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Induced Abortion in Tehran, Iran: Estimated Rates and Correlates By Amir Erfani Amir Erfani is assistant professor, Department of Sociology, Nipissing University, North Bay, Ontario, Canada.
CONTEXT: Abortion is severely restricted in Iran, and many women with an unwanted pregnancy resort to clandestine, unsafe abortions. Accurate information on abortion incidence is needed to assess the extent to which women experience unwanted pregnancies and to allocate resources for contraceptive services. METHODS: Data for analysis came from 2,934 married women aged 15–49 who completed the 2009 Tehran Survey of Fertility. Estimated abortion rates and proportions of known pregnancies that end in abortion were calculated for all women and for demographic and socioeconomic subgroups, and descriptive data were used to examine women’s contraceptive use and reasons for having an abortion. RESULTS: Annually, married women in Tehran have about 11,500 abortions. In the year before the survey, the estimat-
ed total abortion rate was 0.16 abortions per woman, and the annual general abortion rate was 5.5 abortions per 1,000 women; the general abortion rate peaked at 11.7 abortions among those aged 30–34. An estimated 8.7 of every100 known pregnancies ended in abortion. The abortion rate was elevated among women who were employed or had high levels of income or education, as well as among those who reported a low level of religiosity, had two children or wanted no more. Fertility-related and socioeconomic reasons were cited by seven in 10 women who obtained an abortion. More than two-thirds of pregnancies that were terminated resulted from method failures among women who had used withdrawal, the pill or a condom. CONCLUSIONS: Estimated abortion rates and their correlates can help policymakers and program planners identify
subgroups of women who are in particular need of services and counseling to prevent unwanted pregnancy. International Perspectives on Sexual and Reproductive Health, 2011, 37(3):134–142, doi: 10.1363/3713411
In Iran, induced abortion (hereafter referred to as abortion) is strictly prohibited except when a woman’s life is endangered or her fetus is diagnosed with a disease or defect that is recognized as an exception by the country’s Legal Medical Organization.1 If none of these conditions is met, a woman who wants to terminate her unwanted pregnancy must resort to a clandestine and possibly unsafe abortion. Little is known about the extent of maternal mortality and the health risks associated with unsafe abortions in Iran; according to one indirect estimate, 5% of pregnancy-related maternal deaths are due to postabortion complications.2 Many women who are admitted to the hospital for postabortion care have symptoms such as nausea, vomiting, diarrhea, lower abdominal cramps, extensive vaginal bleeding, infection or psychological distress.3 Policymakers and program planners require accurate information on abortion incidence and patterns to assess the extent to which women experience unwanted pregnancies and to determine how to allocate resources for contraceptive services and supplies. The last indirect assessment of abortion incidence in Iran relied on data collected nearly a decade ago:1 The lifetime abortion rate was estimated to be one abortion for every four married women of reproductive age, which translated to 73,000 abortions per year. The estimated rates varied widely among Iran’s provinces,
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depending largely on levels of religiosity and use of modern contraceptives. This earlier study speculated that the abortion rate would decline if women who were using traditional methods adopted modern ones or were informed about the availability of emergency contraception. Updated information on induced abortion is needed to determine the current levels and correlates of abortion in Iran. The present study is the first of its kind to provide direct estimates of abortion levels in Tehran for both all women and selected subgroups. It uses the most recent retrospective data to estimate the abortion rate and the proportion of known pregnancies that end in abortion for the population of married women in Tehran, to examine variations by women’s demographic and socioeconomic characteristics, and to assess reported reasons for having an abortion and the contraceptive method used at the time of conception. METHODS
Data The main source of data was the Tehran Survey of Fertility, conducted by the author in August 2009 in the nation’s capital. Modeled on a standard Demographic and Health Survey, the study questionnaire was designed to collect a wide range of data, including complete histories of live
International Perspectives on Sexual and Reproductive Health
births, contraceptive use and abortions, as well as data on desired number of children and socioeconomic and demographic characteristics of women and their husbands. Thirty trained and experienced female interviewers collected the data during face-to-face interviews. A three-stage stratified cluster random sampling design was used to identify married women aged 15–49 and residing in Tehran’s 22 residential districts. In the first stage, enumeration areas were selected in each residential district; in the second stage, residential clusters were chosen in each selected enumeration area. In both stages, selections were based on probability proportional to population size. The sampling frame for the enumeration areas and clusters was taken from the 2006 census of Iran. In the third stage, 15 households were selected from each cluster by systematic random sampling. A table of random numbers was used to select the first household to be interviewed in each cluster. The remaining households were identified by dividing the total number of households in the selected cluster by 15 to obtain the appropriate sampling interval. One eligible woman from each selected household was then asked to participate in the survey. To provide representative estimates of fertility-related health and demographic indicators, the study randomly selected 3,000 women. Interviews were successfully completed with 2,934 women, for a response rate of 98%. Among the eligible women who were not interviewed, the principal reasons for nonresponse were failure to find them at home after repeated visits and refusal to be interviewed. The nonresponses did not bias the results, as the excluded women were from different socioeconomic and demographic subgroups. Overall, 244 women reported that they had had at least one induced abortion. These women, who reported a total of 311 abortions, were the focus of the study.
