Eligibility criteria.

In line with the research question, we searched for citations which focused on the experiences of those who have direct contact with people who access comprehensive abortion care services. We excluded studies that examined patients’ experience of abortion, technical aspects of abortion care, or providers’ experience of post-abortion care. Due to study constraints, we only included original research articles published in peer-reviewed journals in the English language, excluding all citations that did not meet this. We did not set restrictions for the year, country, or indication for abortion. From inception, we did not plan to conduct a detailed cross-cultural or temporal analysis of the providers’ experiences due to time constraints. For this reason, we chose to include studies regardless of year of publication, as we were interested in exploring providers’ experiences with the services at that time, rather than exploring how changes to the laws may affect their experiences.

Databases.

To identify articles, we conducted a systematic search in six electronic databases: CINAHL, the Cochrane Library, Embase, PsycInfo, PubMed, and Web of Science.

Search strategy.

We designed the search strategy for the electronic databases using the PCC framework (Population, Concept, and Context), as recommended by the Joanna Briggs Institute [12] (Table 1). In addition to searching for articles in the electronic databases, we searched for unidentified articles in the reference lists of studies that were deemed eligible for inclusion and hand-searched relevant journals.

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Table 1. PCC elements for the study selection criteria, including an added “exclusion” Boolean operator.

https://doi.org/10.1371/journal.pone.0303601.t001

Sub-theme 1—Within society.

The stigmatization of abortion care was evident within society. Many providers discussed how inappropriate laws placed on their work can negatively affect public perceptions of abortion care, though some shared good experiences with laws. Many also felt that the media took an often-unbalanced view of abortion care.

Laws governing abortion care. Many described restrictive laws which impacted their ability to provide care, such as state-mandated counselling in the USA [20, 58, 74], mandatory waiting periods in Uruguay [52], and a restriction on abortion medications in Rwanda and the USA [32, 42]. Of state-mandated counselling in North Carolina, the USA, a provider said, “It seems very clearly to be designed to shame women and guilt them out of deciding to have an abortion” [99]. Restrictive laws may also impose undue institutional barriers, such as increases on the time or number of staff required to provide care [58, 74, 75]. Working under restrictive laws also opens providers to the threat of criminalization for completing their job [42, 60, 75, 94, 125]. For these reasons, some stated that restrictive laws stigmatize abortion and can damage the rapport between patient and provider, negatively impacting the standard of care [20, 42, 58, 70, 74].

Providers also said that abortion laws can be ambiguous in their interpretation. Providers in Ethiopia, Ghana, Mexico, and the USA voiced concerns in how to apply the law when providing abortion upon request, for example, deciding who is allowed to provide care, what paperwork is required, and what documentation does the patient need to present [28, 31, 64, 72, 92]. Obstetricians in Ireland and the UK also discussed anxiety in having to decide whether certain fetal abnormalities would be legally recognized as sufficient grounds for an abortion, which may leave providers at risk of criminalization if they unknowingly misinterpret the law [43, 66, 114].

While most studies highlighted the negative impacts of inappropriate laws, some noted positive experiences with abortions laws. Providers in Argentina said that consulting with medical practitioners when writing the laws following liberalization helped to ensure they were appropriate [48], while providers in Bangladesh, Ethiopia, Nepal, and Uruguay noted that liberalizing abortion laws helped to reduce abortion stigma, which in turn reduced the numbers of unsafe abortions [28, 31, 52, 89].

Anti-abortion sentiments in the media. The media also highlighted negative sentiments on abortion care. Most providers in a study from the USA felt that the media rarely or never took a balanced view of abortion care [79], gynecologists working in Spain had been labelled as “aborteros (back-street abortionists)” who provide “unsafe” and “dangerous” procedures in the national media [53], and a midwife in the UK said that the media often present stories “about little fetuses hanging on for dear life, on the back of bins” [101]. Additionally, providers in Ireland and Mexico felt that the media were watching and waiting for a clinical error following liberalization in both nations [43, 92] and providers in India and the USA feared that clinical errors would become news headlines [51, 75].

Sub-theme 2—Within the community.

The stigmatization of abortion care was also evident within local communities. Many described experiences with anti-abortion sentiments both within their wider communities and with family and friends. In response to these, providers discussed the challenge of disclosing their work.

