Abortion Research

Context: The immediate explanation that women often give for seeking induced abortion is that the pregnancy was unplanned or unwanted. However, the myriad social, economic and health circumstances that underlie such explanations have not yet been fully explored.

Methods: Findings from 32 studies in 27 countries were used to examine the reasons that women give for having an abortion, regional patterns in these reasons and the relationship between such reasons and women's social and demographic characteristics. The data come from a range of sources, including nationally representative surveys, official government statistics, community-based studies and hospital- or clinic-based research.

Results: Worldwide, the most commonly reported reason women cite for having an abortion is to postpone or stop childbearing. The second most common reason—socioeconomic concerns—includes disruption of education or employment; lack of support from the father; desire to provide schooling for existing children; and poverty, unemployment or inability to afford additional children. In addition, relationship problems with a husband or partner and a woman's perception that she is too young constitute other important categories of reasons. Women's characteristics are associated with their reasons for having an abortion: With few exceptions, older women and married women are the most likely to identify limiting childbearing as their main reason for abortion.

Conclusions: Reasons women give for why they seek abortion are often far more complex than simply not intending to become pregnant; the decision to have an abortion is usually motivated by more than one factor. While improved contraceptive use can help reduce unintended pregnancy and abortion, some abortions will remain difficult to prevent, because of limits to women's ability to determine and control all circumstances of their lives.


How closely are a woman's reasons for abortion related to her socioeconomic and demographic characteristics? We address this question by examining how the reasons vary by three characteristics—the woman's age, marital status and level of education—in 10 countries. (For two of these countries, Australia and the Philippines, the data are based on the number of responses to an item that allowed women to specify multiple reasons.)

•Age. A woman's age is only moderately associated with why she seeks an abortion (Table 4). In four of the five countries for which data are available on postponing childbirth as a reason for abortion, women younger than age 25 were more likely than those aged 25 and older to say the reason for their abortion was to postpone childbearing. The exception was Zambia, where only 29% of younger women said they sought their abortion for timing purposes, compared with 71% of older women.


However, in three of the eight countries, younger women were more likely than older women to mention socioeconomic factors as their reason (Turkey, the United States and Zambia); the reverse was true in just one country (the Czech Republic), and there was virtually no difference by age in the remaining four (Australia, Colombia, Finland and Romania). As expected, in all five countries in which the "too young" reason was studied, younger women were more likely than older women to note that they were too young or feared their parents' objection.

•Marital status. A desire to stop childbearing and socioeconomic circumstances appear to be the most prominent reasons why married women have abortions,*† while socioeconomic factors and young age or parental objections are the two most important ones among unmarried women. Marital status makes no difference in the likelihood of citing a desire to postpone childbearing as the main reason for having an abortion. However, in five of the seven countries with available data, unmarried women were at least as likely as married women to cite socioeconomic reasons as most important; as expected, the proportion citing being underage and parents' objections as their main reason was consistently higher among unmarried women than married women.

Unmarried women were more likely than married women to say their abortion was mainly motivated by relationship problems (for example, 22% vs. 5% in the Czech Republic, and 30% vs. 4% in the Philippines). In all seven countries, but especially in Colombia, the Czech Republic and the United States, reasons of maternal or fetal health tended to be more important among married than unmarried women.

•Education. No clear association emerged between women's educational attainment and their main reasons for seeking an abortion. Studies conducted in five countries show that the profile of reasons why women have abortion is very similar among both more and less educated women.

DISCUSSION
The universality of the phenomenon of unintended pregnancy illustrates that, worldwide, women and couples have great difficulty in successfully planning births. In the majority of the 49 developing countries for which we examined fertility survey data, a high proportion of women would like to postpone having a child or to stop altogether, but are not using an effective contraceptive method. Even where effective use is quite high, women continue to experience unplanned pregnancy, because of either contraceptive failure or unanticipated changes in their life circumstances, or sometimes as a result of their own ambivalence.

