Key research-

What is unsafe abortion?

Why global maternal health issue?

Why not as prevalent in England?

illegal in England not other countries

Legal/ ethics?

Interventions?

Intervention effectiveness?

Key affected countries?

Challenges to provide effective?

Why potentially not managed as effectively?

lack of legalisations?

global initiatives to manage? statistics?

WHO, MMBRACE,

Role of midwife?

Relevance, why global maternal health issue? Topic, what is getting converted in an essay? What are the issues?

Main body- (2500 words)

What is unsafe abortion?

Why a global health issue?

Initiatives- (legalization, trained practitioners)

Social determinants- culture, family

Challenges and solutions

Ethical/ legal issues

Midwives role ( focus, needs, views, preferences of women)

Conclusion- (250 words)

conclude findings

Six out of 10 of all unintended pregnancies end in an induced abortion. (73 million per year)

Around 45% of all abortions are unsafe, of which 97% take place in developing countries.

a third done unsafely eg untrained people and invasive methods

Unsafe abortion is a leading – but preventable – cause of maternal deaths and morbidities. It can lead to physical and mental health complications and social and financial burdens for women, communities and health systems.

Lack of access to safe, timely, affordable and respectful abortion care is a critical public health and human rights issue

in first 12 weeks can be safely managed outside of health care facility- with accurate information, quality medicines, support health care professional

Developing countries e.g. South and Central Asia and Latin America and Africa face 97% of all unsafe abortions (3/4 unsafe)

In developed regions, it is estimated that 30 women die for every 100 000 unsafe abortions. In developing regions, that number rises to 220 deaths per 100 000 unsafe abortions

Physical health risks associated with unsafe abortion include:

• incomplete abortion (failure to remove or expel all pregnancy tissue from the uterus);

• haemorrhage (heavy bleeding);

• infection;

• uterine perforation (caused when the uterus is pierced by a sharp object); and

• damage to the genital tract and internal organs as a consequence of inserting dangerous objects into the vagina or anus.

Estimates from 2006 show that complications of unsafe abortions cost health systems in developing countries US$ 553 million per year for post-abortion treatments. In addition, households experienced US$ 922 million in loss of income due to long-term disability related to unsafe abortion. Countries and health systems could make substantial monetary savings by providing greater access to modern contraception and quality induced abortion

3000 words

Double line spacing (2.0)

Font- Times new roman or Arial

Size- 11/12

write out full abbreviation (WHO, NHS)

can over 10% over/under

References-

in cite- (last name, (et al 2 or more people) year published)

Alphabetical order (no need to number/bullet point)\

Learning outcomes-

1- Demonstrate knowledge and understanding of global and cultural impact on the human rights of women and children

2-Explore provision of care focus on needs, views, preferences and decisions of women and needs of infant in context different health systems

3- Explore midwifery as a global profession and the contribution of midwives to the survival, health, and well-being woman-newborn across the world

4-Develop skills evaluating health and social inequalities

5-key challenges and potential solutions in global maternal health

6-Awareness of key organizations and frameworks ( UN sustainable development goals, WHO, International Confederation of Midwives) support health, and well-being, promote training skilled birth attendants)

7- reflect and apply ethical and legal principles

Illegal abortions are usually carried out by the individual or non-professionals and by offending doctors or midwives, and often via unsafe methods

(Abdeen, et al, 2024)

is completely avoidable

it is a pandemic and a significant global public health concern

According to WHO- an unsafe abortion is performed by someone who lacks essential skills and takes place in setting does not meet bare minimum medical standards or both.

Unsafe abortion practices have virtually not improved despite advances in medical technology.

Techniques include sharp tool, wire (unbent clothes hanger or knitting needle) to break amniotic sac in uterus- has potential to kill by infecting or damaging internal organs such as uterus or intestines.

A natural item used was a large feather.

Herbal methods such as injecting chilli powder and other chemicals such as alum, lysol, permanganate or plant poison. Can result TSS toxic shock syndrome or death.

Ngwako and Banke-Thomas 2020

1990 - 50.4 million

2014- 56.3 million

highest incidence in sub saharan Africa- rate 18-39 per woman

The main factor contributing to maternal morbidity and mortality. Most prevalent in Sub-Suharan Africa typically illegal, dangerous, and contributes significantly to maternal death.

