Health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data
Identifieur interne : 000716 ( Pmc/Corpus ); précédent : 000715; suivant : 000717Health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data
Auteurs : Ulrika Rehnström Loi ; Kristina Gemzell-Danielsson ; Elisabeth Faxelid ; Marie Klingberg-AllvinSource :
- BMC Public Health [ 1471-2458 ] ; 2015.
Abstract
Unsafe abortions are a serious public health problem and a major human rights issue. In low-income countries, where restrictive abortion laws are common, safe abortion care is not always available to women in need. Health care providers have an important role in the provision of abortion services. However, the shortage of health care providers in low-income countries is critical and exacerbated by the unwillingness of some health care providers to provide abortion services. The aim of this study was to identify, summarise and synthesise available research addressing health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia.
A systematic literature search of three databases was conducted in November 2014, as well as a manual search of reference lists. The selection criteria included quantitative and qualitative research studies written in English, regardless of the year of publication, exploring health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The quality of all articles that met the inclusion criteria was assessed. The studies were critically appraised, and thematic analysis was used to synthesise the data.
Thirty-six studies, published during 1977 and 2014, including data from 15 different countries, met the inclusion criteria. Nine key themes were identified as influencing the health care providers’ attitudes towards induced abortions: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence 8) quality of care and 9) stigma and victimisation.
Health care providers in sub-Saharan Africa and Southeast Asia have moral-, social- and gender-based reservations about induced abortion. These reservations influence attitudes towards induced abortions and subsequently affect the relationship between the health care provider and the pregnant woman who wishes to have an abortion. A values clarification exercise among abortion care providers is needed.
The online version of this article (doi:10.1186/s12889-015-1502-2) contains supplementary material, which is available to authorized users.
Url:
DOI: 10.1186/s12889-015-1502-2
PubMed: 25886459
PubMed Central: 4335425
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PMC:4335425Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data</title><author><name sortKey="Rehnstrom Loi, Ulrika" sort="Rehnstrom Loi, Ulrika" uniqKey="Rehnstrom Loi U" first="Ulrika" last="Rehnström Loi">Ulrika Rehnström Loi</name><affiliation><nlm:aff id="Aff1">Department of Public Health Sciences/IHCAR, Karolinska Institutet, Stockholm, Sweden</nlm:aff></affiliation></author><author><name sortKey="Gemzell Danielsson, Kristina" sort="Gemzell Danielsson, Kristina" uniqKey="Gemzell Danielsson K" first="Kristina" last="Gemzell-Danielsson">Kristina Gemzell-Danielsson</name><affiliation><nlm:aff id="Aff2">Department of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital Stockholm, Stockholm, Sweden</nlm:aff></affiliation></author><author><name sortKey="Faxelid, Elisabeth" sort="Faxelid, Elisabeth" uniqKey="Faxelid E" first="Elisabeth" last="Faxelid">Elisabeth Faxelid</name><affiliation><nlm:aff id="Aff1">Department of Public Health Sciences/IHCAR, Karolinska Institutet, Stockholm, Sweden</nlm:aff></affiliation></author><author><name sortKey="Klingberg Allvin, Marie" sort="Klingberg Allvin, Marie" uniqKey="Klingberg Allvin M" first="Marie" last="Klingberg-Allvin">Marie Klingberg-Allvin</name><affiliation><nlm:aff id="Aff2">Department of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital Stockholm, Stockholm, Sweden</nlm:aff></affiliation><affiliation><nlm:aff id="Aff3">School of Education, Health and Social studies, Dalarna University, Falun, Sweden</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25886459</idno><idno type="pmc">4335425</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4335425</idno><idno type="RBID">PMC:4335425</idno><idno type="doi">10.1186/s12889-015-1502-2</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000716</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000716</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data</title><author><name sortKey="Rehnstrom Loi, Ulrika" sort="Rehnstrom Loi, Ulrika" uniqKey="Rehnstrom Loi U" first="Ulrika" last="Rehnström Loi">Ulrika Rehnström Loi</name><affiliation><nlm:aff id="Aff1">Department of Public Health Sciences/IHCAR, Karolinska Institutet, Stockholm, Sweden</nlm:aff></affiliation></author><author><name sortKey="Gemzell Danielsson, Kristina" sort="Gemzell Danielsson, Kristina" uniqKey="Gemzell Danielsson K" first="Kristina" last="Gemzell-Danielsson">Kristina Gemzell-Danielsson</name><affiliation><nlm:aff id="Aff2">Department of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital Stockholm, Stockholm, Sweden</nlm:aff></affiliation></author><author><name sortKey="Faxelid, Elisabeth" sort="Faxelid, Elisabeth" uniqKey="Faxelid E" first="Elisabeth" last="Faxelid">Elisabeth Faxelid</name><affiliation><nlm:aff id="Aff1">Department of Public Health Sciences/IHCAR, Karolinska Institutet, Stockholm, Sweden</nlm:aff></affiliation></author><author><name sortKey="Klingberg Allvin, Marie" sort="Klingberg Allvin, Marie" uniqKey="Klingberg Allvin M" first="Marie" last="Klingberg-Allvin">Marie Klingberg-Allvin</name><affiliation><nlm:aff id="Aff2">Department of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital Stockholm, Stockholm, Sweden</nlm:aff></affiliation><affiliation><nlm:aff id="Aff3">School of Education, Health and Social studies, Dalarna University, Falun, Sweden</nlm:aff></affiliation></author></analytic><series><title level="j">BMC Public Health</title><idno type="eISSN">1471-2458</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Unsafe abortions are a serious public health problem and a major human rights issue. In low-income countries, where restrictive abortion laws are common, safe abortion care is not always available to women in need. Health care providers have an important role in the provision of abortion services. However, the shortage of health care providers in low-income countries is critical and exacerbated by the unwillingness of some health care providers to provide abortion services. The aim of this study was to identify, summarise and synthesise available research addressing health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia.</p></sec><sec><title>Methods</title><p>A systematic literature search of three databases was conducted in November 2014, as well as a manual search of reference lists. The selection criteria included quantitative and qualitative research studies written in English, regardless of the year of publication, exploring health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The quality of all articles that met the inclusion criteria was assessed. The studies were critically appraised, and thematic analysis was used to synthesise the data.</p></sec><sec><title>Results</title><p>Thirty-six studies, published during 1977 and 2014, including data from 15 different countries, met the inclusion criteria. Nine key themes were identified as influencing the health care providers’ attitudes towards induced abortions: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence 8) quality of care and 9) stigma and victimisation.</p></sec><sec><title>Conclusions</title><p>Health care providers in sub-Saharan Africa and Southeast Asia have moral-, social- and gender-based reservations about induced abortion. These reservations influence attitudes towards induced abortions and subsequently affect the relationship between the health care provider and the pregnant woman who wishes to have an abortion. A values clarification exercise among abortion care providers is needed.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (doi:10.1186/s12889-015-1502-2) contains supplementary material, which is available to authorized users.