13 research outputs found

    Study protocol: Choice within abortion care pathways - perspectives of service providers, managers and commissioners

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    In England and Wales, medical abortions accounted for 74% of abortions in 2019, and this figure has doubled over the last decade. Both medical and surgical abortion are highly safe and effective, have few contraindications and can be provided in an outpatient setting. The 2019 NICE guidelines for abortion state that women should be offered an informed choice of both methods, but choice of methods has been identified as an area of care that requires improvement in previous studies. The aim of this study is to explore how the financing, management and organisation of abortion services can expand or limit abortion method choice, and how providers’ perceptions of abortion and abortion methods influence their provision of services and information. Key informant interviews will be conducted with 15-20 providers of abortion care (including nurses, midwives, obstetricians and gynaecologists), 5- 10 managers of abortion services and 5-10 commissioners of abortion services. Participants will be purposively recruited through email and snowballing sampling with support from two professional associations. Interviews will be conducted by phone or web-call by myself, depending on the preference of the participant. Interviews will be semi-structured, using a topic guide. Interviews will be audio-recorded and transcribed. Data will be analysed using thematic analysis and findings will be disseminated through conference presentations, peer-reviewed journal articles, and a PhD thesis. Research results are intended to inform policies and practice surrounding the provision of choice within abortion care pathways in the UK, and in other countries where medical methods of abortion are increasingly replacing surgical methods

    The illusion of treatment choice in abortion care: a qualitative study of comparative care experiences in England and Wales

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    Treatment choice is a key component of quality, person-centred care, but policies promoting choice often ignore how capacity to choose is unequally distributed and influenced by social structures. In abortion care, the choice of either medication or a procedure is limited in many countries, but the structuring of treatment choice from the perspective of people accessing abortion care is poorly understood. This qualitative study explored comparative experiences of abortion treatment choice in England and Wales, using in-depth interviews with 32 people who recently accessed abortion care and had one or more prior abortions. A codebook approach was used to analyse the data, informed by a multidisciplinary framework for understanding the relationship between choice and equity. Abortion treatment choice was structured by multiple intersecting mechanisms: limitations on the supply of abortion care, incomplete or unbalanced information from providers, and participants' socio-economic environments. Long waiting times or travel distances could reduce choice of both treatment options. In interactions with providers, participants described not being offered procedural abortions or receiving information that favoured medication abortion. Participants' socio-economic environments impacted the way they navigated decision-making and their ability to manage the experience of either treatment option. Individual preferences for care were shaped in part by the interplay between these structural barriers, creating an illusion of choice, as the health system bias towards medication abortion reinforced some participants’ negative perceptions of procedural abortion. The erosion of choice, to the point it is rendered illusory, has unequal impacts on quality of care. People's needs for their abortion care are complex and diverse, and access to varied service models is required to meet these needs. Treatment choice could be expanded by integrating public and private non-profit sector provision, aligning time limits and workforce requirements for abortion care with international standards, addressing financial pressures on service delivery, and revising the language used to depict each treatment option

    Structural barriers or patient preference? A mixed methods appraisal of medical abortion use in England and Wales

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    Although patient choice of abortion method is a key component of quality care, medical abortion (MA) has become the most common method (87%) in England and Wales, as in many countries worldwide. This research aimed to critically examine factors influencing the growth in MA use in England and Wales. Mixed methods were used, combining multi-level regression analysis of national abortion statistics (2011-2020) and key informant interviews with abortion service managers, commissioners, and providers (n=27). Overall trends have been driven by growth in MA use for abortions under 10 weeks in the private non-profit sector. Variation in MA use between patient sub-groups and regions has narrowed over time. Qualitative findings highlight health system constraints that have influenced the shift towards MA, including workforce constraints, infrastructure requirements, provider policies, cost, and commissioning practices involving under-funding and competition, which have caused the private non-profit sector to limit method choice across their services to remain financially viable. While removal of legal restrictions on MA has expanded choice, similar policy progress has not been seen for surgical methods. The study concludes that abortion method choice has been constrained by structural health system factors, with potential negative consequences for service acceptability, inequalities, and patient-centredness

