Clarifying Values and Transforming Attitudes to Improve Access to Second Trimester Abortion

Abstract

Access to safe second trimester abortion services is poor in many countries, sometimes despite liberal laws and policies. Addressing the myriad factors hindering access to safe abortion care requires a multi-pronged strategy. Workshops aimed at clarifying values are useful for addressing barriers to access stemming from misinformation, stigmatisation of women and providers, and negative attitudes and obstructionist behaviours. They engage health care providers and administrators, policymakers, community members and others in a process of self-examination with the goal of transforming abortion-related attitudes and behaviours in a direction supportive of women seeking abortion. This is especially important for women seeking second trimester abortion, which tends to be even more stigmatised than first trimester abortion. This paper reports on some promising experiences and results from workshops in Viet Nam, Nepal and South Africa. Some recommendations that emerge are that values clarification should be included in abortion training, service delivery and advocacy programmes. Evaluations of such interventions are also needed.

Résumé

Dans beaucoup de pays, l'accès aux services d'avortement du deuxième trimestre est médiocre, parfois en dépit de lois et de politiques libérales. Pour s'attaquer aux multiples facteurs qui entravent l'accès à des soins sécurisés, il faut appliquer une stratégie à plusieurs volets. Des ateliers destinés à clarifier les valeurs et transformer les attitudes sont utiles pour lever les obstacles créés par les idées fausses, la stigmatisation à l'égard des femmes et des prestataires de services et aussi par les attitudes négatives et les comportements obstructionnistes. Ils engagent les soignants et les administrateurs, les décideurs, les membres de la communauté et d'autres catégories dans un processus d'auto-examen qui a pour but de réorienter leurs attitudes et leurs comportements, de façon à soutenir les femmes qui souhaitent avorter. C'est particulièrement important pour celles qui veulent avorter au deuxième trimestre, car elles sont en général encore plus stigmatisées que celles qui le font au premier trimestre. Cet article décrit des expériences prometteuses et les résultats positifs d'ateliers au Viet Nam, au Népal et en Afrique du Sud. La clarification des valeurs devrait être incluse dans la formation à l'avortement, la prestation des services et les programmes de plaidoyer. Des évaluations de ces interventions sont également nécessaires.

Resumen

Muchos países carecen de acceso a servicios seguros de aborto en el segundo trimestre, a veces pese a leyes y políticas liberales. Para tratar los diversos factores que obstaculizan el acceso a los servicios de aborto seguro se necesita una estrategia de múltiples facetas. Los talleres de aclaración de valores y transformación de actitudes sirven para eliminar las barreras al acceso que surgen de información errónea, estigmatización de mujeres y prestadores de servicios, actitudes negativas y comportamientos obstruccionistas. En estos talleres, los administradores y prestadores de servicios de salud, formuladores de políticas, miembros de la comunidad y otros participan en un proceso de autoexamen con el objetivo de transformar sus actitudes y comportamientos respecto al aborto con el fin de brindar apoyo a las mujeres que buscan un aborto. Esto es de particular relevancia para aquéllas que necesitan servicios de aborto en el segundo trimestre, que tiende a ser aun más estigmatizado que el aborto en el primer trimestre. En este artículo se informa sobre experiencias y resultados prometedores de talleres en Vietnam, Nepal y Sudáfrica. Algunas recomendaciones que emergen son que la aclaración de valores debe incluirse en la capacitación, la prestación de servicios y los programas de promoción y defensa relacionados con el aborto. También es necesario evaluar dichas intervenciones.

Key Words:

• second trimester abortion
• values clarification
• attitude transformation
• Nepal
• South Africa
• Viet Nam

For various reasons, women sometimes do not seek or cannot obtain abortion care until after the first trimester of pregnancy, and in many countries – even those with relatively liberal abortion laws and policies – access to second trimester services is poor. As an international panel of health experts recently affirmed, ensuring women's access to safe, good quality, second trimester services is critical because such services will always be needed, despite efforts to improve access to comprehensive sex education, effective contraception, and first trimester abortion care.¹

While some health care policymakers, administrators and providers may support the provision of abortion care in certain circumstances, even in the second trimester, individual women often have a limited understanding of their right to services under current laws and policies, and face punitive attitudes and uneven provision of care.^2–4 Consequently, they may be subjected to unnecessary costs, delays leading to abortion later in pregnancy,⁵⁶ and/or unsafe abortion and its consequences. The women at greatest risk are typically the poorest and most vulnerable in society.⁷⁸ Governments, non-governmental organisations and other stakeholders must develop effective, multi-pronged strategies to address the factors hindering women's access to abortion care as early in their pregnancy as possible, including those caused by the facility, the clinician and other health workers, economics, commodities or the procedure itself.⁹ One increasingly important approach is the use of interventions based on values clarification principles, which engage people in the health sector, the community and other groups to address barriers stemming from misinformation, stigmatisation of women and providers, lack of respect for women's rights and obstructionist behaviours.

