UNWANTED PREGNANCY AND ABORTION

 Dr. Shayesteh Jahanfar[a], Dr. Mohammad Jahanfar[b], Mehdi Sadat-Hashemi[c], Dr. Fahimeh Ramazani-Tehrani[d].

ABSTRACT

Objective: To find the role of moral values in a couple’s decision over calling the pregnancy unwanted.

Subjects and Methods: Subjects included 3028 women who attended the prenatal care unit of 10 university hospitals in Teheran.

Results: It was found that 590 (19.5%) had thought of abortion but only 153 (7.2%) actually tried to terminate their pregnancy.  The major reason for not terminating their pregnancy was reported to be religious beliefs.  The majority (55%) of those who thought of abortion said their pregnancy was unwanted as compared to only (1%) of those who did not think about it (P<0.0001). 

Discussion: The main determining factors for considering pregnancy as unwanted among these women appeared to be the socio-economic implications, inappropriate relationship with  husbands, and adequacy of children. 

Conclusion: Poor contraceptive usage contributes to the problem of unwanted pregnancy. There is an urgent need to upgrade reproductive health knowledge.  In addition, it is necessary to put emphasis on religious ideas.

INTRODUCTION

Each year, approximately 20 million unsafe abortions take place around the world, resulting in some 80,000 maternal deaths¹. Unsafe abortion accounts for at least 13% of global maternal mortality, 1 in 8 maternal deaths. In some countries illegal abortion is the most common cause of maternal mortality and morbidity. In developing countries 55000 unsafe abortions take place each day, which leads to the death of more than 200 women daily.

Morbidity due to unsafe abortions also is of great concern. Between 10 and 50 percent of all women who undergo unsafe abortions, need medical care for complications (sepsis, haemorrhage, intra-abdominal injury such as puncturing or tearing of the uterus) some of which are long-term complications such as pelvic inflammatory disease, tubal blockage and secondary infertility.  Other possible complications are ectopic pregnancy and an increased risk of spontaneous abortion or premature delivery in subsequent pregnancies. Such problems can limit women’s productivity and constrain their ability to care for other members of the family.  It can also deprive women of their social and economic roles in the society.

National policies and legislation on abortion vary throughout the world. In 98% of the world’s countries danger to the women’s life is recognised as a legal basis for terminating a pregnancy.  Iran’s abortion law which was promulgated since 1978, like many other Islamic countries, made abortion illegal but some provision were made regarding preserving the women’s physical health as a basis for legal abortion.

Studies have clarified the seriousness of unsafe abortion.  In one study in Tehran, incidence of illegal abortion was estimated around 12.8% of which 90% were had serious complications such as infection and incomplete abortions².

The national policy and legislation on abortion in Iran is based on religious beliefs that treat safe motherhood as a matter of human rights and social justice.  It is believed that the decline in maternal mortality and morbidity was due to the empowerment of women and providing better care for them.  This can act as a new approach to reduce the rate of illegal abortion.

Some developing countries through abortion legislation have managed to reduce abortion-related deaths³. However, there are still a few countries in which abortion is illegal in all circumstances⁴. Determining the cause of unwanted pregnancy should be highlighted in facing illegal abortion. Our study suggests that moral issues have a significant role in women’s decision over abortion. Thus it seems logical to prevent unsafe abortion first by prevention of unwanted pregnancy, secondly by emphasis on moral issues to decrease the tendency for abortion, and third by providing emotional and financial support for those at risk.

METHODS AND SUBJECTS

This study was conducted in 10 university hospitals in Tehran by the National Research Centre for Reproductive Health, Iran. The total sample size was 3028. Subjects were prenatal-care unit visitors who were randomly selected based on a proportion-stratification sampling method. Assuming that the prevalence of unwanted pregnancy was proportional to the number of clinical attendance, subjects were selected and interviewed face-to-face. The questionnaire consisted of various information items related to demographic characteristics of subjects, whether the pregnancy is wanted or not, the risk factors for unwanted pregnancy, contraceptive usage, knowledge and availability the result of which has been published somewhere else⁵. Subjects were then asked if they have thought of abortion, whether they have taken an action to abort their current pregnancy and if not what were the reasons. 

