Addressing Abortion Provider Stigma: A Pilot Implementation of the Providers Share Workshop in Sub-Saharan Africa and Latin America.

CONTEXT: In much of Sub-Saharan Africa and Latin America, abortion is legally restricted, and abortion providers experience stigma and legal jeopardy. The Providers Share Workshop group intervention has been shown to reduce provider stigma in the United States, but has not been evaluated in other settings. METHODS: In 2014-2015, the Providers Share Workshop was adapted and piloted among 59 abortion caregivers from three Sub-Saharan African countries and 93 caregivers from seven Latin American countries. Survey data collected before, directly following and six months after each workshop measured stigma, attitudes, and legal safety and advocacy engagement, using original items and adapted scales. Univariate analyses and baseline pairwise correlations were used to measure changes in outcomes over time, and between demographic characteristics and outcomes. Mixed-effects linear regressions and multivariable models controlling for demographics were used to assess changes in outcomes over time. RESULTS: Six months after workshop participation, total abortion stigma had decreased among caregivers in Sub-Saharan Africa and in Latin America (beta coefficients, -0.2 and -0.4, respectively). Unfavorable attitudes had decreased in Africa (-0.2) but not in Latin America, where attitudes were favorable to start; emotional exhaustion and depersonalization also had decreased in Africa (-2.9 and -1.2), and legal safety had increased (0.8). Increased total abortion stigma was negatively associated with legal safety, in both Africa and Latin America (-1.9 and -0.6), and with legal advocacy in Africa (-1.5). CONCLUSIONS: The Providers Share Workshop is a promising intervention to support the abortion care workforce in Sub-Saharan African and Latin American settings.

RESUMEN Contexto: En gran parte del África subsahariana y América Latina, el aborto está legalmente restringido y los proveedores de servicios de aborto experimentan estigma y riesgo legal. Se ha demostrado que la intervención grupal del Taller de Proveedores para Compartir Experiencias reduce el estigma del proveedor en los Estados Unidos, pero no se ha evaluado en otros entornos. Métodos: Entre 2014 y 2015, el Taller de Proveedores para Compartir Experiencias fue adaptado y puesto a prueba entre 59 proveedores de servicios de aborto de tres países del África subsahariana y 93 proveedores de servicios de siete países latinoamericanos. Los datos de la encuesta recopilados antes, inmediatamente después y seis meses después de cada taller, mediante el uso de elementos originales y escalas adaptadas, midieron el estigma, las actitudes y la seguridad jurídica, así como el compromiso con la defensa y promoción del aborto. Se utilizaron análisis univariados y correlaciones de referencia por pares para medir los cambios en los resultados a través del tiempo y entre la demografía y los resultados. Se utilizaron regresiones lineales de efectos mixtos y modelos multivariables que controlan las variables demográficas para evaluar los cambios en los resultados a través del tiempo. Resultados: Seis meses después de la participación en el taller, el estigma total del aborto había disminuido entre los proveedores en África y América Latina (coeficientes beta, ­0.2 y ­0.4, respectivamente). Las actitudes desfavorables habían disminuido en África (­0.2) pero no en América Latina, donde las actitudes eran favorables para el inicio; el desgste emocional y la despersonalización también habían disminuido en África (­2.9 y ­1.2, respectivamente) y la seguridad legal había aumentado (0.8). El aumento del estigma total del aborto se asoció negativamente con la seguridad jurídica, tanto en África como en América Latina (coeficientes beta, ­1.9 y ­0.6, respectivamente) y con la defensa jurídica en África (­1.5). Conclusiones: El Taller de Proveedores para Compartir Experiencias es una intervención prometedora para apoyar a la fuerza laboral de atención del aborto en entornos de África subsahariana y América Latina.

RÉSUMÉ Contexte: Dans une grande partie de l'Afrique subsaharienne et de l'Amérique latine, l'avortement est limité par la loi et ses prestataires sont en proie à la stigmatisation et au péril judiciaire. Comme l'indiquent les études, l'intervention du groupe Providers Share Workshop réduit cette stigmatisation aux États-Unis; elle n'a cependant pas été évaluée dans d'autres contextes. Méthodes: En 2014­2015, l'atelier Providers Share Workshop a été adapté et piloté auprès de 59 membres du personnel de soins de l'avortement de trois pays d'Afrique subsaharienne et 93 soignants de sept pays d'Amérique latine. Les données d'enquête collectées avant, directement après et six mois après chaque atelier ont mesuré la stigmatisation, les attitudes et l'engagement de sécurité et de défense juridique sur la base des questions originales et d'échelles adaptées. Les changements de résultats au fil du temps, et entre les caractéristiques démographiques et les résultats, ont été mesurés par analyses univariées et par corrélations par paires de référence. Des régressions linéaires à effets mixtes et des modèles multivariés tenant compte des caractéristiques démographiques ont servi à évaluer les changements de résultats au fil du temps. Résultats: Six mois après la participation à l'atelier, la stigmatisation totale de l'avortement s'était réduite parmi le personnel soignant d'Afrique et d'Amérique latine (coefficients bêta de ­0,2 et ­0,4, respectivement). Les attitudes défavorables étaient en baisse en Afrique (­0,2) mais pas en Amérique latine, où les attitudes étaient favorables dès le début; l'épuisement affectif et la dépersonnalisation étaient en baisse aussi en Afrique (­2,9 et ­1,2, respectivement), tandis que la sécurité juridique était en hausse (0,8). Une stigmatisation totale supérieure de l'avortement s'est révélée associée négativement avec la sécurité juridique, en Afrique aussi bien qu'en Amérique latine (coefficients bêta de ­1,9 et ­0,6, respectivement), et avec la défense juridique en Afrique (­1,5). Conclusions: L'atelier Providers Share Workshop est une intervention prometteuse de soutien du personnel de soins de l'avortement en Afrique subsaharienne et en Amérique latine.

