We interviewed 26 MR clients across the three recruitment sites, 16 clients from the call center, five clients from the maternity hospital, and five clients from the NGO clinic. All but one client recruited from the maternity hospital and NGO clinic received surgical MR services and roughly half of them received some local or general anesthesia during their care. Of the clients recruited from the call center, eleven had medication MR, seven of which received care outside of a facility at places such as pharmacies. Parity varied across the sample with five nulliparous clients and the rest with a range of 1–5 children. Table 1 details additional demographic characteristics of clients across service delivery models.
Table 1
Participant Characteristics
Age | n (%) |
≤ 18 years old | 2 (8%) |
19–24 years old | 10 (38%) |
25–30 years old | 9 (35%) |
≥ 31 years old | 5 (19%) |
Marital status | |
Not Married Married | 0 (0%) 26 (100%) |
Employment | |
Employed | 8 (31%) |
Student | 7 (27%) |
Unemployed | 10 (38%) |
Unknown | 1 (4%) |
MR method | |
Surgical (MVA) | 14 (54%) |
Medication | 12 (46%) |
Gestational age | |
≤ 7 weeks | 21 (81%) |
8–10 weeks | 3 (11%) |
11–12 weeks | 2 (8%) |
Recruitment site | |
Public Hospital | 5 (19%) |
NGO clinic | 5 (19%) |
NGO Call Center | 16 (62%) |
Prior MR | |
Yes | 6 (23%) |
No | 20 (77%) |
Prior knowledge and expectations of MR care
Lack of knowledge and fearful expectations of MR
When we asked clients to report their knowledge about MR prior to accessing care, few clients reported knowing about the surgical process or about the option for medication use. This was even true for the clients who had previous MR services, either because they were under anesthesia for their previous MR or they had a different type of MR than the one they were currently seeking. Clients commonly held fears about potential negative consequences from MR based on communication with close female relatives or others in their local community. The most commonly held fears were that MR could lead to future infertility or damage to the uterus or cancer as a result of “dirty instruments”. Clients were also concerned about pain during the procedure and damage to the body caused by infections, especially if a woman had more than one MR, framed as having too many MRs.
What I mean is, they [people] say that if you do it too much, then you can have complications in that area. And then later you will often discover that you might get cancer in your womb. Because you see, if you have this done over and over again, then it becomes like an infection/scarring of that place, doesn’t it? (26 years old, NGO clinic)
The second most common fear women spoke about was a general fear of the MR process itself. This was often a result of not knowing what to expect during the procedure or not feeling informed by their provider going into care. Some clients were able to articulate what they were fearful of, such as the use of instruments or going into surgery, but many were not and just described feeling fearful generally.
Knowledge and expectations about provider interactions
When asked about how they anticipated providers to treat them before seeking care, approximately half of the participants reported anticipating positive treatment and half expressed negative expectations about provider behavior. Negative expectations arose from fear of judgment from staff in the form of verbal shaming and chastising, as explained by this client:
I had very negative ideas about that. I was very worried about it – that they might say all kinds of things to me. First of all, this is not a good thing to do. We are Muslims, and this is a sinful thing. Because of that, they might well say something bad to me. (23 years old, Maternity Hospital)
Another client was worried about being perceived as irresponsible by hospital staff for not using contraception to prevent the pregnancy.
Yes, I was worried that they might tell me off, saying ‘Why did you not use some kind of contraceptive method before this happened? A stable, long term method (is best).’ I was convinced that since I was going to have an MR done, they would definitely behave badly with me – namely, that they would make some digs at my expense. They do the MR for you, but they still say things like that. ‘Why are you doing this? Did you not take any preventive measures in this regard?’ They are bound to say these kinds of things. (22 years old, Maternity Hospital)
Another client who was returning for her second MR service felt concerned her providers would judge her. In addition, during her prior abortion, the providers had encouraged her to have tubal ligation but she never did, so she thought that coming back again for MR would upset them. There was an expectation among clients that unmarried women in particular would be treated differently than married women who presented for MR care. Specifically, that unmarried women would be shamed for having socially unacceptable premarital sex and becoming pregnant. Some clients even felt that unmarried women would be turned away from care. Although every client interviewed reported being married, one young client who sought services from an NGO facility was worried that staff and providers might assume she was unmarried and would be treated as such.
