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Introduction
According to the World Health Organization (WHO), approximately 50 million pregnancies are terminated by abortion every year (1). Illegal abortions are often performed in unsafe and unhealthy conditions by unqualified persons with resultant increased morbidity and mortality in these women of reproductive age (2 - 5).
Unsafe abortion is known as a public health issue and is one of the leading causes of maternal mortality (6). WHO estimates that one in eight pregnancy-related deaths results from unsafe abortions (7, 8).
The life-threatening characteristics and lifelong complications of illegal abortions include uterine bleeding, infection and infertility on one hand, and psychological disorders such as regret, feeling of guilt, smoking, alcoholism, self-destructive behavior, and even suicide on the other (9, 10). The latter will particularly ensue as direct effects of abortion practices (11, 12). It has also been indicated that the social and psychological consequences of abortion are affected by the quality of family life, number of children, planned or unplanned pregnancies, beliefs and genetic background (13).
However, nowadays, abortion can be performed by modern methods and technologies in very healthy and sterilized conditions and could be an extremely safe procedure. Legalization of abortion could help promote conduction of safe abortions, prevention of unsafe abortions and reduction of maternal deaths and complications resulting from illegal abortions (14).
From reproductive health point of view, abortion, either safe or unsafe, may be the result of unwanted pregnancies, overcrowded families, poverty, sex preferences, fetus abnormalities, mothers’ threatening health status, contraception failure, illegal or out of wedlock relationships (15 - 17).
In an anthropological study entitled “Traditional beliefs and cultural behaviors of women of reproductive age in Teheran”, was conducted through face to face in-depth interviews with a number of key legal, social and health policy-makers to compare the appropriateness of clinical settings or attending unhealthy places for a backyard, illegal abortion through unsafe procedures by unregistered non-professional personnel (18). In the past, abortion was practiced mainly through traditional methods (19) by traditional healers in almost unhealthy places. No attention was paid to the consequence of abortion from both the service providers, and abortion seekers. It was regarded as a very private issue with no official involvement of the government or health authorities. But, nowadays, abortion is considered a medicalized procedure with social costs and economic consequences. There are also regulations, government involvement and even influential international agencies in this respect.
The broad consequences of abortion require governmental policies in terms of service provision, resource generation and allocation, social marketing, legalization or illegalization. Because of different contradictory points of views about abortion, among individual communities and governments, policy making and policy implementation (20, 21) both require substantial intellectual efforts, precise planning and community involvement. Such a sensitive issue provides an appropriate context for research on abortion both in general and from policy makers' points of view, in particular.
The approach to abortion in Iran has been influenced by several factors and generally speaking, mothers as abortion seekers and physicians as abortion service providers, have been condemned equally in this respect (22, 23).
The rapid population growth, age at marriage, and urbanization together with social taboos which restrict unmarried individuals from having sexual relationships before marriage and consider these relationships as illegal and illegitimate practices, may be considered as the leading causes of unwanted pregnancies and the high demand for abortion. Absence of an ideal family size among Iranian couples, together with socio-economic hardships also may produce the same results.
Presently, the Iranian Parliament has legalized abortion in a very limited framework which requires medicolegal approvals for abortion. Despite this limitation, abortion is still a concern for policy-makers and religious leaders, as well as families and the pregnant women themselves, particularly with regard to the increased age at marriage, a large youth population, and socio-economic barriers of marriage as the only legitimized way of sexual practices. This is apparently a way which could push abortions, due to unwanted and illegitimate pregnancies to a larger figure. Therefore, it seems that there is an urgent need for a participatory approach to abortion from all main sectors of the population involved in this phenomenon. Since the views of decision-makers affect the approach to abortion in the society, we decided to enquire their knowledge and attitudes in this regard.
Materials and Methods
Understanding the attitudes and knowledge of some high-ranking social, legal and health policymakers towards abortion, with regards to the very sensitive and controversial nature of this subject, was the goal of this study. In lines with this objective, the present study was conducted by taking the following steps.
- All the available and relevant literature including different aspects of abortion was analytically reviewed.
