Prevalence, reasons, and attitude towards abortion among Iranian married women of reproductive age in Qazvin province

Abstract

Background and aims
Abortion influences the composition and size of population. Estimating the overall and type-specific abortion rates, the reasons to choose the abortion can be helpful in designing and implementing preventive intervention. Therefore, the present study was designed to determine the: (i) prevalence of abortion, (ii) attitude of married women of reproductive age towards abortion, and (iii) reasons for choosing abortion by married women of reproductive age in Qazvin province.

Methods
A cross-sectional study was conducted between February and April 2023, and comprised married women of reproductive age (N = 1571) referred to urban and rural comprehensive health centers in five cities of Qazvin province. Utilizing multi-stage proportional sampling process, data for the survey (including demographic and fertility information, reasons for choosing abortion, and attitudes toward abortion) were collected online.

Results
The lifetime prevalence of abortion was 18.6% (among the total sample). The past-year prevalence was 22.3% (among those who reported having had an abortion). Of those reporting having had an abortion, 73.6% reported it was their first one, and 65.1% reported it was non-spontaneous . Women’s reasons for choosing abortion fell into one of three main clusters: (i) couple’s behavior, health and relationship problems, (ii) fertility-related stressful experiences, and (iii) family economic situations. The main reported reason to choose abortion was a couple’s behavior (e.g., drug use), health (e.g., physical disease, psychological problems), and relationship problems (e.g., sexual infidelity, divorce) explaining 27% of the variance. Also, pro-abortion attitude was the most important attitude towards non-spontaneous abortion explaining 26.33% of variance. The variables that increased the likelihood of non-spontaneous abortion included choosing a reason for abortion vs. having no reason (OR = 1.77, p = 0.05), having poor vs. good mental health (OR = 1.74, p = 0.03), having a pro-abortion attitude (OR = 1.09, p = 0.09), and having ≥ 3 children vs. having no children (OR = 0.53, p = 0.06).

Conclusion
Women in high-risk groups for non-spontaneous abortion (i.e., those aged over 35 years, those married for more than five years, those with an infertility history, those with a lower number of children, those living in rural areas, and those having poor mental health status) should be assessed by primary healthcare services during preconception and have early prenatal counseling to help in decisions regarding abortion.

Full text

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Discover Public Health
Research
Prevalence, reasons, andattitude towardsabortion amongIranian
married women ofreproductive age inQazvin province
MehranAlijanzadeh1· NahidYazdi2· MasomehAlamshahi2· MarkD.Griths3· ZainabAlimoradi1
Received: 27 May 2024 / Accepted: 21 October 2024
© The Author(s) 2024 OPEN
Abstract
Background and aims Abortion inuences the composition and size of population. Estimating the overall and type-
specic abortion rates, the reasons to choose the abortion can be helpful in designing and implementing preventive
intervention. Therefore, the present study was designed to determine the: (i) prevalence of abortion, (ii) attitude of
married women of reproductive age towards abortion, and (iii) reasons for choosing abortion by married women of
reproductive age in Qazvin province.
Methods A cross-sectional study wasconducted between February and April 2023, andcomprised married women of
reproductive age (N = 1571) referred to urban and rural comprehensive health centers in ve cities of Qazvin province.
Utilizing multi-stage proportional sampling process, data for the survey (including demographic and fertility informa-
tion, reasons for choosing abortion, and attitudes toward abortion) were collected online.
Results The lifetime prevalence of abortion was 18.6%(among the total sample). The past-year prevalence was
22.3%(among those who reported having hadan abortion). Of those reporting having hadan abortion, 73.6%
reporteditwas their rstone, and 65.1% reported itwas non-spontaneous . Women’s reasons for choosing abortion
fell into one of three main clusters: (i) couple’s behavior, health and relationship problems, (ii) fertility-related stressful
experiences, and (iii) family economic situations. The main reported reason to choose abortion was a couple’s behavior
(e.g., drug use), health (e.g., physical disease, psychological problems), and relationship problems (e.g., sexual indelity,
divorce) explaining 27% of the variance. Also, pro-abortion attitude was the most important attitude towards non-
spontaneous abortion explaining 26.33% of variance. The variables that increased the likelihood of non-spontaneous
abortion included choosing a reason for abortion vs. having no reason (OR = 1.77, p = 0.05), having poor vs. good mental
health (OR = 1.74, p = 0.03), having a pro-abortion attitude (OR = 1.09, p = 0.09), andhaving ≥ 3 children vs. having no
children (OR = 0.53, p = 0.06).
Conclusion Women in high-risk groups for non-spontaneous abortion (i.e., those aged over 35 years, those married for
more than ve years, those with an infertility history, those with a lower number of children, those living in rural areas,
and those having poor mental health status) should be assessed by primary healthcare services during preconception
and have early prenatal counseling to help in decisions regarding abortion.
Keywords Abortion· Prevalence· Attitudes· Iran
* Zainab Alimoradi, Zainabalimoradi@yahoo.com; Mehran Alijanzadeh, mehran_alijanzade@yahoo.com; Nahid Yazdi, n.yazdi@
qums.ac.ir; Masomeh Alamshahi, am.alamshahi@gmail.com; Mark D. Griths, mark.griths@ntu.ac.uk | 1Social Determinants ofHealth
Research Center, Research Institute forPrevention ofNon-Communicable Diseases, Qazvin University ofMedical Sciences, Qazvin,
Iran. 2Deputy ofHealth, Qazvin University ofMedical Science, Qazvin, Iran. 3International Gaming Research Unit, Psychology Department,
Nottingham Trent University, Nottingham, UK.