Measures Age-specific abortion rates are the number of abortions per 1,000 women in each five-year age-group; the total abortion rate is the number of abortions that a woman aged 15–49 would be expected to have during her lifetime if she experienced the prevailing age-specific abortion rates. The annual general abortion rate refers to the number of abortions performed annually per 1,000 women aged 15–49. This study calculated these three abortion rates from the reported number of abortions in the year preceding the interview. Because of the small number of abortions in the 12 months prior to each woman’s interview (19), the three rates were also calculated on the basis of the number of abortions in the five years prior to the survey (76) per 1,000 woman-years of exposure to the risk of abortion. Finally, we were not able to calculate abortion ratios comparable with recent studies4,5 because the Tehran survey did not collect complete pregnancy histories and therefore lacks data on spontaneous abortions. Instead, we calculated the proportion of known pregnancies (live births plus induced abortions) that ended in induced abortion.
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The percentage distribution of abortions by women’s characteristics simply reflects the distribution of women in the Tehran population, and does not necessarily show that different subgroups were more likely than others to obtain an abortion. However, the abortion rates and the proportions of pregnancies ending in abortion across subgroups do show variation in the probability that pregnant women obtained an abortion, and are therefore good measures for comparing women’s abortion behavior. In addition, because no registered, external statistics on abortion in Iran are available for comparison, this study compares its estimated total abortion rate with those in 12 neighboring countries, according to the proportion of women using modern contraceptives. This study examined associations between having an abortion and 12 demographic and socioeconomic characteristics: age at abortion, parity (number of live births), ideal number of children, desire for more children, years of schooling obtained by respondents and their husbands, women’s employment status, importance of religion (ranging from “very important” to “not at all”), ethnicity of respondents and their husbands, income level (measured indirectly by household monthly expenditure) and residential district (categorized as northern, central or southern on the basis of a cluster analysis of couples’ schooling and household expenditure). Residents in the northern districts of Tehran are generally wealthier and more educated, and hold more modern attitudes regarding family formation and childbearing, while those in southern districts generally have lower socioeconomic status and hold traditional attitudes toward family matters. Women were also asked the most important reason for having had an abortion in the five years preceding the survey; 71 respondents answered this question. Five women had had two abortions in this period, yielding a total of 76 abortions; they gave a reason for each abortion. Reasons were grouped into three categories: health-related (risk to maternal health or to fetal health, bleeding during pregnancy), fertility-related (to limit births, space births or postpone childbearing) and socioeconomic (economic difficulty, spousal relationship problem). To address the possibility of social desirability bias in these responses, 666 respondents who knew a neighbor, friend or relative who had had an abortion in the past year were asked the woman’s main reason for having the abortion. RESULTS
Abortion and Contraceptive Use No respondents aged 15–19 reported having had an abortion in the year preceding the survey; the abortion rate was highest among women aged 30–34 (11.7 per 1,000 women), was 9.8 per 1,000 among those aged 35–39 and declined dramatically among older women (Table 1, page 136). Thus, the age-specific abortion rates show an inverted U-shaped pattern (Figure 1, page 136). Furthermore, as shown in Figure 1, the level of abortion was lower than that of fertility among women younger than 30. In gener-
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Induced Abortion in Tehran, Iran
TABLE 1. Selected abortion measures for married women aged 15–49, for the one year and the five years preceding the survey, Tehran Survey of Fertility, 2009 Measure
1 year
Age-specific abortion rate (per 1,000 women) 15–19 20–24 25–29 30–34 35–39 40–44 45–49
5 years
0.0 1.5 4.7 11.7 9.8 2.0 2.1
0.0 5.1 4.9 9.5 7.0 0.8 1.8
Total abortion rate (per woman) 0.16 0.15 Annual general abortion rate (per 1,000 women) 5.5 5.2 Abortions as % of known pregnancies 8.7 7.5 Mean age at abortion 33.5 32.0 Median age at abortion 33.0 32.0 Annual no. of abortions 11,543 na Notes: The proportion of known pregnancies that end in abortion and the mean age at abortion were estimated for married women aged 20–49; other figures were estimated for all women aged 15–49. na=not applicable.
al, the age-specific rates for the five-year period prior to the survey were similar to those for the year before the survey. The total abortion rate for the year prior to the survey was estimated to be 0.16 abortions per married woman aged 15–49. Hence, on average, one of every six women of reproductive age will have an abortion in their lifetime if current age-specific abortion rates remain unchanged. Moreover, the estimated general abortion rate of 5.5 indicates that about six abortions were obtained annually per 1,000 women aged 20–49. According to the 2006 Iran census, the number of women in this age-group living in Tehran was 2,098,790.6 Therefore, this study estimates that women in Tehran obtain 11,543 abortions annually. The estimated total abortion rate for women in Tehran
appears to be low when compared with the rates in selected neighboring countries in Central Asia and Eastern ’Europe, which range from 0.3 abortions per woman in Turkey to 3.7 in Georgia (Figure 2). Though abortion underreporting is one possible reason for the low estimated rate for Tehran, the roles of contraceptive use, intended fertility and the probability of recourse to abortion should be taken into account. According to Bongaarts and Westoff,7 variation in abortion rates among countries is accounted for largely by these three factors. In the present study, 85% of married women reported using a contraceptive method at the time of the survey; 54% used a modern method and 31% used a traditional one. The most commonly used method was withdrawal (30%); fewer than 1% of women used abstinence. Among modern methods, the condom was the most widely used (16%), followed by the IUD (13%), female sterilization (11%), the pill (9%), male sterilization (6%) and the implant (
