Abortion stigma in healthcare: physicians’ perspectives – BMC Medical Ethics

Report on Physician Attitudes Towards Abortion and Implications for Sustainable Development Goals

Executive Summary

This report analyzes the stigmatizing attitudes of physicians towards abortion, revealing a significant disconnect between cognitive acceptance and behavioral intent. While overall stigma scores were low, a substantial portion of physicians expressed unwillingness to perform the procedure and supported restrictive legal conditions. These findings present critical challenges to the achievement of several Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 4 (Quality Education). Key factors influencing these attitudes, including gender, legal perspectives, and support for conscientious objection, create structural barriers that undermine universal access to reproductive healthcare and perpetuate inequalities, directly conflicting with the 2030 Agenda for Sustainable Development.

Analysis of Physician Attitudes and Alignment with Sustainable Development Goals

Overall Stigma Levels and Implications for SDG 3

The study identified a low mean score (26.48 ± 9.06) on the Stigmatizing Attitudes, Beliefs, and Behaviors Scale Towards Abortion (STAS-SABAS) among the physician cohort. This low level of stigmatization is potentially attributable to the participants’ demographic profile as young, educated, and actively employed professionals. However, a critical finding reveals a gap between attitude and practice, which directly impacts SDG 3: Good Health and Well-being, specifically Target 3.7 concerning universal access to sexual and reproductive healthcare services.

• Cognitive vs. Behavioral Discrepancy: Despite low stigma scores, only 31.8% of participants indicated a willingness to perform an abortion.
• Support for Restrictions: Over half of the physicians believed abortion should be legally restricted to medical reasons.
• Barrier to SDG 3: This discrepancy suggests that while physicians may intellectually accept abortion as a medical service, personal, cultural, or ethical reservations prevent them from providing care. This reluctance acts as a significant barrier to ensuring safe and accessible abortion services, a cornerstone of reproductive health and SDG 3.

Gender Disparities in Stigmatization: A Challenge to SDG 5

A significant gender disparity was observed, with male physicians demonstrating significantly higher stigma scores than their female counterparts. This finding has profound implications for SDG 5: Gender Equality, as provider attitudes can perpetuate systemic barriers to women’s health and bodily autonomy.

• Male Physicians’ Attitudes: The study aligns with literature indicating that men often hold more restrictive views on abortion. Male physicians who supported conditional abortion access (only for medical reasons) had notably higher stigma scores.
• Female Physicians’ Perspectives: Female physicians may approach the issue with greater empathy and personal insight due to shared gender-related perspectives and reproductive health experiences, fostering a more patient-centered approach.
• Impact on Gender Equality: Higher stigma among male providers can undermine women’s access to essential healthcare, reinforcing gender inequality and challenging the fundamental principles of SDG 5, which call for the elimination of all forms of discrimination and ensuring universal access to reproductive rights.

Legal Perspectives, Knowledge Gaps, and the Role of SDG 4 and SDG 16

The report highlights a strong correlation between physicians’ legal views and their level of stigma, alongside a concerning lack of legal knowledge among a subset of participants. These issues intersect with SDG 4 (Quality Education) and SDG 16 (Peace, Justice and Strong Institutions).

• Stigma and Legal Views: Physicians who supported abortion on demand had significantly lower stigma scores, indicating that viewing abortion as an individual right rather than a conditional exception reduces stigmatization.
• Knowledge Deficit: Approximately 18% of physicians in Türkiye were unaware that abortion on demand is legal for pregnancies under 10 weeks. This knowledge gap points to deficiencies in medical education, undermining the goal of SDG 4 to ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.
• Institutional Failure: The lack of awareness among healthcare providers about the legal framework they operate within is a failure of institutional strength and justice, as outlined in SDG 16. Effective and accountable institutions rely on well-informed professionals to uphold the law and ensure citizens’ rights are protected.

Conscientious Objection as a Barrier to SDG 3 and SDG 10

The study found overwhelming support for the right to conscientious objection, with 85.3% of physicians endorsing it. This support was significantly correlated with higher stigma scores and presents a formidable obstacle to achieving SDG 3 (Good Health and Well-being) and SDG 10 (Reduced Inequalities).

• Perpetuating Structural Stigma: The widespread acceptance of conscientious objection allows abortion to be excluded from mainstream healthcare, limiting access and reinforcing stigma at both the institutional and individual levels.
• Undermining Health Access (SDG 3): While freedom of conscience is a recognized right, its application in healthcare must be balanced against the obligation to provide patients with access to legal and essential medical services. Unregulated conscientious objection can severely compromise access to safe abortion, jeopardizing patient health.
• Exacerbating Inequalities (SDG 10): The fragility of abortion services resulting from conscientious objection disproportionately affects marginalized populations, thereby increasing health disparities and contravening the core principle of SDG 10 to reduce inequality within and among countries.