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1 Introduction
Childbearing is the most important inuential factor in changing population structure and size [1]. At present, many
developed and developing countries have experienced the total fertility rate (TFR) at or below the replacement level
(TFR < 2.1 children) [2]. Having a TFR > 2.1 is the most important factor in the change and transformation of the size,
growth rate and structure of the population in a country [3].
Over the past four decades, Iran is one of the countries that has experienced a sharp decrease in total TFR from 6.9
children in 1984 [4] to 1.65 children in 2021 [5]. Due to the decrease in TFR and increase in life expectancy in Iran, it is
predicted that the elderly population will increase from less than 10% in 2015 to more than 30% in 2050 [6]. Considering
the importance of fertility level and population structure changes in Iran, research examining the factors inuencing the
population size and structure is needed, especially fertility-related factors.
The fertility level of any population depends not only on a large number of biological factors but also on a wide variety
of cultural norms and social experiences [7]. Desire and tendency to have children depend on various factors such as
lifestyle changes, couple’s education level, increase in women’s employment and their economic and social independ-
ence, family’s economic and social status, economic factors and the provision of welfare facilities by governments, the
age of the couple at the time of marriage, number of children, age at the time of rst pregnancy, and awareness of
contraceptives [8, 9]. In addition to all of these aforementioned factors, abortion is considered as one of important fac-
tors inuencing the composition and size of population [10, 11]. Considering that abortion is still considered a highly
sensitive and socially stigmatized behavior in many countries, it is a dicult to accurately determine the prevalence and
is often underreported [11].
There are two main types of abortion (i.e., spontaneous abortion and induced abortion). Spontaneous abortion refers
to a natural pregnancy loss before 20 weeks of gestation (i.e., miscarriage) [12], whereas induced abortion refers to
deliberate termination of pregnancy [13]. The most common reasons for induced abortions are the timing not being
right to have a baby and limiting the family size [13]. Induced abortion (i.e., intentional medical or surgical termination
of pregnancy for any reason), is one of the factors that aects a country’s fertility rate. Globally, the highest overall abor-
tion rate is observed in middle-income countries and the lowest in high-income countries. The rate per 1000 among
women aged 15–49 years is 44 in middle-income countries, 38 in low-income countries, and 15 in high-income countries
[14–16]. Induced abortions occur for various reasons, including unwanted pregnancies due to the failure or non-use
of contraceptive methods, sexual assault, changes in conditions during pregnancy, including health concerns if the
pregnancy continues, nancial concerns, lack of preparation in accepting the parental role, the need for space or to
limit childbirth, the inuence of important individuals (such as partner and family), lack of support for the pregnancy by
partners or family members, career and educational goals, and the stigma of pregnancies such as teenage pregnancies
or pregnancies due to rape [17–20].
Globally, it is estimated that between 2015 and 2019, approximately 30% of all pregnancies (equivalent to 61% of
unintended pregnancies) resulted in induced abortion [14, 16]. Globally, between 2010 and 2014, 45% of abortions were
unsafe, with 97% of unsafe abortions occurring in low- and middle-income countries. The proportion of all abortions that
are unsafe is approximately four times higher in middle- and low-income countries (49.5%) compared to high-income
countries (12.5%). The rate of unsafe abortion is 0.9% in North America, 2.1% in Northern Europe, 37.8% in Asia, 75.6%
in Africa, and 76.4% in Latin America [15]. While the dierence in rates of unsafe abortion and related morbidity and
mortality varies considerably according to a country’s GDP, the overall rate of induced abortion worldwide is somewhat
similar [17].
In Iran, there are no accurate statistics regarding the rate of abortion in general, and the rate of induced abortions
specically. However, it is estimated that 80,000 induced abortions take place in Iran every year [21, 22]. Because Iran has
experienced a sharp decrease in TFR, one of the targets in the Government’s new population policies is to save the life of
every fetus to increase the country’s TFR [23]. In this regard, identifying the reasons for choosing abortion and attitudes
towards abortion among married reproductive age women is important and could help in the design and implementa-
tion of preventive interventions for successful pregnancies and childbirth among couples [24]. In an attempt to prevent
induced abortion (because abortion is not viewed positively in Iranian culture), repressive laws and policies have been
introduced regarding the act of induced abortion (i.e., in Islamic law, abortion is now a crime punishable by nes and
imprisonment, and revocation of medical licenses), but they appear to have had little eect on decreasing induced
abortion rate [22], and have not been suitable solutions to prevent intentional abortions [25]. Therefore, estimating the
prevalence of both spontaneous and induced abortion rates in Iran and the reasons for having an abortion could be
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helpful in designing and implementing prevention andinterventionprograms [22]. Therefore, the present study was
designed to determine the: (i) prevalence of abortion among married women of reproductive age in Qazvin (a provincein
Iran), (ii) attitude of married women of reproductive age in the province towards abortion, and (iii) reasons for choosing
abortion by married women of reproductive age in the province.
2 Methods
2.1 Study design andsetting
A cross-sectional study was conducted between February and April 2023. The participants comprised married women
of reproductive age referred to urban and rural comprehensive health centers in ve cities of Qazvin province including
Qazvin, Takestan, Alborz, Boyin Zahra and Avaj, utilizing amulti-stage proportional sampling process.
