Spiritual determinants of abortion stigma: the role of socio-cultural and demographic variables in women’s attitudes toward voluntary abortion

Abstract

Abortion must be evaluated not only in medical terms, but also in terms of its socio-cultural, religious, and psychological dimensions. This study aims to examine women’s attitudes toward voluntary abortion in Turkey, their stigmatizing attitudes, and the relationship between these attitudes and their spiritual well-being. A descriptive study design was used. Study data were collected between September 2024 and April 2025 at a hospital in eastern Turkey. The study was completed with 1,240 women. Data collection tools included a Personal Information Form, the Spiritual Well-Being Scale (SWBS), and the Stigmatizing Attitudes, Beliefs, and Actions Scale Toward Abortion (SABAS). Statistically significant differences were found in the SABAS scale according to variables such as educational status, woking status, place of residence, family type, income status, marital status, and presence of children (p<0.001). A statistically significant, positive, and high correlation was determined between the SWBS scale and the SABAS scale (r = 0.523, p<0.001). Additionally, women reported experiencing the most guilt/anger, feelings of having sinned, regret/sadness, and anxiety during and immediately after the decision to undergo an abortion. Abortion should be addressed not only as a medical intervention but also as a human rights issue with cultural and spiritual dimensions. In this context, while developing reproductive health policies, a balanced approach should be adopted between women’s individual autonomy and the cultural and religious sensitivities of society; inclusive and rights-based health services that provide women with both physical and mental support should be provided.

Introduction

Women are an indispensable part of sustainable development, and sustainable development goals affect women’s health. Unsafe termination of pregnancy and the resulting maternal illnesses and deaths have led governments to impose legal restrictions on such termination. These legal restrictions may vary depending on the economic situation, religious beliefs, or health infrastructure of the country¹. Current evidence shows that abortion rates are not lower in countries where abortion is legally restricted; on the contrary, unsafe abortion rates and associated maternal morbidity and mortality are higher in these countries^2,3. In contrast, it has been reported that in countries where abortion is provided within specific legal frameworks and through regulated health systems, unsafe abortion rates are lower and maternal health indicators are more favorable^2–4.

According to Turkish law, which came into effect in 1983 and remains valid today, termination of pregnancies up to 10 weeks is legal upon request. According to legal regulations, abortion may be performed after 10 weeks if there are serious health risks to the mother or fetus and this situation is documented by a specialist physician’s report or committee decision. For example, when the mother’s life is at risk or when the fetus has no chance of survival and serious anomalies are detected, legal regulations allow termination of pregnancy up to the 20th week or later⁵. With this law, voluntary abortion rates in Turkey have been reported to range between 15% and 38.6%^6,7. Although abortion can be performed within the framework of legal rules and practices, it remains one of the most debated issues in human history from socio-cultural, moral, philosophical, and religious perspectives^8,9. This topic is not only debated in the field of health but also in various fields of science such as philosophy, religion, law, psychology, politics, and social sciences. While most debates on abortion focus on women’s bodies or the right to life of the child, women’s thoughts may be overshadowed¹⁰. Additionally, in societies where voluntary abortion is condemned, women may conceal their voluntary abortions due to the stigma, exclusion, or judgment they face¹¹.

In countries where abortion is considered morally wrong and socially unacceptable, women who have abortions are stigmatized. This leads to negative psychosocial effects on women and prevents them from accessing safe abortions^11,12. The stigma of abortion is defined as “a negative characteristic that internally or externally demeans women who attempt to terminate their pregnancies from the ideal of womanhood”¹³. Accordingly, a woman who chooses to have an abortion may perceive or experience stigmatization as directly violating societal norms related to sexuality and motherhood in some societies^12,14. This leads to more negative thoughts about abortion and makes it harder for women to adjust psychologically after having an abortion¹⁵.

Abortion is a highly debated topic not only in terms of women’s bodies and the right to life of the fetus, but also in terms of political debates and changes in legal regulations. In many countries, these debates directly affect access to healthcare services and the professional practices of healthcare workers. In countries such as Poland and Italy in particular, abortion is addressed under the “conscience clause,” and this regulation can lead to ethical dilemmas, legal uncertainties, and professional conflicts among healthcare workers^16,17.