Stigma and abortion complications: stories from three continents.

Complications from abortion, while rare, are to be expected, as with any medical procedure. While the vast majority of serious abortion complications occur in parts of the world where abortion is legally restricted, legal access to abortion is not a guarantee of safety, particularly in regions where abortion is highly stigmatised. Women who seek abortion and caregivers who help them are universally negatively "marked" by their association with abortion. While attention to abortion stigma as a sociological phenomenon is growing, the clinical implications of abortion stigma - particularly its impact on abortion complications - have received less consideration. Here, we explore the intersections of abortion stigma and clinical complications, in three regions of the world with different legal climates. Using narratives shared by abortion caregivers, we conducted thematic analysis to explore the ways in which stigma contributes, both directly and indirectly, to abortion complications, makes them more difficult to treat, and impacts the ways in which they are resolved. In each narrative, stigma played a key role in the origin, management and outcome of the complication. We present a conceptual framework for understanding the many ways in which stigma contributes to complications, and the ways in which stigma and complications reinforce one another. We present a range of strategies to manage stigma which may prove effective in reducing abortion complications.

Stigma and agency: exploring young Kenyan women's experiences with abortion stigma and individual agency.

Although abortion is now legal in Kenya under expanded circumstances, access is limited and many providers and individuals still believe it is illegal. This study aimed to characterise Kenyan women's perceptions and experiences with abortion and post-abortion care (PAC) services in Nairobi regarding barriers to care, beliefs about abortion, and perceived stigma. We conducted 15 semi-structured in-depth interviews with Kenyan women aged 18-24 years who recently received abortion and PAC services at four Marie Stopes Kenya clinic sites in Nairobi. The most significant psychosocial barrier respondents faced in promptly seeking abortion and PAC was perceived stigma. In response to stigma, participants developed a sense of agency and self-reliance, which allowed them to prioritise their own healthcare needs over the concerns of others. To adequately address perceived stigma as a barrier to abortion- and PAC-seeking, significant cultural norm shifting is required.

Expanding Access to a New, More Affordable Levonorgestrel Intrauterine System in Kenya: Service Delivery Costs Compared With Other Contraceptive Methods and Perspectives of Key Opinion Leaders.

BACKGROUND: The levonorgestrel intrauterine system (LNG IUS) is one of the most effective forms of contraception and offers important non-contraceptive health benefits. However, it is not widely available in developing countries, largely due to the high price of existing products. Medicines360 plans to introduce its new, more affordable LNG IUS in Kenya. The public-sector transfer price will vary by volume between US$12 to US$16 per unit; for an order of 100,000 units, the public-sector transfer price will be approximately US$15 per unit. METHODS: We calculated the direct service delivery cost per couple-years of protection (CYP) of various family planning methods. The model includes the costs of contraceptive commodities, consumable supplies, instruments per client visit, and direct labor for counseling, insertion, removal, and resupply, if required. The model does not include costs of demand creation or training. We conducted interviews with key opinion leaders in Kenya to identify considerations for scale-up of a new LNG IUS, including strategies to overcome barriers that have contributed to low uptake of the copper intrauterine device. RESULTS: The direct service delivery cost of Medicines360's LNG IUS per CYP compares favorably with other contraceptive methods commonly procured for public-sector distribution in Kenya. The cost is slightly lower than that of the 3-month contraceptive injectable, which is currently the most popular method in Kenya. Almost all key opinion leaders agreed that introducing a more affordable LNG IUS could increase demand and uptake of the method. They thought that women seeking the product's non-contraceptive health benefits would be a key market segment, and most agreed that the reduced menstrual bleeding associated with the method would likely be viewed as an advantage. The key opinion leaders indicated that myths and misconceptions among providers and clients about IUDs must be addressed, and that demand creation and provider training should be prioritized. CONCLUSION: Introducing a new, more affordable LNG IUS product could help expand choice for women in Kenya and increase use of long-acting reversible contraception. Further evaluation is needed to identify the full costs required for introduction-including the cost of demand creation-as well as research among potential and actual LNG IUS users, their partners, and health care providers to help inform scale-up of the method.