Navigating structural and personal dilemmas: a phenomenological study of midwives providing legal abortion care in Nampula, Mozambique

Legal reform allowing abortion is often considered a proxy for the provision of services. While the law establishes a legal framework, the provision of services is closely tied to the engagement of midwives in service delivery. In 2014, Mozambique decriminalised abortion under specific conditions. Studies of this legal reform focus on the experience of pregnant women, leaving the experience of midwives largely unexplored. This study focuses on midwives providing abortion services to young women (ages 15-24). A qualitative phenomenological study was conducted in Nampula province, northern Mozambique. In-depth interviews were conducted with 10 purposively selected midwives across six primary healthcare facilities in three districts. Inductive thematic analysis was employed, and an intersectionality lens guided the discussion. We employed continuous reflection and adhered to COREQ guidelines for the conduct, analysis and reporting of this study. Despite general support among midwives for abortion service availability and provision, some expressed distress and objections to providing the service themselves. A complex interplay between structural and personal factors was significant in shaping their experiences. Traumatic encounters with abortion-related complications emerged as the central factor behind their distress and objections. The intersections of personal factors with structural dilemmas, including a few health facilities authorised to provide services, a lack of abortion medicines, and legal restrictions for adolescents under age 16, shaped their professional experience, often leading to work-related distress, and challenged their willingness to provide services. Policy efforts should address these barriers, prioritising expansion of service provision, alignment with human rights standards, and midwife training and support.