Sofia Di Mario1, Andrea Minciullo2 & Lucia Filomeno3*

  1. RN, MSN, PhD Student; Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy.
  2. RN, MSN, Gastroenterology and Digestive Endoscopy Unit, Campus Bio-Medico, 00128, Rome, Italy,
  3. RN, MSN, PhD Student; AOU Policlinico Umberto I – Department of Neurosciences and Mental Health, Viale dell’Università, 30, 00185, Rome, Italy.

* Corresponding author: Lucia Filomeno, Department of Neurosciences and Mental Health, AOU Policlinico Umberto I, Rome. E-mail: lucia.filomeno@uniroma1.it

 

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ABSTRACT

Background: Voluntary termination of pregnancy (VTP) is influenced by ethical convictions, religious orientations and knowledge of the law. The latter is essential for students to be improved in University curricula, in order to develop attitudes among future nurses and midwives with the objective to reduce stigma and reluctance in providing VTP. Previous research has shown that nursing and midwifery students’ attitudes and knowledge can be improved.

Aim: The aim of this study is to describe literature regarding knowledge and perception about abortion and voluntary termination of pregnancy in several countries of the world among nurses, midwives and university students.

Methods: This is a scoping review of the literature conducted by following the recommendations of the PRISMA-ScR Statement. The authors selected studies in MEDLINE, Scopus, CINAHL, PsycINFO, Academic Search Index, Science Citation Index and ERIC, published in English and Italian in the last decade. Quality assessment was performed using the Jadad scale.

Results: Initially, 434 studies were selected. A total of 11 articles met the inclusion criteria. The articles included in the scoping review deal with the issue of abortion from different perspectives. From the analysis it emerged that the barriers for VTP are the lack or inadequate knowledge of the legislation and of the practical / technical phases of the procedure.

Conclusions: Health professionals and students have different perspectives and attitudes toward VTP. Nurses and midwives have inadequate knowledge of procedures and legislation. Therefore, it is recommended to implement university curricula on the topic.

Keywords: knowledge, attitudes, voluntary termination of pregnancy, nurses, midwives, students.

 

 

INTRODUCTION

Abortion, originated as birth control, is the termination of pregnancy before 20 weeks of gestation or with the foetus weight less than 500 gr at birth [1,2]. It can happen when at least three events occur: spontaneous or habitual abortion (also called Voluntary Termination of Pregnancy – VTP), criminal or illegal abortion, and therapeutic or legal abortion [3]. In the last decades of the 20th century, many countries all over the world legalised this practice. The World Health Organization (WHO) states that 3 out of 10 (29%) of all pregnancies, and 6 out of 10 (61%) of all unintended pregnancies, ended in an induced abortion [4]. In many societies, a deep conflict about the legality and morality of abortions manifests itself in restrictive laws and strong antiabortion attitudes. Women, including adolescents, with unwanted pregnancies often resort to unsafe abortion when they cannot access a safe one. Barriers to accessing safe VTP include: restrictive laws, poor availability of services, high cost, stigma, conscientious objection of health-care providers and unnecessary requirements, such as mandatory waiting periods, mandatory counselling, provision of misleading information, third-party authorization, and medically unnecessary tests that delay care [5,6]. Kumar et al. [7], defined abortion stigma as “a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to the ideals of womanhood”. According to this definition, women who experience VTP challenge social norms regarding female sexuality and maternity, and their doing so elicits stigmatising responses from the community. Where opposition to abortion is widespread, abortion-related stigma is likely to negatively influence women’s abortion experience.

Increased knowledge and improved attitudes among health care providers and university students have the potential to reduce stigma and reluctance to provide abortion [6]. In a recent study conducted by O’Shaughnessy et al. [8], it was reported that “low levels of knowledge among staff suggests that training is required to ensure the provision of a safe and effective VTP service”. Midwifery and Nursing schools do not provide termination of pregnancy education or, if they do, it is inadequate and so, most staff were left to navigate this procedure without support or prior practice.