Studies conducted in Turkey show that approximately half of women want voluntary abortion to be banned and that women experience psychological problems after elective abortion^6,18. Spirituality is used in various contexts in relation to concepts such as spirituality, religion, and belief, but it is accepted as a broader concept beyond religious beliefs^11,12. Within specific cultural contexts, spirituality is recognized as an important dimension influencing individuals’ coping and well-being in nursing care¹⁹. However, in processes that affect human life, such as pregnancy and voluntary abortion, we focus only on physical, biological, and psychological characteristics, neglecting the dimension of spiritual well-being. Spiritual well-being also gives a person a deep sense of meaning and strength. This sense of meaning and strength can serve as a source of hope in times of distress and difficulty and help individuals cope with their problems. Therefore, spiritual well-being must also be considered in voluntary abortion²⁰. Studies on spiritual well-being and abortion indicate that women’s spiritual well-being affects their thoughts, stigmatizing attitudes, beliefs, and behaviors toward voluntary abortion. In addition, many factors, such as traditional and religious beliefs in society, are also mentioned as being related to women’s spiritual well-being²¹.

Therefore, determining women’s needs through a holistic approach and planning and implementing appropriate interventions in voluntary abortion decisions is of great importance for all health professionals. As a result of our research, we found that there are few studies on this subject in Turkey, and we believe that our study will make an important contribution to the literature. This study aims to examine the relationship between women’s thoughts on voluntary abortion, stigmatizing attitudes, beliefs, and behaviors, and their spiritual well-being in Turkey.

Methods

Design

A descriptive study design was used.

Location

Data were collected by the researchers from women who applied to a hospital in the center of a province in the Eastern Anatolia Region of Turkey for any reason between September 2024-April 2025. Women between the ages of 18–49, who were Turkish-speaking, did not have any psychiatric disorder, and volunteered to participate in the study were included in the study. The researchers contacted the women directly themselves.Women who incompletely filled out the research forms and did not want to continue the study were excluded from the study.

Population and Sample

The sample size was calculated using the power analysis program G*Power (Version 3.1). Since the relationship will be examined in the study, “Correlation: Bivariate Normal Model” was selected as the analysis type and “Exact” was selected as the test family. A similar study conducted previously²². found a weak correlation between the abortion and the spirituality (r = 0.16, p < 0.05). Therefore, the correlation coefficient under the H₁ hypothesis was determined as ρ = 0.16. In the H₀ hypothesis, an effect size different from zero but smaller than the medium-level correlation was predicted and the value of ρ = 0.25 was taken as the basis. This approach aimed to test statistically and practically significant effects, not small differences. The significance level was taken as α = 0.05 and the test power as 1 − β = 0.90, accordingly, according to the obtained results, the minimum sample size required for the study to reliably detect the specified effect was calculated as n = 1190. A margin of error of 50 people was added to the sample as a precaution against potential data losses and a total sample size of n = 1240 people was targeted.After obtaining the verbal and written consent of the women, the study data forms were applied. The administration of the data forms took approximately 15–20 min. The data forms were applied in a quiet room of the hospital. The study was completed with 1240 women. The data collection tools used in the study are scales whose validity and reliability have been previously proven, and they were thoroughly evaluated prior to implementation by experienced researchers in the field who were part of the research team. Therefore, no pilot study was conducted, but consensus on the implementation was reached among the researchers prior to the data collection process.

Data collection methods and tools: Personal Information Form, Spiritual Well-Being Scale (SWBS), and Stigmatizing Attitudes, Beliefs, and Actions Scale Toward Abortion (SABAS).

Personal information form

This form consists of questions regarding age, educational status, working status, place of residence, family type, income status, marital status, presence of children, status of having an abortion by choice, individuals who have decided to have an abortion by choice, reasons for having an abortion by choice, discomfort regarding others knowing about the abortion, and feelings/thoughts experienced during/immediately after the abortion.

