Understanding conscientious objection to abortion in Zambia (ID# - - PDF document

Understanding conscientious objection to abortion in Zambia (ID# 4458) Poster at 2017 International Population Conference Emily Freeman, Ernestina Coast, Bellington Vwalika Contact: e.freeman@lse.ac.uk Introduction In Africa, it is estimated that 13% of all pregnancies end in induced abortion, of which 97% are unsafe (Sedgh et al., 2012). In Zambia, the 1972 Termination of Pregnancy Act makes provision for abortion on a wide range of grounds, including risk of mental harm associated with pregnancy in the context a woman’s environment or her age (GRZ, 1972). Despite this legal provision for safe abortion in Zambia, 70 percent of abortions are estimated to be unsafe (Likwa et al., 2009). Between January and December 2013 we carried out research on unsafe abortion in Lusaka. Reports

• f girls and women who accessed care following an unsafe abortion (n=41) suggest that lack of

access to safe abortion is in part attributable to healthcare providers’ reluctance to offer the abortion services provisioned within the law. Having initially sought abortion at certified clinics and hospitals, these individuals resorted to unsafe methods to terminate their pregnancies when registered medical practitioners turned them away, telling them either that abortion was illegal and/or so sinful she ought to reflect further on her choice. Very little is known about how medical practitioners in Zambia carry out their conscientious

• bjection in practice, how they interpret the law on conscientious objection, how they perceive their

refusal to sit between their moral concerns with abortion verses their role as health professionals and caregivers, or how refusals impact patients. Most evidence from Africa and beyond, as in our previous work in Lusaka, relies on the reports of women who have requested services and been

• refused. These women report having been turned away for abortion services they were legally

entitled to, but not what motivated would-be providers to refuse. Understanding motivations of healthcare practitioners is important to both further understanding of the barriers to access to safe abortion women and girls in Zambia experience, and provide information that could assist Government and other stakeholders to develop strategies to reduced unsafe abortion that engage with all potential service providers. Methods In 2015 we conducted 55 semi-structured in depth interviews with healthcare providers both

• ffering/referring for safe abortion services and not providing/referring for safe abortion services in

urban and rural Zambia Participants were purposively selected from healthcare providers working at all levels of the formal health system, from the unpaid voluntary Community Health Workers who are frequently rural Zambian’s first point of contact, to specialist obstetricians gynaecologists working in Zambia’s largest urban hospital, the principal provider of safe abortion and senior administrative staff (Provincial and District Directors) responsible for delivering safe abortion services across health facilities. Interviews explored participants’ day-to-day practices, their beliefs and the legal, professional, moral, ethical and religious influences shaping their practices around abortion and post-abortion care and their relationships with clients seeking safe abortion services or care following unsafe abortion.

Following previous research on conscientious objection in other settings, in this study conscientious

• bjection is defined as any healthcare worker who feels that “her or his moral, ethical, or religious

beliefs precluded her or him from being willing to perform or assist abortions in some or all situations” (Fink et al., 2015). In addition, reflecting our participants’ understanding of conscientious

• bjection and the legal framework surround abortion, we extend this definition to healthcare

workers who feel that their own or their community’s objection to abortion preclude them from being willing to refer for abortion in some or all situations. The first author read each interview carefully, coding content according to themes identified from this reading and noting down analytical thoughts and ideas. The second author read a 50% randomly selected sub-sample of the interviews, coding them according to the themes identified by the first author, and any previously-unidentified themes. Again, initial analytical thoughts and ideas were noted. We are continuing our thematic analyses now, re-reading coded data and expanding our analysis. Initial results Confused understanding of abortion law While the Law of Zambia makes provision for registered medical practitioners to refrain from performing or assisting with abortions for cases in which abortion has been requested to prevent risk of non-permanent injury, harm to a woman’s existing children, or birth abnormalities, the right to conscientious objection does not allow practitioners to opt out of performing abortions when pregnancy poses a “grave, permanent” risk to the mental or physical health of a woman (GRZ, 1972), referrals for abortion by health practitioners who are not licenced to carry out abortions (e.g. community health workers, pharmacists) or the right to obstruct a woman from seeking an abortion elsewhere (e.g. by giving misinformation) (MoH, 2009). In our study only specialist obstetrician gynaecologists were aware they are permitted to carry out

