Evaluation of Effective Factors on Decision of Families Regarding Medical Abortion Recommended due to Fetal Anomaly

Abstract

Aim:

The study aims to examine the effective factors influencing the decision of families to whom medical abortion was recommended due to fetal anomalies.

Methods:

The cross-sectional study was conducted at İstanbul University Hospital, Department of Gynecology and Obstetrics, High-Risk Pregnancies and Maternity Ward. The sample consisted of 233 pregnant women, to whom medical abortion was recommended due to the diagnosis of foetal anomaly collected inover a 1-year period.

Results:

While 122 of the families decided to have medical abortions, 111 decided to give birth. The rate of deciding on medical abortion was the highest in families whose fetuses had a high expectation rate of lethal anomalies (p < .001). The most effective factor for the families who decided to give birth was their religious beliefs. The most effective factor for the families who decided to have a medical abortion was the information they received from health professionals.

Conclusion:

While the religious beliefs of the parents were effective in the decision to give birth, the information they received from the health professionals was effective in the decision to have a medical abortion.

Introduction

The addition of biochemical markers to screening programs, advances in ultrasonography technology, and genetic tests can lead to earlier prenatal diagnosis of chromosomal abnormalities and fetal structural malformations in such cases. In such cases, patients are offered more pregnancy termination options. This approach as a management option for dealing with fetal health problems but also for the protection of maternal health contributes to the development of a number of medical, ethical, and legal issues it brings with it (Gök et al., 2022; Rydberg & Tunón, 2017). Medical abortion is a form of abortion. In order to protect privacy, pregnant women choose to have abortions with drugs, mainly mifepristone and misoprostol. Side effects were short-term bleeding and cramping (Cohen, 2021). Although large-scale studies reflecting nationwide data on medical abortion rates in Turkey are not available, some single-center studies are available. In one study, it was reported that medical abortions were performed most frequently (32.2%) due to central nervous system malformations, 24.3% due to anhydramnios, 12% due to chromosomal abnormalities (Trisomy 21), and least frequently due to cardiac anomalies (0.6%) (Gök et al., 2022).

Congenital anomalies may be lethal or severe enough to considerably affect normal living conditions. In such a case, some parents may decide to terminate the pregnancy, whereas others may choose to continue the pregnancy (Alshalan & Alfadhel, 2020; Christian et al., 2000; Wool, 2011). Families vary not only in terms of their approaches to screenings and diagnosis procedures but also in their decision-making concerning the continuation of pregnancy after the diagnosis of congenital anomalies (AlAlaiyan, 2014; Korenromp et al., 2005; Skotko, 2005; Tymstra et al., 2004).

Numerous factors, such as psychological, cultural, religious, and economic factors, have been reported to be effective in decision-making concerning the termination of pregnancy after the diagnosis of anomalies in the prenatal period (Alshalan & Alfadhel, 2020; Al-Alaiyan, 2014; Korenromp et al., 2005; Schechtman et al., 2002; Stotland, 2001). It will be useful for healthcare professionals to be aware of the effective factors in families’ decisions and consider the effectiveness of cultural characteristics in these decisions in order to provide families with efficient training and counseling services (Hjort-Pedersen et al., 2022; Kohan, 2022; Sun et al., 2020; Stotland, 2001).

When the literature is reviewed, it is observed that the number of studies examining the effective factors on the decisions of families to whom medical abortion was recommended due to fetal anomalies is limited. In these studies, it has been reported that the severity of the anomaly (Hjort-Pedersen et al., 2022; Graf et al., 2023; Schechtman et al., 2002), location of the defect (Allen, 2014; Hodgson & McClaren, 2018), and demographic characteristics such as race, educational level, and gender family’s income level (Allen, 2014; di Giacomo et al., 2021) are effective on the families’ decisions. These studies have mainly reflected the results of developed countries. The number of studies analyzing the effective factors on the decisions of families to whom medical abortion is recommended due to fetal anomalies, in developing countries and different cultures is limited (Ahmed et al., 2012; AlAlaiyan, 2014; Alshalan & Alfadhel, 2020). In Turkey, in a 10-year retrospective study conducted by Köse et al. regarding families to whom medical abortion was recommended due to severe fetal anomalies, it was reported that the decision of medical abortion was observed among families to whom medical abortion was recommended due to chromosomal abnormalities at the highest rate (93%) (Kose et al., 2015). In another study, it was reported that the majority of the cases where medical abortion was performed had central nervous system malformations, multiple malformations, and genetic malformations (Aslan et al., 2007).