The analysis of the reasons women give for why they had an abortion shows that the most commonly reported ones are postponing childbearing to a more suitable time or stopping altogether to focus energies and resources on existing children. The fact that these two reasons were less important in Latin America and the United States than in Asia and some of the other developed countries may partly be explained by the high prevalence of sterilization at relatively young ages in these first two regions, which reduces the need for abortion to limit family size. The desire to delay or stop childbearing probably reflects a number of underlying, more specific reasons for not wanting to have a child at that time.

The second most commonly reported reason consists of socioeconomic factors, such as being unable to afford a child—either in terms of the direct costs of raising a child or the opportunity costs to a woman who, to care for a child, must interrupt her education or work. This set of reasons is particularly prominent in Sub-Saharan Africa, where the majority of women who seek abortion tend to be young and unmarried, and where pregnancies that end in abortion are likely to occur in unstable relationships.*‡

In the Latin American countries for which we have information, relationship problems are among the most important reasons why women seek abortion; in these societies, where many women are in consensual unions, the issue of being able to support the child should the relationship end is probably a major concern. Being unable to afford a child is also an important reason why women obtain an abortion in the United States.

While at least a small proportion of women in most countries mentioned the risk to their health as their primary motivation for the abortion, this reason was relatively more prevalent in Sub-Saharan Africa and South Asia than in other regions. This finding is not surprising, since we expect abortions for maternal health reasons to be related to large family size and close birth spacing, factors that are much more common in these two regions than in the others.

Only small proportions of women mentioned a risk to fetal health either as the most important reason for having an abortion or as a contributing one. However, in some studies, particularly those in Asian countries, a substantial minority of women mentioned fetal defects as the most important reason for their abortion. We speculate that this category may include women who chose an abortion because of the sex of the fetus. The generally low prevalence of such reasons may stem from women's poor access to modern diagnostic tests in most developing countries rather than to any real population difference in the prevalence of fetal defects.
DEVELOPED COUNTRIES•Australia, 1992: subnational hospital/clinic-based survey; self-administered questionnaire distributed by staff to abortion patients at 11 clinics; N=2,249; all marital statuses (33% married or in de facto unions). Source: Adelson PL, Frommer MS and Weisberg E, A survey of women seeking termination of pregnancy in New South Wales,Medical Journal of Australia, 1995, No. 163, pp. 419-422.

•Czech Republic, 1993: national fertility survey; nationally representative sample of women aged 15-44; N=2,249; all marital statuses (64% married, 3% consensual union).Source: Czech Statistical Office et al., see reference 2. (Micro data files from this study were also used for original analyses.)

•Finland, 1993: official government statistics; women obtaining legal induced abortions; N=10,342; all marital statuses (27% married). Source: Hämäläinen H, Rasimus A and Ritamo M, Tilastotiedote Statistikmeddelande: Aborttitlasto 1993, Helsinki, Finland: National Research and Development Centre for Welfare and Health (STAKES), 1995, No. 14.

•Netherlands, 1983-1987: subnational hospital/clinic-based survey; clinic admission statistics of women of Caribbean descent who had had an abortion; N=230; all marital statuses (12% formally married, 16% common-law marriages). Source: Lamur HE, Characteristics of Caribbean-born women having abortions in an Amsterdam clinic, Genus, 1993, IL(3-4):135-145.

•Romania, 1993: national fertility survey; national household sample of women aged 15-44; N=4,772; all marital statuses (63% married, 4% consensual unions). Source: Romanian Ministry of Health, see reference 2.

•United States, 1987-1988: national survey of facilities; questionnaire distributed to abortion patients; N=1,900; all marital statuses. Source: see reference 8. (Micro data files from this study were also used for orginal analyses.)


References1. Londo#241;o ML, Abortion counseling: attention to the whole woman, International Journal of Gynecology and Obstetrics, 1989, Supplement 3, pp. 169-174.