Yes, I was really very afraid. I thought that because I was relatively young, because my husband had not come with me, they might think that I was a bad woman, that I had fallen pregnant as the result of an illegitimate relationship, and they might say dirty things about me. I was very afraid about whether they would make certain assumptions when they heard that I was having an MR. I thought that they would think that I was lying. (16 years old, NGO clinic)
Among clients who held positive expectations of provider and staff treatment, their expectations were based on positive associations with the facility for providing good care. These positive associations were based on the recommendations clients received from those they trusted to seek care from these facilities, while others had previous positive experiences of their own at these facilities, either for MR care specifically or other sexual and reproductive health care. One call center client who also received services at the facility had positive expectations for MR care because of the facility’s reputation.
No, I had already heard earlier that you people deal with various kinds of problems that women face – like all the private difficulties (we experience), all of those things. And also, that you provide a very good service, and that for this MR procedure, [the call center] provides very good care. This is something that I already heard beforehand. (18 years old, Call Center)
For one client, her positive expectations about the facility was the reason she chose to seek care from that facility.
My expectations were certainly high – I felt that I would be treated well, that there would be a good environment there. I felt that it would be clean, and that they would undertake the procedure with due care. That is I went to them. (32 years old, Call Center)
Experience with MR care
Preparing clients for what to expect during and after care
Most clients who contacted the call center and a few from the NGO clinic and maternity hospital felt well informed about what to expect during either their surgical MR or MMR process. For clients taking medication, this included information about dosage, timing, instructions on how to take the pills after leaving the clinic, suggestions of what to eat before taking the pills, and information about side effects. For surgical clients this meant being informed about what to expect during their time at the facility. However, it was more common for clients at the NGO facility and maternity hospital to feel less informed about the steps of the surgical MR process. One client said that staff were in too much of a hurry to provide sufficient information and as a result she felt unprepared for her surgical MR experience.
In-facility providers tended to reinforce this misperception of physical risk and safety concerns associated with MR, specifically risk of future infertility. At the public facility clients were provided with a pamphlet before their MR care that provided problematic framing and naming of potential consequences from surgical MR. Several women from this facility spoke about reading these negative consequences and one client said that she started feeling bad and uncertain about what could happen as a result of MR. Providers also discussed these risks with clients during counselling sessions when discussing the option of MR.
(She said) [the provider] that the uterus might get perforated, and there might be a lot of bleeding, so you might not be able to have children in the future – these are things that the doctor said and they were also written down on the form. (22 years old, Maternity Hospital)
Yes, if you have an MR, you can damage your uterus. You can get back pain for your entire life, and you can get pain in your abdomen. And on top of that, you can also have an infection in your uterus. You might never be able to have a child again. Those who do the abortions, they tell you not to do it if you have not had your first child, because there are many risks involved. On the other hand, it is also the case that none of this might happen. (23 years old, Maternity Hospital)
Provider counselling on MR decision
Counselling sessions with providers primarily during in-facility care gave clients the perception that MR care was available if absolutely necessary, but that it is not a good thing to do and should be avoided if possible. Five clients experienced instances where their MR providers or other staff involved in their care attempted to discourage or talk them out of their MR procedure. In some instances, providers framed their objections as questions to the clients asking why they did not want to keep the ‘baby’ or other language that suggested the fetus was living. On one occasion, a provider was trying to persuade the client out of their current MR in exchange for a permanent contraceptive method after her pregnancy, indicating that getting an MR service was ultimately a bad thing. ‘They said, “Your baby is little.” One of the doctors said, “You should keep this baby. After you have had it, you can have an, um (ligation), done.”’ (24 years old, NGO clinic)
Providers specifically made pleas to younger nulliparous women, stating that they should keep the pregnancy because it would be their first child. Four clients described their providers trying to convince them out of having MR specifically because it was their first pregnancy and that they should keep it for that reason alone.
‘You have already conceived, so you can continue it (the pregnancy).’ But I said, ‘No, I will not continue it.’ And then she replied, ‘That is not right. And furthermore, it is your first time.’ (22 years old, Maternity Hospital)
They sent me to have an ultrasound done. And there, I spoke to the doctor. She tried to get me to understand that I should discuss this with my husband, that I should keep this baby, because it was my first child (16 years old, NGO clinic)
One client spoke from her experience of seeing other people come for MR services and the judgmental language and hurdles they faced from providers in order to access care because it was their first pregnancy.
