The data were collected from the 72 participants.
Tables 1, 2, 3 summarize the Participants' characteristics.
Table 1. Description of the Women with a History of induced Abortion and Women with History
Variable Women With a History of Induced
Abortion, No. (%) Women With History of Unwanted
Pregnancy, No. (%) Age, y ≤ 20 3 (9.09) 4 (21.5) 21 – 25 4 (12.12) 4 (21.5) 26 – 30 8 (24.24) 4 (21.5) 31 – 35 5 (15.15) 4 (21.5) ≥ 36 13 (39.39) 3 (15.8) Education Illiterate 3 (9.09) 3 (15.8) Grade school 13 (39.39) 2 (10.5) High school 10 (30.3) 11 (57.9) University 7 (21.2) 3 (15.8) Occupation House wife 22 (66.7) 15 (45.4) Student 2 (6.06) - Employee 2 (6.06) 3 (15.8) Other 7 (21.2) 1 (5.3) Contraceptive method before induced abortion or unwanted pregnancy IUD 1 (3.03) 1 (5.3) Pill 1 (3.03) - Condom 5 (15.15) 2 (10.5) Traditional 21 (63.6) 14 Unmet Need 5 (15.15) 2 (10.5) Marital status Married 23 (69.7) 8 (42.1) engaged 3 (9.09) 7 (21.2) single 5 (15.15) 3 (15.8) Others 2 (6.06) 1 (5.3) Gravid 1 3 (9.09) 6 (31.6) 2 6 (18.2) 9 (47.4) 3 7 (21.2) 0 ≥ 4 17 (51.5) 4 (21.5) Parity 0 6 (18.2) 0 1 8 (24.2) 6 (31.6) 2 10 (30.3) 9 (47.4) 3 5 (15.15) 2 (10.5) ≥ 4 4 (12.12) 2 (10.5) Induced abortion 1 19 (57.6) 0 2 11 (33.3) 0 ≥ 3 3 (9.09) 0
Table 2. Description of the Providers
Variable No. (%) Age, y 20 - 30 3 (25) 31 - 40 4 (33.3) ≥ 41 5 (41.7) Education ≤ 16 8 (66.7) ≥ 22 4 (33.3) Occupation Nurses and midwives 8 (66.7) gynecologist 4 (33.3)
Table 3. Description of the Experts
Variable No. (%) Education 18 3 (37.5) ≥ 22 5 (62.5) Proficiency obstetrician 2 (25) gynecologist 2 (25) pediatrics 2 (25) forensic medicine 1 (12.5) lawyer 1 (12.5) Fields policymaker 4 (50) researcher 2 (25) juridical 2 (25)
The results are divided in two major parts. The first part summarizes the causes of induced abortion from the standpoint of the three groups of participant including women with a history of induced abortion, service providers and experts. The second part shows the reasons why some women with unwanted pregnancy did not choose to have an abortion.