2. Jones EF et al., Pregnancy, Contraception and Family Planning Services in Industrialized Countries, New Haven, CT, USA: Yale University Press, 1989; Czech Statistical Office et al., 1993 Czech Republic Reproductive Health Survey Final Report, Atlanta, GA, USA: Centers for Disease Control and Prevention (CDC), 1995; and Romanian Ministry of Health, Institute for Mother and Child Care, Romania Reproductive Health Survey, 1993, Final Report, Bucharest, Romania: Ministry of Health, Institute for Mother and Child Care, and Atlanta, GA, USA: CDC, Division for Reproductive Health, 1995.

3. The Alan Guttmacher Institute (AGI), Family planning improves child survival and health, Issues in Brief, New York, Oct. 1997.

4. Justesen A, Kapiga SH and van Asten H, Abortions in a hospital setting: hidden realities in Dar es Salaam, Tanzania, Studies in Family Planning, 1992, 23(5):325-329; and AGI, Clandestine Abortion: A Latin American Reality, New York: AGI, 1994.

5. Westoff CF, Sharmanov AT and Sullivan JM, The replacement of abortion by contraception in three Central Asian Republics, unpublished manuscript, Office of Population Research, Princeton University, Princeton, NJ, USA, 1998.

6. Fikree FF et al., The emerging problem of induced abortions in squatter settlements of Karachi, Pakistan,Demography India, 1996, 25(1):119-130.

7. AGI, Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York: AGI, 1995, Appendix Tables 5 and 7; Czech Statistical Office et al., 1995, op. cit. (see reference 2); and 1995 National Survey of Family Growth, CDC, National Center for Health Statistics, Hyattsville, MD, USA, special analyses.

8. Torres A and Forrest JD, Why do women have abortions? Family Planning Perspectives, 1988, 20(4):169-176.

9. Fikree FF et al., 1996, op. cit. (see reference 6).

10. Westoff CF and Bankole A, Unmet Need: 1990-1994, DHS Comparative Studies, No. 16, Calverton, MD, USA: Macro International, 1995; and Bongaarts J and Bruce J, The causes of unmet need for contraception and the social content of services, Studies in Family Planning, 1995, 26(2):57-75.

11. Jones EF and Forrest JD, Contraceptive failure rates based on the 1988 NSFG, Family Planning Perspectives, 1992, 24(1):12-19.

12. Westoff CF and Bankole A, 1995, op. cit. (see reference 10).

13. Torres A and Forrest JD, 1988, op. cit. (see reference 8).

14. Westley SB, Evidence mounts for sex-selective abortion in Asia, Asia-Pacific Population & Policy, 1995, May/June, No. 34, pp. 1-4.

15. Czech Statistical Office et al., 1995, op. cit. (see reference 2).

16. Introduction to Rogo K, Leonard A and Muia E, eds., Unsafe Abortion in Kenya: Findings from Eight Studies, Nairobi, Kenya: Population Council, 1996; Renne EP, Changing Patterns of Child-spacing and Abortion in a Northern Nigerian Town, Working Paper, No. 97-1, Princeton, NJ, USA: Office of Population Research, 1997; and Salter C, Johnson HB and Hengen N, Care for postabortion complications: saving women's lives, Population Reports, Series L, No. 10, 1997.

17. Bleek W and Asante-Darko NK, Illegal abortion in Southern Ghana: methods, motives and consequences,Human Organization, 1986, 45(4):333-344; Anarfi JK, The role of local herbs in the recent fertility decline in Ghana: contraceptives or abortifacients? paper presented at the International Union for the Scientific Study of Population Seminar on Socio-cultural and Political Aspects of Abortion from an Anthropological Perspective, Trivandrum, India, Mar. 25-28, 1996; and Oniang'o R, Unwanted adolescent pregnancy: who chooses abortion and why? in Rogo K, Leonard A and Muia E, 1996, op. cit. (see reference 16).

