Abortion stigma
Stigma has been found to be an obstacle in delivery of some health services due to negative consequences for those who are, or who fear being, stigmatized [
1,
2]. Erving Goffman, a key figure in the sociological definition of stigma, conceptualizes it as “an attribute that is deeply discrediting” that “reduces an individual from a whole and usual person to a tainted, discounted one” [
3]. Goffman presents three types of stigma: blemishes of character, deformations of the body, and group identity [
3]. Link and Phelan, in response to the assertion that stigma was “vaguely defined” and “individually focused,” explain it as a social process in which individuals are marked as different, associated with negative attributes, conceived of as “others,” separated from society, and subject to loss of status and discrimination. This process places them in a framework of economic, political, and social power relations that perpetuate stigma in order to maintain the status quo [
4].
Every year over 40 million women in the world have an abortion [
5], making it one of the most common and safe medical procedures [
6]. Yet it is still loaded with strong social stigma expressed in negative attitudes and secrecy by both women who get abortions and clinicians involved in the process. Thus, abortion stigma is one of the main barriers to women seeking termination of an unwanted pregnancy and a challenge to abortion service providers. This stigma translates into shame and silence for women and into marginalization for providers, and creates or perpetuates myths and misunderstandings about abortion [
2,
7]. Stigma manifests differently depending on legal frameworks, religious beliefs, and social and cultural contexts [
8].
Kumar, Hessini, and Mitchell define abortion stigma as “a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood” [
9]. They explain that when a woman has an abortion, she transgresses socially-accepted concepts, such as that sexual relations are only for reproductive purposes; that maternity is inherent in the condition of being a woman, and therefore inevitable; and that the role established for women is motherhood and the nurturing of children [
9].
At the individual level, stigma can be classified into three main manifestations: 1) perceived stigma, which are ideas about what others may think about abortion and about what could happen if their own experience is made public (rejection by the family or partner, impaired social relationships, loss of friendships, criticism, abuse, and isolation); 2) experienced stigma, which are actual acts of discrimination, harassment, and aggression by others; and 3) internalized stigma, which refers to the materialization of the two previous forms in feelings of guilt, shame, anxiety, or other negative ideas [
9,
10].
Shellenberg et al. [
10] and Sorhaindo et al. [
11] focus on how internalized stigma was experienced by women who had abortions in Mexico and Peru. Feelings of guilt, sadness, and shame were common, as well as widespread silence and secrecy around abortion, especially in small communities. Some of the women interviewed by Shellenberg et al. [
10] initially said that their abortions were spontaneous, a strategy to distance themselves from stigma, although they later explained that they had induced abortions. Some women in the study by Sorhaindo et al. [
11], said that they had changed their perception about abortion based on their own experience. Yet despite changing their prejudiced views of women who terminate their pregnancies, they were unable to approve of abortion even after having one. The accounts in these studies reflect experiences of isolation among women who choose to not share their experiences or seek support [
9,
10].
Health care providers who counsel women and dispense abortion medication, as well as pharmacists and other personnel who work in facilities that provide abortion services are also affected by stigma [
10‐
12]. This stigma often discredits them and excludes them from full participation in their professional community. For example, abortion providers have been called “dirty workers” in the social psychology literature. “Dirty work” refers to professions stigmatized by their associations with contamination that is physical (grime, dirt), social (interaction with stigmatized individuals), or moral (primarily sin) [
12]. Studies conducted with abortion providers where abortion is illegal reveal that they frequently feel isolated from the general medical community and that they are afraid to speak openly about their work [
8,
12]. Under these conditions, many choose not to get involved in abortion provision, or if they do, they do not speak openly about it in their social and professional circles [
13].
Even though research that specifically explores how abortion stigma operates among Latin American women and health professionals is incipient, there is a growing body of work that provides solid bases with which to develop theoretical frameworks that are grounded on empirical evidence [
10,
11,
16‐
19].
Although an increasing number of countries Latin America have achieved partial decriminalization of abortion in recent years, it is still estimated that the region has the highest percentage of unsafe abortions in the world [
5,
14]. Furthermore, research shows that in settings where abortion is legal, risks to the lives of women and abortion-related stigma are lower than in those where it is criminalized [
14,
15]. Thus, this paper emerges from the broad idea that perceptions and attitudes toward abortion vary depending on legal contexts, and that these tend to be more favorable when a woman’s legal right to terminate her pregnancy is recognized. The study’s overall objective was to uncover and analyze these patients’ and health professionals’ perceptions and attitudes towards abortion. Specifically, to explore if and how stigma continues to operate in decriminalized clinical abortion settings.
1
Legal framework
In 2012 (Law 18,987), Uruguay decriminalized medicated and surgical abortion, without specifying grounds but under strict compliance with two requirements: to not exceed twelve weeks of pregnancy and that the woman meet with a multidisciplinary team of three health professionals (gynecologist, psychologist, and social worker), which must ensure that she has all necessary information available to make an informed and responsible decision. The law and its regulations (Decree No. 375/012) state that a woman must attend four visits and during the process, the woman must think over her decision for five days except in cases where the pregnancy represents a risk to the woman’s life, is a result of rape, or when there is fetal malformation. In addition, the IVE
2 manual published by the Ministry of Health following decriminalization privileges medicated abortion over surgical procedures. For this reason, women who go through a regular abortion process will routinely receive a medicated abortion and will not be asked for their preference of method. All public facilities in Uruguay’s Integrated Health System are required to follow the law and conscientious objection is permitted among physicians as long as the facilities where objectors work inform women on how and where to access services.
3
In the Uruguayan model of care, teams of health professionals in abortion services are organized in first level clinics and in hospitals, and they include physicians, nurses, midwives, psychologists, social workers, and sonographers. Under the law, abortion clients must follow the following steps: a first appointment where the woman expresses her intent to terminate a pregnancy (Visit 1), a second appointment with the interdisciplinary team where she receives counseling and is informed about the required reflection period (Visit 2), a five-day waiting period, a third appointment where the woman expresses her final decision and the procedure is initiated (Visit 3), and a fourth appointment to confirm whether the abortion has been completed (Visit 4).