Termination is only possible in the rarest of cases: when the pregnancy poses a serious risk to the woman’s life or in the event of foetal malformations [7]. In Italy, as in many countries, it is set at 12 weeks’ gestation according to the law No. 194 enacted on May 22nd, 1978. Before that date, VTP was considered illegal by the criminal code [9]. The law regulates VTP with the aim of guaranteeing the bio-psycho-social integrity and well-being of women. A woman can have an abortion within the first 90 days, or within the fourth and fifth months only for therapeutic reasons [9]. Conscientious objection status does not exempt the professional from assisting the woman before and after the procedure, but from carrying out only those procedures directed towards and aimed at the termination [10-13]. The nurse can raise a conscientious objection to assisting the VTP with a declaration that can be withdrawn at any time [9]. Termination is a woman’s right, and the staff involved must act in accordance with the law and the woman’s right to free choice. A better understanding of factors influencing perceptions may be useful in determining the curricula of university programs and in giving nurses and midwives the tools to cope with their own beliefs towards late abortions [14-16]. Thus, this review seeks to contribute to research on abortion stigma by exploring literature regarding attitude, knowledge and perception differences toward abortion among nursing, midwifery and students, assessing the scientific evidence available to date and thereby delineating directions for future research.

 

METHODS

Identification of Relevant Studies

A scoping review was chosen as the research methodology [17]. This supports what is referred to as a systematic approach to the synthesis of evidence, helping to identify gaps for future studies. In this case, the goal is to determine the strength of the evidence using a consistent best practice approach. The search of the international literature was conducted in accordance with the PRISMA-ScR Statement (PRISMA extension for Scoping Reviews)[18] and was conducted within some main databases of biomedical interest: MEDLINE, Scopus, CINAHL, PsycINFO, Academic Search Index, Science Citation Index and ERIC. The review was carried out from October 2021 to February 2022. The keywords used were “knowledge; attitude; perception; nurse; student; abortion; midwife and questionnaire”. The latter were useful in formulating the research question according to the PCC (Population, Concept and Context) methodology (Table 1).

 

Table 1. Clinical research question identified through the PCC methodology

 

Study Selection and Eligibility Criteria

Research question: “What are the differences in knowledge and attitudes between nursing and midwifery staff and the corresponding university students?”. The search string was created using the Boolean operators (AND and OR), the terms MeshTerms and the truncation function, to ensure maximum search sensitivity and specificity:

 

(Knowledge OR Attitude OR Perception) AND (Abortion) AND (Nurse OR Midwife OR Student) AND (Questionnaire OR Assessment)

The study population were nurses, midwives and nursing and midwifery students. The primary studies concerning the assessment of attitudes, perceptions and knowledge about abortion between the two groups and the efficacy and validity of these arguments within the degree programs were considered eligible. The studies included experimental or quasi-experimental studies and observational studies. Since grey literature (i.e., unpublished conference proceedings or theses or dissertations) was not considered, other potentially relevant studies were not included in this review.

The selection criteria listed below were met to identify suitable studies for the purpose of this review.

 

Inclusion criteria

  • Literature from the last 10 years.
  • Italian or English language.
  • Experimental and observational studies: RCT (Randomised Controlled Trial), quasi-experimental research designs, pretest-posttest, cross-sectional.
  • Nurses, midwives and corresponding university students.

 

Exclusion criteria

  • Other healthcare professionals, physicians, medical students or students of other healthcare professionals.
  • Grey
  • Qualitative and mixed-methods studies.

 

Data Extraction

In the first phase, the results obtained from the research were imported into a software for the management of bibliographic references and duplicates were eliminated. In the second phase, each article uploaded to the database was carefully and independently examined. Initially, they were analysed by reading their title and abstract and, according to the previously established eligibility criteria, the irrelevant ones were excluded, while those relevant for full-text reading were selected. Thanks to the in-depth reading, it was possible to exclude the articles that did not answer the research questions. Two reviewers worked independently. The following data was collected for each article: study title, first author, year of publication, study sample and study design, objective, assessment and a summary of the results. The approach used to group the articles was thematic: the main objective of the thematic analysis is to identify similar concepts in the collected dataset, exploring their relationships of meaning. These reports can be used to further develop and corroborate the interpretation of theories that seek to investigate the phenomena studied [19].