• abortions. Participants in other roles reported that their beliefs about abortion shaped the advice

and counselling they gave to those seeking safe abortion or care following unsafe abortion and whether or not they referred clients for services. No participants were aware of the conditions under which the law permits conscientious objection to performing abortion. Of those expressing conscientious objection to abortion, all reported refusing to perform abortion other than in cases in which continuation of pregnancy was a clear and immediate physical risk to life. Several obstetrician gynaecologists discussed colleagues who refused to provide services even in these emergency cases. Importance of Christian faith All participants reported being Christians. All – both conscientious objectors and non-conscientious

• bjectors (specialist obstetrician gynaecologists performing abortion and lone doctors and nurses in

rural areas supportive of abortion but referring clients because of the belief they were not permitted to carry out procedures themselves) – offered perspectives informed by their religious beliefs. Participants were members of Pentecostal, Jehovah’s Witness, Roman Catholic, Anglican and Seventh Day Adventist Christian fellowships. None of their religious communities collectively interpreted Christianity so as to permit abortion. However non-conscientious objectors had found ways to reconcile their practice with their religious belief. For a minority, this was presented as a straightforward and relatively easy separation of their roles as Christians and healthcare

• professionals. For many, it involved a more complex decision made over time and informed by

having witnessed the consequences of unsafe abortion and the circumstances of those seeking safe abortion. Importance of empathy Indeed, identification with or ‘othering’ of those seeking abortion key distinguishing theme in participants’ narratives. Providers discussed girls’ limited opportunities should they continue pregnancies and drop out of school, married women who could barely afford to feed their existing children, girls frightened of their violent fathers and girls and women pregnant following rape. Objectors reported that the majority of unwanted pregnancies are among school-aged teenagers and adulterous women. They distanced themselves from their clients’ experiences – and importantly, their “mistakes”. In the context of religious beliefs around repentance and the consequences of sin, for them, abortion presented an “easy way out” – forgiveness without penance. Importance of others’ perceptions Fear of being stigmatised further discouraged practitioners from providing legally permitted abortion services. For example, participants recruited from a large urban hospital discussed the importance of hierarchy within the health system for decisions about providing abortion. The career progression of doctors from intern, to resident, to registrar to consultant is dependent upon approval of senior colleagues. Several more junior participants had senior colleagues who frequently discussed their objection to providing abortion care and some contraceptive

• services. These participants reported being held back in their careers for providing abortion and

discussed peers who were too afraid of the consequences to provide services. For the majority of objectors at rural facilities, the sin of abortion was so clear and widely understood that they reported being surprised to learn from the research team that anyone in Zambia would offer such services. While primarily against abortion, a number of these participants discussed extreme cases, such as rape of children, in which they may have been more willing to refer for abortion care. However, grounded in their own understandings of abortion, they expected that their community’s understandings of abortion to be such that a referral would become publically known and they would be subsequently stigmatised as someone who facilitated abortion. Conscientious objectors who referred women for abortion Many conscientious objectors were pragmatic about the provision of safe abortion services. They were open to – if not grateful for – colleagues for performing abortions so that those who had chosen to abort their pregnancies had an option beyond seeking unsafe, sometimes fatal, abortion. Nevertheless referring women for abortion was for some, a difficult decision that required supressing important beliefs. To refer for abortion was to “facilitate” abortion. Conscientious objectors responded to this challenge in two ways. Some participants discussed withdrawing from ever meeting clients wishing to terminate their pregnancies. This strategy, primarily available only to specialists working at large hospitals, involved making it known to nurses who first saw clients that cases should be referred to other colleagues, referring cases immediately to other doctors without beginning a consultation, or specialising in another branch of obstetrics or gynaecology such as gynaecologic oncology. For example, two specialists at a large urban hospital drew parallels between their objection to abortion and practitioners who are Jehovah’s Witnesses

• bjecting to participating in blood transfusions. For both, having colleagues who could provide

services meant that they were able to indirectly fulfil their professional obligations to provide care while “remaining true” to themselves.

