Conflicting laws, policies and guidelines

The papers reviewed identified conflicts that were explicit as well as some that were not explicit, but were perceived by healthcare workers.

Explicit discrepancies occurred when laws, policies and guidelines included provisions that directly contradicted one another. For example, Cleeve et al documented how in Uganda, the constitution, penal code and reproductive health policy were not compatible. Among other incongruities, the national guidelines and service standards specified that abortion was allowed in cases of rape, incest, fetal anomaly, or if the women was HIV positive. These exceptions were not provided for in the penal code, which outlawed abortion.18 While in the case of Uganda, the national guidelines are less restrictive than the law, in the Philippines, the opposite was described. The Philippine Obstetrical and Gynaecological Society’s 2011 ethical guidelines failed to explain Philippine legal exceptions to the criminal prohibition on abortion, and implied that abortion was always illegal.19 In both cases, provider capacity and/or willingness to provide the full spectrum of comprehensive abortion care was undermined, particularly when providers acted according to the more limited interpretation of abortion grounds.18 19

In other contexts, discrepancies identified were not explicit, but might be described as perceived or implicit, creating conditions where healthcare users’ ability to exercise their rights and entitlements were difficult. Two qualitative studies described situations where abortion was allowed by law in several different circumstances, but sex selective abortion was illegal. Providers in these contexts indicated that they felt that it was up to them to determine whether or not the rationale for a given procedure was sex selection, such that they felt like unwilling gatekeepers, arbiters or legally vulnerable.20 21 Several additional papers describing implicit tensions related how laws permitting conscientious objection—ostensibly a measure to protect provider rights to freedom of religion, belief, opinion and expression—could allow conditions where providers (or institutions) undermined legally enshrined entitlements to abortion, particularly where there were not enough providers willing to provide or refer to abortion services.22 More specifically, some conscientious objection laws allowed for institutional objection, such as by Catholic Hospitals; studies assessing the operationalisation of conscientious objection found that such laws made it difficult for women living in the hospital’s catchment area to obtain an abortion, irrespective of their rights to abortion under national law.23 24 Similarly, other papers described settings where a significant percentage of providers in a given geographical area exercised conscientious objection, undercutting or even obviating rights to health or abortion as they were enshrined in national law, as referrals, timely care and other requirements for abortion access were not able to be met.22 23 25 26

Several studies explored how laws and policies interfered in clinical decision-making, thus conflicting with providers’ ethical and legal obligations to ensure patient access to information and services.27 28 For example, state laws in the USA prohibited health providers working in publicly funded clinics from counselling or referring patients for abortion,29 thereby limiting patient care and communication,30 and ‘creating conflicts between professional values and legal obligations’.31–33 Similarly, a case study on Zambia described how a law requiring that three physicians sign a form affirming a patient’s need for an abortion undermined the judgement of the primary doctor as well as the entitlements of the patient in question.34 On the other hand, a study on ethical dilemmas among abortion providers found that some providers opted to break the law and provided abortions because they feared women denied abortions would result to unsafe alternatives.35

Almost all conflicts in law and policy identified related to abortion, but we encountered one in another SRH domain. In South Africa, the law allowed adolescents the right to receive contraception (and to obtain an abortion) after age 12, but the Sexual Offences Act established the age of consent to sex at 16 years. As a result, healthcare providers were expected to provide counselling and care to adolescents 12–16, and also to report sexual activity under the age of consent to law enforcement.36 Providers thus faced a tension between complying with the law and their responsibility to provide confidential care.

Ambiguous laws, policies and/or guidelines complicated healthcare worker rights and responsibilities in a variety of SRH areas. Examples included laws not clarifying which female genital mutilation/cutting practices were being criminalised,37 38 what elements of maternity care were mandated to be free,39 what fell under the health or other grounds for abortion,34 40 41 who could provide abortions and when abortion was permitted,42 the content and limitations of the right to conscientious objection,25 26 43 44 or when adolescents’ life or health were ‘in serious danger’, such that providers were unsure whether they were required to reach out to patients’ parents regarding the patient’s sexual health.45