 

Quality Assessment

The quality of the studies was assessed usingthe Jadad Scale [20], focusing on methods for random allocation, double blinding, and withdrawals and dropouts. Total scores ranged from 0 to 5 points, where studies with 0-2 points were considered poor quality and those with 3-5 points represented high-quality evidence [20].

 

RESULTS

Initially, 434 articles were selected with duplicates removed (Figure1). Of these, 11 met the inclusion criteria and underwent the review process. The main information of the relevant articles was organised in a data extraction table (Table 2). Studies were conducted in 11 different countries: Belgium, Ghana, Iran, Brazil, Israel, Spain, Ethiopia, Finland, Canada, Pakistan and South Korea. This demonstrates a notable absence of literature in Italy. The studies included a sample ranging from a minimum of 74 to a maximum of 647 participants. The most recent one dates to 2020, while the oldest one dates to 2010. From the analysis it emerged that the barriers for abortion treatment are the lack or inadequate knowledge of the legislation and of the practical / technical phases of the intervention [21-24]. The possession of skills is often not enough as in the study by Romina et al. [22] where it emerged that there was no significant relationship between the knowledge of the law and the care performance of health professionals while a statistically significant relationship was observed between their opinion of abortion and their active collaboration[22].

Figure 1. – PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only.

Personal and religious beliefs have been considered to have a profound influence on opinion and behaviour, in some cases resulting in the inability to take care of the patient for fear of remorse [21; 25-27]. The presence of moral and / or religious values in health workers was significantly correlated with the occurrence of the request for conscientious objection (CO) [21-26].

Table 2. Data Extraction Table.

In South Korea, where about half of the population declared themselves irreligious, Chung Mee Ko et al. [26] assessed the opinions of 167 nurses regarding CO; the majority replied that patients’ rights to health care should take priority over nurses’ right to refuse health care, concluding that the nursing profession should seriously consider whether it is necessary to insist on nurses’ right to CO and should be actively involved in the determination process of new abortion laws and related policies [26]. Nieminen et al. [6] studied CO among Finnish nursing students and practitioners. Most of them seemed to consider the continuation of adequate services to patients in the event of the introduction of CO as crucial, while emphasising the surgical act over patient support. Despite their views and beliefs, health workers sometimes faced a conflict with their commitment to care; in the work of Ben Natan et al. [15], they stated that bioethical dilemmas, as well as the reasons for abortion, influenced their ability to actively collaborate during the termination of pregnancy [15]. Nurses attitude and ability to actively participate in late abortions were found to be strongly conditioned by the level of religious observance [21-22]. The study by Roets et al. [28] found that in several neonatal intensive care units in Belgium, healthcare workers practicing late abortion had a high degree of tolerance towards late termination of pregnancy, regardless of the patient’s socio-demographic factors, so much so that they asked the institutions to provide for a change in legislation [28].

Ben Natan et al. [15], however, found that nursing students had more prejudices towards late abortions than experienced nurses, evidence in line with the study conducted by Assefa et al. [24] where it turned out that a predictor of a positive attitude towards VTP was seniority [24]. The role of health workers is very important, especially on a psychological level, even more so when they must help women to deal with a negative event such as a miscarriage. To this end, Engel et al. [27] suggested that health workers should receive specific training to be able to support women and their families [27]. Previous research has shown that university education programs do not provide the tools necessary to achieve the objectivity required in preparation for abortion and that this may have contributed to anti-abortion attitudes and misconceptions about legal regulations that are common among students10. Same results emerged from the work of Baig et al. [29] who studied the knowledge, attitudes and practices of midwives in post-abortion care services [29]. The work highlighted the need to provide comprehensive training and mentoring to midwives and students, building strong networks to enable the development of broader initiatives to reduce the stigma of abortion.