Part1: The causes of induced abortion
Based on the results of the interviews, participants have abortion for following reasons (
Table 4. The Causes of Induced Abortion based on the Results of the Interviews
Category Subcategory Inferior Category Codes Wanted pregnancy Fetal abnormalities Late diagnosis fetal abnormality (20%) Lack of awareness about abortion therapy lows (20%) fetal health Minor fetal anomalies (20%) Concern about fetal health and lack of trust to prenatal diagnostic methods use of drugs by wife or husband in the prenatal period (20%) History of fetal abnormally in the family (20%) Unintended pregnancy and no intake of folic acid (15%) Old pregnancy (15%) Maternal addiction (10%) Maternal disease (25%) Fetal sex Tendency to girl (15%) Tendency to boy (15%) Cultural factors Tendency to sort children sex (15%) Lack of independent and free decision making regarding pregnancy in women Pressure from the spouse or partner made women choose abortion (39%) pressure from the family made women choose abortion (20%) Unwanted pregnancy Socio-economic factors Economic factors High costs of living (80%) Being a tenant (85%) The social, cultural and family status Having small children (86%) Feeling embarrassed around their older children (70%) Having many children (87%) Having enough children (90%) non preparedness for having anothe baby (80%) Multiple pregnancy (8%) Concern about the future of the child (95%) Discord with spouse (65%) Addiction (80%) Pregnancy in unmarried women (75%) Pregnancy in temporary marriage (70%) Being divorced or widowed (50%) Pregnancy in the engagement period (90%) Career problems (40%) desire to continue education (%30) social class (%89) Welfare and tendency to progress (75%) Beliefs and feelings Narcissism When the question was asked in the third person "what is the cause of abortion
by women?” Loss of freshness and comfort (50%) Welfare (50%) Loss of beauty and physical fitness (40%) Indolence and pleasure (20%) affect of others beliefs Pregnancy during the engagement period (90%) Being blamed by others for having many children (85%) own beliefs Impatience (65%) Having high expectations from life (56%) Believing that having children is futile (20%) Belonging to the higher social class with having less children (80%) Lack of side effects in medical methods of abortions (70%) Lack of information about family planning Superficial information (70%) Lack of proper family planning counseling (70%) False beliefs (pregnancy during lactation and in the pre-menopause period is
impossible) (80%) Predisposing factors The religious aspects of abortion lack of information about the religious aspects of abortion Those who were not aware of the religious aspects of abortion (60%) Those who were aware but did not care (80%) Those who were aware of the religious aspects of abortion and also cared but either
had misunderstanding of the religious aspects of abortion in this regard or tried to
bend the rules in their own interest. (70%) drug marketing Easy access to easy abortion methods Easy access to abortion methods (80%) Easy, available and safe medical methods of abortion (80%) 4.1. Wanted Pregnancy
A) Fetal abnormalities: responses of providers, experts and married women with a history of induced abortion showed that sometimes pregnancy is diagnosed late and as a result, fetal abnormalities are diagnosed when gestational age is more than four months. Since abortion is not authorized after four months gestational age, some mothers may choose to have an unsafe abortion themselves.
In some cases, it takes more than 4 months between diagnosing a fetal anomaly and obtaining legal abortion permission and sometimes mothers and their families are not even aware that legal therapeutic abortion is allowed and therefore may choose unsafe abortion. Sometimes, there are minor fetal anomalies and parents decide to have an unsafe abortion because abortion is not permitted in such anomalies.
Engaged and single women did mention these reasons. So fetal abnormality is not an important factor for abortion in these women and other reasons for induced abortion are more important to them.
B) Concern about fetal health and lack of trust to prenatal diagnostic methods: result of interviews showed that in cases such “use of drugs by wife or husband in the prenatal period, history of fetal abnormally in the family, unintended pregnancy and no intake of folic acid, old pregnancy, maternal addiction, and maternal disease” parents chose unsafe abortion because of concerns about fetal health. Engaged and single women did not mention these reasons. So these factors do not influence the decision for abortion in these groups.
A married woman (employee, education level: bachelor’s degree, her husband’s education level: master’s degree) stated that "my husband was using hormonal drugs for the treatment of hair fall when I became pregnant. I had an abortion because we were concerned about fetal health and my husband disagreed with amniocentesis.
C) Fetal sex: The results of the interview with service providers and experts showed some people had an abortion because of the fetal sex. Of course, engaged and single women did not mention this reason. Married women with a history of induced abortion also expressed this reason only when the question was asked in the third person as “why do women have an abortion?” but none of them mentioned they had an abortion for this reason. Of course, some of them stated that they regretted abortion when they found out that the fetal sex was their favorite.
D) Lack of independent and free decision making regarding pregnancy in women: Based on interview analysis, sometimes mothers wished to continue their pregnancy but pressure from the spouse, partner or the family made them choose abortion. This was especially true about the girls who were pregnant before marriage.
An unmarried woman with a history of abortion expressed “I had sex with my boyfriend. When I got pregnant; he became very angry and forced me to have an abortion”.