This article explains the basic principles of values clarification and their application in workshops on abortion, particularly second trimester services. Three country examples are provided of experiences running these workshops and related activities in Viet Nam, Nepal and South Africa. Finally, we discuss some of the lessons learned in these settings and recommend future directions for similar activities and evaluation of their impact.

Values clarification principles

Values clarification, which originated in the field of humanistic psychology, is both a theory and an intervention. The theory was inspired by thinkers such as Maslow and Rogers,¹⁰¹¹ who believed that people are responsible for discovering their values through a process of honest, open-minded self-examination. Values are closely related to and affected by beliefs, ideals and knowledge, and they affect attitudes and behaviours. They serve as an internal roadmap, playing a key role in the decisions people make, how people spend their time and energy, and how they act. According to Rokeach,¹² values clarification is the process of examining one's basic values and moral reasoning. It is done to understand oneself and discover what is important and meaningful.¹³ Raths, Harmin and Simon advanced the notion that values clarification involves three processes: choosing a value freely from alternatives, with an understanding of the positive and negative consequences of that choice; prizing that chosen value, as it is associated with some level of satisfaction, affirmation and confidence; and acting repeatedly on that value, which the individual believes will lead to outcomes they consider positive.¹⁴¹⁵

Traditional values clarification activities and interventions engage learners in a process of values determination and clarification without advocating an agenda or framing values in a specific social or health context. Some social and behavioural interventions have used the principles of values clarification in efforts to effect cognitive or behavioural change.^16–19 Some curricula and interventions also employ activities intended to transform attitudes and behavioural intentions, e.g. regarding provision of and access to safe abortion and other health care.^20–24

Abortion-related values clarification: examples from the literature

Values clarification activities are well-suited to the subject of abortion, given the opposition to or lack of awareness of women's need for and right to safe abortion care, and especially second trimester abortion. Curricula developed in the United States by the National Abortion Federation,²⁴ Association of Reproductive Health Professionals,²⁵ and others, have been used in workshops with various health professional groups, including physicians in family medicine residency programmes.²⁶ Planned Parenthood of South Africa conducted values clarification workshops with service providers and their findings suggest that attitudes and behaviours regarding abortion had shifted.²⁰ In Brazil, Catholics for a Free Choice won support for abortion care services among hospital staff, social workers, nurses, psychologists and physicians by using a values clarification intervention.²⁷

Such interventions have not always been well documented or evaluated, however. In fact, there is scant published literature on evaluations of successful strategies for changing attitudes and behaviours of health care providers or other stakeholders.²⁸²⁹ Although more rigorous research is needed, existing evidence supports the use of values clarification principles as a general strategy to improve attitudes and behaviours for various social and health issues and audiences.³⁰³¹ The World Health Organization recommends inclusion of values clarification in abortion training programmes for service providers.

“Programmes should use a variety of teaching and learning methodologies and should address both technical and clinical skills as well as attitudes and beliefs of the service provider. This may require a values clarification process which allows health providers to differentiate between their own values and the rights of the client to receive quality services.” ⁷

Ipas values clarification workshops on abortion

Over the past several years, Ipas^* has developed training materials based on a theoretical framework to help participants clarify their values and potentially transform their attitudes on abortion,³² and has facilitated and evaluated workshops in numerous countries using these activities.³³³⁴ We have recently begun using the term “values clarification and attitude transformation” rather than “values clarification” alone, because it captures our underlying aim of transforming abortion-related attitudes and behaviours to have a positive impact on whether and how services are delivered and encourage behavioural change supportive of safe abortion care. Our workshops are designed to move participants along a continuum away from resistance towards tolerance, acceptance and support, and ultimately, advocacy for comprehensive abortion and related sexual and reproductive health care and rights. Even movement from active opposition to less resistance or tolerance is considered positive change. These aims are presented in a transparent way to workshop participants (Box 1).³²

short-legendBox 1

Research has consistently demonstrated that beliefs, attitudes and norms are associated with behavioural intention, which in turn is what best predicts behaviour or performance,^14,35–37 including among health workers.³⁸³⁹ The hypothesis is that attitudes may be transformed through the values clarification process, which would then lead to changes in behavioural intentions and ultimately, behaviours.