 

DISCUSSION

Although the total number of studies investigating abortion stigma among undergraduate students and nurses and midwives such as nurses and midwives is low, results indicate that knowledge, personal and religious beliefs significantly affect attitudes about VTP. This is in line with the findings by Madziyire et al. [10] where incomplete comprehension of abortion laws highlights the urgent need for providers education as a key step in reducing stigma and mortality associated with unsafe abortion [10]. Additionally, the lack of expertise evidenced by most of the studies, suggest that even nurses and midwives who have good intentions may unwittingly disseminate misinformation. One study underlined the fact that type of profession and seniority were important in providers’ knowledge about abortion. Also, being male and having high knowledge significantly influenced providers’ attitude. The same findings were highlighted by Hammarstedt et al. [30] who stated that gynaecologists and midwives were less restrictive towards legal abortion the more experience they had, being especially influenced by recently obtained experience within the last year [30]. Claims of conscientious objection must be ethically justified, and not become a strategy to hide prejudices or fear of lawsuits and moral accusations. Such an instrument cannot be an obstacle for women to have access to abortion [31]. Humanized care in the abortion process is part of the reproductive and sexual rights of women, and ensuring it is a duty of all health professionals.

Abortion laws and practice differ between cultures, religions and countries. The Finnish healthcare system is relatively liberal regarding the right for induced abortion until the 12° gestational week. Despite lively discussion, there is no legislation in this country on the possibility of CO [32]. Post-abortion care is important especially in countries like Pakistan, where half of pregnancies are unintended. Demand for abortions is high in Jamaica, but many doctors refer clients to another provider. Patient assessment is good, but support services need improvement [33]. This has been reported in other surveys in other countries. In Ghana, for example, only 45% of surveyed physicians said that they would perform abortions, whereas another 36% said that they would provide counselling prior to abortion but not the procedure itself [33]. Women deserve a well-prepared, informed personnel and similarly, students deserve a thoughtfully inclusive curriculum that accurately addresses ethical topics, as most programs do not require sexual health courses as a part of their curriculum [34-35].

 

CONCLUSION

The role of the health professional assisting the woman who decides to undergo a voluntary termination of pregnancy is very important, especially in the phases before and after the intervention. Assistance must always be provided with respect for the woman’s dignity, confidentiality and freedom of choice. Nurses need to provide a source of support for the woman by establishing a relationship based on trust. Health professionals and students have different perspectives and attitudes toward VTP. Nurses and midwives have inadequate knowledge of procedures and legislation. It is important that the health professional realises the crucial importance of their role in the woman’s grieving process to ensure good care.

 

Limitations of the study

Our study has some limitations that should be mentioned. In our analysis, only research articles published in English and Italian were included, which may have produced a language bias regarding the conclusion, as some scientific papers were published in other languages. Additionally, only studies published in peer-reviewed journals were included; this criterion was meant to ensure reporting quality but may mean that relevant grey literature was missed.

 

Practical implication

Nurse sneed to have adequate training in the bereavement context: they should know what interventions implement and what to avoid. The aim of the scoping review was to analyze the international panorama regarding abortion as a point of departure on which to develop an Italian study to compare legislation knowledge, attitudes and perspective differences among students and nurses and midwives. Therefore, it is recommended to implement university curricula on the topic.

 

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

The authors declared no conflict of interest.

 

