In combating abortion stigma, finding the most responsible—and effective—tools
Posted 13 April 2016 12:00 AM by JoAnn DiLernia, Program Learning Officer, Planned Parenthood Global
Community healthcare client in rural Ecuador, Credit: PP Global/Mark Tuschman
For more than 45 years, Planned Parenthood Global (PP Global) has been working to expand access to safe and legal abortion services, especially where access to providers is most needed. A big part of that work is combating abortion stigma.
While abortion is legally allowed in nearly every country where we work throughout Africa and Latin America, there is limited ability of health care providers to provide the procedure. These restrictions do not decrease the incidence of abortion but only increase the risk of death and disability and create a stigmatized atmosphere and environment that needs to be actively countered to ensure access.
We, at PP Global, take a multi-pronged approach:
For one, the World Health Organization has recommended that abortion be provided at the lowest level of care. PP Global agrees and designed a protocol for misoprostol for first trimester abortion administered by low level health care workers, called Community Based Access to Misoprostol (CBAM). Our trainings and training materials aim to support the delivery of services to women where they are most needed, and access to an abortion provider is limited.
Secondly, we have been working with the University of Michigan to implement Provider Share Workshops (PSWs) with providers in the Latin American countries we work in to help reduce their internalized and felt stigma. These workshops have been used to strengthen PP Global’s Abortion Provider Support Network.
And third, we are beginning to use research to bolster our efforts against stigma through CBAM. Implemented in 2013 by a local partner, we identified a shift in women’s opinions regarding abortion and decided to explore this further. We designed a mixed-method study aimed to compare the prevalence of abortion stigma in three communities based on their access to a provider. This study consisted of community based surveys and in-depth interviews with providers and their clients. We hypothesized that the presence and length of time a community-based abortion provider was in the community would influence and ultimately reduce the existing levels of abortion stigma.
Because abortion is highly stigmatized, it is infrequently discussed in the communities where we work. For example, we feared that conducting research could cause harm to our study respondents by exposing both abortion providers and women seeking abortions. Exposure could put our respondents at risk of being ostracized from the community, shamed, ridiculed, and potentially exposed to legal consequences. We had to ask ourselves what was more important: scientific rigor or the privacy of study respondents.
After further examination we ultimately decided that the protection of our providers’ and clients’ privacy was more important than the rigor of the study. In order to respect the privacy of our study group and also gather important evidence on stigma, we decided to use the PP Global staff who already worked with the providers as interviewers; and in turn had the providers interview their own patients.
In a three day workshop, PP Global staff and a representative from Ibis Reproductive Health trained providers on how to conduct in-depth interviews, use the interview guide, and use digital MP3 players to record the interviews. In all, we conducted seven provider interviews and 30 client interviews.
Following data collection, we conducted a semi-structured debrief with the providers to learn more about their overall experience and gather complementary insight that was not captured via the client interview recordings. The debrief served as an opportunity to identify lessons learned and brainstorm ideas with the providers about future research and interventions.
All in all, this methodology seemed to be a success. The reaction of providers was overwhelming. They were excited about the process of being involved in a research study, and reported that the clients were excited and happy to help the providers who helped them. The providers also mentioned that the women were also extremely grateful to the providers and presented their story as a testimony.
As we continue to analyze data, we are beginning to slowly understand the roots of abortion stigma in these communities. Our methodology seems to have yielded rich results that may not be achieved through a standard research methodology. We were not only able to protect the privacy of all respondents, but gather the information that we needed. Some rigor may have been lost, however, what we gained was more important. We gained a safe space for clients and providers alike to talk about and discuss their experience with abortion and abortion stigma. To us, this has proved to be one of the biggest successes of this project.
To read more about Provider Share Workshops and the projects of inroads members above, take a look at the inroads resource compendium or join discussions on the inroads Collaboration Workspace with your fellow members engaged in this work.
Donald Kasongi said:
4/22/2016 6:47 AM
Thanks JoAnna for sharing this useful daring experience.Yes, I believe it is more important to give visibility to the voices of people affected by abortion stigma than struggling achieving reasonable research rigor(which is endlessly debatable!).Resources allowing , it would be useful to explore ways of getting the community perspective through Focus Group Discussions with community members and leaders(formal/informal).This further step aligns well with the ecological model, and taking into account the fact that cultural competencies of both groups of women experiencing abortion and service providers are likely to explain more about and aligned to "community context".We ultimately need to understand the perspective of the community in order to recommend subsequent actions.