Around the world, a significant proportion of women pass away from pregnancy-related problems LMICs (low-middle-income countries) account for 99% of these figures.

Stringent abortion laws in South Asia nations rate of unsafe abortions high- also preference for a male child rate of selective abortion is high.

(WHO, 2021)

Six out of 10 of all unintended pregnancies end in an induced abortion. (73 million per year)

Around 45% of all abortions are unsafe, of which 97% take place in developing countries.

a third was done unsafely eg untrained people and invasive methods

(Elamin, et al, 2017)

Unsafe abortions are thought to claim 47,000 lives yearly more frequently in developing countries with restrictive abortion laws and limited access to facilities.

(Fullerton, et al, 2017)

The annual number of maternal deaths decreased from 532,000 to 303,000 across the 15-year period of 1990–2015.6 A total of 193,000 (7.9%) of these deaths were attributed to unsafe abortion

1. Autonomy: Women have the right to make decisions about their own bodies and reproductive health. Unsafe abortion often occurs in situations where women lack access to safe and legal abortion services, thus compromising their autonomy.

2. Non-maleficence: This principle emphasizes the obligation to avoid causing harm. Unsafe abortion poses serious health risks to women, including infection, hemorrhage, and death. Therefore, performing or promoting unsafe abortion procedures goes against the principle of non-maleficence.

3. Beneficence: The principle of beneficence underscores the duty to act in the best interest of individuals. Access to safe and legal abortion services is in the best interest of women's health and well-being. Promoting unsafe abortion denies women the benefits of proper medical care and places them at risk.

4. Justice: Justice entails fairness and equal treatment. Denying women access to safe abortion services, forcing them to resort to unsafe methods, disproportionately affects marginalized and vulnerable populations who may lack resources or legal protections. This perpetuates social inequalities.

Unsafe abortion would be putting the woman at risk and endangering her life so classed as unethical

https://www.sciencedirect.com/science/article/pii/S1521693419300793

legal

(Bazmi, et al, 2021)

differences between communities in religious beliefs and cultural context, legal abortion is carried out in different countries through different laws.

e.g Nepal- abortion is allowed before 12 weeks gestation and before 18 weeks if the mother's life is threatened, a fetus has incompatible with life (e.g an anamoly), or a case of rape.

India- abortion allowed above 20-week gestation limit

Iran- only when mother's life is threatened or congenital abnormality or incom[aitable with life not after 19 weeks

Contraception for all women, especially women with

low socio-economic classes and those with a history of

the birth of a newborn with genetic diseases, and also

making law according to religious teachings in order

to reduce unwanted pregnancies and unsafe abortions,

instead of full decriminalization of abortion

Restrictive laws on abortion

(Cosby, 2019)

BPAS- British Pregnancy Advisory Service

If an abortion occurs outside the stringent parameters of the Abortion Act [1967]—regardless of the stage of gestation—the woman and healthcare providers can be prosecuted and face a life prison sentence under the Offences Against the Person Act [1861]. This law is 158 years old - outdated doesn't support women and their choices about their bodies, and must be deemed by 2 doctors before "legal"

BPAS + RCM launched Trust Women campaign scrap outdated law

advocate for women and push for change support to receive the safest highest quality of care.

Education- lack of education about contraception, abortion laws, women/human rights.

Age

Economic stability- employment, income (not everyone employed can afford treatment and safe abortion- limited access to health care)

Geography- in suburb area too long to walk or tp expensive to get transport to clinics or get medical help to get safe abortion

Culture- different traditions and expectations in different countries and areas, can impact health professionals giving safe abortion care (e.g bias if they don't agree with abortions)

Poor quality of care- lack of sanitation, equiptment, medications, trained professionals (more likely infection and complications_

(Bazmi, et al, 2021)

questionnaire- 162 participants (obstetricians and midwives)

9.2% low level knowledge

72.8% moderate

17.9% high

Argentina- Changing the law of abortion in the country due to health workers having insufficient knowledge and people at risk- also review showed women's knowledge of abortion law and restriction was limited- education needed

(Elamin, et al, 2017)

in Sudan and many other developing countries

Due to the illegality of abortions- the scale is unknown

• Restrictive abortion laws- Laws only permit induced abortion in cases of rape, incest, or fetus putting the mother in harm.

