Background: Post-abortion care (PAC) encompasses emergency treatment, counselling, contraceptive services, and referral linkages. Emergency post-abortion care (EPAC), the life-saving component of PAC, addresses acute abortion-related complications, including haemorrhage, sepsis, retained products of conception, and severe pain. In Uganda, where abortion is legally restricted and socially stigmatised, women's care experiences are shaped by clinical urgency, fear, moral vulnerability, provider interactions, and structural health system constraints. Despite EPAC's centrality to maternal survival, qualitative evidence on how women interpret and evaluate their care experiences in referral hospital settings in Uganda remains limited. This study explored women's experiences of EPAC at Kawempe National Referral Hospital (KNRH) and identified the factors that shaped those experiences.

Methods: A qualitative descriptive design employing inductive thematic analysis was used. Sixteen in-depth interview transcripts from women who received EPAC at KNRH in March–April 2026 were analysed. The Socio-Ecological Model (SEM) was subsequently applied as a post-hoc organising framework to situate findings across individual, interpersonal, facility, and community levels.

Results: Six themes were identified: (1) survival and physical relief as the immediate measure of good care; (2) pain, fear, and emotional distress during treatment; (3) reassurance and support as buffers against vulnerability; (4) dignity under pressure: communication and privacy in EPAC; (5) structural barriers across the pathway of care; and (6) experiences beyond discharge: incomplete recovery and uncertainty. Care was frequently evaluated through the lens of survival, yet these accounts co-existed with intense procedural pain, compromised privacy, delays, financial burden, and inadequate post-discharge support. EPAC at KNRH was experienced as a complex encounter shaped by bodily vulnerability, interpersonal dynamics, and system-level constraints.

Conclusions: Strengthening EPAC requires patient-centred approaches that integrate clinical effectiveness with respectful communication, pain management, improved triage, and structured post-discharge support.

Keywords: Emergency post-abortion care; qualitative research; thematic analysis; women's experience; reproductive health; Uganda

Ethics statement

This study was approved by the Makerere University School of Medicine Research and Ethics Committee (SOMREC; approval reference: Mak-SOMREC-2025-913) and by Kawempe National Referral Hospital. All participants provided written informed consent before the interview. Given the legally restricted status of abortion in Uganda, consent procedures included participants were explicitly informed, as part of consent, of the legal implications of audio-recorded disclosures; audio recordings were encrypted and stored separately from identifying information; and a ten-year retention period was specified, after which recordings will be deleted in line with the approved SOMREC protocol. Participants were assigned anonymised codes; no identifying information was included in transcripts or analysis. Participation was voluntary, participants were informed that declining or withdrawing would not affect their clinical care, and could withdraw at any time without consequence. Interviewers were trained to check with participants throughout the interview whether they wished to continue, and participants were permitted to pause or discontinue the interview at any point where distress made this necessary; this protocol was applied during data collection.

Study design

A qualitative descriptive design was employed, using inductive thematic analysis to generate findings grounded closely in participants' own accounts, without commitment to a specific phenomenological, grounded-theory, or narrative analytic tradition [Creswell, 2018]. This design was considered appropriate for a first qualitative account of EPAC experiences at KNRH, where the priority was to represent women's reported experiences in accessible, data-near terms. This approach enabled exploration of the physical, emotional, and social dimensions of women's EPAC experiences, capturing depth and context not accessible through quantitative methods alone. Following inductive theme generation, the Socio-Ecological Model (SEM) was applied post hoc as an organising interpretive lens rather than as an independent analytic method or a deductive coding framework; the rationale for this combination is set out in Data analysis, below.