Stigmatizing attitudes, beliefs, and actions scale toward abortion

It was developed by Shellenberg et al.¹⁴. Its validity and reliability were established by Güner and Öztürk²³. The Cronbach’s alpha value of the scale, which contains a total of 18 items, is 0.90, while the Cronbach’s alpha values of the subdimensions are 0.85 for negative stereotypes, 0.80 for discrimination and exclusion, and 0.80 for fear of contagion. 0.80, and fear of contamination: 0.80. The scale items are on a 5-point Likert scale (ranging from 1 = strongly agree to 5 = strongly disagree), and item 15 is reverse-scored. The scale does not have a specific cutoff point; scores approaching 90 indicate high stigmatizing attitudes, beliefs, and behaviors toward abortion, while scores approaching 0 indicate low stigmatization^14,23.

Spiritual well-being scale

Developed by Ekşi and Kardaş²⁴. The scale assesses how compatible adults’ lives are with their values and their ultimate understanding of meaning in personal, social, environmental, and transcendental terms. The scale is a five-point Likert type scale consisting of 29 items. The scale consists of three subscales: “transcendence,” “harmony with nature,” and “anomie.” High scores on the ‘transcendence’ and “harmony with nature” subscales indicate increased spiritual well-being. Items on the “anomie” subscale are reverse-scored, with high scores indicating negativity and interpreted as negative concepts that lead to unhappiness and loneliness. The score range for the scale varies between 29 and 145²⁴. When examining the reliability coefficients of the scale’s subscales, the transcendence subscale was found to be 0.95, the harmony with nature subscale 0.86, the anomie subscale 0.85, and the total Cronbach’s Alpha value 0.88²⁵.

Variables of the study

The dependent variable of the study is SABAS scores. The independent variables are age, education status, woking status, place of residence, family type, income level, marital status, presence of children, the state of having a voluntary abortion, the person/persons who voluntarily decided to have an abortion, reason for voluntary abortion, discomfort with knowing that others have had abortions, and SWBS scores.

Ethical considerations

Ethical approval

(Approval No. 2024/05 − 04) was obtained from the Van Yüzüncü Yıl University Non-Interventional Clinical Research Ethics Committee and permission was obtained from the hospital where the study was conducted. The women were informed about the study and their verbal consent was obtained in accordance with the principle of “Informed Consent”. The study adhered to the ethical principles of “Respect for Autonomy”, which ensures that participants are aware of their right to freely participate or withdraw at any stage of the study, and “Confidentiality and Data Protection”, which guarantees that all participant information will remain confidential. The research was conducted in accordance with the ethical guidelines of the Declaration of Helsinki.

Data analysis

The data from the study were analyzed using the SPSS 26 statistical package program. For the normality test, the kurtosis and skewness values of the series were used, and if these values were between − 1.5 and + 1.5, the data set was considered to be normally distributed. Both parametric (Pearson) and non-parametric (Spearman’s rho) correlations were examined in the analyses. A correlation coefficient between 0.10 and 0.30 was considered low, between 0.31 and 0.49 was considered moderate, and above 0.50 was considered high. The eta-squared (η2) value was used as the basis for effect size. An eta-squared (η2) value between 0.01 and 0.06 was considered small, between 0.06 and 0.14 was considered moderate, and above 0.14 was considered large. The Student’s t-test (t) was used for independent sample group comparisons with SABAS, and the One-Way ANOVA test was used for multiple group comparisons. Before applying the one-way analysis of variance (ANOVA), the Levene test was performed to test the homogeneity of variances. The p-value of the Levene test (p > 0.05) indicated that the variances were homogeneous. Considering the sample size, post hoc analyses adjusted with the Bonferroni correction were performed to control the Type I error rate for post hoc comparisons. Multiple linear regression analysis was used in the study. The basic assumptions of the model were tested prior to the analysis: For the linearity assumption, the scatter plot created between the standardized predicted values and the standardized residual values was examined, and it was observed that the points were randomly distributed and did not show a clear trend. This situation indicated that the relationship between the dependent variable and the independent variables was linear. Multicollinearity was tested using VIF (Variance Inflation Factor) and Tolerance values. VIF values below 10 (range 1.63–5.62) and Tolerance values above 0.1 (range 0.178–0.941) indicated that this assumption was met. The normality assumption was evaluated using the histogram of residuals and the Normal P–P plot. The histogram graph showed that the residuals were close to a normal distribution, and the Normal P-P Plot graph showed that the points were arranged around the diagonal line. Both graphs indicate that the residuals are normally distributed. For large samples (n > 50), these graphical checks are sufficient. The homogeneity of variances (homoscedasticity) was checked by examining the graph of the standardized residual values against the estimated values. The random distribution of the points indicates that this assumption is met. The independence of errors was tested using the Durbin–Watson test, and the value of 1.831 (within the acceptable range of 1.5 and 2.5) indicates that there is no autocorrelation between observations. Significance was given as p in all statistical tests, and statistical significance was accepted in the analysis when p < 0.05.

