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 of 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 objection 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 offering/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 hos pital, 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 objection 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 objection 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 objectors (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
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