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Gasman, N" uniqKey="Gasman N">N Gasman</name></author><author><name sortKey="Blandon, Mm" uniqKey="Blandon M">MM Blandon</name></author><author><name sortKey="Crane, Bb" uniqKey="Crane B">BB Crane</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Zampas, C" uniqKey="Zampas C">C Zampas</name></author><author><name sortKey="Gher, Jm" uniqKey="Gher J">JM Gher</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Grimes, Da" uniqKey="Grimes D">DA Grimes</name></author><author><name sortKey="Benson, J" uniqKey="Benson J">J 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<front><journal-meta><journal-id journal-id-type="nlm-ta">BMC Public Health</journal-id><journal-id journal-id-type="iso-abbrev">BMC Public Health</journal-id><journal-title-group><journal-title>BMC Public Health</journal-title></journal-title-group><issn pub-type="epub">1471-2458</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25886459</article-id><article-id pub-id-type="pmc">4335425</article-id><article-id pub-id-type="publisher-id">1502</article-id><article-id pub-id-type="doi">10.1186/s12889-015-1502-2</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>Health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Rehnström Loi</surname><given-names>Ulrika</given-names></name><address><email>ulrika.rehnstrom@ki.se</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Gemzell-Danielsson</surname><given-names>Kristina</given-names></name><address><email>Kristina.Gemzell@ki.se</email></address><xref ref-type="aff" rid="Aff2"></xref></contrib><contrib contrib-type="author"><name><surname>Faxelid</surname><given-names>Elisabeth</given-names></name><address><email>Elisabeth.Faxelid@ki.se</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Klingberg-Allvin</surname><given-names>Marie</given-names></name><address><email>mkl@du.se</email></address><xref ref-type="aff" rid="Aff2"></xref><xref ref-type="aff" rid="Aff3"></xref></contrib><aff id="Aff1"><label></label>Department of Public Health Sciences/IHCAR, Karolinska Institutet, Stockholm, Sweden</aff><aff id="Aff2"><label></label>Department of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital Stockholm, Stockholm, Sweden</aff><aff id="Aff3"><label></label>School of Education, Health and Social studies, Dalarna University, Falun, Sweden</aff></contrib-group><pub-date pub-type="epub"><day>12</day><month>2</month><year>2015</year></pub-date><pub-date pub-type="pmc-release"><day>12</day><month>2</month><year>2015</year></pub-date><pub-date pub-type="collection"><year>2015</year></pub-date><volume>15</volume><elocation-id>139</elocation-id><history><date date-type="received"><day>20</day><month>5</month><year>2013</year></date><date date-type="accepted"><day>3</day><month>2</month><year>2015</year></date></history><permissions><copyright-statement>© Rehnström Loi et al.; licensee BioMed Central. 2015</copyright-statement><license license-type="open-access"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/2.0">http://creativecommons.org/licenses/by/2.0</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p>Unsafe abortions are a serious public health problem and a major human rights issue. In low-income countries, where restrictive abortion laws are common, safe abortion care is not always available to women in need. Health care providers have an important role in the provision of abortion services. However, the shortage of health care providers in low-income countries is critical and exacerbated by the unwillingness of some health care providers to provide abortion services. The aim of this study was to identify, summarise and synthesise available research addressing health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia.</p></sec><sec><title>Methods</title><p>A systematic literature search of three databases was conducted in November 2014, as well as a manual search of reference lists. The selection criteria included quantitative and qualitative research studies written in English, regardless of the year of publication, exploring health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The quality of all articles that met the inclusion criteria was assessed. The studies were critically appraised, and thematic analysis was used to synthesise the data.</p></sec><sec><title>Results</title><p>Thirty-six studies, published during 1977 and 2014, including data from 15 different countries, met the inclusion criteria. Nine key themes were identified as influencing the health care providers’ attitudes towards induced abortions: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence 8) quality of care and 9) stigma and victimisation.</p></sec><sec><title>Conclusions</title><p>Health care providers in sub-Saharan Africa and Southeast Asia have moral-, social- and gender-based reservations about induced abortion. These reservations influence attitudes towards induced abortions and subsequently affect the relationship between the health care provider and the pregnant woman who wishes to have an abortion. A values clarification exercise among abortion care providers is needed.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (doi:10.1186/s12889-015-1502-2) contains supplementary material, which is available to authorized users.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Induced abortion</kwd><kwd>Providers’ attitudes</kwd><kwd>Sub-Saharan Africa</kwd><kwd>Southeast Asia</kwd><kwd>Systematic review</kwd><kwd>Thematic analysis</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2015</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1" sec-type="introduction"><title>Background</title><p>Unsafe abortions are directly correlated with poverty, social inequity and the constant, methodical denial of women’s’ human rights [<xref ref-type="bibr" rid="CR1">1</xref>]. The United Nations Committee on the Elimination of Discrimination against Women argue that women alone have the right to decide whether to have an abortion [<xref ref-type="bibr" rid="CR2">2</xref>].</p><p>The denial of a pregnant women’s right to independently make this decision violates or poses a threat to a number of human rights, including a woman’s right to equality, liberty, non-discrimination, privacy, health and to be free from inhumane and degrading treatment, as explicitly articulated by the United Nations [<xref ref-type="bibr" rid="CR2">2</xref>,<xref ref-type="bibr" rid="CR3">3</xref>].</p><p>Unsafe abortions are a public health burden mainly in low-resource settings, with the highest burden in sub-Saharan Africa, Latin America and the Caribbean, followed by South and Southeast Asia [<xref ref-type="bibr" rid="CR4">4</xref>]. At the opposite extreme, the rate of unsafe abortions in Europe and North America is insignificant [<xref ref-type="bibr" rid="CR4">4</xref>]. A systematic literature review by Khan et al. [<xref ref-type="bibr" rid="CR5">5</xref>] found that the maternal abortion-associated mortality ratio was 37 deaths per 100.000 live births in sub-Saharan Africa, 23 per 100.000 in Latin America and the Caribbean and 12 per 100.000 in South Asia. In countries with legal access to safe abortion services, deaths related to abortion are virtually non-existent [<xref ref-type="bibr" rid="CR5">5</xref>]. According to the most recent global estimates for abortion-related deaths by WHO, unsafe abortions are responsible for approximately 47,000 deaths each year [<xref ref-type="bibr" rid="CR6">6</xref>]. Kassebaum et al. indicated that abortion-related maternal deaths significantly decreased during 1990 to 2013 at a global level, except for sub-Saharan Africa where they significantly increased [<xref ref-type="bibr" rid="CR7">7</xref>].</p><p>Induced abortions are legal on various grounds in several sub-Saharan Africa and Southeast Asian countries [<xref ref-type="bibr" rid="CR8">8</xref>]. However, the health care providers in these countries often persist in viewing induced abortion as immoral, rather than recognising the legal status of abortion in their country [<xref ref-type="bibr" rid="CR8">8</xref>].</p><p>In most high-resource countries, abortion laws were liberalised between 1950 and 1985 on safety and human rights grounds [<xref ref-type="bibr" rid="CR9">9</xref>]. The most liberal abortion laws permit an abortion at the request of the women. However, there are vast differences in the abortion laws of different countries [<xref ref-type="bibr" rid="CR10">10</xref>]. The United Nations has identified seven grounds on which an abortion is permitted: (1) to protect life of the mother, (2) to preserve the mother’s physical health; (3) to preserve the mother’s mental health; (4) in cases of rape or incest; (5) for foetal defects; (6) for socioeconomic reasons and (7) on request [<xref ref-type="bibr" rid="CR10">10</xref>]. In most countries in sub-Saharan Africa and Southeast Asia, abortion laws are restrictive [<xref ref-type="bibr" rid="CR10">10</xref>]. An abortion is legal at the request of the women in only two countries in sub-Saharan Africa: Cape Verde and South Africa. Cambodia, Singapore and Vietnam permit an abortion on a broad range of grounds [<xref ref-type="bibr" rid="CR10">10</xref>]. In the last decade, several nations in these regions have liberalised their abortion laws to reduce the incidence of unsafe abortions. In 2005, Ethiopia approved a liberalised abortion law [<xref ref-type="bibr" rid="CR11">11</xref>], and Ghana’s abortion laws have been fairly liberal since 1985. However, safe, legal abortion has not been well implemented until recent years and unsafe abortions are common in Ghana [<xref ref-type="bibr" rid="CR12">12</xref>], and complications of induced abortions are the second leading cause of maternal death [<xref ref-type="bibr" rid="CR13">13</xref>].