Conscientious objection to abortion: Zambian healthcare practitioners' beliefs and practices.

The potential health consequences of limiting access to safe abortion make it imperative to understand how conscience-based refusal to provide legally permitted services is understood and carried out by healthcare practitioners. This in-depth study of conscientious objection to abortion provision in Zambia is based on qualitative interviews (N = 51) with practitioners working across the health system who object and do not object to providing abortion services in accordance with their cadre. Interviews were conducted in September 2015. Regardless of whether practitioners self-identified as providers or non-providers of abortion services, they presented similar religiously-informed understandings of abortion as a morally-challenging practice that is, or is not, shifted from iniquity to acceptability based on the reasons for which it has been requested or the likelihood of unsafe abortion if services are not provided. These contextual factors presented a series of tipping points for participants, rather than a single justification for providing abortion. Subsequently both groups reported that their decisions about providing services were complex and changeable, rather than clear one-time resolutions. This shaped their practices, both in terms of whether or not they provided services, and when and how they delivered them. Practitioners self-identifying as non-providers, and those self-identifying as providers, reported provision, counselling, and referral practices likely to lessen women's access to safe legal abortion. In this way, conscientious objection in practice could be understood as a continuum of behaviours rather than a binary position. Our results suggest that data on prevalence of claims to conscientious objector status may underestimate the impact of practitioners' religious, moral and ethical beliefs on abortion accessibility. In Zambia, eliminating practitioners' right to conscientious objection alone or conducting rights-based advocacy may therefore not significantly increase access to safe abortion.