Background

Abortion remains a major public health concern worldwide, particularly in regions where restrictive legal frameworks, personal beliefs, and social stigma influence the accessibility and delivery of healthcare services (Ministry of Health, 2019; Turner et al., 2011; World Health Organization (WHO), 2024). In Rwanda, the 2018 revision of the Penal Code expanded the circumstances under which safe abortion is permitted, including cases of rape, incest, forced marriage, and risks to the health of the woman or fetus (Ministry of Health, 2019). Despite these legal advancements, challenges persist in the effective implementation of abortion services, largely due to healthcare professionals’ limited knowledge, varying perceptions, and ambivalence regarding the provision of such care (Rutayisire et al., 2022).

Rwanda is among only 12 countries globally that permit abortion on socio-economic grounds (Category II) and one of only three countries in Africa, alongside Ethiopia and Zambia, to do so (Center for Reproductive Rights, 2023). As a leading tertiary healthcare institution in Rwanda, King Faisal Hospital (KFH) plays a pivotal role in providing comprehensive reproductive healthcare services. Assessing healthcare professionals’ knowledge, perceptions, and barriers related to safe abortion is essential to ensuring the provision of high-quality, patient-centered care.

Existing literature indicates that many healthcare providers in Rwanda continue to experience uncertainty regarding their rights and responsibilities under the liberalized abortion law, resulting in ambiguities in clinical practice (Musabwasoni et al., 2022). In addition, healthcare providers frequently experience both professional and personal stigma, which can negatively affect their psychological well-being and willingness to participate in abortion care (Balcha et al., 2022; Bright et al., 2024; Musabwasoni et al., 2022). Consequently, even in legally permissible settings, the availability of safe abortion services may remain limited.

Given these challenges, there is a need to better understand the barriers to safe abortion provision among healthcare providers in Rwanda. This study therefore aimed to assess these barriers among healthcare providers in the Department of Obstetrics and Gynecology at KFH. The findings are expected to inform strategies to improve the quality and accessibility of safe abortion services.

Methods

This was a prospective cross-sectional study conducted to assess the knowledge, perceptions, acceptability, and barriers related to safe abortion among healthcare providers in the Department of Obstetrics and Gynecology at King Faisal Hospital (KFH). Participants included obstetricians and gynecologists, general practitioners, nurses, and midwives working in the department.

Data collection began after ethical approval from the KFH Institutional Review Board (Ref: KFH/2025/331/IRB), and was conducted over four weeks. Trained research assistants distributed structured questionnaires in person to consenting participants. Data were then entered into EpiData version 3.1 and exported to Stata version 13 for analysis. Categorical variables were summarized using frequencies and percentages. A composite knowledge score (range: 0–8) was calculated by assigning one point for each correct response and categorized as poor, moderate, or good knowledge. Chi-square tests and logistic regression were used to examine associations between predictor variables and study outcomes. Statistical significance was set at p < 0.05.

Results

A total of 48 healthcare providers participated in the study. The mean age of the participants was 35.2 ± 5.9 years. Most participants were married (81.3%, n = 39), while 18.8% (n = 9) were single. Midwives constituted the majority of the study population (81.3%, n = 39), followed by gynecology residents (8.3%, n = 4) and nurses (8.3%, n = 4), whereas only one participant (2.1%) was a gynecologist. Regarding religious affiliation, half of the participants were Catholic (50.0%, n = 24), 35.4% (n = 17) were Protestant, and 14.6% (n = 7) reported no religious affiliation. Half of the participants (50%) demonstrated good knowledge of the legal abortion law, while 42% had moderate knowledge and 8% had poor knowledge.

Participants demonstrated generally supportive attitudes toward safe abortion, particularly in relation to its role in women’s rights and health outcomes. A large majority agreed or strongly agreed that safe abortion is a fundamental component of women’s reproductive rights (77.1%) and that its legalization can reduce maternal morbidity and mortality (85.4%). Similarly, 73.0% agreed that women should have the autonomy to decide whether to terminate a pregnancy, although 10.4% were neutral and 16.7% disagreed.

Despite this general support, ethical and personal belief-related tensions were evident. Half of the participants (50.0%) agreed that providing safe abortion services contradicts their personal values or beliefs, while 31.3% remained neutral. In addition, 35.4% reported feeling morally conflicted when involved in abortion-related care.

Regarding professional responsibility, 54.2% agreed that providing safe abortion services is part of their professional role, whereas 25.0% remained neutral and 20.9% disagreed. Most participants (85.5%) also agreed that safe abortion services should only be provided under specific medical or legal circumstances. In addition, 62.5% agreed that providing abortion services might lead to misuse or an increase in unwanted pregnancies, whereas 8.3% were neutral and 29.2% disagreed. Overall, 58.0% of participants reported supporting the provision of safe abortion services, while the remaining 42.0% either opposed or were neutral toward service provision.