- A number of renowned family and reproductive health experts from Medical Sciences Universities, Ministry of Health, NGOs, and the private sector were consulted, and based on the initial findings of the two previous steps a qualitative study was planned through semi-structured individual interviews. The core of the questions were “Definition of abortion”, “Unwanted pregnancies, “The current situation and prevalence of abortion in the society”, “Reasons for and consequences of abortion”, “The health of the mother and fetus”, “Rights of families and individuals”, “Reproductive health and socioeconomic circumstances”, “The role of men as spouses and that of service providers”, “Sex-preference”, “Decision-maker for abortion in families”, “Permissible abortions”, “Quality of services (legally or illegally)”, and “Non-medical/ traditional methods of abortion”.
- The questionnaire was piloted, and then the final draft was prepared. Planning the interviews was the most challenging part of the study because most were unreachable, unwilling, or reluctant to be interviewed on the subject. On the whole, 80 presidents of medical sciences universities, senior executive managers in the legal system, forensic medicine and decision-makers in the health system and a number of top Muslim clerics were chosen for the interviews but only 29 accepted to be interviewed after a considerable follow up.
The collected data were finally summarized and analyzed and the findings were later classified and presented.
Results
Twenty-nine decision makers accepted to have an interview on the issue. The following is a summary of the findings from the interviews:
The respondents were fairly aware of definition and classification of abortion from medical, legal and social points of views.
The respondents' views were positive on practice of abortion, even illegally in the society. Some of them believed that the prevalence of abortion practiced is much higher than formally expressed.
According to our interviewees, the poor, young and overcrowded families were the main groups seeking abortion.
Unwanted and illegal pregnancies, anatomical anomalies, fetal malformations and low social status were considered as the main causes of abortion.
Negative physical, moral and mental consequences of abortion were indicated by the respondents. Although some of them believed that if illegal abortions were conducted under the supervision of a qualified physician in healthy conditions, no negative consequences would follow. According to one of the interviewees, the side-effects of abortion mainly depended on the age of fetus_ the older the aborted fetus, the higher the risks for the mother to experience. Infection, perforation of uterus, infertility and death were parts of abortion complications expressed by the interviewees.
The interviewees considered traditional/ non-medical methods of pregnancy termination as illegal abortion.
In response to the proposed question as “What is a legal abortion?” and “if such a thing existed in reality”, all the interviewees monotonically referred to the safety of the mother and the fetus. In other words, the mother's and fetus' health was considered as the one and only reason for legal and permissible abortion by the respondents.
The role of men in abortion, as husbands, as abortion-related service providers, and as law-makers was emphasized by the interviewees. One of the interviewees believed that a man has no rights to make his wife abort a pregnancy, and another respondent preferred their mutual decision for abortion. However, one of the respondents believed that in case of emergencies and life-threatening conditions woman herself could request an abortion, and there was no need for the husband’s agreement, because the court would decide on behalf of the husband.
There were no clear explanations from the interviewees on the “relation between the individual’s rights, right to choose and abortion”.
A minority of the respondents agreed with abortion in cases of rape or out-of-wedlock or concubine relationships.
It seemed that, a minority of respondents had a slightly pro-abortion views within the framework of reproductive health rights and agreed abortion to be conducted if pregnancy was unwanted, family was overcrowded, mother was over 35 years, pregnancy occurred during breast-feeding, and child spacing had failed or was less than three years from the previous pregnancy.
Almost all of the respondents disagreed with abortion in terms of sex-preference, poverty, maintaining family solidarity or preventing divorce.
A minority of the respondents had positive attitudes towards abortion if pregnancy occurred while being on contraceptive use by the woman.
Regarding the role of the state, the respondents believed that promoting legal abortion, taking preventive measures, providing quality health services for legal abortions, promoting health and sex education, maintaining community well-being through logical and expertised decision-making and implementing appropriate laws and regulations were the main duties of the state in this respect.
In the lack of legalized abortion, children born from unwanted pregnancies may be abandoned or put to trade. These situations were unbelievable for most of the respondents. Some of the interviewees indicated that such instances were much worse than abortion itself. Some of the interviewees described the situation as the results of cultural poverty, social failures and familial disorders.
Discussion
Knowledge and attitude of some social, legal and health policy-makers towards abortion was explored through a qualitative study. Although qualitative studies have some limitations, and one can not generalize the results, but we tried to interview with policy-makers from different and diverse organizations. The participants' overall knowledge was good and they knew the definition of abortion, its frequent practices in the society, unhealthy conditions which abortions were practiced, and complications which resulted from backyard abortions. But the dominant attitude of the participants towards abortion was "Disapproval".
