Abortion quality of care from the client perspective: a qualitative study in India and Kenya.

Quality healthcare is a key part of people's right to health and dignity, yet access to high-quality care can be limited by legal, social and economic contexts. There is limited consensus on what domains constitute quality in abortion care and the opinions of people seeking abortion have little representation in current abortion quality measures. In this qualitative study, we conducted 45 interviews with abortion clients in Mumbai, India, and in Eldoret and Thika, Kenya, to assess experiences with abortion care, definitions of quality and priorities for high-quality abortion care. Among the many aspects of care that mattered to clients, the client-provider relationships emerged as essential. Clients prioritized being treated with kindness, respect and dignity; receiving information and counselling that was personalized to their individual situation and reassurance and support from their provider throughout the entire abortion process, including follow-up after the abortion. Many clients also noted the importance of skilled providers and appropriate care. There were similarities across the two country contexts, yet there were some differences in how clients defined high-quality care; therefore, specific political and cultural influences must be considered when implementing measurement and improving person-centred quality of care. These domains, particularly interpersonal interactions, should be prioritized in India and Kenya when health systems, facilities and providers design person-centred measures for quality in abortion care.

Exploring stigma and social norms in women's abortion experiences and their expectations of care.

Abortion is a common and essential component of sexual and reproductive health care, yet social norms and stigma influence women's decision-making and create barriers to safe abortion care. This qualitative study in Kenya and India explores abortion-related fears, expectations and perceptions of stigma among women who have obtained abortion services. In 2017, we conducted 34 semi-structured interviews and 2 focus groups with women who had obtained abortion services in Maharashtra state in India and Thika and Eldoret in Kenya. Thematic analysis was informed by the individual-level abortion stigma framework and theory of normative conduct. We aimed to learn about the diversity of women's experiences, analysing pooled data from the two countries. Most participants reported that before seeking abortion they had little prior knowledge about the service, expected to be judged during care, and feared the service would be ineffective or have negative health consequences. Many reported that community members disapprove of abortion and that a woman's age or marital status could exacerbate judgement. Some reported limiting disclosure of their abortion to avoid judgement. Negative stories, the secrecy around abortion, perceived stigma, social norms, and fear of sanctions all contributed to women's fears and low expectations. These findings elucidate the relationship between social norms and stigma and how expectations and concerns affect women's experiences seeking care. The results have implications for practice, with potential to inform improvements to services and help organisations address stigma as a barrier to care. This may be particularly relevant for younger or unmarried women.