of early medical abortion to 9 weeks plus 6 days gestation delivered by General Practitioners constitutes the backbone of the Irish abortion policy implementation. We conducted a study in 2020-2021 to examine the barriers and facilitators of the Irish abortion policy implementation. METHODS: We collected data using qualitative in-depth interviews (IDIs) which were conducted in-person or remotely. We coded and analysed interview transcripts following the grounded theory approach. RESULTS: We collected 108 IDIs in Ireland from May 2020 to March 2021. This article draws on 79 IDIs with three participant samples directly relevant to the community model of care: (a) 27 key informants involved in the abortion policy development and implementation representing government healthcare administration, medical professionals, and advocacy organisations, (b) 22 healthcare providers involved in abortion provision in community settings, and (c) 30 service users who sought abortion services in 2020. Facilitators of community-based abortion provision have been: a collaborative approach between the Irish government and the medical community to develop the model of care, and strong support systems for providers. The MyOptions helpline for service users is a successful national referral model. The main barriers to provision are the mandatory 3-day wait, unclear or slow referral pathways from primary to hospital care, barriers for migrants, and a shortage and incomplete geographic distribution of providers, especially in rural areas. CONCLUSIONS: We conclude that access to abortion care in Ireland has been greatly expanded since the policy implementation in 2019. The community delivery of care and the national helpline constitute key features of the Irish abortion policy implementation that could be duplicated in other contexts and countries. Several challenges to full abortion policy implementation remain.

Exploring providers' experience of stigma following the introduction of more liberal abortion care in the Republic of Ireland.

OBJECTIVE: To explore if abortion care providers in the Republic of Ireland experience abortion-related stigma. STUDY DESIGN: The survey was distributed to abortion care providers working in community and hospital units nationwide. We measured stigma using the 35-item version of the Abortion Providers Stigma Scale (APSS). We also collected data on demography, professional involvement in providing abortion care, and risk of burnout (measured by the Maslach Burnout Inventory). RESULTS: Of the 309 providers invited to take part, 156 (50.5%) completed the survey between January to May 2020. The sample reported a mean score of 70.9 on the total scale of the APSS. This was comparable with the scores of providers in a Massachusetts-based study but was lower than a sample of providers from across the USA. Linear regression analyses found that the Irish hospital-based obstetricians (b = 10.51, 95% CI 3.16-17.86) and midwives/nurses (b = 10.88, 95% CI 2.3-19.47) reported higher stigma than their colleagues working in general practice. CONCLUSIONS: Comparing the scores of the current sample to published studies highlight the factors that may drive stigma in the Irish context. The Irish providers reported fewer issues in disclosing their abortion work than providers in the USA, which may be explained as they also reported fewer experiences of judgment and discrimination. They did, however, report higher levels of social isolation. Additionally, the findings suggest that providing surgical and/or later-gestation abortion care and providing within the hospital environment may present additional challenges for staff which increase level of stigma. IMPLICATIONS: Despite widespread support for the expansion of the abortion care services, providers in Ireland still experience stigma related to this work. Our findings suggest that Irish providers, particularly those working in hospitals, may benefit from supports to reduce abortion-related isolation and challenges posed by collegial interactions or later-gestation care.

Safe abortion in South Africa: "We have wonderful laws but we don't have people to implement those laws".

In South Africa, abortion was legalized in 1996, during the nation's transition from apartheid to independence and democracy, under the Choice on Termination of Pregnancy Act (CTOPA). The law drew from both a public health and rights-based framework. A coalition of advocates played a key role in passage. In the years after the CTOPA was passed, abortion services were expanded-in part through a 2008 amendment that allowed trained registered nurses to provide abortions-and deaths from unsafe abortions decreased. However, there have been hurdles to implementation, including competing health priorities such as HIV/AIDS, and a high number of conscientious objectors. There is a geographic disparity in accessibility of abortion services between provinces as well as between urban and rural areas. Women seeking legal abortions face a lack of accessible information on where to obtain an abortion, often experience stigma at facilities, and many obtain illegal procedures.

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

We conducted a comparative case study-based investigation of health sector strategies that were useful in expanding or establishing new abortion services. We selected geographically diverse countries from across the human development index if they had implemented new abortion laws, or changed interpretations of existing laws or policies, within the past 15 years (Colombia, Ethiopia, Ghana, Portugal, South Africa, and Uruguay). Factors facilitating the expansion of services include use of a public health frame, situating abortion as one component of a comprehensive reproductive health package, and including country-based health and women's rights organizations, medical and other professional societies, and international agencies and nongovernment organizations in the design and rollout of services. Task sharing and the use of techniques that do not require much infrastructure, such as manual vacuum aspiration and medical abortion, are important for rapid establishment of services, especially in low-resource settings. Political will emerged as the key factor in establishing or expanding access to safe abortion services.