Researcher positionality

All authors are clinician-researchers affiliated with the Department of Obstetrics and Gynaecology at Makerere University College of Health Sciences and/or Kawempe National Referral Hospital, the study site. This insider position provided contextual and clinical familiarity with EPAC service delivery, but also created the potential for professional norms regarding acceptable procedural pain, standard waiting times, and routine communication practices to shape which participant accounts were interpreted as analytically significant, and for institutional affiliation to influence how provider-level versus system-level explanations were weighted during interpretation. The individual(s) who recruited and interviewed participants held no clinical duties at KNRH and had no treating relationship with any participant, which reduced  though did not eliminate the direct clinical-authority power differential during data collection itself; the insider position discussed above pertains principally to the analytic team, not to the interview encounter. Formal coding and theme development were conducted by the corresponding author, with review by two senior co-authors. This review involved examining the coding log and analytic memo trail maintained throughout analysis by the corresponding author against the coded transcripts, and assessing theme–data fit, following initial theme development. No formal bracketing procedure was applied at the analysis stage; while the interviewers' independence from KNRH's clinical team reduced the risk of clinical framing shaping data collection itself, formal coding and theme development were conducted by the corresponding author, a clinician-researcher. The absence of a formal bracketing or reflexive journaling procedure at the analysis stage remains a limitation, acknowledged in Strengths and limitations, below.

Study setting

The study was conducted at KNRH in Kampala, Uganda, within the gynaecological emergency unit, where women with abortion-related complications are assessed, managed, and reviewed. KNRH is Uganda's national referral centre for obstetric and gynaecological emergencies, handling over 200 EPAC cases per month (approximately seven cases per day) [Kawempe National Referral, 2025]. EPAC is provided free of charge, with out-of-pocket payments required only for ultrasound scans and medications that are out of stock. Services are available 24 hours a day, 365 days a year, delivered by a multi-cadre team ranging from senior consultants to student health workers. During the study period, privacy provisions within the unit were variable: participant accounts (see Theme 4, below) describe curtains being used during some examinations and procedures but not others, consistent with a shared clinical space rather than fully private cubicles for every patient. This description is derived from participant accounts rather than facility records.

Study population and data source

This analysis draws on sixteen in-depth interview transcripts collected as part of a broader parent study of EPAC experiences at KNRH; the present study constitutes a secondary thematic analysis of these transcripts, conducted with the aims and analytic approach described in this Methods section. Participants ranged in age from 18 to 45 years and represented diverse socio-demographic and reproductive backgrounds, including variation in marital status, educational attainment, occupation, and parity.

Sampling strategy

Purposive sampling with maximal variation was used to select participants who had direct experience of EPAC and had been discharged within the preceding 14 days. This window allowed sufficient time for initial physical recovery and reflection while minimising recall bias, without approaching women during the acute treatment period. Eligibility required clinical stability at recruitment, informed consent, and willingness to participate in an interview conducted in English or Luganda. Maximal variation was operationalised using the demographic and clinical characteristics summarised in Table 1 (age, marital status, educational attainment, occupation, and parity); geographic origin relative to KNRH and religious affiliation were not used as sampling variables and are acknowledged as gaps in Strengths and limitations, below. A total of twenty-four women meeting eligibility criteria were approached during the study period, of whom sixteen consented and eight declined (see Data collection, below); this figure reflects women identified and approached within the two-month recruitment window rather than a further sub-sample drawn from a larger caseload.

Sampling was guided by the principle of data saturation: data collection continued until no new codes, categories, or themes emerged from additional transcripts [Guest, 2020]. Saturation was assessed narratively: codes became consistent and repetitive across the later transcripts, and no new codes, categories, or themes emerged from the final transcripts reviewed. This narrative assessment follows the general saturation principle described by Guest, Namey, and Chen [Guest, 2020], but does not apply that paper's quantitative tracking metrics (e.g., base size, run length, or new-code ratio); readers should treat the saturation claim as a qualitative judgement rather than a metrics-based determination. As this study used inductive thematic analysis rather than a phenomenological design, sample adequacy is assessed by thematic saturation rather than by phenomenological criteria such as depth of individual accounts.