Although there are studies in literature examining the correlation of families’ decisions on medical abortion with demographic and obstetric characteristics and fetal anomalies’s type and severity, there is a limited number of studies questioning which factors are effective on families’ decisions (Ahmed et al., 2012; AlAlaiyan, 2014; Alshalan & Alfadhel, 2020; Hjort-Pedersen et al., 2022; Korenromp et al., 2009, 2007). No study questioning which factors are effective on families’ decisions concerning medical abortion and birth has been encountered in Turkey.

The study aims to examine the effective factors influencing the decision of families to whom medical abortion was recommended due to fetal anomalies. The results of this study are thought to be a guide for all healthcare professionals in planning and implementing the scope and contents of training and counseling services to be provided for families in developing countries and different cultures.

Research Questions

1. Are the demographic characteristics of pregnant women, such as age, educational status, and economic status, effective in the decision of medical abortion which was recommended due to fetal anomaly?

2. What are the factors affecting the decision of pregnant women about whether termination of pregnancy was recommended due to fetal anomaly?

Methods

Study Design

This study is designed as a cross-sectional study.

Sample

The population of the study consisted of 416 families to whom medical abortion was recommended by the hospital’s ethics committee due to a severe fetal anomaly at Department of Gynecology and Obstetrics, High-Risk Pregnancies and Maternity Ward of İstanbul University Hospital, unit of prenatal diagnosis and treatment between specified dates. A total of 286 families diagnosed with fetal anomaly were asked to participate in the study. The sample group of the study consisted of 233 families who agreed to participate in the study. While 122 of these families (52.4%) chose medical abortion (medical abortion group-MAG), 111 families (47.6%) made the decision to give birth (birth group-BG).

Inclusion Criteria

Women who were diagnosed with fetal abnormalities during the data collection process, who were offered medical abortion, who had a medical abortion decision or a decision to deliver, and who agreed to participate in the study were included in the study.

Exclusion Criteria

Pregnancies resulting in spontaneous abortion and abortion due to other reasons, as well as women who refused to participate in the study, were excluded from the study.

It was found that the annual birth amount at the hospital where the study was conducted was 44,774; the total number of pregnant women who were diagnosed with fetal anomalies and were recommended with the option of medical abortion was 416; while 224 of these pregnancies (54%) were terminated with medical abortion, 192 pregnancies (46%) eventuated in birth; the incidence of fetal anomalies was 0.9%; and ratio of medical abortion over the total number of births was 0.5%. The sample size was calculated with the Raosoft sample size calculator program (http://www.raosoft.com/samplesize.html). As a result of a 95% CI, a 5% margin of error, and a 50% response distribution rate, the minimum sample size was calculated as 200. Considering the possible losses, 233 women who were offered medical abortion, met the sample selection criteria, and agreed to participate in the study were included in the study.

Data Collection

The data for the study were collected at İstanbul University Hospital, Department of Gynecology and Obstetrics, High-Risk Pregnancies and Maternity Ward, collected over a 1-year period.

Some information related to mothers and the histories of pregnancies was obtained from file records. In this study, “medical abortion” was defined as an abortion performed due to a fetal anomaly. All medical abortions were performed at the same institution. The severity of each anomaly was ranked by a sonologist-geneticist, whose knowledge of severity provided the basis for the genetic counseling. According to the results of the prenatal screening tests, anomalies were divided in four categories by making use of the literature (Kose et al., 2015). Anomalies not affecting quality of life were grouped as grade 1, anomalies not affecting or very slightly affecting quality of life but requiring surgical and medical treatment were grouped as grade 2, anomalies with the potential of severely affecting quality of life were grouped as grade 3, and lethal anomalies were grouped as grade 4.