RESULTS

The mean age of respondents was 25.43 (±5.55 SD) years. Eighty-three percent of subjects were younger than 30 years and 14% were teenagers. The means age of menarche was 13.41 (±1.8 SD).  Forty-six percent of subjects of subjects were primiparous.  Forty-five percent had 4 times delivery and less. History of abortion was reported in 17% of the subjects, 13.9% of which had aborted (spontaneously) only once. Unwanted pregnancy was reported in 33.9% of subjects (32.7% of women and 29% of men considered pregnancy as unwanted). The history of unwanted pregnancy was also investigated. Subjects who considered their current pregnancy as unwanted were 3.8 times more likely to have a positive history of unwanted pregnancy in comparison with those who reported their pregnancy as accepted.

Marriage is almost universal in Iran. Only 0.7 percent of subjects reported having a temporary marriage, 99.2% were permanently married, 0.2% were widowed, divorced or separated. The educational state of women and their husbands were also asked. Most of subjects had passed secondary school (36.5% women and 39.0% men) (Figure 1). The correlation between unwanted pregnancy and occupational state for both men and women were not found to be significant. The relation between unwanted pregnancy and educational state of women and their husbands were also tested and their correlation was found to be significant (p<0.0000). Number of people living in one house-hold was considered important in terms of assesing the economical states of families. Twenty-one percent of subjects had a family size bigger than four. Using a simple logistic regression analysis revealed that there was a significant correlation between family size and unwanted pregnancy (b = 0.26,  p <0.0001).

Of the 3028 married pregnant women attending the clinic who enrolled in the study and included in this analysis, 989 (32.7%) reported that the pregnancy was unwanted in their opinion; 879 (29%) stated that their husband considered the pregnancy to be unwanted.  Overall 1025 pregnancies (33.9%) were considered unwanted according to the man or the woman’s view. In comparison with women reporting the pregnancy as accepted, women reporting that pregnancy was unwanted were 3.8 times more likely to have a history of unwanted pregnancy.  Subjects who stated that their husband and/or themselves considered their pregnancy as unwanted were then asked to state reasons for the pregnancy being unwanted Table 2 shows the number and percentages of frequency for each reason.

Overall, 19.5% (587/3003) of the subject had thought of abortion, 95% of which announced their pregnancy as unwanted. Although about 20% of subjects thought of abortion, only 7.3% (152/3003) actually acted upon aborting their pregnancy. Following questions investigated the reasons for not aborting (Table 3).

DISCUSSION

In Muslim countries abortion is considered legal if the life of the mother is in danger and if the foetus is diagnosed to be genetically abnormal. Induced abortion as a method of contraception is strongly stigmatised generally in the Muslim world as a result of religious considerations. A study in Egypt (Cairo Demographic Centre, 1994) provides results from a survey of family planning clients in a restrictive environment. The study employed a prospective design where by 2227 family planning clients from a service-delivery system catering to the middle and upper classes were surveyed about their contraceptive practices in the period after their initial contact with a family planning clinic four to five years earlier.  This group of women reported a total of 1081 pregnancies during the reference period of which approximately 50 percent were unintentional or unwanted. The majority of these pregnancies prompted no action for abortion (75%). Approximately 19% of the women with unwanted pregnancies made an attempt to terminate their pregnancy without success, an additional 6% of these pregnancies were terminated successfully. The result of this study⁶ and others suggests that questions about attempts to terminate an unwanted pregnancy can elicit a relatively large proportion of responders, even in a socially and legally restrictive environment. Thus the reliability of responses in studies such as ours is of minor concern.

Complications arising from abortion include haemorrhage, sepsis, and genital injury.  These are responsible for most of the mortality amongst these women⁷. Although in many cases, complications of abortions which are performed in the back streets are inevitable, induced unsafe abortion and its related morbidity and mortality are preventable tragedies. Training informed and up-to-date physicians, preparing appropriate protocols for post abortion care,  and reducing the charges can result in better abortion management.