Data collection

Data were collected through semi-structured in-depth interviews following a two-stage recruitment process. In the first stage, women who had received EPAC were identified at discharge; their contact details were obtained, and a scheduled review appointment was confirmed. In the second stage, on or around the review date, the research team confirmed participants' arrival at the hospital. Women who met eligibility criteria were approached by a trained research assistant, given a verbal explanation of the study, and offered time to consider participation before written informed consent was obtained. The research assistant(s) who recruited and interviewed participants held no clinical duties at KNRH.

Of the women approached during the study period (March–April 2026), eight declined to participate citing time constraints or personal concerns; this 33% refusal rate is not further characterised here and is addressed as a potential source of selection bias in Strengths and limitations, below. The sixteen who consented were interviewed individually in a consultation room at the gynaecological emergency unit, prioritising privacy. The interview guide covered: pathway to care and first presentation; reception, triage, and waiting; treatment and procedural experience; privacy and dignity; provider communication and information-giving; pain and emotional responses; social support; challenges during and after treatment; and post-discharge recovery. Interviews were conducted in English or Luganda according to participant preference, audio-recorded, and transcribed verbatim. Translation and back-translation of Luganda-language interviews were conducted by the interviewers themselves rather than by independent professional translators; this is noted as a limitation in Strengths and limitations, below.

Data analysis

Transcripts were read repeatedly to develop familiarity with the data. Meaningful units of text were identified, coded, and grouped into categories based on similarities and patterns across accounts. Themes were generated inductively through thematic analysis, moving iteratively between participants' language and broader interpretive concepts. Constant comparison across transcripts was used to identify both common patterns and divergent experiences [Guest, 2020].

The SEM was applied as an interpretive lens at later stages of analysis to organise findings by the level at which they operated: individual, interpersonal, facility, and community. This framework was originally developed to explain how human experiences are shaped across multiple nested levels of influence [Stokols, 1996] and has since been applied to health service research to guide multi-level interpretive frameworks [Scholmerich, 2016]. This approach, of using the SEM as an organising framework rather than a deductive coding template, allowed themes to remain grounded in participants' narratives while being situated within a theoretically coherent multi-level account.

Combining inductive thematic analysis with a subsequently applied SEM organising lens follows established framework-application approaches in applied qualitative health research, in which a theoretical model is used to structure the presentation of inductively derived findings rather than to generate them. Each theme was assigned to the SEM level at which its central content was most directly located. For example, bodily and psychological experience at the individual level, provider–patient communication at the interpersonal level, resource and service-delivery conditions at the facility level, and stigma and social norms at the community level. Themes with content spanning more than one level (notably Theme 6) were retained under their most proximate level, with cross-level connections addressed narratively in the Discussion rather than through re-coding. The SEM is therefore presented as an organising interpretation of the thematic data rather than as an independent source of findings, and the Discussion distinguishes between conclusions grounded directly in participants' accounts and those introduced through the SEM's organising structure.

Rigour and trustworthiness

Rigour was ensured by applying Lincoln and Guba's criteria for trustworthiness: credibility, dependability, and transferability [Creswell, 2018),[Morse, 2015]. Credibility was enhanced through immersive, iterative engagement with participants' own words, supplemented by senior-author review of theme–quote correspondence, which functioned as informal peer debriefing. Dependability was supported through consistent application of the coding framework, and through a coding log and analytic memo trail maintained throughout analysis by the corresponding author, available to reviewers on reasonable request. Confirmability, the fourth criterion in Lincoln and Guba's framework, was addressed through the same coding log and memo trail, which document the progression from raw data to final themes and can be made available to reviewers to support independent audit. Transferability was supported by detailed descriptions of the study setting, participant characteristics, and analytical process, bounded by the single-site, single-facility nature of the study (see Strengths and limitations, below). Transparency was maintained by attending to both positive and negative experiences, including contradictions within individual accounts, to avoid selective reporting. The single-analyst coding conducted by the corresponding author was reviewed by two senior co-authors, involving independent review of the coding log and memo trail against the coded transcripts to assess theme–data fit, conducted following initial theme development; this served as the primary safeguard against single-analyst bias in this study.