Factors influencing obstetricians' acceptance of termination of pregnancy beyond the first trimester: a qualitative study.

Abstract

Background: In Belgium, termination of pregnancy after the first trimester is exclusively allowed on medical grounds. When faced with fetal or maternal health complications during pregnancy, patients typically turn to obstetricians for guidance on the diagnosis, prognosis, and available options. Patients' decisions and their actual access to termination of pregnancy can be profoundly influenced by the quality of this counselling and the willingness of professionals to present termination as an acceptable option. This paper aims to explore the factors influencing obstetricians' acceptance of TOP requests after the first trimester of pregnancy. We subsequently analyze these acceptance dynamics from a multidisciplinary angle, incorporating ethical perspectives and a socio-legal exploration into how the interviewed health professionals experience, interpret, and apply the law.

Methods: We conducted an interview study with 23 hospital obstetricians who had prior experience with termination of pregnancy decision-making beyond the first trimester in Flanders, Belgium. Interviews, on average, lasted 1h30 and followed a semi-structured format guided by a topic guide. The transcripts were coded with NVivo software and subsequently thematically analyzed by a multidisciplinary research team to provide a comprehensive understanding of obstetricians' acceptance of termination of pregnancy after the first trimester.

Results: Obstetricians' acceptance of termination of pregnancy after the first trimester mainly depends on the presence of compelling clinical factors. Secondary factors, including patient/couple preferences, institutional and collegial processes, timing and viability, technical considerations, obstetricians' ethical and professional values, the wider background of the patient/couple, and perception of alternatives, could sway decisions in the absence of compelling clinical factors.

Conclusions: Secondary factors help sway obstetricians' decisions in favor of or against termination of pregnancy after 12 weeks when a request is characterized by inconclusive clinical factors. The multifactorial acceptance dynamics of obstetricians illustrate the limits of a strong emphasis on fetal interest argumentation. Moreover, they exhibit a degree of divergence and complexity absent from the Belgian Abortion Law. The presented typology of factors could stimulate and guide debates on legal reform and the importance that should be attributed to various factors in professional decision-making on termination of pregnancy.