Qazvin province is one of the 31 provinces of Iran and is located in the northwestern part of the country. The area
of this province is about 15,820 square kilometers. This province has six main cities. According to 2016 statistics, the
population of Qazvin province was 1,273,759 individuals, of which 74.75% were living in urban areas and 25.25% were
living in rural areas. Qazvin was chosen as the study site in the present study because it is one of the provinces that had
a lower total fertility rate than the Iran’s total fertility rate in 2021 (1.44 versus 1.65 [5]). Moreover, there are no accurate
statistics concerning the prevalence of abortion in this province. In Qazvin province, health center ocials and their
employees pay special attention to evidence-based information and actively participate with researchers in studies in
order to help solve the problems of the province [26].
2.2 Sample size estimation
According to the estimated prevalence of abortion based on previous studies [27], the p-value was equal to 30% and the
value of d was equal to 3% and α = 0.05. The total sample size was estimated to be 1000. Considering the design eect
of 1.5 (due to random cluster sampling), 1500 individuals were required to complete the survey.
2.3 Participants
All married women of reproductive age (15 to 49years old) registered in urban or rural comprehensive health centers of
Qazvin province were eligible for inclusion in the study. Lack of consent to participate in the study was the only exclu-
sion criterion. In the present study, 1571 married women of reproductive age participatedand completed the survey.
2.4 Sampling procedure
A multi-stage proportional sampling process was utilized to recruit participants. First, the ve main cities of Qazvin
province (Qazvin, Takestan, Abyek, Buin Zahra, Alborz, and Avaj) were considered as main clusters. In each cluster, the
required sample size was assigned based on city population size. Moreover, the required number of urban and rural
participants were estimated based on the proportion of rural to urban population in each of the main cities. In the next
stage, the number of urban and rural comprehensive health centers in each city was acquired and the required sample
size for each comprehensive health center was estimated. Then the list of married reproductive age women registered
in each center was prepared and based on random sampling method, the required number were selected.
2.5 Data collection process
The survey was completed electronically and hosted on the Porsline online platform. The selected individuals were
initially contacted by telephone based on the prepared lists, and the study’s aims and their voluntary participation
were explained to them. If they provided informed consent to participate, the link was then sent to them. The link to
access the survey was made available to the selected participants (based on aforementioned process) via SMS and
social networking platforms. Internet penetration is high in Iran. Based on Iran’s Regulatory Organization and Radio
Communications’ report, by 2022, 89% of Iranian people were internet users. Qazvin is one of central provinces in Iran
with good infrastructures including internet in both rural and urban areas. Internet access in dierent urban and rural
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area was checkedwith healthcare providers before starting the data collection. Consequently, theresearch team were
assured that a considerable proportion of eligible population in both rural and urban area had internet access and that
online data collection was feasible. The survey link was deactivated once the estimated sample size had been reached.
2.6 Variables andmeasures
A self- devised questionnaire with three section was prepared based on study aims, literature review and expert opinion,
as below:
1. Checklist of demographic and fertility information including fteen items (details reported in Table1)
2. Reasons for Choosing Abortion Scale (RCAS). In order to develop the RCAS, a list of 37 reasons for the abortion was
prepared based on literature review and expert panel (including an obstetrician, a reproductive health specialist, an
epidemiologist, a general practitioner, anda representative from provincial maternal health services). Participants
were asked to indicate (yes/no) whether any of the 37 reasons were a reason for choosing the abortion or not. Partici-
pants could choose more than one response. A score of ‘1’ was given for a yes answer and a score of ‘0’ was given for
a no answer. For theRCAS, there were participants who did not choose any of items as reason for choosing abortion.
Moreover, there was one open-ended question after all of theitems asking participants to write any other possible
reasons which might make them choose to have anabortion. However, no participants answeredthis question. The
participants were divided into two groups based on the answer to this question: the group that did not choose any
of the reasons for abortion were given a total score of ‘0’, and the second group was individuals who chose at least
one reason for abortion. Principal components analysis (PCA) was used to identify the most important possible rea-
sons for choosing abortion (among the 37 initial items). The conditions of using PCA were checked and conrmed
(KMO = 0.92, Bartlett’s test of sphericity < 0.001). To calculate the total score on this scale, the average sum of each
item is calculated (i.e., a number between 0 and 3). Scores range from 0 to 39, and higher scores indicate more rea-
sons to choose abortion. The reliability of the scale with 13 items was very good (Cronbach’s alpha = 0.879). Further
information on the factor analysis and the development of the nal version of the RCAS are in the ‘Results’ section.
3. Attitudes Towards Abortion Scale (ATAS). In order to develop the ATAS, a list of 25 items was generated according to
cultural and social conditions and common attitudes in Iran on the basis of a literature review and the aforemen-
tioned expert panel. An exploratory factor analysis (EFA) using a PCA approach along with the optional variable of
abortion type were used to evaluate the validity of the construct. The conditions of using PCA were checked and
conrmed (KMO = 0.87, Bartlett’s test of sphericity < 0.001). The items are ratedon a ve-point Likert scale from 1
(strongly disagree) to 5 (strongly agree) to. To calculate the total score, the average sum of each subscale is calculated
(ranging from 4 to 20). Higher scores indicate higher pro-abortion attitudes. The reliability of the 25-item scale was
very good (Cronbach’s alpha = 0.893). Further information on the factor analysis and the development of the nal
version of the ATAS are in the ‘Results’ section.