Results

Table 1 shows that 61.5% of participants (n = 763) are high school graduates, 69.1% (n = 857) are not working, 64.8% (n = 803) live in city centers, 79.2% (n = 982) live in nuclear families, 57.0% (n = 707) had income equal to their expenses, 58.3% (n = 723) were married, and 59.5% (n = 739) had children.

Table 1.

Participant-Specific Variables and Their Relationship/Comparison with SABAS (n:1240).

Variables			SABAS
	n.	%	x̄±ss.	r	Statistics
Age
18–25	573	46,2	34 ± 10,6	r:−0,011	F:0,639
26–34	437	35,2	34,4 ± 11,7	p:0,691	p:0,528
35 +	230	18,5	33,4 ± 10,8
Education Status
Primary education (1)	307	24,8	39 ± 12	r:−0,284	F:57,638
Secondary education (2)	170	13,7	35,9 ± 10,1	p:0,000*	p:0,000*
High school (3)	763	61,5	31,6 ± 10	1 > 2, 1 > 3, 2 > 3**	η2:0,09
Working Status
Working	383	30,9	30,1 ± 9,7	r:0,237	t:−8,564
Not working	857	69,1	35,8 ± 11,1	p:0,000*	p:0,000*
					η2:0,07
Place of residence
Urban	803	64,8	32,1 ± 10,3	r:0,228	t:−8,394
Rural	437	35,2	37,5 ± 11,4	p:0,000*	p:0,000*
					η2:0,07
Family type
Nuclear (1)	982	79,2	33,5 ± 10,7	r:0,106	F:14,647
Extended (2)	245	19,8	37,2 ± 12,3	p:0,000*	p:0,000*
Divorced (2)	13	1	36,6 ± 7,6	1 < 2**	η2:0,023
Family Income level
Income is less than expenses (1)	382	30,8	35,5 ± 11	r:−0,115	F:6,804
Income equals expenses (2)	707	57	33,7 ± 10,9	p:0,000*	p:0,001*
Income is more than expenses (3)	151	12,2	31,9 ± 11,1	1 > 2,3**	η2:0,011
Marital status
Married	723	58,3	35,1 ± 11,3	r:−0,115	t:4,043
Single	517	41,7	32,5 ± 10,4	p:0,000*	p:0,000*
					η2:0,013
Presence of children
Yes	739	59,6	35 ± 11,3	r:−0,109	t:3,831
No	501	40,4	32,6 ± 10,5	p:0,000*	p:0,000*
					η2:0,012
The state of having a voluntary abortion
Yes	170	13,7	33 ± 9,2	r:0,012	t:−1,251
No	1070	86,3	34,2 ± 11,3	p:0,682	p:0,211
The person/persons who voluntarily decided to have an abortion
Me	45	26,5	34,5 ± 8,3	r:−0,062	F:0,917
My spouse	17	10	31,7 ± 7,3	p:0,42	p:0,402
Me and my spouse	108	63,5	32,6 ± 9,6
Reason for voluntary abortion
Unplanned pregnancy	49	28,8	33,4 ± 9,2	r:−0,072	t:0,312
Medical reasons	121	71,2	32,9 ± 9,2	p:0,348	p:0,755
Discomfort with others knowing about abortion
Yes	70	41,2	32,3 ± 9,5	r:0,095	t:−0,846
No	100	58,8	33,5 ± 9	p:0,22	p:0,399
SWBS				r1:0,523 p:0,000*	η2:0,144