 At the Last International Conference on Population and Development (ICPD), governments recognised unsafe abortion as a major public health issues and raised several strategies to reduce the risk of unsafe abortion.  These include:

·        To promote high quality and humane medical services to treat the complications of unsafe abortion.

·        To use family planning services more effectively to promote reproductive health, reduce the need for abortion and prevent repeat unsafe abortions and finally

·        To provide safe induced abortion services where there are not against the law.

So far, Iran has been successful in providing family planning services and in treating complications arising from illegal abortions but the third strategy is not applicable to Iran as to some other Islamic countries because of legal, moral and religious constrictions. It is quite obvious that legalisation of abortion cannot prevent the sense of regret and unfaithfulness to religious beliefs. Those with strong religious beliefs will not accept or use the services provided for them. Thus, it seems that the solution is not to confront the religious orders but to act according to them. Our study suggests that moral beliefs play a significant role in determining the decision made by pregnant women to whether continue the pregnancy or terminate it.

Fear of complications was also found to greatly reduce the motivation for abortion. Thus, by enhancement of knowledge and awareness of dangers encountered in illegal and unsafe abortion, there is a hope for achieving fewer illegal abortions. Maybe a goal of every pregnancy being a wanted one is unattainable, but surely we should make more effort to understand why unwanted pregnancies occur and do our best to prevent them without recourse to abortion. Until we come closer to finding a final answer to this question that how can we prevent unwanted pregnancy and control illegal abortions?.  The main question is that how we can prevent unwanted pregnancy more effectively?. The best possible way is to convince women that unsafe abortion can lead to terrible consequences.

Husbands’ disagreement was also found to have a significant role in abortion prohibition.  Male contribution is then suggested to be noted more seriously by health care policy makers. 

Some studies have stated that restrictive legislation is associated with higher rates of unsafe abortions and correspondingly high mortality. In Romania for example, abortion-related deaths increased sharply when the law became very restrictive and fell after 1990 with a return to the less restrictive legislation. Barbados, Canada, Tunisia, Turkey, and The Netherlands have all changed abortion laws for greater access to legal abortion. Although there has been no report of increase in abortion rate in these areas, the expected outcome has been achieved in none of these countries. It seems that improvement of access, is not the only way to obtain the ideal outcome and some other strategies should accompany the legislation laws.  These strategies could include:

·        Making changes in the health care services provided, providing more alternatives for partners to choose from.Providing available family planning services to the full extent particularly in rural and impoverished areas.Training health care service providers to offer high quality services and compassionate counselling.Publicising moral and religious issues related to the use of contraception by religious leaders. (Islam approves the use of contraception and allows abortion if and only the health of the mother is in danger, abortion as a method of contraception is not accepted).Educating women is critical for increasing information related to problems of unsafe abortion.

Table 1. The frequency of occupational state of women and their husbands (n=3028).

Table 2. Reasons stated by those who considered their pregnancy as unwanted.

                       Table 3.  The reasons stated by the subjects for not taking an action for abortion.

REFERENCES

1. Abortion, a tabulation of available information, 3^rd edition, World Health Organisation Publication on Abortion, Geneva, 1997.

2.  Falahinan M., Norozy A.J.  Abortion mortality and morbidity in Tehran.  Journal of Medicine-University of Shahid-Beheshti, 1994, 2:55 59.

3. Address unsafe abortion, World Health Day, Safe Motherhood, WHO publication, April 1998.

4. Henshaw, L. Abortion Laws and practice world-wide, in proceedings: Abortion Matters, International Conference on Reducing the need and Improving the Quality of Abortion Services, Nederland, 1997.

5. Asyen B, Toubia N.  Efficiency and effectiveness of public sector on abortion services in Istanbul.  The university of Istanbul and the Population Council, 1994- unpublished report.

6. Jahanfar S., Sadat-Hashemi M., Ramazani-Tehrani F.  Predicting unwanted pregnancies using a logistic regression model.  Daneshwar Journal, Shahed University Publication (on print).

7. Lema V.M., Macharia J.K.  A review of abortion in Kenya.  7^th Edition.  Nairobia, Kenya, 1992.