'Making abortion safe': abortion and post-abortion care providers' experiences of stigma in Rwanda, Zimbabwe, Sierra Leone and Nigeria

Background: Social stigma and the marginalisation of abortion care within medical settings can negatively affect abortion providers. While some research has evaluated stigma interventions in legally restrictive settings, little work has explored the experiences of healthcare professionals (HCPs) providing abortion and post-abortion care (PAC) outside the USA. This study, part of the Royal College of Obstetricians and Gynaecologists' 'Making Abortion Safe' programme, aimed to understand providers' experiences of abortion stigma in four African countries with restrictive legislation.

Methods: In-depth interviews with 44 abortion and PAC providers were conducted in Nigeria, Rwanda, Sierra Leone and Zimbabwe.

Results: Four themes emerged: personal and professional effects of stigma, multiple manifestations of stigma, driving forces of stigma, and positivity and resilience. Stigma affects providers' professional identity, community belonging and relationships. Restrictive legal frameworks are the main driver of abortion stigma, operating at multiple levels that reinforce each other. The legal status of abortion labels it as 'dirty work', conflicting with healthcare principles. Judgmental attitudes from other HCPs negatively impact providers' well-being and care quality. However, providers showed resilience through professional and personal commitment, and the belief in 'doing the right thing' helped them resist stigma.

Conclusions: Legal changes are crucial for increasing access and reducing stigma among the workforce. In these countries, providers face challenges in offering legal healthcare. Organisational interventions are needed to address stigmatising values and create positive workplaces. Ongoing support is essential for HCPs to remain resilient against abortion stigma, helping to normalise abortion care and those who provide it.