Workshop models

Ipas' values clarification workshops on abortion are usually designed and facilitated by staff in cooperation with local consultants and partners. They may be stand-alone or added to abortion orientations, trainings, advocacy workshops, meetings with key stakeholders, professional meetings or other events. There may be anything from 10–50 participants or more, and activities may last for several hours or several days, depending on the objectives. The content can be focused on abortion in general or second trimester services specifically, and should be relevant and setting-specific. Activities are participatory and based on adult learning principles, with an emphasis on self-reflection, small group work, dialogue and application of new or reframed information to tailored scenarios and case studies that reflect local realities and needs. Facilitators aim to create a safe environment in which individuals engage in honest, open-minded and critical reflection.³² For interventions lasting one or more days, we conduct a pre- and post-assessment that measures knowledge, attitudes, comfort levels and intentions.³³³⁴ We are beginning routinely to follow up with a sample of participants to assess any changes in their attitudes and behaviour over time.

Who are the workshops for

Participants can include a range of stakeholders who influence provision and quality of second trimester abortion care, such as clinicians and other health care workers, health system officials, facility administrators, policymakers, lawyers, faith leaders, journalists, donors, women's groups and community advocates. The process can help to create a more enabling environment for abortion service provision. When participants are already supportive and motivated, sessions can be used to further improve attitudes and behavioural intentions, build solidarity, and explore issues that are typically thorny even among abortion supporters, such as public funding for abortion, parental consent for adolescents, or abortion for sex selection.

Health care providers are an important group to focus on because screening and selection of appropriate personnel for clinical training is essential. Ensuring availability of services and retention of abortion providers can be undermined by lack of administrative support, resource scarcity, staff turnover and transfers, and other factors; low motivation only worsen the situation. This is especially true for second trimester abortion, which is clinically more complex and time-consuming and often involves more stigma and emotional response. Because of this, there is a higher degree of investment in training competent second trimester abortion providers, compared with post-abortion care or first trimester abortion. Values clarification can help assess potential trainees' willingness and motivation and screen out those who are unsure or unlikely to want to provide services, ultimately saving resources, time and effort.

Sample activities

• Four corners

Participants anonymously circle one of four responses – strongly agree, agree, disagree, strongly disagree – on two parallel worksheets to indicate their beliefs regarding second trimester abortion services for women in general and then for themselves. Participants individually compare their responses between the two worksheets, identifying any discrepancies that might signal a double standard. For example, sometimes participants believe adolescents should not be able to have a second trimester abortion without parental consent, yet they would want to have those services available if faced with an unwanted pregnancy personally during adolescence.

The worksheets are collected and randomly redistributed among the participants. The four corners of the room are labelled according to the four response options. For a selected worksheet statement, participants are asked to stand in the corner corresponding to the answer circled on the worksheet they are holding. In each small group, participants discuss the most compelling argument for that perspective and then present their argument to the whole group. By forming and hearing arguments that may agree or conflict with their own beliefs, participants often clarify their values, gain empathy for different viewpoints, and rethink and sometimes transform their attitudes.

• The last abortion

Participants imagine that according to a fictitious country's new policy, only one more legal abortion will be permitted. In small groups, participants read descriptions of six women with difficult circumstances at different second trimester gestations who have requested this last abortion. They must decide which woman will be granted the procedure. The women's circumstances include a peri-menopausal woman already raising a son with profound disabilities whose pregnancy involves fetal anomalies; a student with irregular menstrual cycles and contraceptive failure who is the first from her village to attend university; a young, depressed woman with two young children, financially dependent on her abusive partner; an unemployed, alcoholic woman whose other children born with fetal alcohol syndrome are being raised by her mother; a poor, sick HIV-positive widow with two young children; and a distressed student evicted from her home after being raped by her stepfather. After each group presents their decision and rationale, participants reflect on how their assumptions, biases and preferences influenced their responses. The facilitator concludes that it is impossible to decide objectively who is or is not entitled to a safe abortion, and that no person has the right to decide for another. Participants are asked to consider the health implications when policymakers or providers restrict access to abortion services for certain women for whatever reasons. This activity helps participants recognise the importance of refraining from making assumptions or judgments about women seeking abortion care, whose circumstances can be difficult and complex.^{20, 32–34}

Interventions to improve access and quality

In the three examples of setting up or changing abortion services that follow, the impact of including values clarification activities, or not doing so, clearly emerges.