Even if you have a husband, the first time that you come in to have an MR done, they are unwilling to perform the MR. You end up having to go back and forth for two or three days (to get it done). You have to give a signature here, you have to give a signature there and so on. And then they ask you all kinds of questions about your husband (22 years old, Maternity Hospital)
Some clients were questioned multiple times by a variety of staff throughout service provision at facilities. A client at the NGO facility had multiple interactions with staff throughout her service at the clinic who first asked her, ‘Why don’t you want to have this baby?’ She then had to explain her reasoning to each of the staff and providers up until she received her service.
In some instances, providers also emphasized the importance of using long-acting reversable contraception as a way to avoid the need for future MR services, again emphasizing that MR can be damaging to the body. When a client at an NGO facility said she did not want an injection for contraception, her provider said “’It is not right to keep having an MR done over and over again. That is damaging for your health.’” (26 years old, Call Center). Another client said that her provider was insistent on her receiving a shot or an implant because she sought MR service too close together. Despite the client’s fear of inserting any method into her body, the provider only stopped insisting once the client’s husband stepped in and did not give “permission” for these contraception methods.
Treated nicely and given courage
Clients across the different models of care primarily reported positive perceptions of care from their providers and other staff for in-facility care. Positive experiences were described as being spoken to nicely, pleasantly, or politely and providers behaving well, sometimes described as the absence of bad care. ‘But the way that I understood/saw it, everyone there behaved well. They spoke to me nicely. They did everything properly. I did not notice anything bad about it’ (22 years old, Call Center). Clients also appreciated when providers reassured them of the safety of the procedure, reminding them that there was nothing to worry about. Clients felt encouraged and supported by these verbal affirmations. One client who was feeling tense before her surgical procedure said her doctor helped her by saying, ‘Don’t worry. Nothing bad will happen. You’ll see, you won’t even feel any pain.’ (24 years old, NGO clinic).
Despite instances where providers attempted to dissuade clients from seeking MR services, these clients still felt supported during their MR service, describing their service was ‘quite good’. This discordance was explained by a change in provider treatment once the providers accepted that the client would move forward with her MR; clients felt that they provided more encouraging or supportive care. Clients were also able to rationalize this type of treatment from their providers as either being deserving of this treatment, or that the providers were well intentioned and that clients were spoken to this way for their own benefit. One client who was told to keep her pregnancy by her provider still felt like her provider came from a place of good intention.
No, they told me this – that I am young - because they were thinking of my welfare. I mean, this has been more of a risk for me, because of (the fact that I have) three children already. They said it with the best of intentions. I don’t think that this was a bad thing to say. (24 years old, NGO clinic)
Another client at the maternity hospital who experienced multiple rounds of questioning by staff about her desire to have MR and presenting around 12 weeks’ gestation said that the scolding she received was warranted for how late she was coming for care. She ultimately felt that the care she received was great because providers were kind, patient, explained the procedures, and listened to patients. She also thought that providers did not speak aggressively to her the way they could have and asked for consent before they did anything.
Experience with Bad Care
There were a few instances where clients described feeling that their experiences with staff or providers were bad. Clients defined these negative interactions as providers who were ‘rude’ or short tempered with them. This left some clients feeling upset, hesitant to express concerns, and at times even humiliated by how they were treated. During contraceptive counselling, one client said that the provider grew angry and spoke to her in an ‘unpleasant way’ such that it dissuaded the client from asking additional questions she had. ‘I wanted to ask a couple of questions, but after seeing their attitude, I actually decided against asking them anything.’ (35 years old, Call Center). Another client’s concern that providers would ‘make digs’ at her for seeking MR care came to fruition.
They do the MR for you, but they still say things like that. ‘Why are you doing this? Did you not take any preventive measures in this regard?’ They are bound to say these kinds of things. And that is what happened, after I came here. (22 years old, Maternity Hospital).
Two clients reported feeling humiliated during their interactions specifically with reception staff during in-facility care. For one client this was during the check-in process at the maternity hospital where she was scolded by the receptionist who said, ‘Why do you come to us with all this bad news? Try to come to us with some good news.’ Another client at the NGO clinic was unclear about the processes of care within the clinic, including where to sit when. She said that the receptionist at this facility made her feel worse about her uncertainty by the way she spoke to her.