Hostilities faced by people on the frontlines of sexual and reproductive health and rights: a scoping review.

Frontline workers for sexual and reproductive health and rights (SRHR) provide life-changing and life-saving services to millions of people every year. From accompanying the pregnant, delivering babies and caring for the newborn to supporting those subjected to sexual violence; from treating debilitating infections to expanding contraceptive choices; from enabling access to safe abortion services to countering homophobia: all over the world frontline SRHR carers and advocates make it possible for so many more to experience dignity in sex, sexuality and reproduction. Yet they are also subjected to hostility for what they do, for whom they provide care, for where they work and for the issues they address. From ostracistion and harassment in the workplace to verbal threats and physical violence, hostilities can extend even into their private lives. In other words, as SRHR workers seek to fulfil the human rights of others, their own human rights are put at risk. Yet, as grave as that is, it is a reality largely undocumented and thus also underestimated. This scoping review sets out to marshal what is known about how hostilities against frontline SRHR workers manifest, against whom, at whose hands and in which contexts. It is based on review of six sources: peer-reviewed and grey literature, news reports, sector surveys, and consultations with sector experts and, for contrast, literature issued by opposition groups. Each source contributes a partial picture only, yet taken together, they show that hostilities against frontline SRHR workers are committed the world over-in a range of countries, contexts and settings. Nevertheless, the narratives given in those sources more often treat hostilities as 'one-off', exceptional events and/or as an 'inevitable' part of daily work to be tolerated. That works in turn both to divorce such incidents from their wider historical, political and social contexts and to normalise the phenomena as if it is an expected part of a role and not a problem to be urgently addressed. Our findings confirm that the SRHR sector at large needs to step-up its response to such reprisals in ways more commensurate with their scale and gravity.

Adaptations to comprehensive abortion care during the COVID-19 pandemic: case studies of provision in Bolivia, Mali, Nepal, and the occupied Palestinian territory.

The COVID-19 pandemic impacted comprehensive abortion care provision. To maintain access to services while keeping individuals safe from infection, many organisations adapted their programmes. We conducted a programme evaluation to examine service adaptations implemented in Bolivia, Mali, Nepal, and the occupied Palestinian territory. Our programme evaluation used a case study approach to explore four programme adaptations through 14 group and individual interviews among 16 service providers, facility managers and representatives from supporting organisations. Data collection took place between October 2021 and January 2022. We identified adaptations to comprehensive abortion care services in relation to provision, health information systems and counselling, and referrals. Four overarching strategies emerged: (1) the use of digital technologies, (2) home and community outreach, (3) health worker optimisation, and (4) further consideration of groups in vulnerable situations. In Bolivia, the use of a messaging application increased access to confidential gender-based violence support and comprehensive abortion care. In Mali, the adoption of digital approaches created timely and complete data reporting and trained members of the community served as "interlocutors" between the communities and providers. In Nepal, an interim law expanded medical abortion provision to pharmacies, and home visits complemented facility-based services. In the occupied Palestinian territory, the use of a hotline and social media expanded access to quick and reliable information, counselling, referrals, and post-abortion care. Adaptations to comprehensive abortion care service delivery to mitigate disruptions to services during the COVID-19 pandemic may continue to benefit service quality of care, access to care, routine monitoring, as well as inclusivity and communication in the longer term.

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.

"I look forward. I feel insecure but I am ok with it". The experience of young HIV+ people attending transition preparation events: a qualitative investigation.

Transition programmes which prepare young people with HIV to manage the medical, social and psychological consequences of the condition can provide clinical benefits for both young people and their families. The London-based Looking Forward Project (LFP) is embedded within a National Health Service HIV family clinic. The project uses a group work approach and aims to equip HIV+ young people over the age of 12 years who know their status with the emotional, psychological and behavioural skills necessary to face the challenges of living with HIV. This small scale qualitative study investigated the experience of attendance, explored factors which facilitated participation in the groups and investigated the impact on their lives as a result of participation. Participants reported that the LFP events were educational but different to school-like activities, being with other young people reduced isolation and that receiving a voucher was an incentive to attend. Participation was facilitated through family support. Attendance at the LFP facilitated a positive attitude towards medication and hope for the future.