A large number of the respondents demonstrated their agreement with abortion when the health of the mother or the fetus was threatened. They strongly supported abortion in such circumstances. But the term “mothers’ health" needs to be clarified and defined regarding its physical, mental, social and spiritual aspects (24, 25). In recent years, legalized and therapeutic abortion seems to have reduced illegal abortions in Iran (26). However, the number of women who need to undergo abortion has not been determined (2, 27). A comparative study of the frequency of legal or therapeutic abortion in the Central Department of Tehran Forensic Medicine Organization concluded that some other diseases may be added to the list of indications for legal abortions (28). In the present study, the majority of respondents did not agree with abortion in cases of unwanted pregnancies occurring while on contraceptive use, a large family size, pregnancy during breastfeeding, rape, out-of-wedlock relationships, etc despite knowledge about the complications of illegal and unsafe abortions. In Thailand, abortion is illegal, but it is allowed to be practiced when it is necessary for women’s health or when it is the result of a rape (29). In a study exploring the perception of policy-makers on abortion in Nigeria it was found that one third of the respondents agreed with abortion in cases of rape or incest love (30) contradicting the results of the present study that only a few participants agreed with abortion in these cases.
There are debates about abortion in religious texts, (31) since a conflict of rights, between mother and fetus may arise (32). Mothers may not have full autonomy in making decision whether or not to terminate pregnancy. Moreover, terminating pregnancy may cause prosecution.
Abortion prohibition is discussed in Islamic texts. Though, similar to every other basic rule, it has some exceptions and would be allowed in some circumstances (33). The right of fetus to live is respectable, however, abortion is allowed if the pregnancy is highly risky for the mother and its continuation would be life-threatening or put her in severe difficulties which in Islamic legal context it is referred to as Osr-o-Haraj or severe and intolerable hardship (34, 35).
Currently, many high-ranking Islamic clergymen permit abortion in some conditions such as serious harm to the mother's health, only prior to insufflation of spirit (36 - 43). Nonetheless, consensus on the exact time of insufflation of spirit is another debate that should be discussed elsewhere (44, 45). Beheshti, a renowned Shiite clergy, believed that abortion was not considered manslaughter prior to insufflation of spirit according to the Islamic jurisprudence and views of famous major clergymen (46). Consequently, when pregnancy might harm the mother, saving her life is superior to that of the fetus.
In this study strong disagreement was observed among the respondents towards abortion, particularly if it was to be conducted for female fetus, or in other words, resulted from sex-preference. In contrast, the situation seems to be opposite in some parts of the world, i.e. South Asia, in which high rates of sex-selective abortions are reported (47).
The direct participation of religious leaders and Islamic scientists, as well as legislative bodies is indispensable in solving the current social situation. Specific plans and policies are essentially needed for mental and social health salvation (18, 48, 49).
Conclusion
Performing studies on different dimensions of abortion and advocacy strategies and paying attention to problems of pregnant women as the main beneficiaries in this matter, may help relevant policy-makers make better decisions. Meanwhile, mothers who intend to undergo unsafe abortion should be provided with relevant consultation services (50).
It seems that the interviewed policy-makers were not adequately involved with pregnant mothers’ concerns, risks of abortions and violation of their rights despite their vast knowledge on the issue. Death rates, poor quality of life and disability adjusted life years (DALYs) were the proof of this writing. In fact, mothers expect the direct support of policy-makers who are expected to better realize the realities of abortion (51). It is now the time to employ new approaches and invite mothers, as beneficiaries, for decision making (52).
The acceptance of therapeutic abortion law in Iran was the result of a realistic approach to mothers’ health. Similarly, many other reasons and aspects of abortion should be investigated. Moreover, decision makers' viewpoints on abortion should be modified. “Osr-o-Haraj” should be adequately clarified. Women should be provided with proper social and health services, advocacy programs need to target decision-makers to increase women’s health. In addition, prevention of complications is achieved by increasing the public knowledge in order to reduce intentional abortions.
Acknowledgement
The authors of this paper extend their especial thanks to the Family Planning Association of Iran for cooperating and funding this project. The authors of this study had no conflict of interest.