Anti-abortion sentiments in the community. Experiences with anti-abortion sentiments were common within the local community. Providers across many countries in Africa, Australia, Europe, and North and South America described their discomfort in being known as an “abortionist” in their communities [30, 39, 42, 52, 56, 59, 64, 79, 82, 84, 92], with some recalling times they have been called “assassins” [92], “murderers” [53, 63, 64], or “butchers” [103]. Some recalled discrimination, such as a nurse in Scotland who said that discussing their abortion work is often “a conversation stopper” [39]. Quantitatively, as high as 50% of providers in two USA-based studies said that they have been verbally threatened or attacked because of their involvement in abortion care [56, 79], compared to 15% from a study in Ireland [27].

The studies also highlight that the frequency of anti-abortion experiences may be higher in certain communities. Providers working in a politically liberal state in the USA viewed themselves as “lucky” compared to peers working in more conservative areas, believing that they experienced fewer protests and perceived most people to be supportive of abortion care [99]. This is supported by providers in more conversative US states who discussed the high levels of stigma they face [20, 22, 58, 74]. High levels of stigma were also observed in conservative countries such as Ghana, Ethiopia, and South Africa [35, 45, 49, 64, 82]. Similarly, providers in rural areas of Australia, Canada, and Uruguay saying that they are not afforded the anonymity available to their colleagues in urban areas and experience stigma more often [52, 59, 84, 86]. Providers also acknowledged that many religious organizations oppose abortion [36, 39, 49, 51, 64, 94]. Providers in the USA expressed frustration that anti-abortion advocates often ground their views in religious beliefs, thus erasing the compatibility between holding spiritual beliefs and supporting abortion care [60].

Anti-abortion sentiments from family and friends. Experiences with anti-abortion sentiments were also described in interactions with family and friends. Providers in South Africa and the USA noted that they do not feel comfortable talking about their work at home as their partners think that abortion is “distasteful” [99, 117], an obstetrician in the UK said that their partner does not want their friends to know about their work [66], and providers in Ethiopia and the USA said that some family members or friends would never speak to them again if they knew about their work [33, 49, 94]. Close friends can also be a source of stigma, as a GP in Australia said:

A few of my friends found it very difficult to deal with the thought of me doing [an abortion] and it took me a long time to actually tell them that I was doing it… they responded more negatively than I thought they would.

[59]

Hiding abortion work. In response to anti-abortion sentiments within the community, many described the challenge in deciding whether to share their involvement in abortion care. Choosing not to disclose abortion work may protect providers and their families from abortion stigma. A GP in an Australian study noted that they do not advertise the abortion services in their clinic in fear of community backlash [59], physicians in Canada said that they “fly under the radar” and “keep a low profile” to avoid discrimination [84], and nurses in South Africa and the USA said that disclosing their work could damage existing friendships and make it difficult to create new ones [45, 94]. Providers also may choose to avoid disclosing their work to avoid “danger talk,” e.g. sharing difficult experiences of their work which may further stigmatize or limit access to abortion care [25, 60, 94, 99].

Others highlighted benefits in discussing their work. Most providers in two studies from the USA said they did not hide their work because of widespread support among friends and family [33, 99], while providers in the UK and USA said that disclosing their work allows them to combat stigma and misconceived perceptions about care [33, 39, 99], as well as avoid relationships with those who oppose abortion and identify like-minded individuals [33, 94, 99]. Additionally, sharing their work can help maintain psychological consistency as providers don’t feel the need to hide their work despite supporting access to care [94]. Hearing how colleagues discuss how they disclose their work may encourage providers to share their own experiences [65].

Sub-theme 3—Within the workplace.

Finally, the stigmatization of abortion care was evidenced by experiences within the providers’ workplaces. These included negative experiences with their colleagues and the patients that access care. Despite this, many also highlighted positive experiences with their colleagues. Many also said that their services were inadequately resourced.

