Healthcare workers are on the frontlines of a global battle against abortion stigma, which lingers even as legal access expands in countries like Mexico, India, and Colombia. Educating and supporting these professionals can ensure they provide safe, non-judgmental care.
Abortion stigma is pervasive for women seeking abortion and for healthcare workers conducting the procedure. Photo: Getty Images
While many US states are rolling back the right of women to choose an abortion, many countries have taken large strides in recent years to improve access to the procedure.
In 2023, Mexico’s supreme court decriminalised abortion, following a similar ruling by Colombia’s constitutional court in 2022. In India, where abortion has been legal in certain situations since 1972, women needed permission from three medical practitioners to be granted access to the procedure, but in 2021, this was reduced to one.
But in all three countries, despite the relaxation of rules, abortion stigma remains a sticking point, both for women seeking abortion and for healthcare workers conducting the procedure.
Destigmatising abortion among healthcare workers not only empowers them to provide better care but also ensures that women can access safe and informed reproductive health services without fear of judgment.
Social and religious beliefs fuel abortion stigma
Even though women have been able to access abortion for more than five decades, the procedure “is still a taboo in India,” says Dr Manju Chhungani, dean in the School of Nursing Sciences & Allied Health at Jamia Hamdard, New Delhi and a board member of the Ipas Development Foundation. “The disgrace attached to abortion is cultural. It’s considered a sin. And…it is never brought up in conversations and is not openly accepted.”
Even when a woman has a miscarriage, “the family thinks there is something wrong with the mother,” she says. “And the same if the abortion is her wish.”
Dr Susana Oyamburu, centre coordinator at MSI Reproductive Choices’ Mexico programme, Fundación MSI, explains that “abortion stigma is mainly religious in Mexico, where almost everyone is Catholic. So, with that comes the criticism of society [if you have an abortion].”
Regional differences have become more apparent since the landmark 2023 ruling, Oyamburu says, explaining that “clients from big cities are more open, more relaxed about it, and social media influencers are talking about it more.” But in smaller cities and the countryside, there is still shame. “You can see it in people’s body language,” she says.
Decriminalising abortion has “removed the fear of prosecution [but] it doesn’t end stigma. It makes it more visible, if anything.”
In Colombia too, the Catholic faith plays a huge role in abortion stigma, says Dr Laura Gil of Doctors for Choice Colombia (Grupo Médico por el Derecho a Decidir). “The main sources of abortion stigma are social and religious,” she explains. Decriminalising abortion has “removed the fear of prosecution [but] it doesn’t end stigma. It makes it more visible, if anything,” Gil says.
Abortion stigma persistent in the medical profession
While there are clusters of healthcare professionals working to facilitate and improve access to abortion, stigma among this cohort remains pervasive, affecting knowledge and willingness to perform the procedure.
Chhungani details a survey performed in India among healthcare providers. “We asked healthcare providers if they thought that abortion was legal in India. Sixty percent said yes, it is. But 40% didn’t know if it was legal or not,” she says. “If this is the response among healthcare workers, then what hope does the common man have of knowing the status quo?”
In Mexico, Oyamburu identifies what she views as a glaring gap that contributes to abortion stigma among healthcare workers: “Abortion is not part of the education when you study medicine. It’s still a taboo topic.”
Even for doctors who specialise in obstetrics and gynaecology, “there is this underlying mantra that they are there to bring life,” Oyamburu explains. “They are taught how to do a dilatation and curettage for a spontaneous abortion [miscarriage] but not how to do a manual vacuum aspiration [induced abortion]. Specialists don’t know about abortion; they are not up to date with the guidelines.”
And often, when women don’t have viable pregnancies for one reason or another, they are sent to MSI, Oyamburu says. “Sometimes, the OBGYN gives the wrong medication if they are trying to medically induce an abortion, and when it doesn’t work, they send the client to us.”
Still, Oyamburu says that the court ruling in Mexico did bring relief to the stigma experienced by healthcare professionals. “This gave everyone peace of mind. Even though there is still stigma, there is more openness and people feel safer.”
“Doctors fear rejection from colleagues and their community or the rest of society if they perform abortions. And [they also fear] political stigma—people might think you are a feminist, or a leftist.”
In Colombia, Gil says that the idea of being a ‘conscientious objector’ to abortion is still entrenched as a ‘moral stance’ among the medical profession.
“Doctors fear rejection from colleagues and their community or the rest of society if they perform abortions. And [they also fear] political stigma—people might think you are a feminist, or a leftist,” she says.
“Especially if you live in a small town or city, there is no privacy at all. Your kids might find out at school, or your mother—who might be very religious—and then the priest will know [that you perform abortions]. All these kinds of stigma play a role.”
Stigma drives unsafe abortions
These sorts of attitudes can contribute to situations that drive women toward dangerous alternatives, perpetuating a cycle of risk and harm.
