The intersection of stigma, quality of care, and structural barriers: a qualitative study of interactions between abortion seekers and healthcare workers in Australia

Background: Abortion is common, safe, and necessary but remains stigmatized. Abortion stigma inhibits quality of care, but stigma and care quality are often examined separately. The aim was to identify the types of enacted stigma in the interactions between abortion seekers and healthcare workers, as well as the characteristics of high-quality non-stigmatizing interactions. Methods: This phenomenological qualitative study comprised in-depth interviews with people who sought abortion in Australia between March 2020 and November 2022. We recruited through social media and flyers placed in clinics. We examined the interactions between abortion seekers and healthcare workers, and structural barriers influencing interactions, from the perspective of abortion seekers. We conducted thematic analysis and developed typologies by analytically grouping together negative and positive experiences. Negative typologies show categories of stigmatizing interactions. Each positive typology aligns with a negative typology and represents a category of non-stigmatizing and high-quality interactions. Results: We interviewed 24 abortion seekers and developed five typologies of stigmatizing abortion care: creating barriers to access; judging abortion seekers; ignoring emotional and information needs; making assumptions; and minimizing interactions. The five positive typologies were: overcoming barriers; validating the abortion decision; responding to emotional and information needs; aligning care with preferences and intentions; and providing holistic services that ensure safety. Abortion experiences were influenced by structural factors including abortion regulations, rural health system constraints, and health system adaptations during the COVID-19 pandemic – all of which may influence interpersonal interactions in care. Conclusions: This study elucidates the interrelationship between stigma, quality of care, and structural barriers, and how these interact to impact abortion experiences. The negative typologies identify stigmatizing healthcare worker behaviors to be avoided, and the positive typologies model high-quality care. These can inform development of stigma-reduction training and approaches for quality improvement, with relevance for other maternal and reproductive health services. Stigma-reduction can incorporate a structural lens through engaging whole-of-service approaches, a focus on power and positionality, and illustrating how providers can reinforce, or overcome, structural stigma. Interventions should address the individual, service-level, and structural forms of stigma that shape the behavior of healthcare workers and contribute to poor experiences for abortion seekers.