Other participants responded to the challenge by advising clients to “keep the child” before beginning the referral process. This strategy was more common, and practiced by conscientious

• bjectors of all professions working across the health system interviewed. Participants understood

such advice as part of their obligation as health professionals to offer “counselling” for women and girls seeking abortion, and as their duty as loving Christians to protect both the life of “the baby” and the client, who they believed would come to regret her decision. Some participants were considerably invested in helping their clients in the way they believed would protect them from harm. They sympathetically described the relationships and circumstances that had led to clients seeking abortion and their attempts to resolve those problems, rather than

• ffering the abortion that they understood would only add to them. For example, a number of

conscientious objectors discussed having asked a school girl seeking a termination and afraid of her parents to bring them to the health facility so that they could talk to them together and present the benefits of the pregnancy and a positive way forward. One described offering to go to their clients’ homes to be there with them when they told their parents, to protect her and counsel the whole family. Conceptualising abortion decision as a life-changing decision – with regard to the client and her pregnancy - these conscientious objectors frequently reported asking clients to go away and think on their decision for a few days. Among all professions interviewed and across the health system considered, and for conscientious

• bjectors who referred cases to colleagues and for those who did not, counselling and advice were
• conflated. All conscientious objectors reported situating their conversations with clients within

broad Christian teaching or specific Bible verses with those seeking safe services and those who had already attempted abortion using unsafe methods admitted for incomplete abortion. Some conscientious objectors reported that they believed they could, and had, changed the minds

• f those seeking abortion. More however believed it was their duty to try regardless of outcome

and that those who went on to “insist” on abortion have different beliefs from them. Indeed, there was little acceptance that those seeking abortion – or their colleagues practicing abortion - were also Christians. Conclusions Healthcare providers in this study variously provided abortion clandestinely, provided abortion in some circumstances but not others, referred clients for abortion, or refused to refer clients and gave misinformation about the safe abortion services legally and geographically available. The result is complex and fragmented delivery of abortion care. Whether or not women and girls seeking abortion care receive it in Zambia, especially rural settings, appears to be luck, dependent on which individual healthcare worker they confide in. Some participants’ refusal to deliver abortion care exposes clients to maternal mortality and morbidity from unsafe abortion. References Coast, E. and Murray, S. (2016). "These things are dangerous": Understanding induced abortion trajectories in urban Zambia, Social Science & Medicine, 153, 201-209 Fink, L., Stanhope, K., Brack, C., Richardson, K. and Bernal, O. (2015). Conscientious Objection to Abortion Provision in Bogotá, Colombia: Religion, Respect, and Referral. Population Association of America 2015 Annual Meeting. San Diego, CA

• GRZ. (1972). Termination of Pregnancy Act, Laws of Zambia, Chapter 304. Constitution of Zambia.

Lusaka: Government of Zambia

Likwa, R., Biddlecom, A. and Ball, H. (2009). Unsafe Abortion in Zambia: In Brief, Guttmacher Institute, 2009 Series

• MoH. (2009). Standards and guidelines for reducing unsafe abortion morbidity & mortality in
• Zambia. pp. 1-64). Lusaka: Ministry of Health

Sedgh, G., Singh, S., Shah, I.H., Åhman, E., Henshaw, S.K. and Bankole, A. (2012). Induced abortion:incidence & trends worldwide 1995-2008, The Lancet, 379, 625-632