    Structural stigmatisation of abortion in the health system: perspectives of abortion care-seekers, providers, managers, and funders in England and Wales

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    Abortion has been legally permitted in England and Wales for over fifty years, yet this health service continues to be stigmatised within the health system. Stigma is a dominant focus of abortion research, but a structural stigma framework is rarely used to understand how abortion stigma is produced at a macro-level. This study explored how structural abortion stigma is produced and experienced in the health systems of England and Wales, and its influence on person-centred care, including choice of abortion methods. Data from in-depth interviews with abortion care-seekers in 2022–23 and from key informant interviews with abortion care providers, managers, and commissioners in 2021 were analysed using reflexive thematic analysis. From the perspectives of key informants, structural abortion stigma is produced through the avoidance of abortion by decision-makers, the permitting of conscientious objection, and the exclusion of abortion from mainstream healthcare. These factors create health system pressures which increase abortion service fragility. The resulting vulnerability of abortion services reduces access to person-centred care, including abortion method choice, which can reinforce individual-level stigma. There are tensions between care-seekers’ experiences of specialist abortion care as less stigmatising, while the ‘abortion clinic’ becomes a site of stigma due to its segregation from mainstream healthcare. This research contributes to a structural understanding of abortion stigma by identifying some of the mechanisms through which structural stigma is produced within health system institutions, and how these forms of institutional stigma might be resisted or dismantled. Power is essential to the (re)production of structural stigma within the health system, which can reinforce individual-level stigma for both care-seekers and providers. Restrictions on method choice and the increasing reliance on medication abortion can be a product of structural abortion stigma, and these limitations on method choice can also reproduce stigma at the individual level

    Exploring provider preference and provision of abortion methods and stigma: secondary analysis of a United Kingdom provider survey

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    Introduction: Method choice is an important component of quality abortion care and qualitative research suggests that abortion stigma can influence provider preference and provision of abortion methods. This study is the first to explore the relationships between abortion providers' method preferences, their provision of medication or instrumentation abortion or both methods, and abortion stigma. Methods: We conducted secondary analysis of a survey of United Kingdom (UK) abortion providers (N = 172) to describe and compare providers' self-reported method preferences and provision. We used multinomial logistic regression to assess the association between method preference and provider experiences of abortion stigma (measured using a revised Abortion Provider Stigma Scale (APSS)), adjusting for relevant provider and facility characteristics. Results: Almost half (52%) of providers reported that they only provided medication abortion care, while 5% only provided instrumentation abortion care and 43% provided both methods. Most (62%) preferred to provide both methods while 32% preferred to provide only medication abortion and 6% only instrumentation abortion. There was no significant difference in revised APSS scores by provider method preference or provision. Discussion: Most surveyed UK abortion providers prefer to offer both methods, but over half only provide medication abortion. This may reflect patients' preferences for medication abortion, and health system and legal constraints on instrumentation abortion. Addressing these systemic constraints on method provision could expand patient choice. Providers' method preference was not significantly associated with provider stigma but future research should consider the influence of structural stigma on method provision at the health system level

    Choice within abortion care pathways: perspectives of abortion care users on abortion methods and service options in England and Wales