• limited access to facilities

• high-level unintended pregnancies on a global scale women's inability to make decisions within relationships- partners have the final say regarding pursuing careers or family planning

• relay on partners for financial security so they won't be able to secretly buy contraceptions without their husbands' knowledge so opt for unsafe abortion

• poor access to contraceptives

• socioeconomic concerns- poverty driving factor for termination

• poor knowledge of human rights

• gaps in knowledge- social and cultural factors

• unsafe abortions have been linked to relationship problems with husband directly rape and sexual violence

• Social stigma (single women) - worried about families' reactions motivating women to undertake unsafe abortions. With the high value placed on families in African communities, individual actions affect the social standing of the group. Threaten reputations and families (unlawful sexual intimacy)

Solutions to prevent unsafe abortions and complications-

(Bazmi, et al, 2021)

Findings need more training in professional standards related to prenatal genetic screening and therapeutic abortion

Better access to contraception can decrease unintended pregnancies and unsafe abortions but implementing free contraception can help women access it without being scared to tell their partners (among couples and singles)

Better education on contraception and how to use it effectively- gaps in Sudan knowledge on sexual health.

open dialogue regarding family planning strategies encouraged

community members encouraged about the hazardous nature of unsafe abortions- women affected by community and friends stories within community

Midwives as frontline health care providers have a key

role in informing and preparing the women to make the

right decisions that can save their lives. However, lack

of enough knowledge about professional codes of ethics and regulations will lead to providing inappropriate

information and care for women, which can harm them.

Study

Jamaica- physicians, nurses, and midwives 805 believed abortion should be legal in certain cases and medical staff should provide women with relevant services and information where necessary.

(Crosby, 2019)

Midwife means with a woman

Trust women and respect the decisions that they make- to give birth or terminate

Ensure women's emotional and physical wellbeing

Making referrals out of the scope of practice (e.g- domestic abuse services or long-term psychological support)

BPAS- British Pregnancy Advisory Service

If an abortion occurs outside the stringent parameters of the Abortion Act [1967]—regardless of the stage of gestation—the woman and healthcare providers can be prosecuted and face a life prison sentence under the Offences Against the Person Act [1861]. This law is 158 years old - outdated doesn't support women and their choices about their bodies, and must be deemed by 2 doctors before "legal"

BPAS + RCM launched Trust Women campaign scrap outdated law

advocate for women and push for change support to receive the safest highest quality of care.

(Fullerton, et al, 2018)

International Confederation of Midwives (ICM)

represents 132 midwifery associations in 113 countries

various country specific policies and scope of global midwifery practice- encourages midwives to acquire the necessary knowledge

and skills to perform additional (optional) clinical procedures

across the continuum of perinatal and reproductive health

care to meet the particular needs of the women and families.

ICM statement- “a woman who seeks or requires abortion-related services is entitled to be provided with such services by midwives.”

post-abortion services- PAC provided by midwives is recognized as an efficient and cost-effective way to reduce maternal morbidity and mortality, particularly in developing countries

PAC may include one or more of the following services:

medical or surgical completion of incomplete abortion, including MVA; stabilization of women experiencing complications

from incomplete/unsafe abortion (eg, administration of

antibiotics for infection, uterotonics to control bleeding);

family planning and contraceptive counseling; emotional

support; treatment and/or referral for sexually transmitted

infections; and community empowerment through awareness and mobilization

trying to separate the issues of the global scope of midwifery practice from their personal perspectives and circumstances.

Abortion evokes religious, moral, ethical, sociocultural, and medical concerns which means it is highly stigmatized

(denied access to abortions or delayed by unnecessary examinations)

(ICM, 2023)

In keeping with the above midwives should:  

• Consider such care to be within the role of the midwife as defined by the laws and policies of his/her country 

• Recognise the woman’s right to decide for herself and provide information, counselling and services according to the woman’s needs  

• Refer the woman as appropriate for any further treatment that may be required and that is beyond the scope of midwifery practice 

• Provide the woman (and where appropriate her family) with education concerning her future health, including contraception and planning for future pregnancy  

• Recognise the emotional, psychological and social support which may be needed by the woman and respond appropriately. 

