Structural stigmatisation of abortion in the health system: Perspectives of abortion care-seekers, providers, managers, and funders in England and Wales.

Abortion has been legally permitted in England and Wales for over fifty years, yet this health service continues to be stigmatised within the health system. Stigma is a dominant focus of abortion research, but a structural stigma framework is rarely used to understand how abortion stigma is produced at a macro-level. This study explored how structural abortion stigma is produced and experienced in the health systems of England and Wales, and its influence on person-centred care, including choice of abortion methods. Data from in-depth interviews with abortion care-seekers in 2022-23 and from key informant interviews with abortion care providers, managers, and commissioners in 2021 were analysed using reflexive thematic analysis. From the perspectives of key informants, structural abortion stigma is produced through the avoidance of abortion by decision-makers, the permitting of conscientious objection, and the exclusion of abortion from mainstream healthcare. These factors create health system pressures which increase abortion service fragility. The resulting vulnerability of abortion services reduces access to person-centred care, including abortion method choice, which can reinforce individual-level stigma. There are tensions between care-seekers' experiences of specialist abortion care as less stigmatising, while the 'abortion clinic' becomes a site of stigma due to its segregation from mainstream healthcare. This research contributes to a structural understanding of abortion stigma by identifying some of the mechanisms through which structural stigma is produced within health system institutions, and how these forms of institutional stigma might be resisted or dismantled. Power is essential to the (re)production of structural stigma within the health system, which can reinforce individual-level stigma for both care-seekers and providers. Restrictions on method choice and the increasing reliance on medication abortion can be a product of structural abortion stigma, and these limitations on method choice can also reproduce stigma at the individual level.