Viet Nam

Induced abortion is legally permitted in Viet Nam under a decades-old law;⁴⁰ roughly one-tenth of the estimated one million abortions performed annually occur in the second trimester. In a recent qualitative study of 60 Vietnamese women having second trimester abortions, most respondents had faced multiple delays or barriers to abortion care earlier in pregnancy: 80% reported lack of awareness of their pregnancy; one-fifth reported needing more time to make a decision and many cited structural barriers, such as service fees and difficulty obtaining leave.⁵ Additionally, there were concerns about quality of care. Dilatation and evacuation (D&E) was introduced in Viet Nam only recently. Previously, the only method available was an outdated, risky technique known as the Kovac's method.⁴¹⁴²

For the introduction of D&E, clinical protocols and service delivery guidelines were developed, and the demonstration hospital selected five highly skilled senior obstetrician–gynaecologists to be trained. These physicians were already proficient in first trimester techniques and were leaders in their departments.⁴² Unfortunately, the intervention did not include values clarification or another means of screening and determining the physicians' readiness to perform second trimester abortion, or address any concerns they might have. Shortly after the training, two of the five physicians stopped providing D&E. Probing revealed discomfort with second trimester abortion and concerns that it would bring “bad karma”.

Nepal

Abortion was decriminalised in Nepal in 2002. Abortion is now permitted on request through 12 weeks' gestation, and up to 18 weeks under certain conditions. Previously, abortion was one of the most common causes of maternal death.⁴³ Safe first trimester abortion services have become more widely available in recent years, yet access to safe second trimester abortion remains extremely limited as few providers have received clinical training for it. Health indications for abortion in the second trimester have not been clarified, and awareness of the legality of abortion is poor among women. (Indira Basnett, Ipas Project Director; Technical Committee for the Implementation of Comprehensive Abortion Care Services, Nepal, Personal communication, 25 September 2007).⁴⁴⁴⁵

In early 2007, the Ministry of Health and Ipas initiated plans to train senior physicians in second trimester abortion. Two months before the training, the TCIC organised a 1.5-day values clarification workshop for 22 clinicians, administrators and policymakers. The workshop was intended to garner support for second trimester services, prepare facility personnel for the introduction of these services, and screen potential second trimester providers for training.³⁴

Responses on matched pre- and post-workshop surveys indicated positive shifts. Mean scores increased on five of six measures of comfort level: comfort with working to increase availability of services, talking with closest friends and family about their work in second trimester services, performing the procedure, and why women need second versus first trimester procedures. There were similarly positive trends in mean scores on empathy for women needing services and belief that all women should have access to safe second trimester abortion services. Post-survey responses were also positive:

“This type of workshop is very effective for affirmation of own views/values/opinions and avoiding a conflict between personal belief and professional responsibilities. It is very important for service providers to have this kind of workshop.” ³⁴

After the workshop, TCIC was able to identify nine physicians as suitable for clinical training. Moreover, administrators from the selected sites voiced support for second trimester services. Several issues that could have posed barriers to second trimester service provision were identified in the workshop and policymakers started working to correct them; for example, there was confusion about the legality of second trimester care at various health system levels, more clarification was needed on the criteria for the mental health indication, and existing policy directives had not been disseminated widely. The benefits of the values clarification intervention exceeded the original goals, proactively affecting broader policy and service delivery issues. More than one year after the workshop and clinical training, all nine physicians have provided second trimester services. Three who have been transferred or moved to other facilities are establishing second trimester services there. Holding a values clarification workshop in preparation for clinical training and introduction of services has become the standard. The second values clarification workshop and clinical training on second trimester abortion were underway at this writing (Indira Basnett, Personal communication, 9 June 2008).