Negative experiences with colleagues. Like in the community, many providers noted experiences with anti-abortion sentiments from colleagues. Providers in Mexico, South Africa, the UK, and the USA said that some colleagues who did not support the abortion services created “hostile” work environments [39, 45, 63, 92, 100, 103, 106] and some labelled providers as “serial killers” [103] or “baby killers” [63, 88]. Other examples of anti-abortion sentiments included feelings of disapproval, rejection, and disrespect [43, 53, 56, 59, 78, 94, 103, 106], suspicion around complications [94], questioning of the providers skillset [56, 73], and rude interruptions during abortion consultations [45]. A nurse in Scotland elaborated on the experiences they face in the workplace:

Everybody knows terminations happen […] So I just wish it was a much more open, honest thing and that other staff would come and see we’re not evil, we’re not horrible and how much these patients need the support.

[39]

As in the community, some chose to hide aspects of their work from their colleagues. This may be choosing not to tell people that they provide care [49] or with-holding certain aspects of care, like the fetal remains jar [94] or their own emotional reactions [45]. Providers may also hide aspects of their own lives from colleagues, such as their spirituality in fear that they will be questioned on why they provide care [60]. Others may choose to reduce the number of patients they see or avoid providing care at all in fear of stigma and retaliation from colleagues [100].

While most supported their colleagues’ right to conscientiously object from providing abortion care based on moral or ethical grounds, many felt that unclear “opt-out” procedures mean that staff who did not hold these objections refused to partake [37, 43, 92, 106]. They noted that high rates of conscientious objection can leave a small staff dealing with all abortion cases on top of their designated duties [24, 29, 34, 39, 43, 44, 52, 63, 66, 72, 78, 86, 92, 103, 104, 119]. There may also be little appreciation or renumeration for these additional duties [34, 43, 63, 92, 106]. Providers in Ireland, South Africa, the UK, and the USA said that procedures often need to be planned around those unwilling to participate [39, 43, 63, 100], while providers in community-based practice in Australia, Canada, and the USA said that high rates of conscientious objection creates issues when trying to organize external services, such as access to anesthesia, ultrasound, counselling, or a local pharmacy willing to dispense medication [32, 59, 84, 86]. In addition, some may “conscientiously obstruct” abortion by preventing women timely access to care [43, 53, 63].

Anti-abortion sentiments and high rates of conscientious objection left some feeling isolated, with nurses and midwives in South Africa and the USA feeling”trapped” in abortion care [63, 72, 73, 117], while obstetricians in Ireland said they had to run the services on their own [43]. Providers can also be isolated from one another. For example, providers in Ethiopia could not connect with colleagues as they felt unable to discuss their work due to stigma [49], while physicians in rural Australia, Canada, and the USA said that they lacked opportunities to connect with other providers [20, 22, 59, 84].

Positive experiences with colleagues. Many providers also discussed experiences with supportive colleagues, with one in the USA sharing that “the most sustaining thing is probably the other people I work with. Because working in abortion, it draws really good people” [99]. Providers highlighted the importance of being able to “vent” on the”dangerous feelings” and “suffocating issues” of abortion care and to have someone to “bounce things off” without fear of judgment [24, 25, 43, 45, 60, 61, 65, 94, 99, 101, 104, 115, 116, 121, 123], and colleagues who share similar experiences were identified as crucial [43, 61, 65, 101, 109, 113, 117]. Emotional support can occur through informal conversations between peers or through formal meetings with a peer group or a counsellor [24, 45, 60, 61, 65, 96, 99, 101, 103, 104, 109, 115, 117, 121, 123]. Despite this, however, some believed that access to peer support groups [81, 109, 115, 123], a non-biased psychologist or counsellor [45, 46, 61, 103, 109], and regular debriefing meetings [77, 103, 109, 121] were lacking. Attending local or national professional meetings may also help foster connections among staff [43, 84, 99]. Research on collegial support interventions, such as the Provider’s Share Workshop, has also shown promising results in fostering connections between staff [60, 65, 94].

Colleagues can also offer support in the technical or procedural aspects of care. Providers in Canada, France, Ireland, Italy, and South Africa highlighted the importance of multi-disciplinary debriefings on technically or emotionally challenging aspects of care [20, 43, 45, 61, 71, 81, 103, 109, 121], while physicians in Canada and the USA discussed the importance of being able to attend continuing professional development and education events [20, 84]. As previously highlighted, where laws are ambiguous, obstetricians in Ireland and the UK highlighted the importance of being able to consult with colleagues on whether a fetal condition is compatible with the legal requirements [43, 66, 114].

