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A systematic review of the research evidence on cross-country features of illegal abortions

Health Promotion Perspectives

eISSN: 2228-6497

Health Promotion Perspectives, 7(3), 117-123; DOI:10.15171/hpp.2017.22

Systematic Review

A systematic review of the research evidence on cross-country features of illegal abortions

Farideh Aghaei1, Abdolreza Shaghaghi2,*, Parvin Sarbakhsh3


1 Health Education & Promotion Department, Tabriz University of Medical Sciences, Tabriz, Iran
2 Medical Education Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
3 Department of Biostatistics and Epidemiology, Tabriz University of Medical Sciences, Tabriz, Iran

Email: shaghaghir@tbzmed.ac.ir


© 2017 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: There are contrasting debates about abortions and prohibitory regulations posed serious public health challenges especially in underdeveloped and developing countries. Due to paucity of the empirical evidences this study was conducted to explore the existent cumulative knowledge with special focus on the applied methodology. Methods: A comprehensive review of published articles from January 1995 to December 2015 was performed. Several databases including: Embase, PubMed, Cochrane and also databasesof the Iranian medical journals were searched using combinations of relevant Medical Subject Headings (MeSH terms) and their equivalents, i.e., induced abortion, embryotomy, criminal abortion and illegal abortion. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement for appraisal of the cross-sectional studies and Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for the qualitative reports were utilized. After removal of duplicates and irrelevant publications 36 articles remained for data analysis. Results: A wide heterogeneity was observed in the utilized methodology with no standard data collection tool. Face to face interview and self-administered questionnaire were the most common reported data collection/tool respectively. Married and unemployed women of 26-30 years old age group with low socioeconomic backgrounds were the most typical illegal abortees in the included studies. Conclusion: Despite limitation in accessing all relevant publications and including only those reports written in English or Persian languages, the accumulated knowledge might be applicable to develop a potentially inclusive data collection tool and hence, improve the quality of data collection and/or application of a more robust study design in future investigations.

Keywords: Induced abortion, Criminal abortion, Illegal abortion, Embryotomy

Citation: Aghaei F, Shaghaghi A, Sarbaksh P. A systematic review of the research evidence on cross-country features of illegal abortions.Health Promot Perspect. 2017;7(3):117-123. doi: 10.15171/hpp.2017.22.

Introduction

There are contrasting debates about abortions irrespective of the reasons or circumstances in which they were performed. A wide diversity exists in the abortion law and regulation across the globe e.g., it is restrictively illegal in some countries or legal in other countries only when a woman’s life is endangered by the continuation of her pregnancy or other medical reasons. Prohibitory laws and regulation; however, posed serious public health challenges in different countries especially in underdeveloped and developing countries.1-4Induced abortion by definition is intentional termination of a pregnancy by medical or surgical means before the fetus can be viable.2 Unsafe abortion; however, refers to ending of a pregnancy by individuals who lack the required medical skills to perform the procedure, its administration in a sub-optimal environment condition which is deficient in the basic and minimal medical standards, or both.3In countries where a total ban has been imposed on induced abortion or it is merely legally allowed under certain conditions many women in consequence; search for clandestine abortion or what literally is called backyard abortion, that is too often unsafe and endanger women’s life or leave serious complications.4

It is reckoned that about 13% of maternal death can be attributable to unsafe abortions worldwide and thus considering almost 22 million abortions that are carrying out unsafely each year, 47 000 women die and further 5 million become disabled annually.5Incomplete abortion, post abortion sepsis, hemorrhage, genital injury and abortion related deaths are among the recognized consequences of unsafe abortions. It is predicted that only in developing countries about 5 million women are admitted to hospitals due to complications of unsafe abortion each year and millions of them endure long-term health consequences including infertility and thousands die after an unsafe abortion.6

Varying strategies and methodologies have been applied in different studies on the incidence of unsafe abortions, environmental circumstances in which they were performed or on its contributing factors.7-9, Question about incident(s) of unsafe abortion based on the social networks of abortees7 and use of self-administered questionnaire8 or interview9 as data collection approach, tool or procedure were among the reported applied methodologies in the literature.

Number of conducted studies in Iran on abortion which is only endorsed in cases of life endangerment, rape or severe fetal anomalies is meager. Due to paucity of the empirical evidences both in national and international level about the illegal abortions this study was conducted to explore existent cumulative knowledge on the phenomenon with special focus on the features of conducted studies and applied methodologies to inform future investigations.

Materials and Methods

A comprehensive review of published articles in international and national scope from January 1995 to December 2015 was performed to appraise research evidence on the applied methodology in the studies of illegal and unsafe abortion. Several electronic databases including: Embase, PubMed, Cochrane, Scopus, Web of Knowledge (ISI), Google Scholar, Global Health, Medline, Proquest, Science Direct and also databases of the Iranian medical journals, i.e., Irandoc, Iranmedex, SID and Magiran were searched.