Men sometimes forced their wives to have an abortion due to economic issues, social class, indolence and irresponsibility.
A married woman (employee, education level: bachelor’s degree) stated that” I loved to have children very much but my husband believed that only low class people had many children. I get pregnant for five times but my husband only agreed the first pregnancy. He made me abort other four pregnancies.”
4.2. Unwanted Pregnancy
All participants recognized unwanted pregnancy as the main reason of abortion. They stated that women with unwanted pregnancy had an abortion due to socioeconomic factors including “social, economic, cultural, and family factors” and beliefs and feelings including ” other people’s views, their own beliefs, and lack of correct information about family planning”.
A) Socio-economic factors: the results of the interviews indicated that socioeconomic factors influenced decision making regarding unsafe abortion. Economic problems were the reason for abortion in a large number of women. High costs of living for children, especially costs of education, were mentioned as an important factor for abortion. Because landlords do not rent out their houses to large families, being a tenant was one of the reasons for abortion, especially in big cities.
A married woman "I was very upset after I found out I was pregnant. Because I was a tenant and had a child and landlords do not rent out their houses to large families. I had to abort my child.
A married woman "My husband was addicted and unemployed. He said I had to abort because he did not want unnecessary guests."
Results indicated that the social, cultural and family status influenced decision regarding abortion. women had unsafe abortions for reasons including having small children, feeling embarrassed around their older children, having many children, having enough children, non preparedness for having another baby, multiple pregnancy, concern about the future of the child, discord with spouse, addiction, pregnancy in unmarried women, pregnancy in temporary marriage, being divorced or widowed, pregnancy in the engagement period, career problems, desire to continue education, social class, welfare and tendency to progress. Culture has a great impact on personal decisions in Iran. Decision about abortion in women who became pregnant during the engagement period depended on their culture.
Individuals in more traditional societies (from different ethnic groups including Fars, Gilaki, Mazandarani, Arab, Azerbaijani, and Lor) had an abortion to get rid of the blame because they were expected to become pregnant after marriage. It cost their lives in a few cases because they were not experienced like married people. They could not receive correct information about pregnancy and had an abortion due to fear of disclosure; therefore, they were often involved with non- professional swindlers. However, open-minded families (from different ethnic groups including Fars, Gilaks, Mazandarani, Arab, Azerbaijani, and Lor) performed the wedding ceremony sooner and let their daughters continue their pregnancy safely.
An expert “Last year, an engaged woman from a far city became pregnant. Despite she was educated and her husband wanted the child, due to their culture, she hid it from her family and had an abortion in unsafe and unhealthy conditions resulting in her death.
B) Beliefs and feelings: Analysis of interviews revealed that women’s beliefs and feelings affect their decision about abortion. “Loss of freshness and comfort, welfare, loss of beauty and physical fitness, indolence and pleasure” were reasons for abortion often expressed by providers and experts. Women with a history of abortion stated these reasons only when the question was asked in the third person "what is the cause of abortion by women", but none of them mentioned they had an abortion for any of those reasons. the results of the interviews with some participants in the three groups indicated beliefs such as “pregnancy during the engagement period, being blamed by others for having many children, impatience, having high expectations from life, believing that having children is futile, belonging to the higher social class with having less children, lack of side effects in medical methods of abortions” were reasons for abortion by women.
A married women “First, children are of no use. They do nothing to help their parents and only impose troubles and costs. They increase the population for no good reason. The fewer the children, the better the life.”
A married women "Nowadays, all the high class and educated people have only one child.”
C) Lack of information about family planning: Analysis of the interviews indicated that superficial information, lack of proper family planning counseling, and false beliefs (for example pregnancy during lactation and in the pre-menopause period is impossible) about family planning were reasons for unwanted pregnancy and abortion in women.