n: frequency/sample size; %: percentage; x̄±ss.: mean plus/minus standard deviation; r: Spearman’s rho (nonparametric correlation); r1: Pearson correlation (parametric correlation); F: ANOVA, t: Independent samples t-test; η2: Eta-squared effect size; **Post hoc: Bonferroni-adjusted multiple comparisons; *p < 0.05.

A statistically significant difference was found between participants’ educational status, working status, place of residence, family type, income status, marital status, presence of children, and SABAS scores (p<0.001).

A statistically significant, positive, and high correlation was found between SABAS and SWBS (r = 0.523, p<0.001). As SWBS scores increased, there was a statistically significant increase in SABAS scores.

Table 2 shows the feelings and thoughts experienced by women during and immediately after abortion.

Table 2.

Feelings/Thoughts Experienced During/İmmediately After Abortion.

Feelings/thoughts	n (170)	%
Guilt/anger	56	33,30%
Remorse/sadness	57	33,60%
Thinking you have sinned	63	37,10%
Anxiety	26	15,60%

β0: Unstandardized beta coefficient, SE: Standard error, LL: Lower limit of the 95% confidence interval for β0, UL: Upper limit of the 95% confidence interval for β0, β1: Standardized beta coefficient, t: t-test,, ra: Zero-order correlation, rb: Partial correlation, F: ANOVA, Ra: Adjusted R2, *=p < 0.001.

Table 3 shows ıt has been determined that the regression model established using the Enter method is statistically significant and that at least one of the independent variables has a significant effect on the dependent variable (SABAS) (F(8) = 78.099, p < 0.001). It has been understood that 33.7% of the variance in the dependent variable (SABAS) is explained.

Table 3.

Multiple linear regression analysis findings related to SABAS.

	Non-standardized				Standardized			Correlation
	β0	SE	LL	UL	β1	t	p.	r a	r b
(Constant)	5,93	2,34	1,341	10,516		2,535	0,011
SWBS	0,24	0,01	0,216	0,264	0,47	19,697	0,000*	0,523	0,49
Education status Primary education (1) Secondary education (2) High school (3)	−2,03	0,43	−2,879	−1,19	−0,16	−4,729	0,000*	−0,292	−0,134
Family type Nuclear (1) Extended (2) Divorced (3)	2,07	0,60	0,901	3,24	0,08	3,474	0,001*	0,147	0,099
Place of residence Urban (1) Rural (2)	1,80	0,58	0,662	2,93	0,08	3,108	0,002*	0,232	0,088
Working Status Working (1) Not Working (2)	1,47	0,66	0,183	2,756	0,06	2,242	0,025*	0,236	0,064
Working Status	0,30	0,42	−0,526	1,133	0,02	0,718	0,473	−0,104	0,02
Marital status	−0,68	1,23	−3,093	1,734	−0,03	−0,552	0,581	−0,114	−0,016
Presence of children	0,49	1,18	−1,832	2,809	0,02	0,413	0,68	−0,108	0,012

F:78,099, p:0,000*, R²:0,337, R^a:0,332, sd1:8, sd2:1238.

SWBS positively and statistically significantly explains the change in SABAS (β1 = 0.47, t(1238) = 19.697, p < 0.001). As SWBS increases, participants’ SABAS scores increase to a statistically significant level, forming a positive and meaningful correlation (ra = 0.523, rb = 0.490).

Educational status, family type, place of residence, and working status were found to have a statistically significant effect on SABAS (p < 0.05).