ICM

(Faundes, et al, 2020)

International Federation of Gynecology and Obstetrics (FIGO)

Initiative on Prevention of Unsafe Abortion and its consequences, as well as that of the FIGO Working Group, was to contribute to the reduction of maternal mortality and morbidity

South-Southeast Asia, Eastern-Central Europe and Central Asia, North Africa and Eastern Mediterranean, Eastern-Central-Southern Africa, Western-Central Africa, Central America and Caribbean, and South America.

main barriers to deal with the problem of induced unsafe abortion in a constructive manner is the heavy stigma carried by the word “abortion,

In many countries, policymakers are guided in dealing with abortion by political, moral, and religious considerations rather than by evidence-based approaches

improving access to family planning information and services is a main mechanism to reduce unintended pregnancies

POSTPARTUM CONTRACEPTION AND long term contracpetion

use of manual vacuum aspiration (MVA) legal termination 10/13 of countries implemented by december 2016

the influence of FIGO Initiative is shown in the progressive increase in the use of MVA and medical abortion for safer pregnancy termination in almost every country in this group (the exception is South Africa).

In three countries from the ECECA region (Moldova, Georgia, and Kyrgyzstan), safe abortion and postabortion family planning, MVA and medical abortion, were included in the University and post-graduate curricula.

s a reaction to these findings, the procedure to treat incomplete abortion was changed, substituting the use of curettage with general anesthesia in a surgical theater, by physicians, for Manual Vacuum Aspiration, provided by trained residents and midwives with local anesthesia and outpatient.

most important challenge is to reduce until almost total elimination of the stigma associated to “abortion.”

improve access to safe abortion services does NOT increase abortion rate,

MVA for the treatment of incomplete abortion in their last plan of action: Kenya, Uganda, Tanzania, Mozambique, Benin, Cameroon, Côte d’Ivoire, Gabon, Bangladesh, Pakistan, Sri Lanka, Bolivia, Honduras, Guatemala, Malawi, and Sudan

Bazmi, S. Kiani, M. Saidi, M. Akrami, F. (2021) Research paper: Knowledge and Attitude of Midwives and Obstetricians Towards Therapeutic Abortion Law and Its Ethical Pitfalls. International Journal of Medical Toxicology & Forensic Medicine. Vol 11 (1) pp1-9. (Bazmi, et al, 2021)

BPAS 2024

Crosby, C. (2019) I am a midwife who is proud to work in abortion care. British Journal of Midwifery. Vol 27 (6). (Crosby, 2019)

Desai, A. Maier, B. James-McApline, J. Prentice, D. De-Costa, C. (2022) Views and practice of abortion among Queensland midwives and sexual health nurses. Australian and New Zealand Journal of Obstetrics and Gynaecology, Vol 62 (2) pp.219-225. (Desai, et al, 2022)

Elamin, W. Fazari, A. Elmusharaf, K. (2017) A Qualitative Study Exploring Women's Experiences of Unsafe Abortion in Sudan. Journal of Social Sciences, Vol 5 (3), pp.149-158. (Elamin, et al, 2017)

Faundes, A. Comendant, R. Dilbaz, B. Jaldesa, G. Leke, R. Mukherjee, B. Padilla- de gil, M. Tavara, L. (2020) Preventing unsafe abortion: Achievements and challenges of a global FIGO initiative. Best Practice & Research Clinic Obstetrics & Gynaecology. Vol 62 pp.101-112. (Faundes, et al, 2020)

FIGO 2024

Availble from: https://www.figo.org/figos-member-societies

Fullerton, J. Butler, M.M. Aman, C. Reid, T. Dowler, M. (2018) Abortion-related care and the role of the midwife:

a global perspective. International Journal of Women's Health, Vol 10. pp.751-762. (Fullerton, et al, 2018)

Getahun, G.K. Kidane, M. Fekade, W. Shitemaw, T. Negash, Z. (2023) Exploring the reasons for unsafe abortion among women in the reproductive age group in western Ethiopia. Clinical Epidemiology and Global Health vol 22. (Getahun, 2023)

Goes, E.F., De Souza Menezes, G.M., de Almeida, M.C., Barreto-de-Araujo, T.V., Alves, S.V., De Britto, M.T.S.S. and Aquino, E.M.M., (2021). Barriers in accessing care for consequence of unsafe abortion by black women: Evidence of institutional racism in Brazil. Journal of Racial Ethnic Health Disparities, vol 8(6), pp.1385-94. (Goes, et al, 2021)

Grimes, D.A, Benson, J. Susheela, S. Romero, M Ganatra, B. Okonofua, F.E. Shah, I.H. (2006) Unsafe abortion: The preventable pandemic. The Lancet Vol 368 (9550). (Grimes, D.A 2006)