Many participants had little information about contraception before marriage. Pre-menopause women believed that they did not ovulate anymore and therefore did not use contraceptive methods. Lactating women or those who had administered DMPA did not use contraceptive methods since they believed they did not ovulate any longer. Others did not usually use contraception due to fear of complications and side effects of modern contraceptive methods. Some people imagined withdrawal to be the most reliable method and used abortion as a supplementary contraceptive method. Hence, most women with a history of abortion usually had an abortion more than once to terminate their pregnancy.
A married woman with three abortions (education level: high school diploma, employed) "My first child was born 15 years ago. I do not want more children and use the withdrawal method. I became pregnant three times in the past four years and aborted them. I try not to get pregnant again, but if I get pregnant, I will do the same. "
Some people did not use contraception because they received superficial and inaccurate counseling from their physicians or health care personnel.
4.3. Predisposing Factors
Lack of information about the religious aspects of abortion and easy access to easy methods of abortion are factors that facilitate abortion by women.
Lack of information on religious aspects of abortion: Analysis of interviews in the three groups of participants revealed that although abortion is forbidden in Islam, many people, even religious ones, misunderstood the religious aspects of abortion in Islam and performed it and therefore religion failed to prevent abortion in these individuals. Islam and religion were not concerning issues for unmarried and a lot of married women with a history of abortion.
Easy access to easy abortion methods: Analysis of interviews revealed that an important reason for abortion was that women with a history of induced abortion believed that medical methods of abortion were easy, available and relatively safe and reckoned that there was no reason for not using these methods. They even recommended abortion to their friends and abortion was something common to them and their friends.
Part 2: Some people, despite having unwanted pregnancy due to social, economic, cultural and family grounds, continued their pregnancy and did not have an abortion for the following reasons:
Religious beliefs: Married women who had deep religious beliefs refused to have an abortion and continued their pregnancy. However, none of the unmarried women mentioned religious beliefs as the reason for refusing abortion.
A married woman with unwanted pregnancy (post partum) “I had two children and I did not want another child. But because abortion is a sin and an act of murder, I did not have an abortion”
Beliefs: beliefs including fear of punishment in the afterlife and believing in fate prevented some women from having an abortion although their pregnancy was unwanted.
Attachment to the unborn baby: Someone women expressed that they did want the child at first but when they felt the fetus, they developed an emotional connection and attachment with it and decided to continue their pregnancy.
A married woman “I was very sad in start of my pregnancy and did not like it. When I went for ultrasound and felt its existence, I had a very pleasant feeling. I am now willing to tolerate any difficulty to give birth to a healthy child now”.
Influence of the other people’s opinions: Some married women refused to have an abortion and continued their pregnancy following their physician’s, mother’s or spouse’s advice.
A married woman “When I knew I was pregnant, I went to my doctor to have an abortion but the doctor advised me to keep it. He reminded me that I had only one child and told me that I would grow fond of the baby as time went by. Therefore I did not abort my child.”
Late diagnosis of pregnancy: this was often mentioned by pregnant women that were unmarried or engaged and continued their pregnancy. They found out they were pregnant late because they were inexperienced or had an underlying disease. Some women hid their pregnancy and families realized it very late.
A provider in a city stated: “Recently, a girl from one of the villages with severe abdominal pain came to me. Her Family though that she had appendicitis. When I examined her, she was in the second phase of delivery. She gave birth to a term baby.”
However, it was also noted by a few married women.
4.4. Unsuccessful Abortion Attempts
a) Self-treatment: some women said that their efforts to have an abortion were unsuccessful and therefore they continued their pregnancy.
b) Unsuccessful medical abortion: some women mentioned that despite receiving abortion services from professional health providers, their attempts were unsuccessful.
Economic weakness and arbitrary treatment: some women continued pregnancy due to lack of information about abortion and some because of inability to pay for abortion costs.
A married woman “When I found out I was pregnant, I took two shots of progesterone and four LD tablets to abort but they were useless. Then I went to some doctors for abortion but they charged at least 400-500 dollars and I did not have that money so I continued my pregnancy.”