Face validity and content validity of all items were carried out qualitatively and modications to the items were per-
formed prior to data collection. For face validity, ten reproductive age women were asked to assess the questionnaire’s
items in terms of relevance, diculty, and ambiguity (qualitative face validity). Ten specialists in the eld of reproductive
health, midwifery, and nursing assessed the questionnaire in terms of grammar, wording, anditem allocation (qualita-
tive content validity).
2.7 Statistical analysis
Data were analyzed using SPSS version 25. Descriptive analysis was carried out to report frequencies and percentages
of categorical data, and means and standard deviations of continuous data. Univariable and multivariable binary logis-
tic regression models were applied to investigate the association between history of abortion, history of abortion in
the past year, number of abortions, and type of abortion (spontaneous and non-spontaneous) with demographic and
social variables, mental health, reasons for choosing abortion, and attitude towards abortion. In the logistic regression
method, the response variables were history of abortion, history of abortion in the past year, number of abortions, and
type of abortion (spontaneous and non-spontaneous). In carrying out the analysis, categorical variables were dened
as dummy variables.
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Table 1 Demographic characteristics of the participants (N = 1571)
Variable Total sample: No (%) Having abortion his-
tory (n = 1571) Having abortion in past
year (n = 292) More than one abortion
(n = 292) Having non-spontane-
ous abor tion (n = 292)
No (%) OR
(p)No (%) OR
(p)No (%) OR
(p)No (%) OR
(p)
292 (18.6) 65 (22.3) 77 (26.4) 190 (65.1)
Age Younger than 35 years 941 (59.9) 148 (15.7) 1 38 (58.5) 1 32 (41.6) 1 96 (50.5) 1
35 years and older 630 (40.1) 144 (22.9) 1.59
(< 0.001) 27 (41.5) 0.67
(0.16) 45 (58.4) 1.65 (0.06) 94 (49.5) 1.02 (0.94)
Marriage duration Up to ve years 378 (24.8) 38
(10.1) 1 17 (26.2) 1 6 (7.9) 1 96 (50.5) 1
More than ve years 1145 (75.2) 251 (21.9) 2.51
(< 0.001) 48 (73.8) 0.29 (< 0.001) 70 (92.1) 2.06 (0.12) 94 (49.5) 0.96 (0.92)
Education Primary school 131 (8.3) 23
(17.6) 1 5
(7.7) 1 5
(6.5) 1 14 (7.4) 1
Guidance school 265 (16.9) 56
(21.1) 1.26
(0.40) 14 (21.5) 1.20
(0.76) 10
(13) 0.78 (0.69) 36 (18.9) 1.16 (0.78)
High school diploma 561 (35.7) 109 (19.4) 1.13
(0.62) 22 (33.8) 0.91
(0.87) 35 (45.5) 1.70 (0.33) 74 (38.9) 1.34 (0.52)
University 614 (39.1) 104 (16.9) 0.96
(0.86) 24 (36.9) 1.08
(0.89) 27 (35.1) 1.26 (0.67) 66 (34.7) 1.12 (0.82)
Spouse education Primary school 162 (10.3) 28
(17.3) 1 5
(7.7) 1 6
(7.9) 1 17 (9.0) 1
Guidance school 304 (19.4) 65
(21.4) 1.30
(0.29) 16 (24.6) 1.50
(0.48) 18 (23.7) 1.40 (0.53) 42 (22.3) 1.18 (0.72)
High school diploma 546 (34.8) 98
(17.9) 1.05
(0.85) 25 (38.5) 1.58
(0.40) 23 (30.3) 1.12 (0.82) 67 (35.6) 1.40 (0.45)
Academic 511 (32.5) 98
(19.2) 1.14
(0.59) 19 (29.2) 1.11
(0.86) 29 (38.2) 1.54 (0.40) 62 (33.0) 1.11 (0.81)
Job Housewife 1053 (67.0) 205 (19.5) 1 48 (73.8) 1 52 (67.5) 1 131 (68.9) 1
Employed 518 (33.0) 87
(16.8) 0.84
(0.20) 17 (26.2) 0.79
(0.47) 25 (32.5) 1.19 (0.55) 59 (31.1) 1.19 (0.52)
Spouse job unemployed 80 (5.1) 11
(13.8) 1 2
(3.1) 1 3
(3.9) 1 7
(3.7) 1
Employed 322 (20.5) 60
(18.6) 1.44
(0.31) 13 (20.0) 1.25
(0.89) 23 (29.9) 1.66 (0.49) 44 (23.2) 1.57 (0.51)
Worker 402 (25.6) 63
(15.7) 1.17
(0.66) 17 (26.2) 1.66
(0.54) 14 (18.2) 0.76 (0.71) 42 (22.1) 1.14 (0.85)
Non-governmental 720 (45.8) 144 (20.0) 1.58
(0.18) 32 (49.2) 1.29
