'Doing the wrong thing for the right reason' Australian nurses' and midwives' experience of providing abortion care to people victimised by gender-based violence

When a pregnancy-capable person is assaulted, abused, or killed, it is usually at the hands of a male partner or family member. Fatal and non-fatal injuries, chronic health conditions and risky behaviours are all outcomes of gender-based violence (GBV); furthermore, GBV can often lead to unplanned pregnancies. Abortion is, therefore, a predictable outcome for this population. Nurses and midwives are intrinsically involved in the care of pregnant people victimised by GBV. They could be instrumental in providing reproductive justice outcomes such as early intervention, support, and coordination of support services. However, limited research exists to explain how this occurs within abortion care. Effective GBV responses often require a multiagency approach; therefore, services across a range of Australian sectors such as health, women’s safety, and law enforcement could benefit from understanding how nurses and midwives provide abortion care to people victimised by GBV. To address this gap, I aimed to 1) explain the process through which Australian nurses and midwives provide abortion care to people victimised by GBV and 2) explore how the elements of the broader healthcare situation affect the provision of abortion care to people victimised by GBV. I approached the research with a third-wave feminist lens, designing a two-phased multiple methods study combining constructivist grounded theory and situational analysis—such an approach located research participants’ actions in the larger social and power contexts. To assist readers in understanding the scope of the research topic, I commenced the thesis with a scoping literature review of the role and scope of nurses and midwives in the provision of abortion care. The review demonstrates that abortion care is a common procedure performed across many healthcare settings and shows that nurses and midwives provide technical and psychosocial care within their roles. However, the review also highlights that the scope of practice of nurses and midwives within abortion care is probably unnecessarily restrictive. Notably (and foreshadowing the findings of this thesis study), it exposes a lack of person-centred models of abortion care. My research reveals that the Australian abortion arena is expansive and contains multiple sites of power and contested action, which contributed to the research participants’ belief that people seeking abortions in the context of GBV were mostly uncatered for. Participants described a workforce unprepared to provide abortion care generally, or a GBV safety-net more specifically. Pro-life colleagues were seen to centre conscientious objection over patient care, and the workplace environment placed clinicians’ and patients’ safety at risk. Consequently, participants underwent a process I labelled working with or against the system contingent on the degree to which the system was person-centred. When participants encountered barriers to person-centred abortion care, they bent or broke the law, local policy, and cultural norms to facilitate timely holistic care. Though many participants felt professionally compromised, their resolve to continue working against the system continued. They were aided by larger social groups – Smugglers, Navigators, Marie Stopes Australia, and the Family Safety Framework – which came together to resist systemic oppression in an attempt to achieve reproductive/social justice. I used the theoretical conceptualisation of resistance in health and healthcare to unify the findings of the thesis project. My thesis findings support a cultural shift and reorientation of health services to support reproductive justice. First and foremost, my findings support the involvement of nurses and midwives in the creation of healthcare policy, programming, and legislation. This includes their involvement in pro-choice hiring policies, design and facilitation of GBV and abortion care training, and the implementation and evaluation of comprehensive abortion care frameworks, that cater for diversity and offer trauma-informed and flexible care. Furthermore, expanding the scope of nurses and midwives to provide medical abortion, particularly in primary care, would address the current service gap, which compels these clinicians to undermine the current system. Many of these changes could be achieved if health services adopted the World Health Organisation’s technical and policy guidelines for abortion care. However, this will require amendments to regulatory structures, funding models and relaxation of prescribing and abortion procurement restrictions. My findings also highlight a dual loyalty issue between the Nursing and Midwifery Board of Australia’s (NMBA) requirement for clinicians to provide person-centred care and comply with legislation, regulations, policies, and guidelines. A key recommendation is that the NMBA reconsider their position where such complicity would lead to human/reproductive rights violations. This thesis has made a significant contribution to the body of knowledge concerning abortion care of marginalised people. Looking forward, the thesis findings and recommendations could be implemented at the practice level and beyond to improve reproductive justice outcomes for people in Australia.