18. Renne EP, The pregnancy that doesn't stay: the practice and perception of abortion by Ekiti Yoruba women,Social Science and Medicine, 1996, 42(4): 483-494.

19. Paiewonsky D, El Aborto en la República Dominicana, Santo Domingo, Dominican Republic: Centro de Investigación Para la Acción Femenina, 1988; Romero M, Carrillo LL and Langer A, Determinantes del aborto en adolescentes Mexicanas, paper presented at the Meeting of Researchers on Induced Abortion in Latin America and the Caribbean, Bogotá, Colombia, Nov. 15-18, 1994; and Chizuru M et al., Determinants of induced abortion among poor women admitted to hospitals in Fortaleza, North Eastern Brazil, paper presented at the Meeting of Researchers on Induced Abortion in Latin America and the Caribbean, Bogotá, Colombia, Nov. 15-18, 1994.

20. Mora M and Villarreal J, Unwanted pregnancy and abortion: Bogotá, Colombia, Reproductive Health Matters, 1993, No. 2, pp. 14-28.

21. Forrest JD and Frost JJ, The family planning attitudes and experiences of low-income women, International Family Planning Perspectives, 1996, 28(6): 246-255.

Akinrinola Bankole is senior research associate, Susheela Singh is director of research and Taylor Haas is research associate, all at The Alan Guttmacher Institute, New York. The authors would like to thank Jacqueline E. Darroch and Stanley Henshaw for their helpful comments. The research upon which this article is based was supported in part by a grant from the Wallace Global Fund.

*The U.S. study (see reference 8) is one example of this approach. The survey used a self-administered questionnaire, which may have had the added advantage of encouraging women to be open and truthful in their answers.

†Estimates of induced abortion from fertility surveys in Kazakstan, Uzbekistan and Romania, for example, compare favorably with official statistics. (See: National Institute of Nutrition, Kazakstan Demographic and Health Survey, 1995, Calverton, MD, USA: Macro International, 1996; Institute of Obstetrics and Gynecology, Uzbekistan Demographic and Health Survey, 1996, Calverton, MD, USA: Macro International, 1997; and Romanian Ministry of Health, Institute for Mother and Child Care, see reference 2.) However, this is not always the case: In the 1993 Czech Republic Reproductive Health Survey, for instance, women's reported level of induced abortions was estimated to be only 45-50% of the official level of abortion (see: Czech Statistical Office et al., reference 2).

‡For example, the Finnish study used reason categories of "40 years or older " and ">=4 children " to mean a woman had had an abortion to limit births because she was too old to have a child or because she already had a large family; in the Philippines, the categories "already old " and "children growing up " were also classified in the "limiting " category of reasons. Further, studies in Indonesia, Kenya and Honduras did not have the childspacing and stopping reasons used by many other countries. Instead, they used other categories related to birth timing, such as "having a child will disrupt education or job " and "being too young to have a child right now. "

§The question that elicits this response is typically posed as follows: "Would you like to have a (another) child or would you prefer not to have any (more) children? " For pregnant respondents, the question is preceded by "After the child you are expecting… . "

**Although comparison of women's responses on these two types of questions would have been valuable, this is not possible because only one study (the 1987-1988 U.S. study) asked the question in both ways.

*†More than half of unmarried women in Turkey cited the desire to stop childbearing as their main reason for having an abortion, but this group consisted of formerly married women only.

*‡For example, according to a Zambian study, 81% of women hospitalized for abortion complications were students who did not want the pregnancy to interrupt their education (see: Salter C, Johnson HB and Hengen N, reference 16). Similarly, a Ugandan study concluded that the bulk of abortion patients were young, single, of low parity and enrolled in either secondary school or university (see: Miremble FM, A situation analysis of induced abortions in Uganda, African Journal of Fertility, Sexuality and Reproductive Health, 1996, 1[1]:79-80).