Studies explored how explicit and implicit conflicts and/or ambiguities in laws, policies and guidelines resulted in the non-provision of care, the provision of non-standardised care, and/or created space for competing normative paradigms for provider decision-making, stigma and fear, and provider’s pecuniary motivation to play a larger role in healthcare worker decision-making. For example, in Mexico, healthcare workers reported not wanting to ‘get mixed up’ in providing abortion services, because they were not sure what their responsibilities were under the law,41 and in Tanzania, healthcare workers benefited from ambiguity about the cost of maternal health services to demand informal payments.39 In the case of abortion and the provision of contraception to adolescents, studies found that uncertainty had sometimes translated to provider hostility or reluctance to see patients seeking services for which the guidelines were unclear as providers preferred to avoid ambiguity and risk.19 46–48 On the other hand, some studies found that providers used the discretionary space provided by ambiguous laws or policy to act in favour of service provision. For example, in Ethiopia, many physicians exercised significant latitude in deciding when a pregnant woman’s life was in danger, and provided abortion services accordingly.34 In Colombia, there were few formal rules regarding the provision of fertility treatment, and so providers who had been trained in fertility treatment provided services, but were forced to ‘negotiate treatment boundaries based on their own morals, social values and professional obligations’ due to the lack of standardised clinical guidelines.49

Pressure to achieve goals

We identified several ways and SRH areas where the pressure to meet coverage, quality, and other goals engendered healthcare worker behaviour that was inconsistent with healthcare worker responsibilities to patients and, in some cases to their fellow providers, as these responsibilities are commonly defined in human rights and medical ethics. This included healthcare provider behaviours such as coercing women into giving birth in health facilities due to pressure to increase the percentage of births in health facilities, and falsifying hospital maternal death records or other data.50 51 One paper described single-minded governmental emphasis on institutional delivery in India as leading to safe, but violent deliveries, where patients in overwhelmed facilities experienced disrespect and abuse and health workers struggled to realise their responsibilities in facilities with unsupportive management and inadequate supplies.52 In Tanzania, where there was governmental pressure to decrease stillbirths, midwives reported that they would slap women during the second stage of labour because they feared stillbirths and the investigations associated with them.53 Punitive supervision was one way that compliance with aggressive performance improvement goals was exacted. For example, an ethnographic study found that facility managers compelled auxiliary nurse midwives to meet unrealistic targets by threatening to withhold their salaries, public scolding or limiting their ability to exercise their full scope of practice.51

Rights and professionalism of healthcare workers not respected, undercutting their ability and motivation to fulfil their responsibilities

Healthcare worker desire and ability to fulfil their responsibilities and respect the rights of their healthcare worker peers depended on the conditions in which they worked, including the extent to which their rights were respected, and the morale and overall culture of the workplace, among other factors.

Several studies revealed how gender-based mistreatment and violence against female health workers affected the disproportionately female SRH workforce. Women health workers from varying cadres reported widespread verbal abuse, bullying, and sexual harassment in the workplace by colleagues and by people in the community.51 54–56 Midwives—who often occupy a lower status by virtue of their being women—experienced disrespect, lack of support and lack of recognition from their supervisors.56–59 This disrespect could manifest in blame, with midwives reporting that they were blamed irrespective of who—if anyone—was at fault for a complication.51 57 58 60

Midwives also experienced disrespect and aggression from patients and their families, including violence, particularly when the midwife was young and/or when the patient was of a higher social status than the midwife.58 59 61 Other SRH healthcare providers also experienced violence, such as actual or threatened violence by patients’ partners against providers who reported likely intimate partner violence to law enforcement,62 or fear of violence among providers who provided contraception to women under 18 years of age.63 Providers who were low in the health facility hierarchy explained in multiple contexts that these infringements on their rights engendered behaviour at odds with their mission as healthcare providers, such as reluctance to provide care or mistreatment of patients.60

A significant subset of articles explained how the stigma associated with SRH may lead to social or professional isolation of health workers providing these services. In some contexts, health workers assisting in childbirth have lower status than other health workers, as childbirth was believed to be ‘women’s work’ or ‘dirty’.54 56 64 Studies on abortion stigma and abortion providers found that some experienced significant stress resulting from exclusion and condescension from their professional peers, at times so deep that they felt they had no colleagues to whom they could turn for clinical or moral support; and social condemnation of them and their families.65–72 Stigma can have a range of impacts on providers, including enhanced feelings of legal jeopardy.73 In addition, abortion providers in various contexts experienced violence, including murder66 68 as well as regular harassment from the police, even if they were acting within the confines of the law.18 74

While these studies are diverse in terms of focus, together, they illustrate some of the many ways that material, political, and social factors influence healthcare providers’ labour and other rights, and their experience of the workplace more broadly. Many papers linked these experiences to their ability and willingness to provide care, as assessed primarily through self-report.

