Pregnancy recognition.

The majority of women recognized their pregnancies during the first trimester, including all the women who ultimately terminated their pregnancies and two of the four women who carried to term. When asked how they recognized that they were pregnant, some women explained that they experienced delays in menstruation and/or common signs of pregnancy, such as dizziness and exhaustion. Two women found out they were pregnant in the second trimester. One woman reported that she believed her symptoms were related to an illness rather than pregnancy: ‘I only found out when I fainted. So I went for some tests thinking that it was perhaps diabetes, since there is a history of this disease in my family. Then I decided to do a [pregnancy test], which turned out positive’ (ID8, 20 weeks, carried to term). The other woman who was in her fourth month when she recognized the pregnancy explained that her menstruation was irregular, sometimes with delays up to 28 weeks, and that she took a test only when she started feeling tired and dizzy (ID1, 16 weeks, carried to term). Five women reported using pharmacy-bought pregnancy tests, available to women without prescription in pharmacies but at a cost, before seeking abortion services at a facility. Pregnancy tests are more accessible to women who are able to pay for them, thereby potentially delaying pregnancy recognition and consequently abortion-seeking for many women.

Reasons for seeking an abortion.

Across the sample, one of the primary reasons reported for seeking abortion was maternal health concern. Three out of four of the women who ultimately carried to term and three out of nine who terminated their pregnancies sought abortion for health reasons. Health concerns varied, from fainting, dizziness, and anemia, thrombosis and blood clots, diabetes and large organ failure.

Several others reasons for abortion were also mentioned, including lack of financial resources, birth spacing, advanced age, and being unmarried. Some women explained that they did not want any more children, due to the physical, financial, social and psychological demands required. One woman concerned that having a child would prohibit her from being able to work and meet financial requirements: ‘You have no idea how difficult it is to rent. It is very, very expensive. It is impossible! My husband cannot pay for everything alone, and as I told you, I cannot put my daughter in baby daycare to be able to go and work. I have to wait until she is one year old’ (ID13, 6 weeks, medication and surgical abortion). Another woman explained that she already had young children and wanted to space her births: ‘And me pregnant, taking care of my 10-month-old daughter, how would I have managed? When I am fainting? Should my husband take a leave from work? Should my mother leave her work?’ (ID13, 6 weeks, medication and surgical abortion).

All four women who identified as single and nulliparous said their relationship status was part of the reason for seeking abortion. One of these women was pressured to seek abortion by her fiancé because they were not married, even though she wanted to continue the pregnancy: 'Yes, he was always saying “you have to have an abortion, you have to have an abortion” so that I would go ahead. I was saying “no” and he was saying “yes”. In the end this created some problems in our relationship, and finally I gave in to avoid any escalation’ (ID8, 20 weeks, carried to term). Another woman talked about the consequences she felt she deserved: ‘I did not want to have a child without being married. I accepted all the punishment and my responsibilities, and I swore to myself that I would never [have sex again] except after being married’ (ID10, 9 weeks, surgical abortion).

Denied for gestational age.

Women denied for gestational age were turned away for being too early and too far along in pregnancy. One woman was told she was too early for medical abortion, one woman reported denial both for being too early and, later in the pregnancy, for being too far along, and two other women were denied from public facilities because they were beyond the facility gestational limit.

One woman who was denied medical abortion for being too early in her pregnancy sought abortion at three weeks gestation and explained: ‘…they did not go ahead at first, because they told me that the fetus had to grow a bit more before they could give me pills’ (ID11, 3 weeks, methotrexate and medication abortion). She was later diagnosed with and treated for an ectopic pregnancy.

The other woman who sought services early in her first trimester, reportedly at one week, was originally told to return later: ‘In fact when I was already one week pregnant, she told me that the fetus was too small for a sonogram…I responded that I had a blood test which was positive. She told me to come to see her in one month. They made me come and go until the fetus was big enough’ (ID12, 1 week, carried to term). She later returned for a sonogram and was then referred from one public hospital to another, until she was ultimately sent back to the original facility where she sought care. There, she was denied abortion again due to advanced gestational age, even though she believed that she was only six weeks pregnant at the time and that the provider was inaccurately reading the ultrasound: ‘When I went the last time, she did a sonogram and she lied telling me that I was at the third month. I responded that the previous time she had told me that I was one week pregnant and now I am three months pregnant, and how could that happen so fast? [The provider said] “He’s developed, it’s a sin”‘ (ID12, 1 week, carried to term).