Some also highlighted the benefits of working with an experienced colleague [59, 73, 112]. Nurses in the USA said that experienced colleagues can help new providers develop empathy [73], while providers in Ghana said that experienced mentors could validate the concerns of newer providers and give advice [35]. Mentors may also be a source of emotional support. Experienced providers in Canada and the UK said they teach new providers strategies to deal with the difficult parts of care [81, 122], while nurses who worked as both providers and facility managers in South Africa said that they “strive to make [their] co-workers feel at ease. I make them feel comfortable. We support each other" [45].

Anti-abortion sentiments from patients. Some also noted anti-abortion sentiments from patients. These experiences may be indirect, such as patients in the UK and USA surprisedly saying “you’re so nice here” and "I wasn’t expecting people to be as nice as they were" [39, 99, 101]. Others may be more direct. Providers in separate studies from the USA said that patients sometimes express pro-life sentiments [94] or call the medical team “killers” when accessing care [60], while nurses and obstetricians in South Africa noted that some patients pressure them to provide care despite being over the legal gestation [45, 119]. Providers in the USA said that patients in a “very difficult place” may take their anger out on clinic workers and highlighted the importance of “letting it go” and not taking hostility from patients “personally” [111], while a doctor in the UK believed that “the stigma [means] they think that the staff are going to be horrible to them” [39].

Under-resourced services. Issues relating the human resources included a lack of staff willing to participate [22, 34, 41, 45, 63, 71, 78, 81, 88, 92, 98, 103, 106]. As previously noted, this may leave a minority of staff supporting the services and providers may be forced to take on an additional workload. Further, providers in Ghana, Italy, Mexico, Spain, and the USA highlighted the need for more providers to be trained in technical aspects such as surgical procedures or pain relief [42, 52–54, 64, 72, 88, 92, 115]. Providers in Mexico and South Africa said that more providers would allow the abortion workload to be shared [92, 103], while midwives in Italy and nurses in the USA said that providers should always work with a supportive colleague [71, 73].

In addition to human resources, providers across many studies noted the irregular supply of necessary equipment, such as instruments for vacuum aspiration [41, 63, 64, 78, 82, 92, 103], and medications and anesthetics [57, 63, 92, 115]. Providers in Canada, Nepal, South Africa, and the USA also noted that the space allocated for abortion care was often inappropriate [31, 41, 45, 57, 63, 72, 88, 89, 106, 115], while providers in Australia, Canada and Mexico said that it was difficult to secure rooms at all [59, 84, 92]. Providers also noted that it can be difficult to build a career in abortion care. Nurses in the USA said that opportunities to observe and participate in abortion during their training were lacking [73], while GPs in Australia and physicians in rural Canada highlighted that an irregular workload with periods of inactivity could make it difficult to acquire and retain skills [59, 84]. Nurses in the USA highlighted the lack of “activities of legitimacy,” such as professional meetings and societies, within abortion care, which help to foster career development and staff retention [73].

Sub-theme 1—Providers’ views on abortion.

Most providers said that they supported the right to bodily autonomy and self-determination. Many said that these views were informed by experiences which evidenced the need for a safe, legal abortion service, such as providers in Bangladesh, Ethiopia, Nepal, South Africa, Switzerland, and the UK who said that by providing abortion, they are helping to reduce unsafe abortion, maternal mortality, and the occurrence of unwanted or abused children [28, 29, 31, 38, 49, 89, 90, 104, 118, 119]. Further, providers in the USA said that experiences within the workplace, such as hearing patients’ stories, force providers to constantly refine, reinforce, and potentially reshape their beliefs around abortion to become more supportive [47].

Many also perceived a sense of duty to provide access to abortion care, such as providers in Canada, Italy, the UK, and Uruguay who said that only the patient should be allowed to decide what is right for them [39, 52, 66, 71, 101, 104, 115]. Affirming their sense of duty, nurses and physicians in the USA referred to their work as a “calling” and a “passion” [58], a midwife in Japan said that "care during the delivery procedure is part of our professional responsibility… hence, I think that the midwife should play a part, even if this procedure means the end of a life” [85], and a doctor in Nepal said that abortion care “is a service to be given. We are the best persons to give them” [89]. A minority, however, felt that their work was in contradiction to their professional duty to preserve life. Midwives and nurses in Japan, Switzerland, Taiwan, and the UK said that their typical responsibilities saw the creation of life while their abortion work sounded the “the death knell” [69, 98, 101, 120], while doctors in South Africa said that “elective” abortions were contrary to their oath to “do no harm” [119].