</p><p>Women, particularly adolescent women and those who are poor and/or living in rural areas, often lack information about the legal status of abortions in their country and where to seek safe abortion services. In addition, they may lack the decision-making power and money to seek such services, or they might be discouraged by health care providers’ negative attitudes and a lack of confidentiality and privacy [<xref ref-type="bibr" rid="CR14">14</xref>]. In many societies, abortion is a highly explosive topic, with stigma attached [<xref ref-type="bibr" rid="CR15">15</xref>]. The latter may prevent women from accessing safe abortion services.</p><p>In many low-resource countries, the stigma associated with abortions means that the providers offering these services suffer discrimination in and outside the workplace [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR17">17</xref>]. The discrimination causes many providers to cease providing abortion services [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR17">17</xref>]. Furthermore, abortion providers’ attitudes may be in conflict with the national abortion law [<xref ref-type="bibr" rid="CR18">18</xref>,<xref ref-type="bibr" rid="CR19">19</xref>]. These conflicts may cause moral distress and hamper the professional–patient relationship. The lack of willingness and commitment among health care providers to deliver timely, thoughtful and supportive abortion care may directly or indirectly contribute to maternal mortality due to unsafe abortions. Therefore, it is important to understand health care providers’ perceptions of and attitudes towards induced abortions, as they have a substantial effect on the accessibility to abortion services and the quality of these services.</p><p>The aim of this systematic literature review was to identify, summarise and synthesise available research addressing health care providers perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia.</p></sec><sec id="Sec2" sec-type="materials|methods"><title>Methods</title><sec id="Sec3"><title>Study identification</title><p>A comprehensive literature search of three databases (PubMed, CINHAL and Web of Science) and a manual search of reference lists of the identified studies were undertaken. All the searches took place during November 2014 and included all peer-reviewed articles, regardless of the year of publication (1977 – 2014). Each database was searched systematically for relevant citations using a high-sensitivity and low-specificity approach, as follows.</p><p>The systematic search was segregated into three elements: 1) health care provider, 2) abortion and 3) sub-Saharan Africa/Southeast Asia. For each of the elements, a list of relevant medical subject headings (MeSH), free text words, synonyms, abbreviations and alternate spellings that the authors might have used was accumulated. All the MeSH words and free text words were then combined using ‘OR’ to provide a large range of studies for each element. The three lists for each of the elements were then combined with ‘AND’ to generate high-sensitivity and low-specificity citations that were relevant to all three elements of the research question. The reference lists of the retrieved articles were screened to identify further relevant papers.</p></sec><sec id="Sec4"><title>Inclusion criteria</title><p>We decided to limit our review to sub-Saharan African and Southeast Asian countries, where the burden of maternal mortality is high. A thorough global analysis of health care providers’ attitudes towards abortion in other settings is beyond the scope of this paper and deserves attention in its own right.</p><p>The inclusion criteria for this literature review were: all primary quantitative and qualitative research studies that used data collection methods, such as surveys, self-completed questionnaires, in-depth interviews, focus-group discussions and observations to explore health care providers’ and students’ attitudes towards and perceptions of induced abortion in sub-Saharan Africa and Southeast Asia. The publications had to be written in English and pass a quality check developed by the first author (see Table <xref rid="Tab1" ref-type="table">1</xref>).<table-wrap id="Tab1"><label>Table 1</label><caption><p><bold>Quality assessment criteria*</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th></th><th><bold>Criteria</bold></th></tr></thead><tbody><tr valign="top"><td><bold>Aims</bold></td><td>General aims, specific objectives or research question clearly described.</td></tr><tr valign="top"><td><bold>Background</bold></td><td>A comprehensive literature review included. Explanation and justification for the study.</td></tr><tr valign="top"><td><bold>Context</bold></td><td>Context of the research adequately described.</td></tr><tr valign="top"><td><bold>Sampling/recruitment</bold></td><td>Clear description of the sample, including the size and characteristics of the sample Selection procedure appropriate and clearly described Study units are representative of the target population Exclusions and refusals accounted for and described</td></tr><tr valign="top"><td><bold>Data collection</bold></td><td>Suitable research design to address the aims of the research. Appropriate data collection instruments are used, piloted, pretested and described Clear description of the research methodology used Researcher - participation relationship adequately considered Ethical issues considered</td></tr><tr valign="top"><td><bold>Data analysis</bold></td><td>Clear description of the data analysis method, process and findings.</td></tr><tr valign="top"><td><bold>Data interpretation</bold></td><td>Clear discussion of the research findings. The study presents sufficient original data to support the findings, and to demonstrate that these and the conclusions are grounded in the data Clear integration of the data, interpretation and conclusions Study context and sample considered in the findings</td></tr><tr valign="top"><td><bold>Reliability/validity</bold></td><td>Reliability and validity of the analysis has been addressed Rigorous data analysis</td></tr></tbody></table><table-wrap-foot><p>*Adapted from the Critical Appraisal Skills Programme (CASP) within the Public Health Resource Unit (PHRU) and existing instruments for studies on reproductive health [<xref ref-type="bibr" rid="CR18">18</xref>,<xref ref-type="bibr" rid="CR19">19</xref>].</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec5"><title>Selection of studies</title><p>The first author selected and collected the articles for the review. This procedure included four steps (Figure <xref rid="Fig1" ref-type="fig">1</xref>). First, all 1,014 potentially relevant records identified from the electronic searches underwent an initial title and abstract review to determine their relevance according to the inclusion criteria. These records were then imported into bibliographic software EndNote® for reference management. The EndNote® library was later searched to identify duplicate files. All duplicates were deleted, and a single copy of each record was retained. Second, a hard copy of all the potential studies was obtained and analysed according to the inclusion criteria. Studies that did not meet the inclusion criteria were excluded. Third, all articles that met the inclusion criteria were reviewed to determine the quality of the study (see Table <xref rid="Tab1" ref-type="table">1</xref>). Studies that did not meet the pre-set methodological quality criteria, described below, were excluded. This process is clarified under the next section. Finally, the reference lists in the retrieved articles were screened to identify further relevant papers according to the inclusion and quality criteria. Figure <xref rid="Fig1" ref-type="fig">1</xref> describes the reasons for the exclusion of studies.<fig id="Fig1"><label>Figure 1</label><caption><p><bold>Flow chart for identifying relevant studies.</bold></p></caption><graphic xlink:href="12889_2015_1502_Fig1_HTML" id="MO1"></graphic></fig></p></sec><sec id="Sec6"><title>Assessment of the quality of the study and data extraction</title><p>To assess the methodological quality (internal and external validity) of the included studies, the main author developed a checklist of quality criteria based on the critical appraisal skills programme and existing instruments for studies on reproductive health [<xref ref-type="bibr" rid="CR19">19</xref>,<xref ref-type="bibr" rid="CR20">20</xref>]. The following eight criteria were assessed: 1) aim, 2) background, 3) context, 4) sampling, 5) data collection, 6) data analysis, 7) data interpretation and 8) reliability/validity. Table <xref rid="Tab1" ref-type="table">1</xref> provides a detailed description of the quality criteria.</p><p>Following the initial reading of the 36 included studies; each study was read several times by the main author to appraise the content. Its findings were then summarised on a data extraction form by the main author. The following information was recorded: background of the study, country of research, study population, study characteristics, design and methods, methodological quality, data sampling, data collection, analysis methods and key findings.