Neither this woman, nor the other two women who were turned away for being over the gestational limits were aware of their legal right to access abortion after 12 weeks for mental and physical health reasons and only one of them was evaluated for a second trimester abortion according to the physical and mental health exceptions. This woman, whose husband pressured her to have an abortion despite her desire to carry the pregnancy to term, received a psychiatric assessment at 20 weeks gestation but did not receive a certificate for abortion.

High costs and lack of partner support prevented two women from obtaining care at the private clinic where they had been referred after being denied services for being beyond the gestational limit at a public facility. The woman who was denied during her process for both early and later gestation was asked whether she tried to go to a private clinic she replied: ‘No, I would have liked to. I talked to my husband about it, but he refused, and asked me to keep the baby. He is the one who told me to keep the baby. He said he could spend two hundred dinars for me, but “Imagine how god will punish you after”‘ (ID12, 1 week, carried to term). Another woman also describes trying to get financial support from her husband: ‘He promised to give me money for an abortion and now that it is the fourth month, I will not be able to have an abortion. He was just making fun of me’ (ID6, 16 weeks, carried to term). The third woman did seek private care after being denied at a public facility only to then be intimidated and persuaded by the private doctor to not have the abortion after all: ‘When I went to the doctor’s he told me that I was taking a bigger risk in aborting the pregnancy than in staying pregnant, meaning that if I stayed pregnant I would be under control but if I had an abortion I would risk a hemorrhage and I would become sick. In brief, I kept the baby because I was at risk and that’s it’ (ID1, 16 weeks, carried to term).

Denied for health conditions.

Women were also denied services and referred for various health reasons. Women reported being referred to other facilities because they were diabetic, had asthma, and had previously taken an anticoagulant medication for blood clotting. Women expressed confusion about why their health conditions were impacting their access to abortion care. The woman who was referred from one hospital to another because she was asthmatic believed her condition had nothing to do with her abortion.

[At Hospital 4] they told me that since I had asthma, I had to go to Hospital 2[…]. I told her that I wasn’t ill, and that she should prescribe the abortion. […] She told me that I had to go to Hospital 2 for an abortion and that here [at Hospital 4] they no longer performed abortions. When I told her I wasn’t ill, and that I was sure of my decision, she told me to go to Hospital 2, and that they performed abortion there’ (ID13, 6 weeks, medication and surgical abortion).

Later when she went to Hospital 2, she was told that they did not perform abortions (‘There at the counter, I saw a woman who told me that they did not do abortions there…Directly! She did not even ask me why or how!’) and was then sent to another hospital, where she was told she would have to wait two months (‘Same thing there, the midwife said: “Now, no. We will do it in a month or two.”‘).

The woman who was denied care because of potential blood clotting explained that her denial was based on the fact that she had taken an anticoagulant medication during her previous pregnancy. But since she was no longer taking the medication (a provider told her that she no longer needs it), she was confused as to why this would preclude her from getting an abortion:

I: In your opinion, why did they turn you down on an abortion?

Honestly, I do not know. Maybe because previously, with my youngest son, I was taking Sintrom. She told me that because I was taking Sintrom, they could not do an abortion.

I: And why are you taking Sintrom?

Because during my previous pregnancy one of the arteries in my lungs became obstructed. …I took it for two years, or perhaps one year and a half. Then they saw that I was doing better, and they told me to stop completely.

I: But now that you are pregnant, you are not taking Sintrom.

No, now luckily, now I am doing fine. (ID12, 1 week, carried to term)