Inclusion Criteria

Types of studies

This systematic review involved all quantitative and qualitative non-interventional publications published in English and Persian language from January 1995 to December 2015 that recruited women who themselves or their close relatives or friends underwent medical or surgical illegal abortions at any age. The chosen time span was decided to warrant up datedness and propensity of the study findings.

Types of outcome variables

Considered primary outcome variables were applied data collection tools and strategies to study illegal abortion. Characteristics of the women who reported to have illegal abortion, attributes of the illegal abortion providers, reasons to seek for induced abortion and conditions in which the abortions had been carried out also incorporated.

Search strategy

Combinations of Medical Subject Headings (MeSH terms) and their equivalents, i.e., induced abortion, abortion rate, embryotomy, criminal abortion and illegal abortion were used to search for relevant scientific evidence (e.g., [illegal abortion [Title/Abstract]) OR criminal abortion [Title/Abstract]) OR Induced abortion [Title/Abstract]) OR embryotomy [Title/Abstract] Filters: Journal Article; Meta-Analysis; Multicenter Study; Observational Study; Published Erratum; Review; Systematic Reviews; Full text; published in the last 10 years; Humans] string was used to search PubMed).

Selection of studies and data extraction

Two reviewers (FA and AS) independently assessed the eligible studies based on a uniform set of priori quality criteria and all discrepancies in the assessment results were resolved by consensus. A generic data extraction template was constructed to obtain the required data about the pre-determined properties of the included publications.

Results

The primary study search yielded 10 572 articles and after removal of duplicates and irrelevant publications 1020 articles remained for further scrutiny. In the next step, title and abstracts of the articles were investigated to retrieve those publications that fulfill the study objectives. Thus; full text of the 201 articles that considered to have the inclusion criteria were obtained and carefully inspected. Each publication at this stage was assessed based on its quality and strength. To minimize probability of selection bias the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) statement10for assessment of the cross-sectional studies and COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist11for appraisal of the qualitative study reports were utilized. All disagreements about the quality and eligibility of the identified publications were resolved by consensus and finally 36 articles remained for data analysis (Figure 1).

Figure 1. Flow diagram of the included studies in the systematic review of the research evidence on cross-country features of illegal abortions‏.

The extracted data from the identified relevant studies based on the researchers’ names, study type, sample and location were tabulated in Table 1.

Table 1. Attributes of the included studies in the systematic review of the research evidence on cross-country features of illegal abortions
Author/ Date Location Study Type Population Sample size
Koster-Oyekan12 (1998) Zambia Cross-sectional 1) School girls, 2) Women 1273, 803
Ahmed et al13 (1999) Bangladesh Qualitative Women seeking abortion-related care 143
Rasch et al14 (2000) Tanzania Cross-sectional Patients with the diagnosis of incomplete abortion 603
Uygur et al15 (2000) Turkey Cross-sectional Women who requested abortion 588
Mogilevkina et al16 (2000) Ukraine Case-control Women of fertile age (15–49) 1694
Rasch et al17 (2002) Denmark Case-control Pregnant women 809
Larsson et al18 (2002) Sweden Cross-sectional Women requesting an early pregnancy termination 591
Ban et al19 (2002) Sri Lanka Cross-sectional Clients at an abortion clinic 356
Ganatra and Hirve20 (2002) India Qualitative 1) Married women who had an induced abortion
2) Abortion services’ providers
1717, 159
Ilboudo et al8 (2014) Burkina Faso Cross-sectional Women seeking post abortion care 549
Sihvo et al21 (2003) France Cross-sectional 18 to 44 year old women 1034
Perera et al22 (2004) Sri Lanka Cross-sectional Pregnant women 210
Bozkurt et al23 (2004) Turkey Cross-sectional Ever married women 1491
Senbeto et al24 (2005) Ethiopia Cross-sectional Women aged 15 to 49 1346
Adanu et al25 (2005) Ghana Cross-sectional Cases of complicated abortions 150
Osur et al7 (2015) Kenya Mixed-method Women treated for complication of unsafe abortion 963
Nojomi et al26 (2006) Iran Cross-sectional Women aged 15 to 55 years 2470
Lara et al27 (2006) Mexico Cross-sectional Women ages 15 to 55 1792
Maral et al28(2007) Turkey Cross-sectional Women aged 15 years or older 2455
Dahlbäck et al29 (2007) Zambia Cross-sectional Girls aged 13 to 19 years 34
Hess et al30 (2007) Africa Qualitative Women with a history of induced abortion 5
Tsakiridu et al31 (2008) Spain Cross-sectional Women prostitutes 212
Rahim and Ara32 (2008) Pakistan Cross-sectional Married women in reproductive age 50
Dibaiee and Saadati33 (2008) Iran Cross-sectional Women undergone abortion 85
Rasch et al34 (2009) Tanzania Cross-sectional Women admitted with alleged miscarriage 751
Erfani9 (2011) Iran Cross-sectional Married women aged 15–49 2934
Motavalli et al35 (2012) Iran Cross-sectional Married women aged 15–49 1200
Veisi and Zangene36 (2012) Iran Cross-sectional Women with a history of induced abortion 91
Ranji37 (2012) Iran Cross-sectional Women aged 15 to 45 3250
Nur38(2012) Turkey Cross-sectional Ever-married women aged 15-49 years 1264
Souza et al39 (2014) Brazil Cross-sectional Women of childbearing age 860
Fusco et al40 (2012) Brazil Cross-sectional Women 15-54 years 375
Rocca et al41 (2013) Nepal Cross-sectional Women admitted for post abortion care 527
Motaghi et al42 (2013) Iran Qualitative Women with a history of abortion / unwanted pregnancy/ service providers 72
Awoyemi and Novignon43 (2014) Nigeria Cross-sectional Women between 19–49 years 308
Klutsey and Ankomah44 (2014) Ghana Case-control Case: women who had induced abortion
Control: never had an induced abortion
380