</p></sec><sec id="Sec7"><title>Synthesis</title><p>In the review, both qualitative and quantitative data were assessed, and each study was analysed individually. The results from the selected studies were analysed using a thematic analysis that was used previously for synthesising results in systematic literature reviews of qualitative and quantitative studies [<xref ref-type="bibr" rid="CR20">20</xref>-<xref ref-type="bibr" rid="CR22">22</xref>]. The 36 studies included in this review were first assessed to categorise key descriptive themes. The key descriptive themes were then systematised in a matrix, and similarities, differences and contradictions were examined. To answer the review question about the attitudes of health care professionals towards induced abortions in sub-Saharan Africa and Southeast Asia, analytical themes were created.</p></sec></sec><sec id="Sec8" sec-type="results"><title>Results</title><sec id="Sec9"><title>Description of the studies included in the review</title><p>The 36 studies included in the review were published between 1977 and 2014 and described health care professionals’ perceptions of and attitudes towards induced abortions. The studies were conducted in 15 countries: Ethiopia (1), Ghana (5), Indonesia (1), Kenya (1), Mozambique (1), Myanmar (1), Nigeria (4), South Africa (13), Swaziland (1), Thailand (2), Timor Leste (1), Uganda (1), Vietnam (2), Zambia together with Kenya (1) and Zimbabwe (1). In total, 29 studies were conducted in sub-Saharan Africa, and seven took place in Southeast Asia. Table <xref rid="Tab2" ref-type="table">2</xref> describes the characteristics of the studies included in the review.<table-wrap id="Tab2"><label>Table 2</label><caption><p><bold>Characteristics of the studies included in the review</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>Nr.</bold></th><th><bold>Country</bold></th><th><bold>Year of publication</bold></th><th><bold>Study period</bold></th><th><bold>Abortion law</bold><sup><bold>*</bold></sup></th><th><bold>Aim</bold></th><th><bold>Sample size/characteristics</bold></th><th><bold>Data collection</bold></th><th><bold>Reference</bold></th></tr></thead><tbody><tr valign="top"><td><bold>1.</bold></td><td>Ethiopia</td><td char="." align="char">2011</td><td>March – April 2008</td><td>A B D E H +</td><td>To answ er the questions; “what does perceptions on safe abortion look like among health care service providers?” “What are the factors which affect the perception of health providers towards safe abortion?”</td><td>431 health providers</td><td>A structured, self-administered questionnaire</td><td>ABDI, J. et al. [<xref ref-type="bibr" rid="CR32">32</xref>]</td></tr><tr valign="top"><td><bold>2.</bold></td><td>Ghana</td><td char="." align="char">2013</td><td>No information</td><td>A B C D E H</td><td>To examine in in what ways provider attitudes and values affect the implementation of abortion policy.</td><td>43 health professionals</td><td>In-depth interviews</td><td>ANITEYE, P. et al. [<xref ref-type="bibr" rid="CR30">30</xref>]</td></tr><tr valign="top"><td><bold>3.</bold></td><td>Timor Leste</td><td char="." align="char">2009</td><td>2006 -2007</td><td>A</td><td>To describe the socio-legal context of unsafe abortion in Timor-Leste</td><td>21 doctors and midwives</td><td>In-depth interviews</td><td>BELTON, S. et al. [<xref ref-type="bibr" rid="CR24">24</xref>]</td></tr><tr valign="top"><td><bold>4.</bold></td><td>South Africa</td><td char="." align="char">2000</td><td>No Information</td><td>A B C D E F G -1st H</td><td>To investigate health care ethics regarding Termination of pregnancy</td><td>1200 registered nurses</td><td>Questionnaires and Focus-group discussions</td><td>BOTES, A. [<xref ref-type="bibr" rid="CR16">16</xref>]</td></tr><tr valign="top"><td><bold>5.</bold></td><td>South Africa</td><td char="." align="char">2002</td><td>No Information</td><td>A B C D E F G -1st H</td><td>To assess attitudes of medical students to induced abortion</td><td>247 medical students</td><td>Self-administered questionnaire</td><td>BUGA, G.A. [<xref ref-type="bibr" rid="CR33">33</xref>]</td></tr><tr valign="top"><td><bold>6.</bold></td><td>South Africa</td><td char="." align="char">2005</td><td>Nov. 2001 – March 2002</td><td>A B C D E F G -1st H</td><td>To explore attitudes of health care providers towards medical abortion</td><td>20 public health nurses and doctors</td><td>In-depth interviews</td><td>COOPER, D., et al. [<xref ref-type="bibr" rid="CR25">25</xref>]</td></tr><tr valign="top"><td><bold>7.</bold></td><td>Indonesia</td><td char="." align="char">1993</td><td>Oct. 1990 – April 1991</td><td>A</td><td>To contribute to the search for ways to make pregnancy and childbirth safer</td><td>28 Physicians, 16 Midwives,16 TBA 16 PLKB Total: 76</td><td>In-depth interviews</td><td>DJOHAN, E., et al. [<xref ref-type="bibr" rid="CR26">26</xref>]</td></tr><tr valign="top"><td><bold>8.</bold></td><td>Nigeria</td><td char="." align="char">2003</td><td>No Information</td><td>A</td><td>To examine the knowledge, attitude and practice of private medical practitioners on abortion</td><td>48 private practitioners</td><td>Structured questionnaire</td><td>ETUK, S.J. et al. [<xref ref-type="bibr" rid="CR34">34</xref>]</td></tr><tr valign="top"><td><bold>9.</bold></td><td>Mozambique</td><td char="." align="char">2004</td><td char="." align="char">2002</td><td>A B</td><td>To document the strengths and deficiencies of abortion care</td><td>99 Midwives and nurses</td><td>Questionnaire</td><td>GALLO, M.F., et al. [<xref ref-type="bibr" rid="CR35">35</xref>]</td></tr><tr valign="top"><td><bold>10.</bold></td><td>South Africa</td><td char="." align="char">2000</td><td>No Information</td><td>A B C D E F G - 1st H</td><td>To explore and describe nurses’ experiences of being involved with abortion care</td><td>Nurses</td><td>Phenomenological interviews</td><td>GMEINER, A.C., et al. [<xref ref-type="bibr" rid="CR31">31</xref>]</td></tr><tr valign="top"><td><bold>11.</bold></td><td>South Africa</td><td char="." align="char">2012</td><td>July – October 2008</td><td>A B C D E F G - 1st H</td><td>To explore health service providers’ perceptions of abortion services</td><td>19 providers and hospital managers</td><td>In-depth interviews</td><td>HARRIES, J. et al. [<xref ref-type="bibr" rid="CR27">27</xref>]</td></tr><tr valign="top"><td><bold>12.</bold></td><td>South Africa</td><td char="." align="char">2009</td><td>2006 - 2007</td><td>A B C D E F G - 1st H</td><td>To explore knowledge, attitudes and opinions of health care providers’ attitude to abortion</td><td>34 health care providers</td><td>In-depth interviews and one focus group discussion</td><td>HARRIES, J. et al. [<xref ref-type="bibr" rid="CR53">53</xref>]</td></tr><tr valign="top"><td><bold>13.</bold></td><td>South Africa</td><td char="." align="char">2000</td><td>No Information</td><td>A B C D E F G - 1st</td><td>To study attitudes and beliefs about abortion among nurses</td><td>24 male and 114 female nurses In total 138</td><td>Self administered questionnaire</td><td>HARRISON, A., et al. [<xref ref-type="bibr" rid="CR36">36</xref>]</td></tr><tr valign="top"><td><bold>14.</bold></td><td>Zimbabwe</td><td char="." align="char">1999</td><td>No Information</td><td>A B D E H</td><td>To determinate the attitudes of professional health workers to medically supervised abortion</td><td>196 doctors, 1 053 nurses In total 1249</td><td>Self administered anonymous questionnaire</td><td>KASULE, J., et al. [<xref ref-type="bibr" rid="CR37">37</xref>]</td></tr><tr valign="top"><td><bold>15.</bold></td><td>Kenya</td><td char="." align="char">1992</td><td>April 1991</td><td>A</td><td>To determine nurses’ knowledge and attitudes towards abortion</td><td>218 nurses</td><td>Self-administered questionnaire</td><td>KIDULA, N. A., et al. [<xref ref-type="bibr" rid="CR38">38</xref>]</td></tr><tr valign="top"><td><bold>16.</bold></td><td>Vietnam</td><td char="." align="char">2006</td><td>March – April 2002</td><td>A B C D E F G</td><td>To explore the midwives’ perspectives on adolescent sexuality and abortion, and what they consider to be quality abortion care</td><td>40 Midwives; 28 doctors In total 68</td><td>Observations and focus-group discussions (FGD)</td><td>KLINGBERG-ALLVIN, M., et al. [<xref ref-type="bibr" rid="CR54">54</xref>]</td></tr><tr valign="top"><td><bold>17.</bold></td><td>Vietnam</td><td char="." align="char">2007</td><td char="." align="char">2003</td><td>A B C D E F G H</td><td>To investigate midwifery students’ values and attitudes towards adolescent sexuality, abortion and contraception</td><td>235 midwifery students</td><td>Quantitative survey complemented with 18 qualitative interviews</td><td>KLINGBERG-ALLVIN, M., et al. [<xref ref-type="bibr" rid="CR55">55</xref>]</td></tr><tr valign="top"><td><bold>18.