According to the Turkish constitution, abortion can be performed until the tenth week upon the request of the family. Also, Turkish law has permitted the Termination of Pregnancy (TOP) at any period of gestation if the ongoing pregnancy is hazardous for a woman’s health and/or the fetus has a high risk of severe disability or incurable fatal disease (law number: 2827-5, 1983; Aslan et al., 2007; RG. Ministry of Health, Law Number: 2827 on population planning). In addition, there is a country-wide consensus that the upper limit is 24 weeks for terminating the pregnancy in cases of fetal anomalies (Kose et al., 2015).

Data Collection Tools

The data were obtained with a data collection form consisting of a total of 27 questions, including 8 questions to determine the sociodemographic characteristics of women (age, height, weight, education levels, etc.), 11 questions to determine obstetric characteristics (abortion, number of pregnancies, number of vaginal births, etc.), and 8 questions to determine their decisions regarding medical abortion. All study data were collected by the same researcher using the face-to-face interview technique. It took approximately 10–15 minutes to complete the questionnaire.

Statistical Analysis

The Statistical Package for the Social Science Statistics software for Windows, version 16.0 (SPSS Inc.; Chicago, IL, USA), was used for the assessment of data. The t-test was used to compare continuous variables such as age, number of pregnancies and births, number of previous abortions and curettage, and time of detection of fetal anomaly, while percentage and chi-square tests were used to compare categorical variables such as gender, educational status, employment status, types of fetal anomaly, severity of anomalies and family decisions. The results were evaluated at a confidence interval of 95% and a significance level of p < .05.

Ethical Considerations

The research protocol was approved by the Ethics Committee of Bakırköy Sadi Konuk Education and Research Hospital, before the study began (Approval No: 2011/89; Date: December 5, 2011). All participants gave written informed consent before the study began. All of the participants volunteered to participate in the study, and written informed consent was obtained from all participants.

Results

When Table 1 was examined, it was observed that the educational level of fathers in families who made the decision of medical abortion was higher than that of those who made the birth decision in a statistically significant (p < .05), and there was no difference between groups in terms of other sociodemographic and obstetric characteristics (p > .05) (Table 1).

Table 1.

Examining the Correlation Between the Sociodemographic and Obstetric Characteristics of Pregnant Women and the Family’s Decisions (N = 233)

Characteristics	Made the Decision of Medical Abortion (n = 122) Mean ± SD		Made the Birth Decision (n = 111) Mean ± SD		Z	p a
Mother’s age	29.4 ± 5.8		29.9 ± 5.4		−0.926	.354
Father’s age	31.6 ± (-6.1)		31.9 ± 5.6		−0.840	.401
Mother’s education	n	%	n	%	χ 2	p b
Primary school and below	63	51.6	68	61.3	2.186	.139
High school and above	59	48.4	43	38.7
Mother’s employment status
Employed	75	61.5	73	65.8	0.462	.497
Unemployed	47	38.5	38	34.2
Father’s education
Primary school and below	49	40.2	59	53.2	3.943	.047
High school and above	73	59.8	52	46.8
Location of residence
City	109	89.3	104	93.7	1.401	.237
District-village	13	10.7	7	6.3
Characteristics	Made the Decision of Medical Abortion		Made the Birth Decision		Z	P a
	Minimum–Maximum	Mean ± SD	Minimum–Maximum	Mean ± SD
Number of pregnancies	1–11	2.4 ± 1.6	1–6	2.1 ± 1.1	−0.926	.354
Number of births	1–5	1.5 ± 0.9	1–4	1.5 ± 0.7	−0.279	.780
Number of abortions	1–10	1.8 ± 1.8	1–3	1.2 ± 0.5	−1.706	.088
Number of curettages	1–4	2.0 ± 1.4	1–1	1.0 ± 0.0	−1.323	.186
The week when fetal anomaly was identified	12–37	23.1 ± 5.5	14–37	23.8 ± 0.5	−1.056	.291

^a t test.