(0.76) 33 (42.9) 0.79 (0.74) 88 (46.3) 0.90 (0.87)
Retired 47
(3.0) 14 (29.8) 2.66
(0.03) 1
(1.5) 0.35
(0.41) 4
(5.2) 1.07 (0.94) 9
(4.7) 1.03 (0.97)
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Table 1 (continued)
Variable Total sample: No (%) Having abortion his-
tory (n = 1571) Having abortion in past
year (n = 292) More than one abortion
(n = 292) Having non-spontane-
ous abor tion (n = 292)
No (%) OR
(p)No (%) OR
(p)No (%) OR
(p)No (%) OR
(p)
292 (18.6) 65 (22.3) 77 (26.4) 190 (65.1)
Place of residency Rural 523 (33.3) 109 (20.8) 1 27 (41.5) 1 20 (26.0) 1 74 (38.9) 1
Urban 1048 (66.7) 183 (17.5) 0.80
(0.11) 38 (58.5) 0.80
(0.43) 57 (74.0) 2.01 (0.02) 116 (61.1) 0.82 (0.44)
City Qazvin 690 (43.9) 144 (20.9) 1 31 (47.7) 1 39 (50.6) 1 90 (47.4) 1
Booien Zahra 227 (14.4) 38
(16.7) 0.76
(0.18) 12 (18.5) 1.68
(0.20) 11 (14.3) 1.10 (0.82) 28 (14.7) 1.68 (0.20)
Avaj 59
(3.8) 7
(11.9) 0.51
(0.10) 2
(3.1) 1.46
(0.66) 3
(3.9) 2.02 (0.37) 5
(2.6) 1.50 (0.64)
Takestan 217 (13.8) 49
(22.6) 1.11
(0.59) 9
(13.8) 0.82
(0.64) 9 (11.7) 0.61 (0.23) 30 (15.8) 0.95 (0.87)
Abyek 85
(5.4) 15
(17.6) 0.81
(0.49) 3
(4.6) 0.91
(0.89) 4
(5.2) 0.98 (0.97) 8
(4.2) 0.69 (0.49)
Alborz 293 (18.7) 39
(13.3) 0.58
(0.006) 8 (12.3) 0.94
(0.89) 11 (14.3) 1.06 (0.89) 29 (15.3) 1.74 (0.17)
Independent life status No 183 (11.6) 37
(20.2) 1 11 (16.9) 1 12 (15.8) 1 24 (12.8) 1
Yes 1340 (85.3) 252 (18.8) 0.91
(0.65) 54 (83.1) 0.65
(0.26) 64 (84.2) 0.71 (0.37) 164 (87.2) 1.01 (0.98)
Infertility history No 1423 (90.6) 256 (18.0) 1 60 (92.3) 1 59 (77.6) 1 167 (88.8) 1
Yes 100
(6.4) 33
(33.0) 2.25
(< 0.001) 5
(7.7) 0.58
(0.29) 17 (22.4) 3.55 (< 0.001) 21 (11.2) 0.93 (0.86)
Mental health status Good mental health 916 (58.3) 155 (16.9) 1 30 (46.2) 1 38 (49.4) 1 91 (47.9) 1
Poor mental health 655 (41.7) 137 (20.9) 1.30
(0.05) 35 (53.8) 1.43
(0.20) 39 (50.6) 1.23 (0.45) 99 (52.1) 1.83 (0.02)
Number of children 0 214 (13.6) 28
(9.7) 1 15 (23.1) 1 8 (10.5) 1 19 (10.1) 1
1 494 (31.4) 89
(30.8) 1.46
(0.11) 20 (30.8) 0.25
(0.002) 20 (26.3) 0.73 (0.51) 59 (31.4) 0.93 (0.88)
2 603 (38.4) 125 (43.3) 1.74
(0.02) 25 (38.5) 0.21
(0.001) 38 (50.0) 1.09 (0.85) 87 (46.3) 1.08 (0.86)
≥ 3 212 (13.5) 47
(16.3) 1.89
(0.02) 5
(7.7) 0.10
(< .001) 10 (13.2) 0.68 (0.48) 23 (12.2) 0.45 (0.11)
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Table 1 (continued)
Variable Total sample: No (%) Having abortion his-
tory (n = 1571) Having abortion in past
year (n = 292) More than one abortion
(n = 292) Having non-spontane-
ous abor tion (n = 292)
No (%) OR
(p)No (%) OR
(p)No (%) OR
(p)No (%) OR
(p)
292 (18.6) 65 (22.3) 77 (26.4) 190 (65.1)
Access to healthcare providers
(Mean (SD) on 1-5likert scale) Midwife 4.08 (0.79) 4.02 (0.86) 0.88
(0.11) 3.85 (0.91) 0.75
(0.07) 3.85 (0.91 0.88 (0.41) 4.0 (0.82) 0.94 (0.64)
GP 4.13 (0.75) 4.08 (0.77) 0.91
(0.25) 3.95 (0.74) 0.89
(0.36) 3.95 (0.74) 0.83 (0.28) 4.03 (0.75) 0.75 (0.09)
Obstetrician 3.59 (1.03) 3.51 (1.06) 0.91
(0.13) 3.40 (1.10) 0.76
(0.13) 3.40 (1.10) 0.84 (0.17) 3.44 (1.04) 0.84 (0.15)
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First, the association between response variables and demographic and social variables, mental health, RCAS scores,
and ATAS scores were investigated using univariable models. Then, variables with a signicance level of less than 0.2 in
univariable models were entered into multivariable model. In the multivariable logistic regression method, independ-
ent variables were entered into the model using a backward stepwise approach. The signicance level of other tests
was p < 0.05.