In some cases, women sought abortion due to concerns about health conditions, but instead the clinic used those conditions as a reason to deny care. For example, one woman, aged 43 years old, sought abortion because of her diabetes and her advanced age but was then denied care because she was diabetic: ‘The doctor denied the abortion. She said it was because I was diabetic and that I had to go to the hospital. But [at the hospital], they sent me back because my glucose levels were not very high… [even though] the doctor had told me that if she did it, it would be complicated because of the diabetes’ (ID3, 4 weeks, medication abortion). In other cases, women were not given the opportunity to explain their health concerns to their providers. One woman explained why she believed she was not physically able to have another child: ‘My body will not be able to cope. I have anemia, and sometimes I get dizzy. My situation is hard… I am exhausted at the highest level!’ (ID6, 16 weeks, carried to term). But when she went to a hospital for care, they denied her services immediately without asking why she wanted an abortion and referred her to a private clinic instead (due to her advanced gestational age), where she was unable to afford the cost of services. Another woman, who was left with no choice but to continue the pregnancy, sought abortion because she was anemic and had thrombosis but was denied at a public hospital without being asked why she wanted an abortion: ‘[At the hospital] she told me that we were not having an abortion, without asking me any questions, she told me we weren’t having an abortion because the child was already developed’ (ID1, 14 weeks, carried to term). In contrast, one woman who did have the opportunity to explain her health concerns to her provider received very different treatment: ‘I told [the provider] that I was ill, and you know the conditions of my life and all, and my health. I consulted him, and he said that if you are ill, you are obliged to have an abortion, and the doctor who was monitoring my health [at another facility] said the same thing. She told me to have an abortion’ (ID4, 5 weeks, medication abortion).

Denied for logistical and bureaucratic delays.

Several women were not explicitly denied care but instead told to wait long periods or to go home and return later for care. This was considered a denial of care because women were not able to get the care they wanted on that day and they reported it was unlikely that they would ever have successfully obtained an abortion at the given facility. Some women were made to wait for many hours: ‘To begin with at the hospital, you have to find a doctor […] we spent the whole day there. We went from 8 am to 5 pm and in the end the doctor did not come, and sometimes, when you are waiting in line, you go for a snack, and then come back, and you cannot find the doctor and you cannot say anything’ (ID7, 8 weeks, medication abortion). Many women described being referred back and forth between departments at a hospital or between facilities: ‘…as you know they send you from one service department to another, and this one will not handle your case, nor the other. We really had a hard time then’ (ID11, 3 weeks, methotrexate and medication abortion). Other women were told to return on another day, sometimes weeks in the future; for example: ‘You have to wait more than a week. It does not matter to them that this is an emergency … They take their time…Can you imagine waiting 3 days for a test, and 3 more days for a sonogram, and 4 days to see the doctor… If you add up the days you will see that the whole month has gone by…’ (ID9, 6 weeks, surgical abortion).

Many of the women who faced delays in public facilities left and went to private clinics because they were worried the delays would limit their ability to have an abortion. One woman was sent back and forth between providers at Hospital 2 for five days, during which time she said it was difficult to leave her children at home alone. She explained: ‘It was already my second month, and when I went to see them they gave me an appointment for a sonogram in two weeks. And I thought that in the interim the fetus would …grow too much. So I went to a private practice doctor’ (ID2, 8 weeks, surgical abortion). Another woman returned to the same hospital eight times and then decided to seek care at a private clinic: ‘I don’t remember when I went there, but I know that I went there eight times, and that this took too much time, and so I went to a private clinic…’ (ID5, unknown gestation, medication and surgical abortion). Two women refused to wait for services at a hospital after they realized that the doctors had gone on strike; instead they went to private clinics where they obtained surgical abortions:

At Hospital 1 they are slow…they said either that the doctors were on strike, or that the test results would only be ready in three to six days, or this, and that…so that it meant everything would take a lot of time, do you understand? […] And this didn’t work for me considering that I was already one and half months pregnant. It was an emergency, and I was not going to wait. (ID9, 6 weeks, surgical abortion)

[…] I went for the test and the sonogram but the doctor was not there because they were on strike. I understood that this meant more delay. I borrowed money from someone and I went for an abortion at a [private] clinic for 250 DT (~$150). (ID10, 9 weeks, surgical abortion)

Women were frustrated that they could not hold the providers and facilities responsible for delaying their care and potentially making it more difficult if not impossible to receive an abortion. One woman who had an incomplete medication abortion following care at a hospital endured bleeding for a month and a half until she could receive a surgical procedure at a private facility to complete the abortion. She visited two health centers and then two hospitals before she gave up on the public sector due to delays and explained how the referral system failed her:

‘The problem is that they do not give any written papers, no proof which could harm them… Normally, Hospital 4 should have given me a paper. They did not give me one… they do not give you any proof and just leave you as is… if I wanted to file a complaint, I do not have any papers… There was no supervision. If there were supervision for everything, then things would not happen this way’ (ID13, 6 weeks, medication and surgical abortion).