Recommendations for Advancing SDGs in Reproductive Healthcare

1. Enhance Medical Education (SDG 4): Medical school curricula must be reformed to include comprehensive education on reproductive health law, patient rights, and stigma reduction techniques. This will equip future physicians with the knowledge and ethical framework needed to provide non-judgmental care.
2. Promote Gender-Transformative Policies (SDG 5): Implement training programs for all healthcare providers that address unconscious gender bias and promote empathy. Fostering a deeper understanding of the gendered dimensions of reproductive health is crucial for closing the attitudinal gap between male and female physicians.
3. Strengthen Health Systems (SDG 3 & 16): Develop and enforce clear institutional guidelines that regulate conscientious objection. These policies must ensure that a provider’s refusal to perform a service does not create a barrier to patient care, for instance, by mandating effective and timely referral systems. This strengthens institutions and guarantees access to care.
4. Foster Supportive Professional Environments (SDG 3 & 10): Create networks and support systems for physicians who provide abortion care to combat professional isolation and stigma. Ensuring that abortion provision is treated as an integral and respected component of healthcare will help normalize the service and ensure its equitable availability.

Methodological Considerations

The study’s findings are subject to certain limitations. The cross-sectional design prevents causal inference, and the use of self-reported data on a sensitive topic may be influenced by social desirability bias. However, the large sample size and the use of a culturally validated scale enhance the relevance of the findings within the specified healthcare context.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 3: Good Health and Well-being

   The article directly addresses health by focusing on abortion as a healthcare service. It discusses physicians’ attitudes, willingness to perform the procedure, and the impact of stigma on access to safe abortion care, which is a critical component of reproductive health and overall well-being.

2. SDG 5: Gender Equality

   The article connects to gender equality by examining differences in abortion stigma between male and female physicians. It highlights that men tend to have more stigmatizing attitudes and discusses how women’s reproductive health experiences may lead to greater empathy. The entire discussion is framed around access to a healthcare service predominantly required by women, making it a core issue of gender equality and reproductive rights.

3. SDG 4: Quality Education

   The article emphasizes the role of education in shaping attitudes and knowledge. It explicitly recommends that “medical school curricula should place greater emphasis on reproductive health and the legal framework surrounding abortion” to reduce stigma and correct misinformation, such as the finding that 18% of physicians were unaware of the legality of abortion in Türkiye. This points to the need for quality education for healthcare professionals.

4. SDG 16: Peace, Justice and Strong Institutions

   This goal is relevant through the discussion of legal frameworks, human rights, and conscientious objection. The article notes the tension between the right to conscientious objection (protected under international human rights law) and the obligation to provide non-discriminatory access to lawful medical services. It also points out a gap in the implementation of the law, as many physicians are unaware of the legal status of abortion, which undermines the rule of law and access to justice in healthcare.

2. What specific targets under those SDGs can be identified based on the article’s content?

• Target 3.7: Ensure universal access to sexual and reproductive health-care services.

  The article’s central theme is the barriers to abortion access created by stigma and physicians’ personal beliefs. The finding that “only 31.8% of participants indicated willingness to perform an abortion” directly relates to the availability and accessibility of reproductive healthcare services.

• Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights.

  The discussion on whether abortion should be legally available “on demand” versus “only for medical reasons” is a debate about reproductive rights. The article shows how stigma, particularly among male physicians, can impede women’s ability to exercise their right to make decisions about their own bodies and access necessary healthcare.

• Target 4.7: Ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including… human rights, gender equality…

  The article’s recommendation to enhance medical school curricula on reproductive health and its legal framework is a direct call to action for this target. It argues that such education “enhances students’ understanding of abortion as a fundamental aspect of women’s healthcare” and can reduce stigma, thereby promoting human rights and gender equality within the medical profession.

• Target 16.b: Promote and enforce non-discriminatory laws and policies for sustainable development.

  The article explores how conscientious objection can “limit access to person-centered care” and “be in tension with the obligation to provide equitable and non-discriminatory care.” This highlights the need for policies that balance individual provider rights with the enforcement of non-discriminatory access to legal healthcare services for all patients.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

• Stigma Level Among Healthcare Providers

  The article explicitly uses the “Stigmatizing Attitudes, Beliefs, and Behaviors Scale Towards Abortion (STAS-SABAS)” and reports a mean score of 26.48. This quantitative score can be used as a direct indicator to track changes in stigma over time, which is a key barrier to accessing care (relevant to Targets 3.7 and 5.6).

• Percentage of Physicians Willing to Provide Abortion Services

  The finding that “only 31.8% of participants indicated willingness to perform an abortion” serves as a clear, measurable indicator of the workforce available to provide these services. An increase in this percentage would indicate progress towards Target 3.7.

• Awareness of Legal Frameworks

  The article states that “approximately 18% of the study group was unaware of this legal provision [abortion on demand being legal].” This percentage is a specific indicator of the knowledge gap among professionals. A decrease in this percentage would measure the effectiveness of educational interventions as suggested for Target 4.7.

• Prevalence of Support for Conscientious Objection

  The statistic that “85.3% of physicians believed that there should be a right to conscientious objection regarding abortion” is an indicator of attitudes that can create structural barriers to care. Monitoring this belief and its impact on service availability is relevant for measuring progress toward non-discriminatory access under Target 16.b.

4. Table of SDGs, Targets, and Indicators

Source: bmcmedethics.biomedcentral.com