</bold></td><td>South Africa</td><td char="." align="char">2005</td><td>No Information</td><td>A B C D E F G - 1st H</td><td>To explore the lived experience of midwives who assist with TOP</td><td>3 nurses</td><td>In-depth interviews</td><td>MAYERS, P.M. et al. [<xref ref-type="bibr" rid="CR28">28</xref>]</td></tr><tr valign="top"><td><bold>19.</bold></td><td>Swaziland</td><td char="." align="char">2008</td><td>January – March 2005</td><td>A B C D E H</td><td>To explore health workers’ perceptions of adolescent SRH services in Swaziland</td><td>56 midwives</td><td>Self-administered questionnaire</td><td>MNGADI, P. T., et al. [<xref ref-type="bibr" rid="CR39">39</xref>]</td></tr><tr valign="top"><td><bold>20.</bold></td><td>South Africa</td><td char="." align="char">2008</td><td>No information</td><td>A B C D E F G 1<sup>s t</sup>H</td><td>To investigate professional nurses’ attitudes towards abortion care</td><td>25 nurses</td><td>Questionnaire</td><td>MOKGETHI, N. E. et al. [<xref ref-type="bibr" rid="CR40">40</xref>]</td></tr><tr valign="top"><td><bold>21.</bold></td><td>Ghana</td><td char="." align="char">2007</td><td>August 2003</td><td>A B C D E H</td><td>To assess physician’s knowledge and attitude towards abortion</td><td>74 physicians</td><td>Self-administered questionnaire</td><td>MORHE, E.S. et al. [<xref ref-type="bibr" rid="CR41">41</xref>]</td></tr><tr valign="top"><td><bold>22.</bold></td><td>Nigeria</td><td char="." align="char">2005</td><td>No information</td><td>A</td><td>To investigate the attitudes and practices of physicians towards abortion</td><td>232 private practitioners</td><td>Structured questionnaire</td><td>OKONOFUA, F. E. et al. [<xref ref-type="bibr" rid="CR42">42</xref>]</td></tr><tr valign="top"><td><bold>23.</bold></td><td>Nigeria</td><td char="." align="char">2011</td><td>No information</td><td>A</td><td>To assess the attitudes of staff at reproductive health services</td><td>136 senior practitioners</td><td>Questionnaire</td><td>OMO-AGHOJA, L.O. et al. [<xref ref-type="bibr" rid="CR43">43</xref>]</td></tr><tr valign="top"><td><bold>24.</bold></td><td>Nigeria</td><td char="." align="char">2009</td><td>27 December 2005 to 25 March 2006</td><td>A</td><td>To understand PAC services provided by private medical practitioners</td><td>96 private medical practitioners</td><td>Questionnaire</td><td>ONAH, H. E. et al. [<xref ref-type="bibr" rid="CR44">44</xref>]</td></tr><tr valign="top"><td><bold>25.</bold></td><td>Uganda</td><td char="." align="char">2014</td><td>February - March 2012</td><td>A</td><td>To explore physicians’ and midwives’ perceptions of PAC</td><td>10 Doctors and 17 Midwives In total 27</td><td>In-depth Interviews</td><td>PAUL, M., et al. [<xref ref-type="bibr" rid="CR29">29</xref>]</td></tr><tr valign="top"><td><bold>26.</bold></td><td>Ghana</td><td char="." align="char">2013</td><td>Fall 2009</td><td>A B C D E H</td><td>To explore the reasons women continue to die from unsafe abortion</td><td>4 Physicians</td><td>Open ended interviews and Focus-group discussion</td><td>PAYNE, M.C., et al. [<xref ref-type="bibr" rid="CR51">51</xref>]</td></tr><tr valign="top"><td><bold>27.</bold></td><td>Thailand</td><td char="." align="char">1986</td><td>1980 - 1981</td><td>A B C D E</td><td>To demonstrate health professionals’ attitudes toward abortion</td><td>625 Doctors, Nurses and social workers</td><td>Self-administered questionnaire</td><td>PHUAPRADIT, W., et al. [<xref ref-type="bibr" rid="CR45">45</xref>]</td></tr><tr valign="top"><td><bold>28.</bold></td><td>South Africa</td><td char="." align="char">1998</td><td>No information</td><td>A B C D E F G - 1st H</td><td>To explore and describe nurses’ experience of abortion</td><td>1200 nurses</td><td>Focus-group discussions, interviews and observations</td><td>POGGENPOEL, M., et al. [<xref ref-type="bibr" rid="CR56">56</xref>]</td></tr><tr valign="top"><td><bold>29.</bold></td><td>South Africa</td><td char="." align="char">2004</td><td>No information</td><td>A B C D E F G - 1st H</td><td>To compile a profile of the characteristics and/or beliefs held by nurses who choose to become abortion providers</td><td>22 nurses</td><td>Focus-group discussion and deep-interviews</td><td>POTGIETER, C [<xref ref-type="bibr" rid="CR57">57</xref>]</td></tr><tr valign="top"><td><bold>30.</bold></td><td>Ghana</td><td char="." align="char">2013</td><td>March – April 2008</td><td>A B C D E H</td><td>To understand pathways to induced abortion in Ghana and the role health care providers play</td><td>11 Family planning nurses and 8 obstetricians/gynaecologists In total 19</td><td>Focus-group discussion and in-depth interviews</td><td>SCHWANDT, H.M., et al. [<xref ref-type="bibr" rid="CR51">51</xref>]</td></tr><tr valign="top"><td><bold>31.</bold></td><td>Myanmar</td><td char="." align="char">2012</td><td>March – May 2011</td><td>A</td><td>To find out medical students’ knowledge of and attitudes toward abortion</td><td>1,060 Medical students</td><td>Questionnaire</td><td>TEY, N.P., et al. [<xref ref-type="bibr" rid="CR50">50</xref>]</td></tr><tr valign="top"><td><bold>32.</bold></td><td>Thailand</td><td char="." align="char">1977</td><td>No information</td><td>A B C D E</td><td>To evaluate the attitudes of medical students towards abortion</td><td>318 medical students</td><td>Questionnaires</td><td>VARAKAMIN, S. et al. [<xref ref-type="bibr" rid="CR46">46</xref>]</td></tr><tr valign="top"><td><bold>33.</bold></td><td>Ghana</td><td char="." align="char">2010</td><td>February 2007</td><td>A B C D E H</td><td>To assess the capacity and willingness of midwifery tutors to teach abortion care</td><td>74 Midwifery tutors</td><td>Structured questionnaire</td><td>VOETAGBE, G. et al. [<xref ref-type="bibr" rid="CR47">47</xref>]</td></tr><tr valign="top"><td><bold>34.</bold></td><td>South Africa</td><td char="." align="char">1995</td><td>No information</td><td>A B C D E F G - 1st H</td><td>To explore the understandings and responses of nurses towards abortion</td><td>35 Primary Health Care Nurses</td><td>Observations and interviews</td><td>WALKER, L. [<xref ref-type="bibr" rid="CR58">58</xref>]</td></tr><tr valign="top"><td><bold>35.</bold></td><td>Kenya and Zambia</td><td char="." align="char">2006</td><td>Sept. – Dec. 2001</td><td>Kenya A Zambia A B C E F</td><td>To investigate attitudes among Kenyan and Zambian nurse-midwives toward adolescent SRH problems, in order to improve services for adolescents.</td><td>322 Nurses from Kenya 385 Nurses from Zambia In total 707 Nurses</td><td>Questionnaires</td><td>WARENIUS, L. U., et al. [<xref ref-type="bibr" rid="CR48">48</xref>]</td></tr><tr valign="top"><td><bold>36.</bold></td><td>South Africa</td><td char="." align="char">2012</td><td>2005 - 2007</td><td>A B C D E F G - 1st H</td><td>To assess attitudes about abortion provision and future practice intentions of medical students</td><td>1308 medical students</td><td>Self-administered questionnaire</td><td>WHEELER, S.B. et al. [<xref ref-type="bibr" rid="CR49">49</xref>]</td></tr></tbody></table><table-wrap-foot><p>A = To protect woman’s life D = Rape G = On request 1st - First trimester only.</p><p>B = Physical health E = Foetal defects H = Incest.</p><p>C = Mental health F = Socio-economic factors.</p><p>+ = Abortion permitted on additional enumerated grounds relating to such factors as the woman’s age or capacity to care for a child.</p><p>*Source: CENTER FOR REPRODUCTIVE RIGHTS (2009) World Abortion Laws 2009 Fact Sheet.</p><p><ext-link ext-link-type="uri" xlink:href="http://reproductiverights.org/sites/crr.civicactions.net/files/documents/pub_fac_abortionlaws2009_WEB.pdf">http://reproductiverights.org/sites/crr.civicactions.net/files/documents/pub_fac_abortionlaws2009_WEB.pdf</ext-link>.</p></table-wrap-foot></table-wrap></p><p>According to the World Bank’s analytical income categories [<xref ref-type="bibr" rid="CR23">23</xref>], the studies were conducted in one upper middle-income country, seven lower middle-income countries and five low-income countries.</p><p>Seven of the studies [<xref ref-type="bibr" rid="CR24">24</xref>-<xref ref-type="bibr" rid="CR30">30</xref>] used in-depth interviews as the method of data collection, one study used a phenomenological approach to interviews [<xref ref-type="bibr" rid="CR31">31</xref>], and 19 of the studies used self-completed questionnaires [<xref ref-type="bibr" rid="CR32">32</xref>-<xref ref-type="bibr" rid="CR50">50</xref>]. Nine of the studies [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR51">51</xref>-<xref ref-type="bibr" rid="CR58">58</xref>] had used more than one data collection method, such as surveys, observations, focus group discussions and in-depth-interviews.</p><p>The health care providers’ attitudes towards induced abortions were classified into nine key descriptive themes: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence, 8) quality of care and 9) stigma and victimisation. These nine key descriptive themes were collapsed into five analytical themes based on their content.