A validated data collection instrument was not identified to be applied in studies on illegal abortion. However, different data collection methods including face to face interview, filling of a self-administered questionnaire, in-depth interview, telephone interview and focus group discussion were suggested in the literature for data collection purposes (Table 2).

Table 2. Applied data collection methods in the included studies within the systematic review of the research evidence on cross-country features of illegal abortions
Data collection methods Number of reporting studies
Face to face -interview 24 (7, 9, 12 ,13, 14, 15, 19, 22, 23, 25, 26, 27,28, 29, 34, 36, 37, 38, 39, 40, 41, 44)
Self-administered questionnaire 13 (8, 12, 16, 17, 18, 24, 31, 32, 33, 35, 43)
In-depth interview 3 (20, 30, 42)
Telephone interview 1 (21)
Focus group discussion 1 (12)

Other studied features of abortees in the retrieved publications included age, marital status, numbers of children, educational level, employment and socioeconomic status (Table 3).

Table 3. Characteristics of the illegal abortees in the included studies within the systematic review of the research evidence on cross-country features of illegal abortions
Characteristics No. of reporting publications
Mean age
≤19 5 (14, 24, 29, 34, 35)
20-25 6 (8, 17, 33, 34, 35, 44)
26-30 18 (13, 15, 16, 18, 21, 22, 23, 25, 26, 27, 28, 31, 35, 36, 37, 38, 41, 42)
31-40 2 (9,19)
≥40 Not reported
Marital statues
Married 14 (9, 13, 21, 22, 23, 25, 26, 27, 31, 33, 35, 38, 39, 41, 43)
Single 11 (8, 12, 14, 16, 17, 29, 34, 40, 42, 44)
Number of children
0 6 (12, 14, 17, 18, 21, 44)
1-2 11 (9, 13, 16, 19, 25, 31, 34, 35, 37, 41, 43)
≥3 4 (22, 23, 38, 39)
Educational level
Illiterate 2 (13, 23)
Lower than high school 16 (14, 15, 16, 17, 18, 19, 22, 27, 29, 37, 38, 39, 40, 41, 43, 44)
High school and above 8 (8,9,21, 25, 26, 31, 35,42)
Employment status
Unemployed 16 (8, 12, 13, 14,17, 23, 25, 26, 27, 29, 35, 37, 38, 40, 43, 44)
Employed 7 (9, 18, 21, 31, 39, 41,42)
Socioeconomic status
Low 10 (7,13, 16, 17, 21, 27, 38, 39, 40, 42)
Moderate 3 (33, 35, 37)

Extricated data about the reported providers of illegal abortion in the identified publications were summarized in Table 4. As indicated non-skilled individuals were the most reported provider of illegal abortion in the included studies.

Table 4. Types of the illegal abortion service providers in the included studies within the systematic review of the research evidence on cross-country features of illegal abortions
Service providers No. of reporting studies
Patient 5 (12, 13, 25, 31, 41)
Midwife 5 (13, 25, 34, 36, 43)
Friend/relative 2 (13, 37)
Traditional healer 2 (29, 37)
Gynecologist 2 (24, 35)
General practitioner 1 (12 )

The reasons stated by the abortees for requesting an illegal abortion in the included studies were presented in Table 5. Having an unplanned/unwanted pregnancy was the most frequent declared rationale to illegally terminate pregnancy.