Regardless of personal views, most saw their main responsibility as providing non-biased information and empathetic care to all patients. Exhibiting commitment to these skills, providers in the USA affirmed that their “role isn’t to second-guess or question [the patient’s] decision” but to “support that decision and to help women in choosing what method is best for them … without judgment or any negativity” [58], while a midwife in Italy said that "it is fundamental to be empathic with the woman … because some women really need psychological support" [71]. Providers noted that experience may aid the development of these skills, as a nurse in the UK explained, "I’ve been here long enough to judge how they’re feeling… it vibrates off you… I can usually always win them round, even if they’re not on my side at first" [62]. Experiences within the providers’ personal lives may also help in the development of these skills, with providers in South Africa, the UK, and the USA saying that experiences with pregnancy, parenthood, pregnancy loss, and abortion helped them to develop empathy [30, 47, 72, 99, 104, 123].

Sub-theme 2—Challenging aspects of abortion care.

Despite generally positive views on abortion, many said that they were morally challenged by certain aspects of care. These included experiences with the fetus, differences between surgical and medical methods, providing care for cases that are medically indicated versus those that are not, and select cases where providers believed that abortion is being used as a method of contraception.

The fetus. Many discussed how contact with the fetal remains is a difficult aspect of care. Midwives in Japan noted sadness, confusion, and guilt when handling the remains [98], while nurses in the UK described the experience as “undignified”, “horrible”, and “like a bereavement” [104]. Increasing gestational age at the time of abortion was also a significant challenge, as a nurse in South Africa explained:

"With first trimesters it is not so difficult or real, as the terminated pregnancy is more like a small blood clot or tissue but now with second trimesters… they have a human shape, something that we recognize and that suddenly makes it an awful lot more real"

[88].

Procedures in the second and third trimesters may also be more technically and emotionally demanding than in the first trimester, with midwives and nurses in the UK describing second trimester abortion due to fetal abnormalities as “going through the motions” of a normal delivery and how patients are often “so upset because it’s a perfectly formed little baby" [107]. The short difference in time between later-gestation abortions and premature deliveries can also present a challenge, as highlighted by a midwife in Sweden, “emotionally it is very hard … you save lives at 22–23 gestational weeks” [96]. At later-gestations, the fetus may show signs of life at delivery, which many described as deeply distressing and the most challenging part of their work [43, 50, 71, 77, 83, 88, 98, 104, 109, 114, 115, 117, 121].

Contact with the fetus coupled with increasing gestational age and signs of life forced many to reflect on the unborn’s right to life and their involvement in care [36, 46, 47, 50, 60, 62, 71, 85, 88, 98, 101, 104, 116, 117, 119, 120, 125]. Providers in Japan, Sweden, Taiwan, the UK, and the USA described strategies to reduce their moral discomfort, such as looking away or suppressing thoughts while handling the remains [60, 69, 77, 98, 101]. A provider in a study from the USA, however, believed it is important to acknowledge that abortion results in the loss of potential life and disagreed with prominent pro-choice discourse that the fetus is just “a clump of cells”:

You always see the pictures that anti-choice people protest with mangled fetuses and stuff. I had never really connected that to our work, so I was like, ‘wow, this actually is, at that point, a little fetus.’ Which is surprising to me, but it didn’t change the way I feel about abortion at all … if anything, it probably made me more prochoice somehow, because I think it’s really important to understand every aspect of abortion.

