Ten OB/GYN clinicians and five OB/GYN medical residents participated in the study. Eight participants identified as male and seven identified as female. The average age of clinicians was 45.6 years, and the average age of medical residents was 30.0 years. Almost half of the participants were Catholic (n = 7) and five expressed some kind of spirituality. The average length of practice for clinicians was 20.0 years and the average length of practice for residents was 2.2 years. All participants worked in the public sector, with eight also working part-time in the private sector. The majority (n = 12) of participants worked in tertiary facilities and fourteen identified the facilities in which they worked as urban. Table 1 displays further demographic details of study participants and characteristics of the facility in which they worked.

Table 1 Demographic characteristics of study participants

Knowledge of extra-legal abortion and PAC

All clinicians and medical residents expressed knowledge of at least one way that individuals induce abortions themselves. Participants identified medication as the most common method to induce abortion outside of the formal health system; some participants referred only to this generically as “medicine,” whereas others specifically called out the use of prostaglandins for induced termination of pregnancy. For example, one clinician stated:

“Well, here there has always been a clandestine market of prostaglandins, of misoprostol, so patients buy them and take them, ingest them, apply them intravaginally and thus begin their process of terminating their pregnancy.” – Clinician, male, 61 years old.

While participants were aware of the use of medication to induce abortion and the process by which it worked, study participants were less knowledgeable about the correct dosage, with one clinician saying:

“… I also have no experience prescribing dosage and prescribing treatments of induced abortions, so I do not feel comfortable giving advice that I have not done and that I do not feel comfortable doing…” – Clinician, male, 31 years old.

Instead, study participants discussed their familiarity with providing care to individuals who spontaneously miscarried, noting that “there is a guide for abortions, but the abortion guide that exists… are abortion guides for spontaneous abortion” (Clinician, male, 58 years old).

Regarding medication abortion, most study participants discussed their awareness of the use of medication abortion, procured extra-legally, among their patients. They often noted their inability to distinguish between induced and spontaneous abortions:

“… I’ve probably given care to more than one [induced abortion client], but without them telling me it was induced. On the other hand, they just arrive at the institution with the abortion happening, and we don’t have a way to know if it was induced or not. So, well, we put them in, too, the induced ones and the spontaneous ones together.” – Clinician, female, 42 years old.

A few study participants were more specific, stating that if an individual had used abortion medication to induce a termination of pregnancy that was accomplished, “… through pills… they have already been dissolved when [patients] come in for a consult” (Clinician, male, 40 years old). The same clinician noted that individuals are unlikely to disclose that they had induced an extra-legal abortion, unless speaking out of fear for their health.

Study participants also discussed other ways that individuals induce termination of pregnancy or seek abortion outside of the Costa Rican healthcare system. Methods discussed included travel to other countries where abortion medication could be purchased over the counter, or where safe abortion services could be provided legally, using Google to locate abortion services, or finding a private clinician in Costa Rica to provide services clandestinely. Only one clinician suggested that individuals with an unwanted pregnancy would insert a foreign object to induce an abortion, while another stated that she did not believe foreign objects were used to induce abortion in Costa Rica anymore.

Attitudes towards extra-legal abortion and PAC

More than half of the study participants spoke about the importance of non-judgement when providing PAC for both individuals with spontaneous abortions and individuals that had obtained extra-legal abortions. One clinician, who, unlike others, believed that he could distinguish between induced and spontaneous abortions, stated:

“Yes, many times it is known. One touches and pulls misoprostol pills from [the] back of the vagina. And you know that happened, but you don’t judge.” – Clinician, male, 58 years old.

These same participants emphasized the importance of providing support to the patients under their care. They defined this care as providing not only healthcare but emotional and educational support. One medical resident spoke at length about his beliefs about what happens when individuals seek out extra-legal abortion services, and the role that a clinician should play versus what actually happens:

“… It seems to me that there should be a personal connection… So, my feeling is that it’s due to the fact that it’s an illegal situation, so to speak, [there is] … a lot of abandonment of the patient and perhaps a very lonely experience for the woman.” – Medical resident, male, 33 years old.

Ultimately, many study participants spoke about the positive feelings they have providing care to individuals in need. They clarified that their job was to provide care in line with what the patient needed:

“I feel good from the point of view that I … tend to be a professional who gives you the appropriate support. And I’m clear that I give it even when I know it was an induced abortion… It is something that happened, that she decided and that’s it. And, as I tell you, it doesn’t change my care. I see a miscarriage as exactly the same as an induced abortion. So, I feel like I’m at least contributing from that side as well as respecting their decision. I think I feel, let’s just say good.” – Clinician, male, 31 years old.

A medical resident summarized the experience of many other study participants succinctly emphasizing the importance of empathy:

“I think this is more about empathy with the patients. Knowing how to understand them, to put yourself in their shoes, seems to me to be important. So I do consider that I have the ability or the facility to be empathetic with patients.” – Medical resident, female, 28 years old.

Despite the illegality of most induced abortions, many study participants did not express bias towards individuals who needed treatment for complications from unsafe abortions. Instead, they highlighted their role as a sympathetic healthcare provider to all individuals in need.

Practices around extra-legal abortion and PAC

When asked about providing induced abortion services, study participants almost always first stated that induced abortions were not provided at their place of work. No participants disclosed direct experience with providing extra-legal abortions or those permitted within the Norma Técnica. Most participants did describe receiving training to care for pregnant individuals experiencing incomplete spontaneous abortion. As one clinician explained:

“… [In medical residency] we learned very little about abortion techniques. We just learned in the specialty, but for retained abortions, little ones who died inside the womb. Things like that.” – Clinician, male, 58 years old.

After discussing their learning about how to provide PAC for retained products of conception, study participants often spoke about their actual practice. The same study participants reiterated that the techniques they learned in medical school and residency were targeted towards evacuating fetal remains after a spontaneous abortion. They were not trained to induce abortions, but only provided services to patients who were carrying a deceased fetus. Participants did not discuss the use of medication to remove fetal remains, but instead spoke about expectant management. As one participant explained:

“Okay, if you have an abortion it means the fetus is dead. That is, if the fetus has already died, then there are several alternatives for management. One, which is expectant management, which is waiting until the body induces the termination of pregnancy, either with contractions, bleeding and all that. Two, here we don’t have prostaglandins. Well, we have Dinoprostone [prostaglandin E2]. We don’t have misoprostol for use.” – Clinician, male, 61 years old.

With regards to suspected extra-legal abortions, clinicians and medical residents spoke mostly about policies and procedures that they were expected to follow and not their own personal practices:

“If she arrives at the hospital and has the misoprostol pill in her vagina, you have to call the OIJ, the Judicial Investigation Agency; and the Judicial Investigation Agency begins the process, because she is being tried for homicide… then, the police arrive and if the girl is not unstable or if she does not require emergency medical attention, they even take her away.” – Clinician, female, 48 years old.

Although study participants stated that there was sometimes difficulty determining who had induced an abortion versus suffered a spontaneous abortion, only one study participant specifically stated that clinicians would not notify authorities if they knew they were caring for a patient who had sought extra-legal abortion services, saying:

“Nothing happens, they are not interrogated, the police are not going to be called to do something to them. They are given care, the uterus is cleaned and they are offered a method of postabortion planning, psychological counseling if necessary and that’s it, done. Nothing happens.” – Clinician, male, 58 years old.

No study participants discussed their personal opinion about their place of work’s policies or procedures, but rather, detailed the steps that they were expected to take when confronted with potential illegal activity without disclosing what they would do themselves.

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