</p></sec><sec id="Sec10"><title>Human rights and quality of life</title><p>The synthesis revealed that health care providers, in general, were uncertain about the legal status of abortion in their countries [<xref ref-type="bibr" rid="CR24">24</xref>-<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR32">32</xref>,<xref ref-type="bibr" rid="CR37">37</xref>,<xref ref-type="bibr" rid="CR41">41</xref>,<xref ref-type="bibr" rid="CR43">43</xref>,<xref ref-type="bibr" rid="CR47">47</xref>,<xref ref-type="bibr" rid="CR53">53</xref>]. Some health care providers considered induced abortion as a significant public health problem and perceived the legalisation of abortion as a positive step because, otherwise, women would opt for an unsafe abortion, risking their lives [<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR29">29</xref>-<xref ref-type="bibr" rid="CR32">32</xref>,<xref ref-type="bibr" rid="CR37">37</xref>,<xref ref-type="bibr" rid="CR47">47</xref>,<xref ref-type="bibr" rid="CR49">49</xref>,<xref ref-type="bibr" rid="CR57">57</xref>]. However, nurses and midwives from South Africa, which has a more liberal abortion law, concluded that if women had the right to make choices regarding the termination of their pregnancy, health personnel should have the right to choose whether to work in abortion clinics [<xref ref-type="bibr" rid="CR27">27</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR53">53</xref>,<xref ref-type="bibr" rid="CR56">56</xref>].</p><p>The health care personnel who participated in the studies conducted in South Africa and Vietnam considered that an increase in urbanisation and improvements in access to education had changed the context of sexual and reproductive behaviour [<xref ref-type="bibr" rid="CR27">27</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR53">53</xref>,<xref ref-type="bibr" rid="CR54">54</xref>]. As a result, they believed that women and adolescents were in need of sexual and reproductive health information, including family planning, to prevent unwanted pregnancies and induced abortions [<xref ref-type="bibr" rid="CR27">27</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR53">53</xref>,<xref ref-type="bibr" rid="CR54">54</xref>].</p><p>According to the results, the majority of health care providers were supportive of abortions in cases where the pregnancy was due to rape or incest, severe genetic disorders were present, or it was necessary to save the life of the woman [<xref ref-type="bibr" rid="CR24">24</xref>,<xref ref-type="bibr" rid="CR26">26</xref>-<xref ref-type="bibr" rid="CR30">30</xref>,<xref ref-type="bibr" rid="CR35">35</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR38">38</xref>,<xref ref-type="bibr" rid="CR40">40</xref>,<xref ref-type="bibr" rid="CR45">45</xref>,<xref ref-type="bibr" rid="CR46">46</xref>,<xref ref-type="bibr" rid="CR49">49</xref>,<xref ref-type="bibr" rid="CR53">53</xref>]. Only one study included in this literature review explored nurses’ attitudes towards abortions among women living with HIV/AIDS [<xref ref-type="bibr" rid="CR40">40</xref>]. In this South African study, the respondents suggested that these women should have access to abortion services.</p><p>Regardless of the liberal abortion laws in South Africa, the nurses and midwives stated that the foetus should also have rights [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR40">40</xref>]. They asserted that national hospitals were established to save lives, not to eliminate them [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR40">40</xref>]. In addition, the nurses disapproved of childless women having an abortion [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR40">40</xref>].</p><p>A South African study revealed that nurses who had been trained in abortion care considered a woman’s access to an induced abortion as a human right [<xref ref-type="bibr" rid="CR57">57</xref>]. They felt that their training would enable them to reduce the maternal mortality and morbidity caused by unsafe abortions [<xref ref-type="bibr" rid="CR57">57</xref>]. A recent study among medical students in South Africa found that 70 per cent of the respondents believed that it is the right of the woman to decide whether to have an abortion [<xref ref-type="bibr" rid="CR49">49</xref>]. In one study from Ghana, it was found that human rights arguments were used both for and against abortion care [<xref ref-type="bibr" rid="CR30">30</xref>].</p></sec><sec id="Sec11"><title>Gender, stigma and victimisation</title><p>In three of the studies, the nurses and midwives stated that women should give birth and care for their children and expressed the view that induced abortion was ‘<italic>terminating motherhood</italic>’ [<xref ref-type="bibr" rid="CR17">17</xref>,<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR28">28</xref>]. In the same studies, these nurses and midwives considered that women who choose an abortion denied their role as mothers and thus rejected their identity as women.</p><p>Three studies conducted in Southeast Asia (Indonesia and Thailand) reported differences between the sexes regarding attitudes towards induced abortion, with female health care providers apparently having more conservative attitudes than male personnel [<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR45">45</xref>,<xref ref-type="bibr" rid="CR46">46</xref>]. Only one study from Thailand reported differences in attitudes towards abortion in relation to the respondent’s age [<xref ref-type="bibr" rid="CR45">45</xref>]. This study suggested that the attitudes of younger nurses towards abortions were more liberal than those of older nurses.</p><p>In several studies, abortion providers mentioned they were perceived by their colleagues as murderers or ‘<italic>baby killers’</italic> [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR25">25</xref>,<xref ref-type="bibr" rid="CR28">28</xref>,<xref ref-type="bibr" rid="CR33">33</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR40">40</xref>,<xref ref-type="bibr" rid="CR54">54</xref>,<xref ref-type="bibr" rid="CR56">56</xref>-<xref ref-type="bibr" rid="CR58">58</xref>]. In two studies from South Africa, the providers considered that an abortion was a threat to the community, an act of disgrace and a waste of taxpayers’ money [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR58">58</xref>].</p><p>However, some nurses from South Africa indicated that they would assist a woman who suffered complications following an unsafe abortion. They considered that the stigma associated with the induced abortion would be attached to the individual who performed the abortion procedure, rather than the nurse who was only fulfilling her professional duty in saving a woman’s life [<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR56">56</xref>]. At the same time, they verbalised that they had chosen nursing because they wanted to preserve life and promote health, not act as murderers [<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR56">56</xref>]. Gynaecologists and general practitioners participating in an Indonesian study articulated that the life of a foetus commences after 120 days of pregnancy [<xref ref-type="bibr" rid="CR26">26</xref>]. Therefore, they did not consider ‘<italic>menstrual regulation’</italic> as a form of abortion, and it was thus widely accepted [<xref ref-type="bibr" rid="CR26">26</xref>].</p><p>In both sub-Saharan Africa and Southeast Asia, the health care providers experienced personal conflicts, stigmatisation and victimisation because of the negative attitudes of family, community, fellow health care workers and policymakers [<xref ref-type="bibr" rid="CR18">18</xref>,<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR28">28</xref>-<xref ref-type="bibr" rid="CR30">30</xref>,<xref ref-type="bibr" rid="CR40">40</xref>,<xref ref-type="bibr" rid="CR51">51</xref>,<xref ref-type="bibr" rid="CR52">52</xref>]. Colleagues and friends rejected them and voiced negative comments, for example, calling them ‘<italic>killers</italic>’ [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR25">25</xref>,<xref ref-type="bibr" rid="CR27">27</xref>,<xref ref-type="bibr" rid="CR28">28</xref>,<xref ref-type="bibr" rid="CR40">40</xref>].</p><p>Moreover, the synthesis emphasised that nurses in Southeast Asia and South Africa strongly disapproved of pre-marital sex, although this was described as a modern trend among the young and unmarried [<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR39">39</xref>,<xref ref-type="bibr" rid="CR52">52</xref>,<xref ref-type="bibr" rid="CR54">54</xref>,<xref ref-type="bibr" rid="CR55">55</xref>]. Nevertheless, pregnancy outside of marriage was not accepted [<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR39">39</xref>,<xref ref-type="bibr" rid="CR54">54</xref>,<xref ref-type="bibr" rid="CR55">55</xref>]. Nurses in Vietnam considered that not having pre-marital sex was the best solution to reduce abortion rates among unmarried young women [<xref ref-type="bibr" rid="CR54">54</xref>,<xref ref-type="bibr" rid="CR55">55</xref>].