Inadequate stewardship of the private sector

We considered both for profit and non-profit institutions not run by the government to be the private sector. Overall, we found few articles exploring private sector SRH provision and its regulation. The articles that we did find addressed a few discrete areas, including private sector midwifery, contraception services and abortion.

Several studies explored instances where, in the absence of adequate regulation, the profit motive potentially undermined the ethical obligations of health workers or the mission of the health sector overall. For example, a study assessing a government-supported private midwifery programme in Pakistan found that, in the context of financial pressures, skilled birth attendants from the private sector were disincentivised from providing services to poor, non-fee-paying patients.75 While the private sector provides family planning services to many patients in Uganda, Nalwadda et al found that these services were not necessarily well-regulated or monitored as part of the national reproductive health strategy.76

In the context of conscientious objection, we identified an article finding that some providers claimed conscientious objection in the public sector, and then provided the service (for a fee) in the private sector.41 Relatedly, people seeking abortion in legally restrictive environments could be diverted to the private sector, where there was a higher financial payoff for the risk assumed by the provider.77 In contrast, a study on a programme that contracted out maternity care in India found that at least some private providers felt that the contracting merely outsourced the risk of maternal mortality to private providers; these providers lacked the protection of a government employer.78

In sum, though limited in scope, the articles reviewed suggest that poor regulation of the private sector contributed to fragmentation and the impingement of financial motives in a way that could undercut fulfilment of healthcare worker responsibilities, altering their role to be more focused on making money. Providing SRH services in the private sector carried a different risk calculus, though this was found to be different in diverse contexts.

Competing paradigms for decision-making that are inconsistent with professional responsibilities

Many articles referred to or explicated conceptual frames that guided healthcare worker behaviour in ways that were inconsistent with professional responsibilities. These paradigms fell into a number of categories, but were typically in the general family of social mores and moral/religious values. Providers themselves acknowledged that these beliefs sometimes guided their decision-making about what kind of SRH care to provide and to which patients.43 Studies detailed provider stigma associated with a variety of patient populations, including adolescents45 76 79–81 LGBT individuals,81 unmarried women seeking SRH services82; HIV positive women who try to become pregnant or who are pregnant83–85 HIV positive people overall86; pregnant women with high parity or who are undocumented87; people who have mental illness83 or men who have sex with men seeking sexual health services.88 Beliefs were manifest in provider decisions such as refusal to provide certain services or making judgemental statements when providing care.89 90

Studies exploring the provision of abortion services found that providers might judge the patients based on a variety of factors relating to a religious or moral values or stigma, such as on whether or not the person seeking abortion was married,91 92 raped,41 the duration of her pregnancy and whether she was ‘convincing enough’ in articulating her desire for abortion, whether or not the sexual act that resulted in the pregnancy was socially sanctioned, and if contraception was used.41 43 93 94

Many papers explicitly sought to describe and assess the impact of provider religiosity on SRH care, sometimes as their primary research question. In contexts both with and without a formal conscientious objection regime, there were healthcare workers who explicitly said that they objected to abortion on religious grounds and would not provide it.35 43 65 93–97 A study in Malawi documented how this moral or religious objection extended to the provision of postabortion care, with healthcare workers interviewed describing women seeking post abortion care as ‘sinners’ or ‘criminals’.98

Quantitative cross-sectional studies assessing the association of provider religiosity with particular practices found that it was associated with support for conscientious objection,99 HIV stigma,100 negative attitudes towards abortion care101 and pharmacist unwillingness to dispense emergency contraception and medical abortifacients.102 Religiosity and other moral approaches to decision-making that compete with SRH guidelines and ethical guidelines were not static or monolithic; papers reviewed suggested they changed over time and in different contexts, with a diversity of opinions likely held by healthcare workers in the same facility.93 96 103

Providers are not just shaped by the broader social environment; they too, are active agents that shape that environment. For example, one study found that providers used their institutional power to encourage others to use conscientious objection, advancing their objective of decreasing the number of providers willing to provide abortions.44 In a different setting, hospital leadership, based on their own religious or moral codes, sought to limit the provision of abortion services in their own department by not facilitating staff training and not procuring manual vacuum aspiration kits.42 Finally, providers can seek to directly influence the decision-making of their own patients, such as by trying to convince women seeking an abortion not to obtain one, even if they have a legal right91; or dissuading adolescents from obtaining contraception,76 or anyone seeking fertility treatment.49