2.8 Ethics
The study protocol was reviewed and approved by the institutional review board and the ethics committee aliated to
Qazvin University of Medical Sciences (Decree code: IR.QUMS.REC.1401.281). All required permissions were obtained.
Informed consent was provided by all participants. Prior to the study, information regarding the research objectives
were explained, participation was voluntary, and participants were assured that all data collected would be condential
and anonymous.
3 Results
3.1 Abortion profile
The lifetime prevalence of abortion was 18.6%among the total sample (292 out of 1571). For approximatelythree-quar-
ters of the women(73.6%), it was their rst experience of abortion (215 out of 292). The prevalence of non-spontaneous
abortion was 65.1% among those who reported having had an abortion(190 out of 292), and 69.2% of overall abortions
in the past year(n=65)were non-spontaneous (n=45). The prevalence of abortion in the past year among those who
reported having had an abortionwas 22.3%. The demographic and fertility characteristics of the participants and its
relationship with history of abortion, history of abortion in the past year, number of abortions, and non-spontaneous
abortions (results of univariable logistic regression analysis) are shown in Table1.
3.2 Reasons forabortion
In the PCA, RCAS items with aloading factor less than 0.4, and items loading on two subscales with a factor load dier-
ence of less than 0.2 were removed. This process resulted in the RCAS comprising 13 items and three subscales, which
explained 56.28% of the variance. The rst subscale labelled ‘Couple’s behavior, health and relationship problems’ (e.g.,
mother’s and/or spouse’s self-reported smoking and addiction to drugs, mother’s and/or spouse’s physical diseases and/
or psychological problems, sexual indelity, decision to divorce and unstable marital relationships) explained 27% of the
variance. The second sub-scale was labelled ‘fertility-related stressful experiences’ (e.g., dicult experience of previous
childbirth, dicult experience of previous pregnancy, worrying about their own health during childbirth) explained
15% of the variance. The third sub-scale was labelled ‘family economic situations’ (e.g., poor economic situation, spouse’s
unemployment) and explained 14% of the variance. The correlation between the subscales was moderate (between
0.39 and 0.57).
3.3 Attitude towardabortion
In the PCA, 18 ATAS items remained in four subscales, explaining 62.88% of the variance. The rst subscale was labelled
‘pro-abortion attitude’ (e.g., abortion should be for couples who do not currently want children; abortion should be for
unwanted pregnancies that interfere with occupational and/or educational circumstances; abortion is an appropriate
method to control the number of children [family planning]; women have the right to abortion freely; abortion should
be cheap and widely available; abortion should be carried out in the rst trimester of pregnancy; abortion should be
freely provided for women who think they do not have the ability to care for the child; abortion should be carried out if
there is a threat to married life [due to marital disputes]; abortion should be freely provided for pregnant women who
are not married), and explained 26.33% of the variance.
The second sub-scale was labelled ‘abortion in controlled conditions’ (e.g., government institutions must strictly control
abortion; abortion must be for in those who have been raped; abortion must be for those whose pregnancy is dangerous
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for their health; abortion should be performed when fetuses are suspected of mental or physical abnormality) and
explained 13.66% of the variance.
The third subscale labelled ‘abortion in cases of suspected fetal damage’ (e.g., ‘If I have taken medicine with probable
fetal side eects before knowing I am pregnant, I should have the right to have an abortion’; ‘If the fetal heart activity is
not seen in the ultrasound assessment, abortion should be allowed’) and explained 13.64% of the variance.
The fourth subscale was labelled ‘couple interaction for fertility decisions’ (e.g., the husband must have a role in decid-
ing whether to have an abortion; abortion should be allowed if the pregnancy was unplanned) and explained 9.25% of
the variance. The correlation between the subscales was moderate (between 0.24 and 0.58).
3.4 Association ofabortion profile withparticipants’ ATAS andRCAS scores
A total of 672 participants declared that they did not consider any of the items as a reason for abortion (42.8%). Uni-
variable regression analysis showed that in the group that chose a reason for abortion compared to the group that did
not choose any of the reasons for abortion, the likelihood of abortion was three times higher (p < 0.001), the likelihood
of abortion in the past year was 84% higher (p = 0.10), and the likelihood of non-spontaneous abortion was 72% higher
(p = 0.05). No signicant association was observed between the likelihood of abortion more than once and choosing
the reason for abortion (p = 0.92). The RCAS total score was signicantly associated with lifetime abortion prevalence
(p < 0.001), i.e., higher scores were associated with greater frequency of abortion. However, RCAS total score was not sig-
nicantly associated with experience of abortion in the past year (p = 0.44), having non-spontaneous abortion (p = 0.88),
or having more than one abortion (p = 0.67). The likelihood of abortion and non-spontaneous abortion increased by 6%
(p = 0.04) and 10% (p = 0.3) respectively with increasing mean scores on the ATAS. There was no signicant association
between ATAS score. and history of abortion in the past year (p = 0.96) or having more than one abortion (p = 0.62).
3.5 Predictors ofabortion
The results of the multivariable logistic regression model (Table2) showed that the likelihood of abortion was signicantly
higher among women aged 35 years and over than among women aged under 35 years (OR = 40%), among women
married for more than ve years compared to those married for ve years or fewer (OR = 2.3), and among women with
infertility history (OR = 2.12). The likelihood of abortion was 2.9 times higher among women who chose a reason for
abortion than those who did not choose any of the reasons for abortion. Moreover, the likelihood of abortion increased
by 7% with each unit increase in the mean score on the attitude towards abortion scale. Likelihood of abortion was 37%
lower in Alborz city than in Qazvin city (no signicant dierence between other cities with Qazvin as reference group).