Reported barriers to the provision of safe abortion services were multifactorial, encompassing policy, institutional, knowledge-related, and personal domains. Among the policy-related barriers, fear of legal consequences was the most frequently reported (52.1%, n = 25), followed by the lack of institutional protocols (47.9%, n = 23), limited support from hospital leadership (33.3%, n = 16), and ambiguity in national abortion laws (20.8%, n = 10). Personal beliefs constituted the most prominent barrier overall, with 87.5% (n = 42) of participants reporting that religious or moral beliefs influenced the provision of abortion services. More than half of the participants (58.3%, n = 28) also reported insufficient knowledge or training related to safe abortion. In addition, fear of legal repercussions (47.9%, n = 23), fear of stigma (31.3%, n = 15), and ethical concerns (31.3%, n = 15) were commonly reported barriers, highlighting the legal, institutional, and personal challenges that may limit the provision of safe abortion services.

Most sociodemographic characteristics, including age, sex, marital status, profession, and religion, were not significantly associated with good knowledge of safe abortion (all p > 0.05). However, receiving formal training on safe abortion was significantly associated with good knowledge. Participants who had received formal training were more likely to demonstrate good knowledge than those without training (75.0% vs. 32.1%; OR = 6.33, 95% CI: 1.75–22.91; p = 0.005) (Table 1).

Table 1.Sociodemographic and Training-Related Factors Associated with knowledge level of healthcare providers, in Obstetrics and Gynecology at King Faisal Hospital
Predictors Good Moderate/Poor OR (95% CI) P value
Age
≤35 17 (53.1%) 15 (46.9%) 1.46 (0.43-4.87) 0.541
>35 years 7 (43.7%) 9 (56.3%) Ref
Gender
Male 12 (66.7%) 6 (33.3%) 3.0 (0.88-10.18) 0.078
Female 12 (40.0%) 18 (60.0%) Ref
Marital status
Married 18 (46.15%) 21 (53.85%) 2.33 (0.51-10.70) 0.275
Single 6 (66.67%) 3 (33.33%) Ref
Profession
Gynecologist/Resident 2 (40%) 3 (60%) Ref
Nurse/Midwife 22 (51.2%) 21 (48.8%) 1.51 (0.24-10.36) 0.639
Religion
Catholic 10 (41.7%) 14 (58.3%) Ref
Protestant 10 (58.8%) 7 (41.2%) 2.0 (0.56-7.06) 0.282
No religion 4 (57.1%) 3 (42.9%) 1.86 (0.34-10.24) 0.472
Received formal training on safe abortion
Yes 15 (75.0%) 5 (25.0%) 6.33 (1.75-22.91) 0.005
No 9 (32.1%) 19 (67.9%) Ref

Age, sex, and formal training were significantly associated with the acceptability of safe abortion service provision. Participants aged ≤30 years had significantly higher odds of reporting greater acceptability than those aged >30 years (OR = 9.00, 95% CI: 2.25–35.98; p = 0.002). Male participants were also more likely than female participants to report greater acceptability (OR = 6.54, 95% CI: 1.56–27.46; p = 0.010). Similarly, participants who had received formal training on safe abortion had significantly higher odds of accepting safe abortion service provision than those without formal training (OR = 5.33, 95% CI: 1.41–20.10; p = 0.013). Marital status, profession, and religion were not significantly associated with the acceptability of safe abortion service provision (Table 2).

Table 2.Sociodemographic and training-related factors associated with acceptability of abortion services provision, in Obstetrics and Gynecology at King Faisal Hospital
Predictors Good Moderate/Poor OR (95% CI) P value
Age
≤30 24 (75%) 8 (25%) 9.0 (2.25-35.98) 0.002
>30 years 4 (25%) 12 (75%) Ref
Gender
Male 15 (83.33%) 3 (16.67%) 6.54 (1.56-27.46) 0.01
Female 13 (43.33%) 17 (56.67%) Ref
Marital status
Married 21 (53.85%) 18 (46.15%) 3.0 (0.55-16.31) 0.203
Single 7 (77.78%) 2 (22.22%) Ref
Profession
Gynecologist/Resident 4 (80%) 1 (20%) Ref
Nurse/Midwife 24 (55.81%) 19 (44.19%) 3.17 (0.32-30.73) 0.32
Religion
Catholic 14 (58.33%) 10 (41.67%) Ref
Protestant 11 (64.71%) 6 (35.29%) 1.31 (0.36-4.73) 0.681
No religion 3 (42.86%) 4 (57.14%) 0.53 (0.09-2.94) 0.472
Received formal training on safe abortion
Yes 16 (80.0%) 4 (20.0%) 5.33 (1.41-20.1) 0.013
No 12 (42.96%) 16 (57.14%) Ref

Discussion

The findings of our study demonstrate that formal training on safe abortion was the most consistent factor associated with both good knowledge of abortion law and greater acceptability of safe abortion service provision, whereas most sociodemographic characteristics, including age, marital status, profession, and religion, were not significantly associated with knowledge.