The findings of the regression analysis are summarized visually in the following figures (Figs. 1 and 2, and Fig. 3). Upon examining Fig. 1, it is observed that the independent variables affecting SABAS are SWBS (continuous variable), educational status (categorical variable), family type (categorical variable), place of residence (categorical variable), and woking status (categorical variable). The lines connecting these variables to SABAS vary in thickness, indicating the magnitude of their effects. In this context, it is understood that the variables affecting SABAS in order of magnitude are SWBS, educational status, family type, place of residence, and working status.

Fig. 1.

Variables affecting SABAS.

Fig. 2.

Variable categories affecting SABAS according to coefficients and direction of effect.

Fig. 3.

Dot plot of the variables associated with SABAS. Note: The blue dots and the values displayed above them indicate the mean SABAS scores across categories.

When examining Fig. 2, it is understood that the categories of variables affecting SABAS are shown according to their coefficient weights and direction of effect. Blue lines contribute positively to SABAS, while orange lines contribute negatively, and the thickness of the lines indicates the magnitude of the contribution.

In this context, SWBS has a positive and significant effect on SABAS. The educational status variable has a positive effect on SABAS in the primary and secondary education categories; however, the primary education category has a greater effect on SABAS than the secondary education category. Therefore, SABAS scores are primarily increased by primary school graduates, followed by secondary school graduates. The family type variable has a negative effect on SABAS. The nuclear family category of the family type variable reduces SABAS scores. Similarly, the place of residence and working status variables also have a negative effect on SABAS, and the city category of the place of residence variable and the woking category of the working status variable reduce SABAS scores.

Figure 3 shows the SABAS averages according to the categories of variables affecting SABAS. There is a linear correlation between SWBS and SABAS. As educational status increases from elementary school to high school, SABAS scores decrease. SABAS score averages increase when moving from a nuclear family to an extended or broken family, from an urban area to a rural area, and from the working category to the not working category. All differences in Figs. 1 and 2, and 3 and 4 are statistically significant (p<0.05).

Fig. 4.

Scatter plot showing the correlation between SABAS and SWBS. Note: Blue dots represent the distribution of the scales, and the black line indicates the linear relationship.

Discussion

Although abortion can be performed within the framework of legal rules and practices, it has been one of the most important topics of discussion since the dawn of humanity from a socio-cultural, philosophical, and religious perspective²². It is reported that women around the world mostly resort to abortion for social, medical, and economic reasons, and that most voluntary abortions occur due to unplanned pregnancies. Studies have determined that factors such as the young mother’s age, number of children and their ages, serious illnesses, the death or divorce of her spouse, and low educational level increase the frequency of elective abortions^6,22,26. In the current study, individuals who are unemployed and have lower educational and economic levels have higher SABAS scores. Additionally, unemployed individuals were found to have higher SABAS scores than employed individuals. Previous studies support our findings, indicating that stigmatization and negative feelings toward abortion are more prevalent among unemployed individuals with lower educational and income levels^27–30. The study’s findings reveal that individual and environmental factors play a decisive role in shaping stigmatizing attitudes and feelings toward abortion. In particular, low levels of education and economic status are associated with increased negative feelings and stigma toward abortion. This finding suggests that individuals with low socioeconomic status may develop more conservative or judgmental attitudes toward abortion due to difficulties in accessing healthcare services, lack of information, and the influence of cultural norms. In the current study, the average SABAS score was higher among those living in rural areas than among those living in urban centers. Studies in the literature have indicated that stigmatization and negative feelings toward abortion are more prevalent among those living in rural areas, villages, and districts compared to those living in urban centers^29,30. Those living in villages and rural areas also represent segments of society where traditional values and religious norms are more internalized and social control is more intense. Especially in rural areas, community solidarity and surveillance are strong; individual choices are shaped by social approval and concerns about “what others will say.” This situation shows that decisions regarding abortion are determined not only by the woman’s own health and living conditions but also by social pressure from her surroundings. In the study, married women had higher SABAS scores than unmarried women. This finding is consistent with the literatüre^28,30. In the study, those with children had higher SABAS scores than those without children. In the studies conducted, women with children had higher SABAS scores than those without children, and women with two or more children had higher SABAS scores than those with one child. Our finding is supported by the literature^28–30.