Predictors of abortion in the past year were number of children (higher abortion among those with fewer children)
and selecting a reason for abortion. Predictors of having more than one abortion were living in urban areas and having
history of infertility. Predictors of non-spontaneous abortion were having three or more children, having poor mental
health status, choosing a reason for abortion, and having higher scores on the ATAS.
4 Discussion
The present study was designed to determine the: (i) prevalence of abortion among married women of reproductive age
in the province, (ii) attitude of married women of reproductive age in the province towards abortion, and (iii) reasons for
choosing abortion by married women of reproductive age in the province.
The results of the study showed that the lifetime prevalence of abortion was 18.6%, and the past-year prevalence of
abortion was 22.3%. The prevalence of non-spontaneous abortion was 65.1% of overall the lifetime abortions and 69.2%
of overall abortions in the past year. The lifetime prevalence of abortion is similar to the prevalence of 18.8% in a previ-
ous Iranian study, [28] and similar to rates of induced abortion between 8% and 17% in other Iranian studies [29–31].
Dierent prevalence rates of abortion have been reported in other countries including 19% in Peru [32], 16.7% in China
[33], and between 7% [34] and 21% [35] in the United States. The global estimate of abortion was 30% of all pregnan-
cies between 2015 and 2019, and approximately 61% of unintended pregnancies, ended in induced abortion [14, 16].
Therefore, lifetime prevalence of abortion in present study is in line with studies from thesame country but lower than
global estimates. This inconsistency with global estimates might be due to reasons such as the stronger perceived social
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Table 2 Results of multi-variable logistic regression for identifying independent predictors of abortion
*No signicant dierence between other cities with Qazvin as reference group
Dependent variable Predictors Odds ratio (OR) 95% C.I. OR Sig. Variance
explained
Abortion history Choosing reason for abortion vs. having no reason 2.87 2.13; 3.88 < 0.001 11.5%
Marriage duration more than ve years vs. up to ve years 2.29 1.55; 3.38 < 0.001
Having infertility history 2.12 1.34; 3.36 0.001
35 years and more vs. less than 35 years 1.40 1.06; 1.85 0.019
Attitude toward abortion 1.07 1.02; 1.13 0.009
Alborz city vs. Qazvin city as reference group * 0.63 0.43; 0.91 0.015
Having abortion in past year Choosing no reason for abortion vs. having a reason for abortion 1.95 0.91; 4.17 0.08 10.6%
Number of children 0 1 – –
1 0.25 0.10; 0.62 0.003
2 0.21 0.09; 0.51 0.001
≥ 3 0.10 0.03; 0.33 < 0.001
More than one abortion City vs. rural 1.93 1.07; 3.49 0.03 7.8%
Having infertility history 3.55 1.67; 7.52 0.001
Having non-spontaneous abortion Choosing a reason for abortion vs. having no reason 1.77 1.00; 3.15 0.05 8.1%
Poor vs. good mental health 1.74 1.05; 2.89 0.03
Attitude toward abortion 1.09 0.99; 1.20 0.09
Number of children ≥ 3 (vs. no child) 0.53 0.28; 1.03 0.06
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stigma regarding induced abortion in Iran and participation of only married women in present study (because sex before
marriage is culturally unacceptable in Iran, therefore the present study did not investigate all women of reproductive age).
The results of present study showed that women’s reasons for choosing abortion fell into one of three main clusters:
(i) couple’s behavior, health and relationship problems, (ii) fertility-related stressful experiences, and (iii) family economic
situations. Each of these reasons have been separately reported in previous studies but no previous study has ever
assessed all the reasons simultaneously (or using a psychometric scale which was specically developed for the present
study). For example, previous studies have reported that reasons for abortions include already having sucient number
of current children and being in an unfavorable economic situation [29] which concur with those of the present study.
Specic demographic factors have also been reported as having higher associations with those having an abortion in
previous studies such as higher education status among women and being an employed woman (because more highly
educated women tend to have better paid jobs and having a baby may impede career progression), and living in a slum
(because they do not want to bring up a baby in poor living conditions) [30]. A recent study which synthesized the
reasons why women from 14 countries have induced abortions reported that the most frequent reasons for having an
abortion were socioeconomic concerns or to limit the number of children being raised. With a few exceptions, little vari-
ation existed in women’s socio-demographic characteristics (e.g., women’s age, marital status, educational attainment,
and residence). Data from Sweden and the US hasshown that women often have more than one reason for having an
abortion. Overall, it was concluded that personal, cultural, economic, social and familial factors were related to abortion
choice at country level and that future research should examine these factors in greater depth [13]. The present study
attempted to assess these reasons in an Iranian context and items related to couple’s health and relationships problems
had the highest variance in explaining the reasons to choose abortion.