Healthcare providers who had received formal training on safe abortion were significantly more likely to demonstrate good knowledge of abortion law and greater acceptability of safe abortion services than those without formal training. These findings are consistent with evidence from Ipas (2020) and the Guttmacher Institute (2019), which emphasizes that structured training and continuing professional education improve healthcare providers’ knowledge of abortion laws, eligibility criteria, and clinical protocols (Bankole et al., 2020; Ipas, 2011).

The findings further support the argument that legal reform alone, such as Rwanda’s 2018 revision of the Penal Code, is insufficient without parallel investments in provider education and capacity building. This is consistent with previous studies from Rwanda showing that limited dissemination of legal guidance and inadequate provider training contribute to inconsistent implementation of safe abortion services despite a supportive legal framework (Musabwasoni et al., 2022; Påfs et al., 2020).

Although perceptions were not evaluated as independent predictors in the regression analyses, the overall findings suggest that formal training may help healthcare providers balance professional responsibilities with personal beliefs when providing abortion care. Religion and marital status were not significantly associated with knowledge or acceptability, suggesting that individual characteristics may have less influence than institutional and training-related factors in this setting.

These findings are consistent with those reported by Musabwasoni et al. (2022), who demonstrated that healthcare providers in Rwanda often experience tension between their professional responsibilities and personal beliefs regarding abortion care (Musabwasoni et al., 2022). The absence of a significant association between religion and the study outcomes may indicate that structured training and professional practice can mitigate the influence of personal beliefs on the provision of safe abortion services.

Most sociodemographic characteristics, including age, marital status, profession, and religion, were not significantly associated with knowledge of abortion law. However, age and sex were significantly associated with the acceptability of safe abortion service provision, with younger healthcare providers and male participants demonstrating greater acceptability. These findings suggest that while demographic characteristics may have limited influence on providers’ knowledge, they may still shape attitudes toward the provision of abortion services.

The findings are partially inconsistent with those of Balcha et al. (2022), who reported that profession and familiarity with abortion law significantly influenced attitudes toward safe abortion among healthcare providers in Ethiopia (Balcha et al., 2022). Nevertheless, the present findings are consistent with broader evidence suggesting that institutional context and structured professional training are important determinants of healthcare providers’ knowledge and acceptance of abortion care (Ipas, 2011; Sedgh & Keogh, 2019).

The lack of a significant association between religion and either knowledge or acceptability is particularly noteworthy, given that previous studies in Rwanda and other low-resource settings have identified religion as an important determinant of abortion attitudes (Loi et al., 2015; Rutayisire et al., 2022). This finding may reflect increasing professionalization of healthcare providers and the use of standardized clinical guidelines within tertiary hospitals, where evidence-based practice may reduce variability arising from personal beliefs.

The findings of this study have important implications for policy and practice. They suggest that strengthening institutional training programmes may be more effective than interventions targeting demographic characteristics alone. Expanding access to structured training, disseminating national abortion guidelines, and integrating safe abortion care into continuing professional development programmes could improve healthcare providers’ knowledge and increase the acceptability of safe abortion service provision.

Overall, these findings are consistent with regional and international evidence highlighting the importance of structured training and institutional support in translating legal reforms into effective clinical practice. However, the study was conducted in a single department at one tertiary hospital, which may limit the generalizability of the findings to other hospitals in Rwanda and the East, Central, and Southern Africa (ECSA) region.

Conclusion

This study demonstrates that formal training on safe abortion was the strongest factor associated with good knowledge of abortion law and greater acceptability of safe abortion service provision among healthcare providers. Providers who had received formal training were significantly more likely to demonstrate good knowledge and greater acceptance of safe abortion services than those without training. These findings highlight the importance of strengthening provider capacity through structured education and continuous professional development to support the effective implementation of safe abortion services in Rwanda.

Recommendations

To implement regular, standardized training on safe abortion, including legal frameworks, clinical protocols, and ethical considerations, targeting all healthcare providers in obstetrics and gynecology.

To ensure that safe abortion care is incorporated into ongoing medical education and in-service training to sustain knowledge and improve provider competence over time.

To provide accessible, facility-level protocols aligned with national laws to reduce ambiguity and enhance providers’ confidence in delivering safe abortion services.

To establish systems that reduce stigma, encourage professional support, and foster a nonjudgmental approach to reproductive healthcare to improve service acceptability and delivery.

To support multi-country studies, invest in data collection on barriers to safe abortion care delivery.

The study was approved by the King Faisal Hospital-Rwanda Institutional Review Board (Ref: KFH/2025/331/IRB).

Not applicable.

Availability of data and materials

Data are available from the corresponding author upon reasonable request and in accordance with Rwanda Ministry of He33 alth guidelines.

Competing interests

The authors declare no competing interests.

Funding

No funding was received for this study.

Authors’ contributions

All authors contributed to the study design, data interpretation, and manuscript preparation. All authors read and approved the final manuscript.

Acknowledgements

The authors are grateful to the administration and staff of King Faisal Hospital-Rwanda, particularly the Department of Obstetrics and Gynecology, for their support. Mentorship from ECSACOG trainers is highly appreciated.