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    The aim of this qualitative study is to explore abortion service users’ perceptions and comparative experiences of choice within abortion care pathways. In-depth interviews will be conducted with individuals who have sought abortion services in the study period, and who have at least one previous abortion experience. Participants will be recruited from BPAS and NHS services. For BPAS services, participants will be retrospectively recruited from a database of clients who have consented to be contacted about future research. For NHS services, patients will be invited to learn more about the research at the point of service by their health care professional, after the patient has completed their consultation, either by email or verbally at the end of the phone or in-person consultation. Interested participants will then be contacted by phone call or email by the researcher to provide more information, to answer any questions, confirm interest, go through the informed consent process, and arrange a time for the interview to take place. Informed consent will be recorded by the participant through an online form. Participants will be offered a digital copy of the information sheet and consent form if they wish. Interviews will be conducted by phone or web-call by the lead researcher, depending on the preference of the participant. Interviews will be semi-structured, using a topic guide. Interviews (including confirmation of verbal consent) will be audio-recorded and transcribed by the lead researcher. Data will be analysed using thematic analysis and findings will be disseminated through conference presentations, peer-reviewed journal articles, and a PhD thesis. Research results are intended to inform policies and practice surrounding the provision of choice within abortion care pathways in the UK

    Adapting to a global pandemic: a qualitative assessment of programmatic responses to COVID-19 in the multi-country Women’s Integrated Sexual Health (WISH) programme

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    The COVID-19 pandemic caused significant disruption to sexual and reproductive health and rights (SRHR) globally but there is little published evidence on the COVID-19 response of SRHR programmes, or lessons learned through their adaptations. To document the COVID-19 response of a global SRHR programme (the Women’s Integrated Sexual Health programme), in-depth interviews were conducted between April-July 2021 with 22 key informants from implementing partners in Sierra Leone, Ethiopia and central or regional offices, the UK Foreign, Commonwealth & Development Office and the third-party monitoring partner. Framework analysis methods were used. Several rapid COVID-19 adaptations were identified: the development of crisis management and communication teams; increased partnership and engagement with government; reduced contact and risk in service delivery; reformulated community mobilisation; flexible performance management and remote methods of quality assurance; and sharing of learnings alongside development of new guidance and tools. Throughout the pandemic, the programme was able to continue high-quality service delivery, though equity goals proved more difficult to reach. Challenges included the continually changing environment, competing pressures on governments, burdensome reporting, and staff burnout. The pandemic response was facilitated by prior experience of health emergencies, strong government relationships, a supportive workforce and some pre-existing approaches, tools, and systems. This study has identified important lessons that can inform programming in future crises, including the need for immediate recognition of SRHR as essential, sustained support for staff, use of multiple mechanisms to reach marginalised groups, adequate funding for equity goals, and better balance between the burden of reporting and accountability needs

    Adapting to a global pandemic: a qualitative assessment of programmatic responses to COVID-19 in the Women’s Integrated Sexual Health (WISH) programme

    No full text
    The COVID-19 pandemic caused significant disruption to sexual and reproductive health and rights (SRHR) globally but there is little published evidence on the COVID-19 response of SRHR programmes, or lessons learned through their adaptations. To document the COVID-19 response of a global SRHR programme (the Women’s Integrated Sexual Health programme), in-depth interviews were conducted with 22 key informants from implementing partners in Sierra Leone, Ethiopia and central or regional offices, the UK Foreign, Commonwealth & Development Office and the third-party monitoring partner. Framework analysis methods were used. Several rapid COVID-19 adaptations were identified: the development of crisis management and communication teams; increased partnership and engagement with government; reduced contact and risk in service delivery; reformulated community mobilisation; flexible performance management and remote methods of quality assurance; and sharing of learnings alongside development of new guidance and tools. Throughout the pandemic, the programme was able to continue high-quality service delivery, though equity goals proved more difficult to reach. Challenges included the continually changing environment, competing pressures on governments, burdensome reporting, and staff burnout. The pandemic response was facilitated by prior experience of public health emergencies, strong government relationships, a supportive workforce and some pre-existing approaches, tools, and systems. This study has identified important lessons that can inform programming in future crises, including the need for immediate recognition of SRHR as essential, sustained support for staff, use of multiple mechanisms to reach marginalised groups, adequate funding to reach equity goals, and better balance between the burden of reporting and accountability needs
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