Table1_Stigma towards women requesting abortion and association with health facility staff facilitation and obstruction of abortion care in South Africa.docx

BackgroundAbortion stigma has been shown to influence provider attitudes around abortion and may decrease provider willingness to participate in abortion care, or lead some to obstruct care. However, this link remains understudied.
MethodsThe present study uses baseline data collected through a cluster-randomized controlled trial in 16 public sector health facilities in South Africa in 2020. A total of 279 clinical and non-clinical health facility workers were surveyed. Primary outcome measures included: 1) willingness to facilitate abortion care in eight hypothetical scenarios, 2) facilitation of abortion care in the last 30 days, and 3) obstruction of abortion care in the last 30 days. Logistic regression models were used to assess the association between level of stigma as measured through the Stigmatizing Attitudes, Beliefs and Actions Scale (SABAS) and the primary outcomes.
ResultsOverall, 50% of respondents in the sample were willing to facilitate abortion care in each of the eight scenarios, with differences in willingness based on the abortion client's age and personal situation in each scenario. Over 90% reported facilitating abortion care in the last 30 days, but 31% also reported having obstructed abortion care in the last 30 days. Stigma was significantly associated with willingness to facilitate abortion care and actual obstruction of abortion care in the last 30 days. Controlling for covariates, odds of willingness to facilitate abortion care in every scenario decreased with every one-point increase in SABAS score (reflecting more stigmatizing attitudes), and odds of obstructing abortion care increased with every one-point increase in SABAS score.
ConclusionsLower abortion stigma on the part of health facility workers was associated with willingness to facilitate abortion access but not actual facilitation of abortion services. Higher abortion stigma was associated with actual obstruction of an abortion service in the last 30 days. Interventions to reduce stigma towards women seeking abortion, and particularly negative stereotyping, among all health facility staff is key to ensuring equitable and non-discriminatory access to abortion.
Trial registrationRetrospectively registered on clinicaltrials.gov (ID: NCT04290832) on February 27, 2020.
Plain english summaryThe link between stigma against women seeking abortion and decisions around whether to provide, abstain, or obstruct abortion care remains understudied. This paper assesses how stigmatizing beliefs and attitudes towards women seeking abortion in South Africa affects willingness to facilitate abortion care and actual facilitation or obstruction of abortion care in practice. A total of 279 clinical and non-clinical health facility workers were surveyed between February and March 2020. Overall, half of respondents in the sample were willing to facilitate abortion care in each of the eight scenarios, with important differences in willingness by scenario. Almost all respondents reported facilitating an abortion procedure in the last 30 days, but one in three also reported having obstructed abortion care in the last 30 days. More stigmatizing attitudes corresponded to decreased willingness to provide abortion care and increased odds of obstructing abortion care. Results show that stigmatizing attitudes, beliefs, and actions toward women who seek abortion shape how clinical and non-clinical staff in South Africa feel about their participation in abortion services and whether they obstruct this care. Facility staff hold great power in determining whose abortions are facilitated and whose are obstructed, resulting in stigma and discrimination being openly perpetuated. Continuous work to reduce stigma towards women seeking abortion among all health workers is key to ensuring equitable and non-discriminatory access to abortion for all.

研究背景
已有研究表明，堕胎污名会影响医疗服务提供者对待堕胎的态度，降低其参与堕胎护理的意愿，甚至导致部分从业者阻挠堕胎护理服务的提供。然而，目前学界对二者间的关联仍缺乏充分研究。

研究方法
本研究采用2020年在南非16家公立医疗机构开展的整群随机对照试验（cluster-randomized controlled trial）所收集的基线数据，共调查了279名临床及非临床医护人员。本研究的主要结局指标包括：1）在8种假设场景下参与堕胎护理的意愿；2）过去30天内提供堕胎护理的情况；3）过去30天内阻挠堕胎护理的情况。本研究采用逻辑回归模型，分析通过污名化态度、信念与行为量表（Stigmatizing Attitudes, Beliefs and Actions Scale, SABAS）测得的污名化程度与上述主要结局指标间的关联。

研究结果
整体而言，样本中有50%的受访者在全部8种假设场景中均愿意参与堕胎护理，且不同场景下的意愿会因堕胎服务对象的年龄与个人处境存在差异。超过90%的受访者表示过去30天内曾提供堕胎护理，但同时有31%的受访者称自己在过去30天内阻挠过堕胎护理。污名化程度与受访者参与堕胎护理的意愿，以及过去30天内实际阻挠堕胎护理的行为均存在显著关联。在控制协变量后，SABAS量表得分每升高1分（即污名化态度更强），受访者在所有场景下愿意参与堕胎护理的优势比均会降低，而阻挠堕胎护理的优势比则会升高。

研究结论
医疗机构从业者的堕胎污名化程度更低，与其参与堕胎服务的意愿正相关，但与实际提供堕胎服务的行为无显著关联；而更高的堕胎污名化程度，则与过去30天内实际阻挠堕胎服务的行为相关。在全体医护人员中开展针对堕胎求助女性的污名化干预，尤其是减少负面刻板印象的相关工作，是确保堕胎服务获得公平、无歧视可及性的关键。

试验注册
本研究于2020年2月27日在clinicaltrials.gov平台进行了回溯注册（注册编号：NCT04290832）。

通俗摘要
针对堕胎求助女性的污名化，与医疗从业者决定是否提供、拒绝或阻挠堕胎护理之间的关联仍缺乏充分研究。本研究旨在分析南非地区针对堕胎求助女性的污名化信念与态度，如何影响从业者参与堕胎护理的意愿，以及实际工作中提供或阻挠堕胎护理的行为。研究于2020年2月至3月间调查了279名临床及非临床医护人员。整体而言，样本中有半数受访者在全部8种假设场景中均愿意参与堕胎护理，且不同场景下的意愿存在显著差异。几乎所有受访者均表示过去30天内曾实施堕胎护理，但仍有三分之一的受访者称自己在同期阻挠过堕胎护理。更强的污名化态度与更低的堕胎护理参与意愿、更高的堕胎护理阻挠概率相关。研究结果显示，针对堕胎求助女性的污名化态度、信念与行为，会影响南非临床与非临床医护人员参与堕胎服务的意愿，以及是否阻挠此类护理服务。医疗机构从业者在决定为哪些女性提供堕胎护理、阻挠哪些女性的堕胎需求上拥有极大权力，这也导致污名与歧视得以持续公开存在。持续在全体医护人员中开展针对堕胎求助女性的污名化消减工作，是确保所有人群都能公平、无歧视地获得堕胎服务的核心所在。