REFERENCES

  1. Lobo RA, Gershenson DM, Lentz GM, Valea FA. Comprehensive gynecology E-book. Elsevier Health Sciences, 2016.
  2. Echeverría BC, Serani MA, Arriagada U AM, Goic G A, Herrera CC, Quintana VC, et al. An ethical and medical perspective on the voluntary termination of pregnancy. 2015;143(11):1478–83. https://doi.org/10.4067/S0034-98872015001100014
  3. Narayan KS, Reddy M. Essentials of Forensic Medicine and Toxicology. JAYPEE Brothers MEDICAL P, 2017.
  4. World Health Organization. (2021). Access to medical abortion medicines in the South-East Asia Region-a status report.
  5. Bearak J, Popinchalk A, Ganatra B, Moller A-B, Tunçalp Ö, Beavin C, Kwok L, Alkema L. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. Lancet Glob Health. 2020 Sep; 8(9):e1152-e1161. https://doi.org/10.1016/S2214-109X(20)30315-6
  6. Nieminen P, Lappalainen S, Ristimäki P, Myllykangas M, Mustonen A-M. Opinions on conscientious objection to induced abortion among Finnish medical and nursing students and professionals. BMC Medical Ethics. 2015 Mar 25;16(1):17. https://doi.org/10.1186/s12910-015-0012-1
  7. Kumar A, Hessini L, Mitchell EMH. Conceptualising abortion stigma. Culture, Health & Sexuality. 2009;11(6):625–39. https://doi.org/10.1080/13691050902842741
  8. O’Shaughnessy E, O’Donoghue K, Leitao S. Termination of pregnancy: Staff knowledge and training. Sexual&Reproductive Healthcare. 2021 Jun1;28:100613. https://doi.org/10.1016/j.srhc.2021.100613
  9. Italiana R. Legge 22 maggio 1978, n. 194. Norme per la tutela sociale della maternità e sull’interruzione volontaria della gravidanza. Gazzetta Ufficiale, 22. https://www.gazzettaufficiale.it/eli/id/1978/05/22/078U0194/sg
  10. Madziyire MG, Moore A, Riley T, Sully E, Chipato T. Knowledge and attitudes towards abortion from health care providers and abortion experts in Zimbabwe: a cross sectional study. Pan AfrMed J. 2019 Oct16;34:94. https://doi.org/10.11604/pamj.2019.34.94.18107
  11. Aragaw Y, Sinishaw W, Daba W, Mekie M. Attitude of Nursing and Midwifery students towards clinical practice and its associated factors in Northwest Ethiopia: a cross-sectional study. BMC Research Notes. 2019 Apr 3;12(1):205. https://doi.org/10.1186/s13104-019-4230-3
  12. Jafari H, Khatony A, Abdi A, Jafari F. Nursing and midwifery students’ attitudes towards principles of medical ethics in Kermanshah, Iran. BMC Medical Ethics. 2019 Apr 25;20(1):26. https://doi.org/10.1186/s12910-019-0364-z
  13. Biggs MA, Casas L, Ramm A, Baba CF, Correa SP. Medical and midwifery students’ views on the use of conscientious objection in abortion care, following legal reform in Chile: a cross-sectional study. BMC Medical Ethics. 2020 May 24;21(1):42. https://doi.org/10.1186/s12910-020-00484-4
  14. Glenton C, Sorhaindo AM, Ganatra B, Lewin S. Implementation considerations when expanding health worker roles to include safe abortion care: a five-country case study synthesis. BMC Public Health. 2017 Sep 21;17(1):730. https://doi.org/10.1186/s12889-017-4764-z
  15. Ben Natan M, Melitz O. Nurses’ and nursing students’ attitudes towards late abortions. Int Nurs Rev. 2011 Mar;58(1):68–73. https://doi.org/10.1111/j.1466-7657.2010.00840.x
  16. Harries J, Stinson K, Orner P. Health care providers’ attitudes towards termination of pregnancy: A qualitative study in South Africa. BMC Public Health. 2009 Aug 18;9(1):296. https://doi.org/10.1186/1471-2458-9-296
  17. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005 Feb 1;8(1):19–32. https://doi.org/10.1080/1364557032000119616
  18. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine. 2018 Sep 4;169(7):467–73. https://doi.org/10.7326/m18-0850
  19. Allodola V.F. Metodi di ricerca qualitativa in MedicalEducation: Approcci, strumenti e considerazioni di rigore scientifico. Educ. Sci. Soc. 2014, 5, 121–144.