</p></sec><sec id="Sec12"><title>Religion</title><p>Eighteen studies from sub-Saharan Africa and Southeast Asia identified religion as the most important factor influencing the attitudes of health care providers towards induced abortions. [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR24">24</xref>,<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR28">28</xref>,<xref ref-type="bibr" rid="CR30">30</xref>-<xref ref-type="bibr" rid="CR34">34</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR37">37</xref>,<xref ref-type="bibr" rid="CR40">40</xref>,<xref ref-type="bibr" rid="CR43">43</xref>,<xref ref-type="bibr" rid="CR44">44</xref>,<xref ref-type="bibr" rid="CR47">47</xref>,<xref ref-type="bibr" rid="CR56">56</xref>-<xref ref-type="bibr" rid="CR58">58</xref>]. The respondents in those studies believed that only God can decide between life and death and that abortion was a sin. However, in a recent study from South Africa, the nurses viewed abortions differently, depending on whether they were medical or surgical [<xref ref-type="bibr" rid="CR25">25</xref>]. They perceived that a medical abortion was in the hands of the woman and therefore the woman, not the nurse, had to answer to God for her actions [<xref ref-type="bibr" rid="CR25">25</xref>].</p></sec><sec id="Sec13"><title>Unpreparedness and ambivalence</title><p>In the majority of the studies, the health care providers and students revealed that they felt unqualified and unprepared for work in the area of induced abortions [<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR28">28</xref>,<xref ref-type="bibr" rid="CR29">29</xref>,<xref ref-type="bibr" rid="CR31">31</xref>,<xref ref-type="bibr" rid="CR34">34</xref>-<xref ref-type="bibr" rid="CR41">41</xref>,<xref ref-type="bibr" rid="CR44">44</xref>,<xref ref-type="bibr" rid="CR45">45</xref>,<xref ref-type="bibr" rid="CR47">47</xref>,<xref ref-type="bibr" rid="CR48">48</xref>,<xref ref-type="bibr" rid="CR50">50</xref>,<xref ref-type="bibr" rid="CR53">53</xref>-<xref ref-type="bibr" rid="CR58">58</xref>]. In addition, they reported a lack of standard care guidelines and support and highlighted the need for cognitive, emotional and spiritual support [<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR28">28</xref>,<xref ref-type="bibr" rid="CR31">31</xref>,<xref ref-type="bibr" rid="CR34">34</xref>-<xref ref-type="bibr" rid="CR41">41</xref>,<xref ref-type="bibr" rid="CR44">44</xref>,<xref ref-type="bibr" rid="CR45">45</xref>,<xref ref-type="bibr" rid="CR47">47</xref>,<xref ref-type="bibr" rid="CR48">48</xref>,<xref ref-type="bibr" rid="CR53">53</xref>-<xref ref-type="bibr" rid="CR58">58</xref>].</p><p>Nurses from South Africa considered abortion to be against the nurses’ professional code, which requires them to save lives [<xref ref-type="bibr" rid="CR36">36</xref>]. The nurses expressed ambivalence between their professional responsibilities and personal norms and values. They were angry with the patients who requested induced abortions, blaming them for destroying the nurse’s pledge to be a caregiver [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR28">28</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR56">56</xref>].</p></sec><sec id="Sec14"><title>Access and quality of care</title><p>In general, the nurses and midwives disliked being involved with abortion services, and they commonly reported hesitance in providing these services [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR28">28</xref>,<xref ref-type="bibr" rid="CR38">38</xref>,<xref ref-type="bibr" rid="CR40">40</xref>,<xref ref-type="bibr" rid="CR48">48</xref>,<xref ref-type="bibr" rid="CR53">53</xref>,<xref ref-type="bibr" rid="CR55">55</xref>,<xref ref-type="bibr" rid="CR56">56</xref>,<xref ref-type="bibr" rid="CR58">58</xref>]. Midwifery students from Vietnam revealed that the main reason for choosing midwifery as a profession was to care for women in labour and delivery, and hardly any of the students wanted to work in the area of abortion services [<xref ref-type="bibr" rid="CR55">55</xref>]. Similar attitudes were reported among physicians [<xref ref-type="bibr" rid="CR53">53</xref>]. Furthermore, managers in two studies from South Africa expressed difficulties when recruiting, retaining and scheduling health care providers for induced abortion procedures [<xref ref-type="bibr" rid="CR28">28</xref>,<xref ref-type="bibr" rid="CR53">53</xref>]. Three other studies from South Africa concluded that nurses’ resistance to providing abortion services was a powerful barrier against access safe abortion services, with nurses’ and midwives’ strong opposition to abortion affecting rural women in particular [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR25">25</xref>,<xref ref-type="bibr" rid="CR36">36</xref>].</p><p>Several studies from sub-Saharan Africa showed that nurses and midwives have judgmental attitudes towards abortion patients [<xref ref-type="bibr" rid="CR31">31</xref>,<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR40">40</xref>,<xref ref-type="bibr" rid="CR58">58</xref>]. In general, the nurses seemed to withdraw from the patients and ignored their responsibilities as caregivers [<xref ref-type="bibr" rid="CR16">16</xref>,<xref ref-type="bibr" rid="CR31">31</xref>,<xref ref-type="bibr" rid="CR39">39</xref>,<xref ref-type="bibr" rid="CR40">40</xref>,<xref ref-type="bibr" rid="CR54">54</xref>]. Furthermore, respondents from both sub-Saharan Africa and Southeast Asia said they could not provide holistic nursing care to women undergoing an induced abortion because they had negative feelings about the woman’s decision [<xref ref-type="bibr" rid="CR36">36</xref>,<xref ref-type="bibr" rid="CR55">55</xref>]. The nurses and midwives also recognised that these women received inadequate care due to the poor relationship between the nurse and the patient [<xref ref-type="bibr" rid="CR28">28</xref>,<xref ref-type="bibr" rid="CR39">39</xref>,<xref ref-type="bibr" rid="CR40">40</xref>,<xref ref-type="bibr" rid="CR55">55</xref>,<xref ref-type="bibr" rid="CR56">56</xref>].</p><p>On the other hand, a study by Cooper et al. [<xref ref-type="bibr" rid="CR25">25</xref>] gave a positive view on nurses’ and midwives’ attitudes towards abortion. In this study, the nurses expressed a strong interest in medical abortions. In other studies, health care providers, in general, preferred medical abortions, as these required minimal involvement on their part in the abortion process [<xref ref-type="bibr" rid="CR25">25</xref>,<xref ref-type="bibr" rid="CR27">27</xref>]. Furthermore, early termination of pregnancy (i.e. menstrual regulation) was more accepted among health care providers than second-trimester abortions [<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR27">27</xref>,<xref ref-type="bibr" rid="CR46">46</xref>].</p></sec></sec><sec id="Sec15" sec-type="discussion"><title>Discussion</title><sec id="Sec16"><title>Main findings</title><p>In total, 36 studies with qualitative or quantitative data from 15 different countries met the inclusion criteria. A thematic analysis of the data indicated that health care providers in sub-Saharan Africa and Southeast Asia have negative feelings about induced abortions.</p></sec><sec id="Sec17"><title>Strengths</title><p>To our knowledge, this is the first systematic review to evaluate health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The data are based on the individual participant’s perspective of induced abortions.</p></sec><sec id="Sec18"><title>Limitations</title><p>It is critical to note that the review is limited to 15 countries: 10 in sub-Saharan Africa and five in Southeast Asia. Although the key themes were common across most of the studies, we do not suggest that health care providers’ perceptions of and attitudes towards induced abortions will be homogenous in all countries in sub-Saharan Africa and Southeast Asia. Non of the studies that we reviewed measured the effect of health care providers’ perceptions of and attitudes towards induced abortions on access to safe, high-quality abortion care.</p><p>Further limitations of the review include the following: 1) 36 percent of the studies were from South Africa, making it difficult to generalise the findings to other populations or settings; 2) only one article reported provider attitudes in Ethiopia, which is the second largest country in sub-Saharan Africa and the abortion law was liberalized almost ten years ago and legal, induced abortion services have rolled out nationwide since then. Provider attitudes might be more positive toward abortion and abortion care in Ethiopia than in other countries in the region. 3) The method of data collection was different in each study, and the research question varied between the studies; 4) none of the studies used questions/statements in a Likert format when assessing the perceptions’ of or attitudes towards induced abortions, and they were thus not able to capture the intensity of the providers’ feelings about induced abortions, 5) most of the studies asked for provider’s opinions on induced abortions rather than directly measuring practice, 6) many studies did not consider other influencing factors, such as sex, age and further education or training, 7) the sample selection of the respondents differed according to the study, and 8) the articles were published during a long period (1977–2014), and attitudes towards abortions might have changed in the two regions during this time. Thus, caution is needed with regard to generalisation of the results.