South Africa

In South Africa, despite liberalisation of the abortion law in 1996, access to safe, legal services remains inadequate. According to the Choice on Termination of Pregnancy Act, abortion is available on request in the first 12 weeks of pregnancy, and under certain circumstances thereafter.⁴⁶ According to the third report by the National Committee on Confidential Enquiry into Maternal Deaths 2002–2004, of deaths from pregnancy-related sepsis, 57.7% were considered to be avoidable within the health system. One of ten overall recommendations was to reduce the number of unsafe abortion deaths, and the strategies for this included regular values clarification workshops and expanding sites for second trimester terminations.⁴⁷ Second trimester abortions account for more than 20% of all terminations in South Africa. Although the overall incidence of abortion-related deaths have decreased dramatically since the law changed, all the abortion-related deaths in 2005 due to complications occurred in the second trimester.⁴⁸

Because of stigma, women have expressed reluctance to seek a termination in their own communities for fear of being recognised and ostracised.⁴⁹ Some women encounter rudeness, hostility, and judgmental attitudes from staff members and protestors at public facilities. Stories of moralising and attempts at dissuasion by facility personnel include quoting the Bible during a consultation. Long waiting periods are common in some locations, whereas in others, women have difficulty even locating a provider; inappropriate referrals are also an issue. Even some designated facilities have refused to provide services in the name of conscientious objection, even though it is an individual, not an institutional, right. Some nurses lack sufficient knowledge of patients' right to care under the law and the nurses' professional code.⁴⁶ Adding to these problems are the hostile reactions and harassment abortion providers encounter from their colleagues and communities.^22,50–52 All of these can lead to delays in women seeking care or being unable to access services until later gestations; these barriers can also push women to seek unsafe services outside designated health care facilities.

To address some of these issues, in 2002, Ipas held a series of 22 values clarification workshops at the request of provincial health officials. The focus was on abortion in general but also addressed second trimester services. Participating in these three-day workshops were individuals from six stakeholder groups with gate-keeping and service delivery roles: health facility managers, midwives, traditional healers, traditional leaders, members of faith-based organisations and municipal councillors. In follow-up interviews with 188 of the original 645 participants, 70% of respondents reported behavioural changes six months after the workshop, such as disseminating information about services, making incremental changes in quality of care, providing abortion counselling and petitioning local government for improved provision of services, and 93% reported increased compassion for women seeking abortion services and their providers. Knowledge was still somewhat lacking, however, concerning the circumstances under which second trimester abortion is legal.⁵⁰

Discussion and recommendations

Activities to clarify values and potentially transform attitudes can be integrated into pre-service and in-service training to ensure that providers are more aware of their feelings and beliefs about abortion and knowledgeable about their professional duties and responsibilities with respect to human rights, women's sexual and reproductive rights, relevant laws and policies, providers' rights and the limits of conscientious objection. This wider approach to training could lead to more empathetic abortion service delivery for women.²⁰⁵⁰ As illustrated in the Viet Nam and Nepal examples, values clarification can also be used as a screening tool to determine which providers are prepared to undergo specialised clinical training, including for second trimester abortion. Additionally, given providers' reports of stress and harassment and their desire for more support, values clarification can help to create a more enabling environment and strengthen coping mechanisms.^7,25,51,53

Programmatic experiences described here indicate that values clarification can have a positive impact on the attitudes and behaviours of a variety of stakeholders. To what extent values clarification can positively influence policy, service delivery, quality of care, access to services and community support for women seeking abortion and providers offering care remains to be studied. On the basis of our experience to date, however, we can confidently recommend values clarification and attitude transformation workshops as an important element in any strategy to fulfil women's right to safe, second trimester abortion.

Acknowledgements

Parts of this paper were adapted from a poster presentation at the 2006 American Public Health Association Annual Meeting; Kimberly Chapman Page's 2006 Values Clarification for Abortion Attitude Transformation: Developing the Global Toolkit [MA thesis]; and the 2008 Abortion Attitude Transformation: A Values Clarification Toolkit for Global Audiences by Katherine L Turner and Kimberly Chapman Page. We thank our colleagues, consultants and partner agencies in Nepal, South Africa and Viet Nam: Nepal Family Health Division, Nepal Technical Committee for the Implementation of Comprehensive Abortion Care, Ipas Nepal, South Africa National Department of Health, Limpopo Department of Health and Welfare, Ipas South Africa, Viet Nam Ministry of Health, Ipas Viet Nam, Will Alexander, Traci L Baird, Deborah Billings, Kimberly Chapman Page, Ellen MH Mitchell, Kym Register, Amanda Sissine, Kathryn Andersen Clark, Elese Stutts, Annie Hughes, and Cris Coren.

Notes

* Ipas, an international non-governmental organisation, works to protect women's health and advance women's sexual and reproductive rights, and to reduce abortion-related deaths and injuries.