Pivotal Positions: Transforming Abortion Provider Stigma

This post is by Jennifer Coletti, and is part of Tsk Tsk: Stigma, Shame, and Sexuality, a series hosted by Gender Across Borders and cross-posted with RH Reality Check in partnership with Ipas.

Few of us would sign up for a job that would pose risks to our personal safety and our family’s safety, threaten to stifle or derail our career, cause our community to ostracize us, and cause us to continually face judgment and stereotyping from people we see every day. Yet that is exactly what many—if not most—health-care providers sign up for when they decide to deliver abortion care in the United States. And it’s the same for providers in many countries around the world. 

The tentacles of social disapproval around abortion don’t end with women, but reach everyone—including family and community, all the way up to hospital administrators and lawmakers. Within this complex web of influences, abortion providers wage a daily battle to provide safe abortion care to women.

“Providers are not all on their own,” explains Anu Kumar, Ipas executive vice president. “They’ve got to relate to the health system, the legal system and the educational system, and they’ve got their bosses and their family. So it’s not so simple. When you walk into the provider’s office, you’re not getting just that person, you’re getting the institution behind that person.”

Of course, abortion providers experience stigma in drastically different ways depending on their country and community. For example, in Uruguay abortion providers may be viewed as accomplices to murder due to deep-seated Catholic opposition to the procedure there. On the other hand, communities in Zambia tend to respect the professional judgment of abortion providers but severely disapprove of women who seek them. And provider experiences differ vastly even within the United States: Some physicians who work in more progressive urban settings face less discrimination and fewer social effects of stigma than their counterparts working in conservative rural communities.

Guts Has Nothing to Do with It

Given the complicated history of U.S. abortion politics, Americans often assume that physicians who provide abortion believe it’s morally acceptable and have the guts to go through with it, while those who do not are morally opposed and/or intimidated by society’s stigma. But in truth, who provides abortion in the United States often has little to do with moral or political resolve. For her book Willing and Unable: Doctors’ Constraints in Abortion Care, author and University of California, San Francisco researcher Lori Freedman interviewed physicians practicing obstetrics and gynecology nationwide and found many providers who were willing to perform abortions but unable to overcome the structural barriers that abortion stigma and U.S. politics create.

“While several of these physicians would have liked to continue to perform abortions after residency and even took steps toward it, they found that there would be significant professional and social costs in doing so—costs that they were not willing to bear,” Freedman writes. Professional obstacles cited by physicians included workplaces with an anti-abortion climate; the surprisingly widespread “no-abortion policies” that quietly exist in many private practices, HMOs, and hospitals across the country; the risk of being pigeonholed as just an abortion provider; and the risk of being ostracized by the local medical community and patient population. On a more personal level, some physicians worried that providing abortions would cause their families to suffer discrimination and even danger.

In addition, many providers are stigmatized by the very patients who come to them for abortions. Physicians who staff specialized abortion clinics report disheartening interactions with patients who ask “How do you do this on a regular basis?” or “Isn’t this really hard for you?” Even though these patients are willing to have abortions, they have absorbed society’s beliefs about abortion providers and convey that to their doctors.

Specialized Clinics: Separate but Not Equal

Separation is a hallmark of any stigmatized practice, and the fact that 93 percent of abortions are now performed at specialized clinics is no accident. Years of abortion prohibitions, threats and a professional medical culture that refuses to treat abortion inclusively has caused “multilevel, institutionalized buck-passing that marginalizes abortion practice,” Freedman writes.

While specialized abortion clinics are often able to cultivate a more positive environment for women in need of services, their complete separation from all other health-care facilities only perpetuates the idea that abortion is not a “normal” part of women’s reproductive health care. And now that abortion practice is firmly established as a very separate type of patient care, there are professional incentives for providers to stick with the model.

“If you’re going to do something that’s highly stigmatized in our culture, it’s not surprising that many people would like to do it in a setting where it’s not stigmatized, in a setting where everyone feels it’s normal and good, rather than in a setting where everyone is questioning what you’re doing,” Freedman tells Because.

The separation of abortion services from mainstream health care here in the United States is mirrored in many countries abroad thanks to U.S. foreign aid policy that strictly prohibits funding to any organization that provides abortion services.

“The he assessments of the impact of the global gag rule and the Helms Amendment shows that these policies have led to the isolation and separation of abortion, effectively delinking it from reproductive health and family planning,” explains Leila Hessini, Ipas director of community access.

Solution: Add More Settings and More Providers

To reduce the marginalization of abortion care in the United States and abroad, one solution is obvious: “If you simply diffuse abortion provision across many more sites and many more providers and many more contexts, then the clinics aren’t so targetable and aren’t so focused on by protestors and people who want to perpetuate violence,” Freedman tells Because.

“If there are more providers in more places,” Kumar agrees, “it will become more routine and less specialized.”

In addition to expanding the settings where abortion is provided, diversifying the types of providers performing abortion is also key. In the United States, only physicians are permitted to perform first-trimester aspiration abortions—except in a few states which have granted limited rights for some nurse practitioners, physician assistants and certified nurse midwives to perform the procedure.

“The diversification of this provider pool is so critical,” Kumar stresses. And many countries in which Ipas works are already doing this. “Ethiopia, Nepal, Ghana and South Africa all permit midlevel providers to provide abortion services,” she points out.

Researchers and advocates are working to make this a reality in the United States as well. The Primary Care Initiative (PCI)—a project of the University of California, San Francisco’s research group Advancing New Standards in Reproductive Health (ANSIRH)—is in the middle of a training and evaluation project for certified nurse midwives, physician assistants and nurse practitioners that seeks to prove the safety and effectiveness of allowing these types of providers to perform abortions, with the ultimate goal of affecting policy changes.

“With our study we’re looking to normalize abortion within women’s primary care and within reproductive health care, and so part of that is training more clinicians and health-care workers and teams of workers in providing safe abortion,” says PCI’s Principal Investigator Diana Taylor. Many states now allow midlevel providers to administer medical abortion pills, and this “is certainly normalizing the experience” for this abortion method, she adds.

Support for Providers = Support for Women’s Reproductive Rights

The complex tapestry of abortion stigma and its negative influences on providers, patients and society at large won’t unravel easily. But supporting abortion providers could be a critical first step.

“Providers are in a really pivotal position, and how we as a system and a society treat them translates into how we treat women,” Kumar explains. “So if we really hope to change how women experience abortion and to save women’s lives with safe abortion services, then we also really need to change the way we treat providers who perform these services.”