The higher rate of stigmatization among married women and individuals with children reflects the fact that women in Turkish society are identified with their role as mothers³⁰. Social control over women’s bodies is particularly legitimized through “motherhood,” while abortion is perceived as a threat to this social identity and becomes subject to moral scrutiny. In this context, abortion can be coded not as an individual health right but as a violation of the “sanctity of womanhood.” In the current study, those living in extended families (mother-in-law, father-in-law, spouse’s siblings, etc.) had higher SABAS scores than those living in nuclear families. The findings of the study support our findings³⁰. This reflects a social reality consistent with Turkey’s dominant cultural and religious structure. Turkey is a country where both traditional family values and Islam play an important role in social life. In this context, decision-making processes related to a woman’s body and fertility, such as abortion, are evaluated not only individually but also within the framework of moral, religious, and cultural norms and are given social meaning. This social pressure is fed not only by cultural values but also by religious norms. In Islam, there is a general acceptance that after a certain stage of pregnancy (usually 120 days), the fetus has “come to life” and abortion carries serious religious^31,32. In extended family structures, elders often use these religious references as moral norms and attempt to limit women’s decisions about their bodies on religious grounds. This situation may cause women considering abortion to experience religious-based concerns such as “committing a sin,” “bringing shame to their family,” or “defying God’s will.” Furthermore, women’s right to make decisions about their own bodies and health often becomes a “family decision” within these traditional structures. The pressure on women to obtain approval not only from their husbands but also from their mothers-in-law, fathers-in-law, and even their neighborhood community demonstrates a serious violation of individual autonomy.

The decision to have an abortion is a challenging process. Women may experience different emotions and problems before and after an abortion. The women who participated in this study reported experiencing the most feelings/thoughts of guilt/anger, sinning, regret/sadness, and anxiety during and after the decision to have a voluntary abortion. Kumar et al. (2009) defined abortion stigma as “a negative quality attributed to women who seek to terminate a pregnancy that marks them internally or externally as inferior to ideals of femininity”¹³. In addition, the American Psychological Association (2008) has identified stigma as a significant risk factor for the mental health of women who have an abortion, including anxiety, depression, physiological distress, and social withdrawal³³. In short, studies have overwhelmingly found that abortion stigma is associated with harmful psychological outcomes^12,15,22. In conclusion, the psychological burden of abortion cannot be reduced solely to the individual’s “courage to make a decision”; this process should be evaluated in the context of the social norms, religious/moral codes and systematic stigmatization that women are exposed to. Every emotion a woman experiences is a reflection of the cultural atmosphere, social expectations and internalized gender roles she is in. Therefore, it is not possible to provide effective support to women without understanding the psychosocial dimension of abortion. Individual psychological counseling and group-based support services should be provided to women before and after voluntary abortion. During this process, professionally addressing feelings such as guilt, regret and anxiety will have a protective effect on mental health. Culturally sensitive education and communication programs should be developed through health workers, media, educational institutions and civil society organizations to reduce the social stigma towards abortion.

The study found a positive relationship between the SWBS and the SABAS. In other words, it was determined that as women’s spirituality increases, stigma and negative feelings towards abortion increase. A study conducted in Turkey supports our finding²². The strong integration of traditional family structure and religious values ​​with women’s identity in Turkey further reinforces the effect of spirituality on women’s reproductive decisions. Therefore, as spirituality increases, social and internal judgments towards abortion also increase; abortion becomes not only a medical issue but also a conscientious issue. This finding reveals that spirituality is a strong determinant when making sense of abortion not only at the individual level but also at the social and cultural level. Other studies in the literature point to similar results. Baker et al. (2023) stated that spiritual commitment increases negative beliefs and stigmatization towards abortion³⁴ Frohwirth et al. (2018) stated that individuals with strong religious beliefs experience higher levels of guilt and regret in their decisions regarding abortion³⁵. Berer (2017) and Selebalo-Bereng et al. (2019) emphasize that religious, cultural and spiritual norms regarding abortion directly affect women’s decision-making processes^21,36. All these studies show that stigma towards abortion has a multidimensional structure and that religious-spiritual norms in particular play a decisive role in both the decisions of individuals and their emotional reactions to these decisions. Therefore, when developing reproductive health policies, not only medical but also psychosocial and cultural components should be taken into account; the effects of spirituality on the individual should be addressed in both supportive and restrictive aspects. Therefore, when developing strategies to reduce social stigma, religious and spiritual sensitivities should be aware, but these sensitivities should be addressed with a balanced approach that does not overshadow individual rights.

