Development of a conceptual model and survey instrument to measure conscientious objection to abortion provision

Background and Objective: Conscientious objection to abortion, clinicians’ refusal to perform legal abortions because of their religious or moral beliefs, has been the subject of increasing debate among bioethicists, policymakers, and public health advocates in recent years. Conscientious objection policies are intended to balance reproductive rights and clinicians’ beliefs. However, in practice, clinician objection can act as a barrier to abortion access-impinging on reproductive rights, and increasing unsafe abortion and related morbidity and mortality. There is little information about conscientious objection from a medical or public health perspective. A quantitative instrument is needed to assess prevalence of conscientious objection and to provide insight on its practice. This paper describes the development of a survey instrument to measure conscientious objection to abortion provision. Methods: A literature review, and in-depth formative interviews with stakeholders in Colombia were used to develop a conceptual model of conscientious objection. This model led to the development of a survey, which was piloted, and then administered, in Ghana. Results: The model posits three domains of conscientious objection that form the basis for the survey instrument: 1) beliefs about abortion and conscientious objection; 2) actions related to conscientious objection and abortion; and 3) self-identification as a conscientious objector. Conclusions: The instrument is intended to be used to assess prevalence among clinicians trained to provide abortions, and to gain insight on how conscientious objection is practiced in a variety of settings. Its results can inform more effective and appropriate strategies to regulate conscientious objection. See Fig 1 for a summary of methods. The literature review process was conducted from November 2013 to May 2015. PubMed, Google scholar, and Hein Online were used to search for published scholarship and opinion pieces in public health, ethics, and law. Professional networks of the authors were used to cull unpublished work and gray literature (e.g. conference proceedings). Literature in English, Spanish, French and Portuguese was included. The subjects reviewed included bioethical, policy, public health, and clinical aspects of CO, as well as relevant literature on related subjects, such as abortion stigma and the social and political context of abortion provision. LFH spoke with GDC lead and co-lead physicians from four of the five GDC country action centers (Columbia, Ghana, Mexico and South Africa) between February and May 2014; physicians from the Brazil action center were not available for consultation during this period. Discussions included the content areas of CO research that the lead and co-lead physicians thought were most important, how research could relate to their advocacy efforts, and their methodological and logistical considerations in conducting this research. These conversations and the literature review were used to design stakeholder interview guides. LFH conducted semi-structured, in-depth interviews with key stakeholders in Colombia in June and July 2014. Although Ghana was the site for pilot interviews and the first site for the survey administration, Colombia was chosen for initial interviews for several reasons. GDC has an action center in the country, and is interested in administering the survey in Colombia as well. Additionally, although Colombia has a lower maternal mortality rate and more elaborated CO policies than Ghana, the context in the two countries is similar in important ways. In both, abortion is legal for rape or incest, fetal abnormality, and physical or mental health of the woman [20,21]. Abortion access in both countries has expanded recently—Colombia legalized abortion in 2006, and Ghana adopted comprehensive abortion provision guidelines that same year which significantly increased access. Thus, both countries are still transitioning to more liberalized abortion access, and most clinicians in these countries underwent their pre-clinical training and early clinical practice when access was more restricted. In both countries, CO is a limited right; objecting clinicians must counsel patients on all options and refer to a willing provider [8,20,21]. Unsafe abortion is common in both, and abortion is stigmatized in both. Thus, it was considered that findings from Colombia interviews could provide a reasonable starting point for developing a tool that would be useful in Ghana as well–and ultimately in a variety of contexts. Stakeholders in Colombia included conscientious objectors, abortion providers, psychiatrists, activists, health administrators, and legal experts. Psychiatrists were included because OB/GYNs in Colombia sometimes request that psychiatrists confirm patients’ claims of seeking abortion for mental health reasons. Responses were recruited via email from the professional networks of GDC/Colombia country lead and co-lead physicians, and were purposively selected to ensure variation in profession, place of work, and known opinions about CO. Interviews were conducted in Spanish or English depending on respondent preference. Interviews conducted in Spanish were facilitated by a Spanish language interpreter. The interviews were audio recorded and transcribed verbatim. Transcripts were analyzed in NVivo by LFH using thematic analysis. Initial themes were derived from the transcripts, discussed with authors, and revised accordingly. All interviews undertaken as part of this research received IRB approval from UC Berkeley (CPHS # 2014-03-6178). The IRB waived the need for written consent from respondents. All respondents gave verbal informed consent prior to being interviewed, consistent with protocol. Respondents were not compensated. Interview guides for formative and pilot interviews available on request. A conceptual model of conscientious objection was formulated from the themes of the interviews and literature review. Domains for the survey were based on the conceptual model as well as themes from the interviews and literature review. Survey instruments and interview guides from related fields and topics of study were collected for review. Research tools included instruments or excerpts thereof that accompanied published articles, instruments that were publicly available online, and unpublished instruments and guides used in both published and unpublished research (collected with authors’ permission). Instruments were in English, Spanish, French, and Portuguese. Of the 14 instruments collected, six were close-ended survey instruments [4,22–26], and eight were open-ended, in-depth interview guides [27–31] (personal communication with Joanna Mishtal and Bethany Kotlar). The citations given are for tools that are publicly available, or for published work analyzing data gathered by the tools. The tools were entered into a database for comparison, with emphasis placed on identifying phrasing that could be used for the present survey. Items were developed within the survey domains based on interview and literature review findings. When possible, questions from other surveys were used as written or in adapted form, to maximize questions that had already been field-tested and validated, and to provide opportunities for comparisons between survey instruments. The survey was tested for basic comprehension and subjective impression of validity with colleagues from the Upper East Regional Health Bureau in Ghana, who suggested some wording changes. The survey was pilot tested in January 2015 with doctors and midwives who were currently practicing in hospitals in three regions in northern Ghana. Pilot respondents were recruited in person from hospitals in the Upper East and Northern regions of Ghana, both of which were part of the planned study area for administration of the finalized survey. Respondents were purposively selected for variation between clinician type (physicians or midwives) and ownership of health facility where employed (public, private, or Christian Hospital Association of Ghana). In Ghana, some midwives have received training in comprehensive abortion care (CAC); others have received more limited abortion training through other programs, might participate more peripherally in abortion services, or might not have received any training. Both CAC-trained and non-CAC-trained midwives were interviewed. Respondents completed the survey instrument via one of three methods: self-administration using a tablet, self-administration using paper, and administration via interview by LFH. After completing the survey, LFH asked respondents open-ended questions about their thoughts on the instrument’s content and phrasing. These post-survey interviews were audio-recorded and transcribed. Transcripts were analyzed in NVivo using thematic analysis, and were triangulated with survey instrument responses. Themes were discussed with the authors, and revised accordingly. All respondents gave verbal informed consent prior to participation. Respondents were not compensated. The survey instrument was modified based on results from the pilot study. A team of experts reviewed this modified instrument; their feedback was incorporated. As a pre-test, the modified survey was administered to a midwife who was working at a hospital in the survey area, to check comprehension of items. Small modifications were made to instrument wording based on the results of this pre-test. See Fig 1 for an overview of the methods used to develop this survey instrument. All interviews were conducted and analyzed by LFH.