Unsafe abortions still far outnumber legal procedures in India, where an estimated 60% of abortions performed are unsafe. “Often women will try a ‘home’ remedy first—such as turmeric with hot milk—or some herbs or natural abortifacients. If that doesn’t work, they may go to a ‘quack’,” explains Chhungani.
Despite improved access to abortion for many women globally, stigma still drives many toward dangerous alternatives. Photo: Brett Sayles
Another route that is often taken by women, or more often their husbands, is to go to a pharmacy and ask for a type of medication that ends pregnancy called misoprostol. Although this is not legal—abortion pills require a prescription in India—there is no shortage of pharmacists willing to sell these illegally, says Chhungani. “They are only concerned with the sale of their products, and they don’t provide much advice on how to use them.”
Mexico similarly still has a huge problem with illegal, unsafe abortions, Oyamburu acknowledges. “We cannot reach everyone, so this is still a problem. Many people use Indigenous remedies, such as certain medicinal plants or herbs and teas to try and induce abortion.”
In Columbia, Gil says there are multiple causes for unsafe or clandestine abortions. For example, “many women don’t know that their medical insurance will cover a medical abortion with mifepristone and misoprostol, and so instead of sourcing it at an abortion clinic, they will obtain the pills illegally where they will pay five or 10 times the price. They get scammed,” she says.
“Another example is some clinics that might have a permit for ultrasound but not for abortion tell [women] lies, such as it will take longer if they go to a proper abortion clinic. But they shouldn’t be ashamed to go to a licensed medical provider,” Gil adds.
And in small towns and rural areas of the country, it is still sometimes difficult to find abortion providers, so women might try to use medical abortion pills alone at home, “which is okay if you have enough information,” says Gil, noting that the World Health Organization (WHO) provides a guide to medical abortion for healthcare workers, “but not if you don’t.”
Conversely, in large cities in Columbia, the presence of protesters outside abortion clinics can be very off-putting, for both staff and patients, and can drive the latter to seek help elsewhere, she explains.
“Some of these protesters sing outside the clinic the whole day—it’s psychological trauma. They intimidate and harass staff and clients,” Gil says. “So instead of facing a wall of protesters outside the clinic, women will seek out clandestine abortion providers instead.”
Harnessing the power of education and social media
In all three countries, there are many initiatives ongoing to try to reduce stigma and improve education and acceptance of abortion among healthcare professionals.
“There has been some change in thinking in the last five years, particularly among healthcare workers in India,” says Chhungani, explaining that training programmes now educate healthcare workers about abortion and, importantly, communicate the importance of counselling women before and after an abortion.
She is hopeful that modern technology can further contribute to turning this tide. “On social media, if we could create some small video clips explaining the needs of the mother and making people understand everything she undergoes when having an abortion, I think that would be a great help. If we can get this point across digitally, then healthcare workers in villages would learn from that too, as well as women who may not be literate.”
Engender Health, a global nonprofit that seeks to advance sexual and reproductive health and rights, has launched several apps for pharmacists on family planning. More apps for healthcare workers that detail what to expect from medical abortion are in the works.
Meanwhile in Mexico, MSI is helping to reduce the stigma surrounding abortion by providing education programmes. “We talk about abortion as a normal thing, along with family planning,” Oyamburu says. MSI has also presented to police departments, “who are now more open as a result,” she notes.
In addition, MSI Mexico, along with Ipas’ Mexico branch, is educating specialists and teaching obstetricians and gynaecologists about abortion. MSI provides mental health support for healthcare professionals who may be struggling with stigma and associated stresses related to abortion.
“We have an app and a telephone chat line to provide support,” Oyamburu says, explaining that these initiatives began during the covid-19 pandemic.
In Colombia, Gil and her colleagues are working to help healthcare workers view abortion provision “in the same way as any other aspect of medicine—you just need to know how to do it,” she explains. “You don’t need to necessarily be an advocate or make any political statement.”
The amount of education about abortion that medical students and residents receive varies greatly depending on location, Gil explains. Before 2006, when abortion was illegal in Colombia, there was no education, but since the procedure was decriminalised, it has improved.
“However, it’s all about the teacher, and where you study,” she says. “Many [educators] are old male doctors who have been practising for years. Not many of them are pro-choice.”
Doctors for Choice now has an information campaign on social media called ‘Medsplaining’ to help doctors talk to other doctors about abortion. It is an approach that Gil says can help healthcare workers enhance the quality of the care they provide.
“I have been performing abortions since before it was legal, and I don’t feel stigmatised. And now I see others who were nervous before; they are coming out of the closet.”
“Many doctors are afraid to ask about abortion because [they worry] they are going to be judged,” she notes. “And they have many questions, ranging from doubts about performing abortions in certain patient groups, to concerns about different gestational age limits, and anxieties about being targeted by anti-abortion campaigners.”
However, says Gil, “I have been performing abortions since before it was legal, and I don’t feel stigmatised. And now I see others who were nervous before; they are coming out of the closet.”
Oyamburu in Mexico feels similarly: “Stigma is still a problem, but there has been a big change.”
Commentaires