</p></sec><sec id="Sec19"><title>Interpretations</title><p>This systematic literature review demonstrated that health care providers in sub-Saharan Africa and Southeast Asia have conservative attitudes towards induced abortions. These attitudes were manifested in a judgmental approach towards women with unwanted pregnancies who requested an induced abortion. The health care providers described how these women were ignored and treated with a lack of respect.</p><p>In general, the participants viewed an induced abortion as ending a human life and considered it a mortal sin. Religious beliefs affected these views. However, many providers considered that menstrual regulation was acceptable and did not view it as an abortion. Likewise, nurses in South Africa perceived medical abortion as different from surgical abortion, with the former widely accepted as being in the hands of the women who had to answer to God for their actions, not the nurse. In cases where the pregnancy was due to rape or incest, the health care providers seemed to have more sympathy for the woman, and they did not blame the abortion on her not using contraceptives.</p><p>One important finding of this review was that some of the nurses and midwives considered that the expectation to provide an induced abortion conflicted with their professional duty to protect life, based on the Code of Ethics for Nurses. Many of the nurses cited this code and highlighted how it contradicted the provision of abortion care services and thus created feelings of guilt, ambivalence and anxiety among nurses.</p><p>Midwives mentioned that they were trained to assist women in labour and delivery, not to assist during the termination of a pregnancy. Both the “Essential Competencies for Basic Midwifery Practices 2010” and the new ICM model for the midwifery curriculum by the International Confederation of Midwives include abortion care and family planning services [<xref ref-type="bibr" rid="CR59">59</xref>,<xref ref-type="bibr" rid="CR60">60</xref>]. However, a striking finding in this review was that the nurses and midwives seemed to be unprepared to care for women with unwanted pregnancies.</p><p>The World Health Organization recommends task shifting, which is a practice of delegation, whereby certain tasks are distributed from physicians to nurses and midwives [<xref ref-type="bibr" rid="CR61">61</xref>]. In task shifting, the heath care workforce is used in a more efficient way, as the roles of health care workers are optimised [<xref ref-type="bibr" rid="CR61">61</xref>]. Studies conducted in South Africa, Vietnam and Nepal showed that the provision of abortion care by midlevel health care providers is as safe and effective as the abortion care provided by physicians [<xref ref-type="bibr" rid="CR62">62</xref>,<xref ref-type="bibr" rid="CR63">63</xref>]. However, task shifting might be challenging to implement if nurses and midwives are reluctant to provide abortion care. This review emphasises that health care providers, in general, and nurses and midwives, in particular, need values clarification and technical training in comprehensive abortion care before they can commit to the responsibility of providing quality abortion care.</p><p>Access to safe, legal induced abortion, postabortion care (which occurs after an unsafe abortion) and family planning is fundamental to reduce maternal mortality and morbidity related to unsafe abortions [<xref ref-type="bibr" rid="CR64">64</xref>,<xref ref-type="bibr" rid="CR65">65</xref>]. The conservative attitudes towards induced abortions among health care providers in sub-Saharan Africa and Southeast Asia might also affect access to post-abortion care and, consequently, post-abortion contraceptive counselling.</p><p>It is essential to highlight that the majority of the studies included in this review were conducted in South Africa, where it is known that many health care providers are conscientious objectors to the provision of safe abortions [<xref ref-type="bibr" rid="CR17">17</xref>,<xref ref-type="bibr" rid="CR66">66</xref>]. The refusal to assist in abortion services is frequently based on moral, religious, ethical or philosophical beliefs. As reported elsewhere, such conscientious objections to abortion provision are an abuse of women’s rights and potentially harmful to women’s health [<xref ref-type="bibr" rid="CR67">67</xref>]. A recent study from Ghana indicates that a favourable attitude toward abortion among health care providers’ is not associated with safe abortion provision. On the other hand, it was noticed that the odds of providing safe abortions lowers by 57 percent when the health care provider is Catholic in comparison to other religions. Furthermore, the same study found that providers’ confidence in their capability to offer safe abortion is fundamental [<xref ref-type="bibr" rid="CR68">68</xref>].</p><p>Abortion care providers need to be prepared, supported and assisted [<xref ref-type="bibr" rid="CR67">67</xref>,<xref ref-type="bibr" rid="CR68">68</xref>]. The ethical dilemmas of reproductive health care providers charged with providing abortion services require more attention in pre-service and in-service training programmes. The pre-graduation curricula for health care providers in sub-Saharan Africa and Southeast Asia should include training in comprehensive abortion care, such as technical skills, interpersonal skills, value clarification, and communication and counselling in family planning and abortion [<xref ref-type="bibr" rid="CR69">69</xref>]. Some researchers have argued that value clarification, together with supportive follow-up, may have a positive impact on health care workers’ attitudes [<xref ref-type="bibr" rid="CR70">70</xref>,<xref ref-type="bibr" rid="CR71">71</xref>].</p><p>The impact of health care providers’ attitudes on access to abortion care and the availability of quality abortion care, in addition to what extent value clarification can positively influence these attitudes, remains to be studied. Finally, strategies to decrease barriers to midwifery-led induced abortion and post-abortion care need to be evaluated to expand access to abortion care.</p><p>The findings of this review can be used to design interventions to increase women’s access to safe abortion care, post-abortion care and family planning services in specific regions.</p></sec></sec><sec id="Sec20" sec-type="conclusion"><title>Conclusions</title><p>This systematic literature review suggests that religious convictions, beliefs about professional roles and ethics and feelings of unpreparedness frequently give rise to dilemmas among health care providers responsible for the provision of abortion care in sub-Saharan Africa and Southeast Asia. Moral-, social- and gender-based reservations about induced abortions appear to influence health care providers’ perceptions of and attitudes towards induced abortions and, consequently, their relationship with the patient who wants an abortion. Political commitments and resources are needed to ensure that health care providers are trained to develop the competencies to enable them to perform safe, high-quality abortions and to advocate for abortion care.</p><p>Furthermore, this review found that health care providers considered menstrual regulation and medical abortion more acceptable than manual vacuum aspiration. Hence, stakeholders and policy planners urgently need to introduce these two abortion methods, especially in rural health districts, to improve access to abortion services and, consequently, reduce maternal morbidity and mortality due to unsafe abortions. The findings from this review have implications for policy makers and hospital managers when organising health care services. Introducing value clarification and training in abortion care and services might increase the availability and accessibility of quality abortion care.</p><sec id="Sec21"><title>Details of ethical approval</title><p>Ethical approval was not necessary because the literature review used secondary data from published articles.</p></sec></sec></body><back><fn-group><fn><p><bold>Competing interests</bold></p><p>The authors declare that they have no competing interests.</p></fn><fn><p><bold>Authors’ contributions</bold></p><p>MKA visualised the systematic literature review and, together with EF and KGD, secured funding for the same. URL conducted the literature search, reviewed the identified studies, extracted the data and synthesised the findings for the analysis. URL wrote the first draft of the article. 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