As well as the predicting role of attitude towards abortion and having reasons to choose abortion, some predictors
were identied which increased the likelihood of abortion including being over 35 years, being married for over ve
years, having a history of infertility, living in rural areas, and having poor mental health status. Contrasting ndings have
been reported in previous studies regarding the association between age and abortion rate. In some studies, higher
abortion rates have been reported among older age group [36–38], while other studies have reported higher rates of
abortion among younger age groups [39–42]. This inconsistency might be due to the cultural dierence and dierent
study populations in these studies. In the present study, women with a history of infertility had a higher rate of more than
one abortion, which is consistent with the previous studies [24, 43]. Women with a history of infertility are a high-risk of
group for recurrent abortion and should be appropriately monitored [44].
Another predictor of abortion in present study was the number of children. Women with three or more children were
less likely to have an abortion than childless women. A previous study by Jones etal. noted that in 2014, most abortions
occurred among women who had already given birth. In the US, the abortion rate among women with only one previous
birth has been reported to be 22.0 per 1000, among women with more than one previous birth 13.2 per 1000, and among
women who have not given birth 13.0 per 1000 [45]. A study conducted in Ghana also reported that the prevalence of
abortion was lower among women with an increasing number of children [38]. In an Iranian study, the results showed
that the lifetime prevalence of abortion among mothers without children or with one child was higher than the lifetime
prevalence of abortion in the present study [27]. In the present study, individuals without children had a greater likeli-
hood of having an abortion and can be considered as a group at-risk of abortion (given that in Iran, abortions are not
culturally acceptable and policies have been introduced to prevent abortions).
In the present study, the likelihood of non-spontaneous abortion was higher among women with poor mental health
status than among women with favorable mental health status. Due to cross-sectional nature of present study, the direc-
tion of association cannot be determined. It is unknown whether poor mental health is consequence of a previous abor-
tion or was a reason which led to abortion. It has been reported that the risk of mental health problems after abortion
is moderate to very high [46]. However, there is no evidence that abortion has therapeutic eects in reducing mental
health risks caused by unwanted or unintended pregnancy. There is evidence that having an abortion may be associated
with a small to moderate increase in the risk of some mental health problems [47]. Therefore, longitudinal studies are
needed to identify the eect of poor mental health on occurrence of non-spontaneous abortion.
4.1 Limitations
The present study benefits from a large sample size with participants from different parts of province which reflected
the variability of cultural and social factors. Moreover, a multi-variable regression analysis led to the identification
of the most important predictors in each variable of interest. However, some limitations should be considered when
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interpreting the findings. First, (as aforementioned) the cross-sectional nature of the study meant that establishing
causality between the variables could be determined. Second, the use of self-report measures to investigate the
experience, attitudes and reasons to choose abortion are sensitive topics and could a source of underreporting due
to perceived social stigma regarding these issues (i.e., due to social desirability). Third, sampling was conducted from
one province of Iran which limits generalizability of findings to other parts of Iran. Fourth, the selected participants
were only married women and the results cannot be generalized to single women who have had sexual relations
and experienced abortion.
5 Conclusion andclinical implication
The results of present study can be used in clinical practice for designing strategic plans to reduce non-spontaneous
abortion. Women’s reasons for choosing abortion fell into one of three main clusters of (i) couple’s behavior, health and
relationship problems, (ii) fertility-related stressful experiences, and (iii) family economic situations. The other ndings
of present study were identication of predictors for non-spontaneous abortion. Women in high-risk groups for non-
spontaneous abortion (i.e., those aged over 35 years, those married for more than ve years, those with an infertility
history, those with a lower number of children, those living in rural areas, and those having poor mental health status)
should be assessed by primary healthcare services during preconception and have early prenatal counseling to help
in decisions regarding abortion. First, healthcare providers should be informed regarding the main reasons to choose
abortion and high-risk groups for non-spontaneous abortion via in-service empowerment training workshop. In next
step it is suggested that healthcare providers who visit reproductive age women for preconception and early prenatal
counselling, assess these aspects as themain factorsthat increase the probability of womenchoosing to have anabor-
tion. Also, some of healthcare providers in obstetric eld can be trained specically for counselling with high risk pregnant
women (who decide to abort their fetus) to maintain pregnancy and avoid abortion. Further research can be designed to
implement and assess the eectiveness of the aforementioned suggested strategies to identify the best clinical practice.
Acknowledgements We woulld like to thankall thepregnant women whoparticipated in the study.
Author contributions Z.A. and N.Y. contributed to the conception, Z.A., M.A. and N.Y. contributed to the design of the study, N.Y. and M.A. con-
tributed in data collection in supervision of M.A. Z.A. and M.A. contributed in data analysing and interpretation of data. Z.A. and M.A. drafted
the manuscript. M.D.G. provided contributions to the literature review and discussion and prepared the nal version of the manuscript. M.D.G.
revised the manuscript and copy-edited the manuscript. All authors revised the manuscript, agreed to be fully accountable for ensuring the
integrity and accuracy of the study, and read and approved the nal version of the manuscript to be published. All the authors met the criteria
for authorship, and they are listed as co-authors on the title page.
Funding No nancial support received.
Data availability The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate In present study, the Declaration of Helsinki was adhered and study protocol was approved by the
ethics committee aliated to Qazvin University of Medical Sciences, Qazvin, Iran (approval number: IR.QUMS.REC.1401.281). After obtaining
the necessary permits, the individuals were invited to participate in the research, andinformed consent was obtained from all participants.
Consent for publication Not applicable.
Competing interests The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which
permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modied the licensed material. You
do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party
material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If
material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds
the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco
mmons. org/ licen ses/ by- nc- nd/4. 0/.
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