Gunarathne, L. Bhowmik, J. Apputhurai, P. Nedelijkovic, M. (2023). Factors and consequences associated with intimate partner violence against women in low- and middle-income countries: A systematic review. PLOS ONE Vol 18 (11) (Gunarathne, et al ,2023)

International Confederation of Midwives (ICM). (2023) Midwives’ Provision of Abortion-Related Services. [Date accessed 28th February 2024] Available from: https://internationalmidwives.org/resources/midwives-provision-of-abortion-related-services/

Makleff, S. Wilkins, R. Wachsmann, H. Gupta, D. Wachira, M. Bunde, W. Radhakrishnan, U. (2019) Exploring stigma and social norms in women’s abortion experiences and their expectations of care. Sexual and Reproductive Health Matters, Vol 27 (3) pp.50-64. (Makleff, et al, 2019)

Mishra, S. and Rath, K.S. (2021) Unsafe abortion: Combating the silent menace. Indian Journal of Obstetrics and Gynecology Research. Vol 8 (2), pp.146-149. (Mishra and Rath, 2021)

Ngwako, K. Blake-Thomas, A. (2020). ‘I guess we have to treat them, but … ’: health care provider perspectives on management of women presenting with unsafe abortion in Botswana. Taylor & Francis Online. Vol 15 (9) pp.1308-1321. (Ngwako and Blake-Thomas, 2020)

Norris, A. Bessett, D. Steinberg, J.R. Kavanaugh, M.L. Zordo, S.D. Becker, D. (2011) Abortion Stigma: A Reconceptualization of Constituents, Causes, and Consequences. Women's Health Issues, Vol 21 (3). (Norris, et al, 2011)

Singh, S. (2010) Global Consequences of Unsafe Abortion. Sage Journals Women's Health. Vol 6 (6) (Singh, 2010)

World Health Organisation (WHO), 2021. Abortion [Date accessed 23rd February 2024] Available from:

Statistics

(146) 13 women die in India everyday due to unsafe abortions

annually 6.4 million pregnancys terminated

unsafe abortion countries leading cause maternal death (8% all deaths each year)

Study

(146) Medical termination of pregnancy (MTP) Act India- 1971 adopted to legalise abortions involing ingestion of oral drugs (mifepristone and misoprostol)

key benfits

complete abortion rates- >90%

avoidance of anesthesia and surgical intervention

improves womens health, quality of life, secure and legal abortion considered vital

(147) 100 women- complaints between sept 2018- june 2020

<20 years- 10

21-20 years- 87

>30 years- 3

primip- 28

gravida- (2-3)- 65

gravida- 7

MTP kit- termation of interuterine pregnancy up tp 63 days gestation- taking beyond increases complications

majority (52%) taken 7-9 weeks

(148)

12 suffered severe anaemia and 22 required blood transfusion to correct anameia

1-2 units blood- 18

3 units- 4

10 diagnosed incomplete abortion

12 found out they had etopic pregnancy (as no assessment prior to assess uterus size)

72 women had suction and evacuation + 6 of them given supplementry misoprostol

10 with complete abortion- blood transfusion

12 (etopic) had laparotomy or paro

(146) Unsafe abortion dangerous and expensive several reasons women resort to it:

unintended pregnancy

economic status

low education

living deprived neighbourhoods

(146)Women that dont have access safe abortion subject to unsafe life threatening procedures

short term-

incomplete abortion (non expulsion 5%)

hemorrhage (78%)

abdominal pain (7%)

infection -sepsis

long term-

chronic pain

pelvic inflammatory disease

infertility

(146) unsafe abortion not only impacts women, family and health care systems but using blood products, antibiotics, anesthesia, surgical intervention for women admitted post- fincaially and logistically impacts emergancy crae and overhwlems health system

(149)

medical methods as per WHO (world health organisation) safe, effective and performed under supervision.

all women in study purchased medication without consultation or ultrasonography and mostly instilled by husband or family.

necessary to address need to educate women use of over counter medication (risks, benefits to make informed choice)

Urgent need for legalisation and restriction of drugs used for medical termination- made available by health care facilities to reduce morbidity and mortality.