[25]

Medical vs surgical care. Many made distinctions between providing care using medical or surgical methods. Staff generally viewed medical abortion as less technically and emotionally challenging, with providers in Uruguay saying that medical abortion requires less training than surgical methods [52], while an obstetrician in the USA shared surprise in “how not emotional” medical abortion can be [54]. Some also said that medical procedures are less morally challenging, as providers play a less active role and may not need to be present during expulsion of the fetus [50, 52, 62]. By contrast, involvement in surgical procedures, such as vacuum aspiration, dilation and curettage, or dilation and evacuation, ensure that providers have physical contact with fetus and may feel responsible for ending the pregnancy [47, 52–54, 63]. Some described surgical procedures as more emotionally demanding, with some referring to them as “unpleasant”, “horrible”, “powerful”, and “traumatic” [53, 54, 63]. Surgical abortion, however, may be preferable in certain circumstances. Midwives and nurses in the USA and Wales said that surgical procedures at later-gestations are much faster than medical induction and that the use of general anesthesia reduces the emotional weight of the procedure for patients and providers [107, 116].

Value judgments about patients. Many also believed it was easier to provide care if they perceived a legitimate reason for the abortion, for example, FFA, to protect maternal health, or in cases of rape or incest. Many differentiated between these and so-called “elective” or “voluntary” abortions [23, 47, 53, 66, 71, 89, 95]. A midwife in Sweden expressed sorrow at the termination of healthy fetuses in contrast to women struggling with fertility issues [77], providers in Ethiopia found it more difficult to justify their involvement if the motivation for abortion was not “safeguarding the women’s health” [28, 29, 36], and a nurse in the USA said their colleagues are more empathetic “if they feel that the client … had no control over [the decision to end the pregnancy]” [72]. Abortion for non-lethal fetal abnormalities was also viewed negatively [71, 114, 115, 121], with midwives and obstetricians in France raising concerns over the place of disability in modern society [121].

Some also shared concerns that abortion can be used as a method of contraception, with repeat abortions and refusal of contraception being common examples. These were often referred to as “unnecessary” and less “acceptable” or “worthy” than medically indicated cases [26, 28, 47, 53, 68, 89, 91, 106, 117]. While these cases often evoked feelings of anger and frustration, some viewed them as a personal or systemic failure to provide effective education and access to contraception [26, 52, 68, 102]. A minority feared that discussing contraception during the abortion process could be judgmental or coercive [26, 68].

Sub-theme 3—Providers’ emotional responses.

Finally, providers highlighted the emotions they experience through their work. Many studies highlighted the difficult emotions related to abortion work, though many also highlighted positive emotions.

Difficult emotions in abortion work. Feelings of moral uncertainty were common and many providers in African, Asian, European, and North American studies expressed unease in the fact that abortion resulted in a loss of potential life. While supportive of patients’ right to access care, one nurse in the UK reflected on the unavoidable reality of abortion care, “I don’t particularly like the outcome, that is that you’re terminating all these fetuses” [62]. For many, moral doubts were a source of confusion, sadness, and guilt, with a midwife in Japan saying, “Why should this baby have life, but that baby cannot?… I don’t know what human destiny is… (I have this) growing sense of guilt" [98]. Some spoke about using prayer or reflection and evoked their religious moral norms of compassion and helping those in need to find comfort in the face of moral uncertainty, though this may be harder to do for “elective” procedures [36, 45, 47, 60, 82]. Others spoke about how they “switched off” during the procedure or while handling the fetal remains to protect themselves from moral doubts [97, 104, 111, 117]. Providers in a study from the USA, however, welcomed these challenges and reframed them as proof that they were still thoughtful and engaged with their work, with one physician saying that “I am more guarded about not feeling, I never want to not feel” [60].

Positive emotions in abortion work. Positive emotions encompassed pride, satisfaction, and happiness in providing care in an emotionally, physically, ethically, and morally challenging situation. A midwife in Italy said that "receiving thanks at the end of the process is something wonderful, as it means that a woman has been completely satisfied during her difficulties" [71], while nurses in the UK said that they take satisfaction in having “done a good job” in a “challenging situation” [104]. Providers in Nepal and the USA said that they take pride in their ability to care for patients and to make a positive impact on both their lives and society in general [58, 89], with a doctor in Nepal explaining, “I feel very happy… every day I think I have relieved a woman of her burden” [89]. In quantitative studies, most providers in two studies from the USA and one study from Ireland felt proud to be involved in abortion care [56, 79]. Reflecting on their abortion work, a physician in the USA said:

I like to get a big return on investment of my time and there are very few areas of medicine where one can spend fifteen minutes with a little skill, and a little passion, have such a dramatic impact on a patient, her family, and society at large. The good work that we do just ripples out in ever broadening circles.

[58]