Conclusion

As a result, reducing the stigma against abortion is possible not only with individual awareness but also by questioning the value judgments, religious norms and stereotypes regarding women’s roles in the social structure. At this point, nurses and health professionals have a critical role in preventing the stigma against abortion and supporting the psychosocial well-being of women. Healthcare professionals should adopt a respectful, compassionate and impartial approach to women’s decisions during the voluntary abortion process. In particular, nurses should address the psychological, social and spiritual needs of individuals during the transition processes they experience (pregnancy, birth, abortion, etc.) from a holistic perspective. Informative and empowering counseling services play an important role in supporting women’s decision-making processes and reducing the impact of internalized stigma. Individualized counseling services provided by nurses to pregnant women and women of childbearing age can facilitate the early recognition and management of feelings such as guilt, shame and anxiety. In addition, psychoeducation programs that include spirituality can help women make decisions that are compatible with their own value systems. As a result, health professionals should not only be practitioners who provide physical care; they should also be guides who recognize and strengthen the psychosocial and cultural context of the individual. This holistic approach will help ease the emotional burden experienced by women who resort to voluntary abortion, both during the decision-making process and afterwards, and help them benefit from health services in an equal, respectful and supportive manner.

Limitations and Generalizability

This study has some limitations. First, the research only included women who had elective (voluntary) abortions and did not include women who terminated their pregnancies due to fetal genetic disorders or medical necessity. Therefore, the attitudes, experiences of stigmatization, and psychosocial responses of women with different reasons for abortion could not be evaluated comparatively. The literature indicates that the experiences of women who terminated their pregnancies for medical reasons may differ from those who had voluntary abortions, which limits the generalizability of the findings to all abortion experiences.

Furthermore, the study was conducted in a single provincial center in the Eastern Anatolia Region of Turkey. This limits the generalizability of the findings to women living in different regions of Turkey with different socio-cultural, economic, and religious characteristics. However, considering the prevalence of traditional family structures and religious values in social life in Turkey, the findings are thought to be instructive for communities with similar socio-cultural characteristics. Future multi-center and comparative studies will contribute to both revealing differences based on reasons for abortion and increasing the generalizability of the findings.

Author contributions

Conceptualization: [Emine Kurt Can]; Methodology: [EmineKurt Can], [Nesrullah Ayşin], [Mesut Yılmaz], [İbrahim Nas]; Formal analysis and investigation: [Pınar Kurt Uman]; Writing - original draft preparation: [Emine Kurt Can, [İbrahim Nas], [Nesrullah Ayşin]; Writing - review and editing: [Emine Kurt Can], [Pınar Kurt Uman], [Nesrullah Ayşin], [Mesut Yılmaz]; Funding acquisition [Mesut Yılmaz, [İbrahim Nas], [Pınar Kurt Uman]; Resources: [Pınar Kurt Uman]; Supervision: [Emine Kurt Can], [Nesrullah Ayşin]

Funding

No funds, grants, or other support was received. The authors have no relevant financial or non-financial interests to disclose.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due, but are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Informed consent statement

Informed consent was obtained from all participants.

Institutional Review Board Statement

For this study, ethical approval numbered 2024/05 − 04 was obtained from the Van Yüzüncü Yıl University Non-Interventional Clinical Research Ethics Committee, and study permission was obtained from the hospital where the study was conducted. Written and verbal consent was obtained from mothers.