  20. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996 Feb;17(1):1–12.https://doi.org/10.1016/0197-2456(95)00134-4
  21. De Roose M, Tency I, Beeckman D, Van Hecke A, Verhaeghe S, Clays E. Knowledge, attitude, and practices regarding miscarriage: A cross-sectional study among Flemish midwives. 2018 Jan;56:44–52. https://doi.org/10.1016/j.midw.2017.09.017
  22. Romina S, Alamshahi M, Moafi F, Mafi M, Hajnasiri H. Relationship of Knowledge and Attitude Towards Legal Abortion Laws with the Performance of Midwives in Qazvin, Iran. Health, Spirituality and Medical Ethics. 2019 Jun 10;6(2):17–23. http://dx.doi.org/10.29252/jhsme.6.2.17
  23. Cacique DB, Passini Junior R, Duarte Osis MJM, Oliveira HC, Padilha KM, Tedesco RP, et al. Perspectives of healthcare workers on the morality of abortion: a multicenter study in seven Brazilian public hospitals. Health Care Women Int. 2020 Jul;41(7):761–76. https://doi.org/10.1080/07399332.2019.1672169
  24. Assefa EM. Knowledge, attitude and practice (KAP) of health providers towards safe abortion provision in Addis Ababa health centers. BMC Women’s Health. 2019 Nov 14;19(1):138. https://doi.org/10.1186/s12905-019-0835-x
  25. Voetagbe G, Yellu N, Mills J, Mitchell E, Adu-Amankwah A, Jehu-Appiah K, et al. Midwifery tutors’ capacity and willingness to teach contraception, post-abortion care, and legal pregnancy termination in Ghana. HumResour Health. 2010 Feb23;8:2. https://doi.org/10.1186/1478-4491-8-2
  26. Ko CM, Koh CK, Lee YS. An ethical issue: nurses’ conscientious objection regarding induced abortion in South Korea. BMC Med Ethics. 2020 Oct 27;21(1):106. https://doi.org/10.1186/s12910-020-00552-9
  27. Engel J, Rempel L. Health Professionals’ Practices and Attitudes About Miscarriage. MCN Am J Matern Child Nurs. 2016 Feb;41(1):51–7. https://doi.org/10.1097/nmc.0000000000000207
  28. Roets E, Dierickx S, Deliens L, Chambaere K, Dombrecht L, Roelens K, et al. Healthcare professionals’ attitudes towards termination of pregnancy at viable stage. Acta ObstetGynecolScand. 2021 Jan;100(1):74–83. https://doi.org/10.1111/aogs.13967
  29. Baig M, Jan R, Lakhani A, Ali S, Mubeen K, Ali S, et al. Knowledge, Attitude, and Practices of Mid-Level Providers regarding Post Abortion Care in Sindh, Pakistan. Journal of Asian Midwives (JAM). 2017 Jun 1;4(1):21–34.
  30. Hammarstedt M, Jacobsson L, Wulff M, Lalos A. Views of midwives and gynecologists on legal abortion–a population-based study. Acta ObstetGynecolScand. 2005 Jan;84(1):58–64. https://doi.org/10.1111/j.0001-6349.2005.00695.x
  31. Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. Conscientious Objection and Legal Abortion: Medical Students’ Attitudes. Rev bras educ med. 2016 Mar;40:86–92. http://dx.doi.org/10.1136/medethics-2013-101482
  32. Gissler M, Ulander VM, Hemminki E, Rasimus A. Declining induced abortion rate in Finland: data quality of the Finnish abortion register. Int J Epidemiol. 1996 Apr;25(2):376–80. https://doi.org/10.1093/ije/25.2.376
  33. Fletcher H, Gordon-Strachan G, McFarlane S, Hamilton P, Frederick J. A survey of providers’ knowledge, opinions, and practices regarding induced abortion in Jamaica. Int J Gynaecol Obstet. 2011 Jun;113(3):183–6. https://doi.org/10.1016/j.ijgo.2010.12.022
  34. Baba CF, Casas L, Ramm A, Correa S, Biggs MA. Medical and midwifery student attitudes toward moral acceptability and legality of abortion, following decriminalization of abortion in Chile. Sexual&Reproductive Healthcare. 2020 Jun1;24:100502. https://doi.org/10.1016/j.srhc.2020.100502
  35. Burnes TR, Singh AA, Witherspoon RG. Sex Positivity and Counseling Psychology: An Introduction to the Major Contribution. The Counseling Psychologist. 2017 May 1;45(4):470–86. https://doi.org/10.1177%2F0011000017710216


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