Several studies researched directly the question of how competing paradigms for decision-making might be reconciled with public health imperatives and healthcare worker responsibilities as these are enshrined in relevant national guidelines. Many providers included in these studies explained that their own or others’ religious convictions or moral concerns should be overridden by professional obligation to provide care18 93 94 99 104 or by their obligations to their employer or the ‘ethos of the hospital’70 105 by religious values relating to forgiveness106 or by payment to provide services to which they are purportedly religiously or morally opposed, such as abortion or FGM.26 37

Donor conditionalities and fragmentation

Most of the articles identified in this category evaluated the impact of the Global Gag Rule (GGR) or other conditionalities. As per the most recent iteration of the Rule (2017–2021), providers working for non-governmental organizations (NGOs) and private facilities that received bilateral US global health assistance or that had donors who received US global health assistance were disallowed from counselling their patients on abortion, undercutting their professional responsibilities, particularly in countries where abortion is permitted.107 108 Healthcare workers narrated how the GGR limited their ability to realise what they felt were their professional obligations, due to limited resources and limitations on what they could say, even in environments where abortion was already illegal or available on very limited grounds.109

In addition to research documenting the impact of the GGR, we identified one paper exploring how funding restrictions shape the environment in which healthcare workers work. The Helms Amendment, a US law that restricts the use of US government funds to provide or support abortion services, has reportedly had a chilling effect on NGO and health provider ability to provide abortion in humanitarian emergencies, despite the heightened need.110

Finally, one narrative review found that ‘new public management’ and other donor trends that resulted in cuts to the public sector wage bill and the marketisation of healthcare could harm healthcare worker rights and their ability to meet their responsibilities in providing maternal health services, though our search terms did not produce any other research assessing the impact of these broader trends on healthcare worker rights, roles and responsibilities within SRH.111

Persistence of embedded practical norms that are at odds with healthcare worker rights and responsibilities

Several papers that applied a social science lens to the SRH workforce relied on theories of informal norms or produced findings that the authors then pointed to as evidence of the importance of such informal norms. A review on midwives’ perspectives on disrespect and abuse of patients during the intrapartum period in sub-Saharan Africa found that prevailing professional norms played out in ways that established social distance between midwives and other providers and their patients, through controlling women’s bodies (eg, not letting them choose a birthing position) or withholding information about their status and care, relegating the woman in labour to the role of bystander; the review authors grouped these normative behaviours under an analytical theme of ‘maintaining midwives’ status’.64 Of the papers that explicitly described social distancing and disrespect and abuse as an informal norm, there was agreement that differences in social status between patients and providers as well as hospital set up and operations (eg, design of space, organisation of services, distribution of tasks) and medical education and training buttressed social distance.56 58 64 83 112 113 Research in India found further that provider fear of formal and informal accountability mechanisms mobilised by patients and their families deepened provider/patient distance; providers remained remote and invoked administrative safeguards to help to protect themselves from such mechanisms.113

Social distance did not apply to all patients equally. One study examined the quality of care for certain populations, finding that social distance and prioritisation of provider needs was more acute in the context of refugees, ethnic minorities and others for whom the health system setup is foreign.114 Such distinctions among clients may be expressed by, for example, an implicit norm of preferences—such as shorter wait times and nicer treatment—for patients who were friends and relatives of providers or who paid for the services provided.57 83 115

Papers exploring informal norms were not solely focused on provider responsibilities and roles regarding patient care. These norms can also undercut provider rights, particularly for those providers at the bottom of the hierarchy, and particularly for women providers. In addition to the vulnerability to assault mentioned earlier, nurses and midwives often worked within rigid hierarchical systems where disrespectful treatment by providers above them in the hierarchy was normalised, demands that they undertake unpleasant tasks outside of their scope of practice were prevalent, and seemingly arbitrary assertions of power by more senior providers were not easily mutable.2 54 116 117

Providers created informal arrangements in order to navigate a challenging environment, make a poorly resourced health facility function and protect their own rights. These arrangements were not necessarily consistent with their responsibilities. For example, in the face of unreasonable expectations and insufficient resources, Auxiliary Nurse Midwives in India sometimes intentionally decided not to apply their clinical knowledge to service provision (the so-called ‘know do gap’), by such behaviours as not sterilising equipment and augmenting labour. This included creating their own informal management system, such as informal rosters and manipulated labour room registers.51 Health providers explained that since they are the main interface with patients, they were often the ones who have to devise or implement such informal systems, such as asking women to pay for services or medicines that should be free because the governmental system of funding was not functioning properly39 or because they felt their remuneration was insufficient,51 and referring women in ways that were inconsistent with protocol because they lacked requisite personnel or equipment.118