Table 5. Stated reasons to request an illegal abortion in the included studies within the systematic review of the research evidence on cross-country features of illegal abortions
Stated reasons No. of reporting studies
Having enough number(s) of child(ren) 10 (9, 13, 15, 23, 32, 35, 36, 37, 41, 43)
Proper spacing between deliveries 3 (19, 20, 22)
To continue education 3 (12 ,14, 29)
Fear of public or parents misjudgment 2 (12, 25)
Poor economical status 1 (18)
Being single 1 (12)
Not being able to afford a baby 1 (30)
Relationship problems with partner 1 (7)

Reported places that had been used to perform illegal abortions in the identified studies were displayed in Table 6. Based on the summarized data the frequency of studies that reported performing of abortion cases in unhealthy and improper places (private house or office) is comparable to performing the procedure in healthy and reliable settings (hospitals).

Table 6. Reported illegal abortion places in the included studies within the systematic review of the research evidence on cross-country features of illegal abortions
Abortion places No. of reporting studies
Private hospitals 4 (20, 23, 28, 33)
Private house 3 (25, 34, 37)
Private office 3 (20, 28, 37)
Public hospitals 2 (14, 34)

Discussion

Main purpose of this study was to accumulate the existent scientific evidence about methodological features of empirical studies on illegal abortion. The prime focus; however, was on the data collection tools and methods. A wide heterogeneity was observed in the utilized methodology with no standard data collection tool that was validated for research purposes. Face to face interview36-41,44and application of a self-administered questionnaire31-33,35,43in queries about illegal abortion were the most common reported data collection method respectively. The study’s findings have also revealed that married25-27,31,33,35,38,39,41,43and unemployed women25-27,29,35,37,38,40,43,44of 26-30 years old age group35-38,41,42with 1-2 children9,13,16,19,25,31,34,35,37,41,43and low socioeconomic backgrounds7,13,16,17,21,27,38,39,40,42were the most typical illegal abortion seekers in the included studies. The observed partial inconsistency in the attributes of the abortees in the quoted studies; however, may reflect inherent cultural differences regarding pre-marital sexual relationship, out of wedding pregnancies or aberrant methodologies used.

A sizable number of included studies have reported that illegal abortions had been performed by an unskilled person12,13,25,31,37,41in unhealthy non-standard or suboptimal conditions.20,25,28,34,37 Having desired number of children was the most referred rationale35-37,41,43 to seek for illegal termination of a pregnancy in communities where abortion laws for mothers is criminalized.

In general; liberal abortion related laws and regulations may justify the sparse number of studies that were reported to examine illegal abortion in the developed countries17,18,21,31 but this may pose restriction in the applicability of the research evidence originated mostly from less developed or developing countries to design research in other countries of the world.

Limitation in accessing all relevant publications and including only those reports written in English or Persian languages were potential sources of bias in this study. In contexts where abortion cases due to prohibitory laws are executed underground, study respondents might be reluctant to give explicit answers regarding their or their relatives and friends experiences on abortion. Therefore, due to all above mentioned reasons interpretation of the findings must be conservative and tempered by the limitation of the imprecise data.

Conclusion

Conducting research on illegal abortion is challenging specially due to its stigmatized nature and its surrounded prohibitory laws and regulations that might prevent active participations of target populations. To the best of our knowledge this study was the first systematic investigation of research evidence on characteristics of illegal abortees and methodologies that were used to examine illegal abortions.

No gold standard method was identified to pinpoint for recommendation in future studies. However, the existent evidence might be applicable to develop a potentially inclusive data collection tool and hence improve the quality of data collection and/or application of a more robust study design in future investigations.

Use of innovative data collection instruments or methods may potentially surmount challenges in conducting research on this subterranean and criminalized phenomenon in many countries of the world.

Ethical approval

The study was granted approval from the Medical Ethics Committee of the Tabriz University of Medical Sciences (approval No. TBZMED.REC. 1393.198).

Competing interests

There are no competing interests.

Authors’ contributions

FA contributed to the conceptualization and study design, data collection and interpretation, manuscript drafting and its editing. AS’s major role was conceptualization and study design, help in interpretation of the data and critically revising several drafts of the article for improvement of its intellectual content. PS helped greatly in conceptualization and design of the study, data analysis and interpretation and also preparation of the final draft of the article. All authors have read and approved the submitted and revised final version of the manuscript and confirm that no part of this paper is copied from other sources.

Disclaimer

The authors claim that no part of this paper is copied from other sources.

Acknowledgments

The authors would like to acknowledge the authors of the published articles and their guidance to design and perform research on illegal abortions that may help to save lives of innocent mothers and unborn babies. This study was financed by a grant from the Research & Technology Vice-Chancellor Office of the Tabriz University of Medical Sciences, Iran.

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Submitted: 31 Oct 2016
Revised: 04 Dec 2016
Accepted: 04 Dec 2016
First published online: 14 Jun 2017
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