Also advised ultrasonographic evaluation befor eintake of pills prevent missed etopic pregnancies

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E- worldwide statistics

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L- link to barriers and soloutions

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Semi-structured open-ended interviews (qualitative methodology)

Barriers to communication between couples

"he never talks to me"

“I can’t tell him everything. He is much older than me and doesn’t always understand what I am saying”

single women working as housemaids experienced involuntary sex whilst at work- "I struggled to get away from him but he kept holding on."

Inability to control family planning

"My husband wanted us to have a second child. I didn’t want one so quickly… He wouldn’t let me use the medication to stop the pregnancy”

The majority of participants only used traditional methods like avoiding sexual intercourse on certain days and pulling out methods.

One woman used contraception regularly

Maintaining secrecy was paramount

Scared to go to the doctor in case husband or neighbors found out

searched online methods

To induce an abortion, they tried wearing “high heels”, “Punching themselves” or taking “a lot of malaria pills”. One woman “started to exercise very hard, I made myself fall on the ground a few times and once I tried jumping out of a window. I even considered drinking henna but I was afraid to die”

Another invasive method was inserting a cannula into the uterus

Single women asked friends to help- "They inserted a metal wire and started scrapping inside me themselves … my mother doesn’t know about this."

Complications experienced-

women did not rush to seek medical assistance and waited days before going

4 women had abdominal surgery

1 had to have the uterus removed due to severe damage

1 still pregnant

• Heavy bleeding

• fever

• nausea

• vomiting

• tiredness

unconscious

Coming to terms

Devoted Muslims and Christians referred to "Allah" and "god" multiple times throughout

one woman felt the pain and suffering were "punishment" for engaging with sex outside of marriage

"i thank Jesus for saving me, I'm so blessed"

common themes were guilt, shame, and regret

"depressed all the time"

scared and frightened to tell the family

“NO, no, no. I can’t tell my family in Eritrea. They would kill me. Sex before marriage is not allowed in our religion. They would be very angry!”

many follow rule of keeping secret about abortion (58% felt this)

varies due to religion, cultural values and economic status

women perceived others looking down on her for having abortions

public discourse perspective of women having abortions steering "good' " bad" abortions due to reasons

good- more socially acceptable like malformations, or whilst using contraception, for the first time, young women or rape or incest

bad- multiple, later gestations are by "selfish people", without using contraception

Violates "feminine ideals" of womanhood- nurturing motherhood and sexual purity

notions women should on sex to procreate

"nonprotective sex" exerts control over reproduction and sexuality which threatens gender norms

stigmatization may be due to not abortion fetus but the shame of sexual practices

legal restrictions

• representing 132 midwife associations in 113 countries, recommends referral for abortion and post-abortion care be designated as essential knowledge or skills for all midwives and trainees

• Four hundred and thirty-two (69.3%) participants believed that abortion should be provided publicly

• 579 (92.9%) respondents felt that knowledge of the availability, practice and possible complications of abortion should be part of the core curriculum for midwifery and/ or nursing students in Australia

• ‘I have personal/religious views that believe that termination should not be given to any woman regardless of gestation. However, as a clinician, and over the early years of my career, I have seen women in many difficult circumstances that have chosen to go ahead with termination and it is always a difficult decision. As it is her body, it should also be her choice, regardless of my religious views.’

• ‘I do believe in choice for women, but feel it should be limited to early abortion with only exceptional cases being considered for later term terminations.’

• ‘I believe an elective termination is a fundamental healthcare right for women and families in Australia and globally. It is a safe medical procedure and access to it will improve the health of Australians.’

• ‘A woman has a right to an abortion. However, the support for this service in the public sector does not belong in a birth suite. It should be a dedicated service that nurses and midwives choose to be a part of not encompassed into current midwifery practice. Midwives prepare women for birth not prepare them to terminate their babies.

Many reported that community members disapprove of abortion and that a woman’s age or marital status could exacerbate judgement. Some reported limiting disclosure of their abortion to avoid judgement. Negative stories, the secrecy around abortion, perceived stigma, social norms, and fear of sanctions all contributed to women’s fears and low expectations. These findings elucidate the relationship between social norms and stigma and how expectations and concerns affect women’s experiences seeking care

several women said that before their abortion they had considered women who seek the service to be “irresponsible” or “immoral,” and others referred to abortion as a “sin” or “crime.”

One participant said that most community members think abortion “is like an abomination”

“In society, the way people view [abortion negatively] … that’s why people do it secretly”