^b χ² test.

When the medical abortion and birth decision frequencies of the families according to the diagnosis of fetal anomalies were examined, the most commonly determined fetal anomaly was Cardio Vascular System (CVS) anomalies at a rate of 26.6%. All 100% of families whose fetus was diagnosed with chromosomal abnormality, 62% of families whose fetus was diagnosed with Central Nervous System (CNS) anomaly, and 54.7% of families whose fetus was diagnosed with an anomaly of the musculoskeletal system were observed to have made the decision of medical abortion. A fetal Gastro Intestinal System (GIS) defect was found in all of the families who decided to deliver, and a GUS defect was found in 74.4% of them. Table 2 illustrates other data.

Table 2.

Examining Families’ Frequencies of Medical Abortion and Birth Decision According to Diagnosis of Fetal Anomaly (N = 233)

Anomaliesa	N = 233	Medical Abortion		Birth Decision
		n %		n %
		122	52.4	111	47.6
CVS	62 (26.6)	25	40.3	37	59.7
Musculoskeletal	53 (22.7)	29	54.7	24	45.3
CNS	50 (21.4)	31	62.0	19	38.0
GUS defect	43 (18.4)	11	25.6	32	74.4
Chromosomal Abnormalities	38 (16.3)	38	100	-	0
GIS defect	8 (3.4)	-	0	8	100
Hydrops fetalis	4 (6.8)	2	50.0	2	50.0
Abdominal Wall Defect	10 (4.3)	3	30.0	7	70.0

^aMore than one anomaly was diagnosed in some fetuses.

When the groups were compared in terms of the severity of the anomaly, the expectation of lethal anomalies (Grade 4) was higher (MAG: n = 36; 29.5%/DG: n = 5; 4.5%) in a statistically significant way, and the expectation of anomalies not affecting quality of life (Grade 1) was significantly lower (MAG: n = 2; 1.6%/DG: n = 43, 38.7%) in the group of families who made the decision of medical abortion, whereas no difference was found between groups in terms of the other grades (p < .001) (Table 3).

Table 3.

Comparison of the Groups in Terms of Severity of the Anomaly (N = 233)

Severity Grade	Made the Decision of Medical Abortion (n = 122)		Made the Birth Decision (n = 111)		χ2 p
	n %		n %
1	2	1.6	43	38.7	64.432
2	19	15.6	10	9.0	.001
3	65	53.3	53	47.7
4	36	29.5	5	4.5

Fisher’s chi-square test was performed.

When families were asked what reasons were effective in their decisions, 86% of those in the medical abortion group (n = 105) stated the information they received from healthcare professionals, 81% (n = 90) stated the difficulties that could be experienced in infant care, and 70.4% (n = 86) stated the difficulties that the infant may have as an effective reason for their decisions. While 99% of those who made the birth decision (n = 110) stated religious reasons (believing that it would be a sin, belief in fatalism), 90.9% (n = 101) were convinced by their family elders and husbands about the infant’s being healthy, and 85.5% (n = 95) were convinced by people around them (relatives/neighbours) about the infant’s being healthy. It was found that the information received from the healthcare personnel was not effective in the group of families who made the birth decision (Table 4).

Table 4.

Examination of effective factors on families’ decisions according to their statements (N=233)

Group/Effective factors a
Medical Abortion (n = 122)	n (%)
Information received from healthcare personnel	105 (86)
Difficulties we may experience in infant care	99 (81)
Difficulties the infant may have	86 (70.4)
Financial difficulties we may have	62 (50.8)
Family elders and husband’s request	56 (45.9)
Being able to have another baby	30 (24.6)
Mother’s request	15(12.3)
Religious beliefs	3 (2.4)
Birth group (n = 111)
Religious beliefs (belief of fatalism, believing it would be a sin, etc.)	110 (99)
Family elders and husband’s request	101 (90.9)
Friends/relatives, etc. convincing the mother that the infant may be healthy	95 (85.5)
Believing that the infant’s risk of being disabled/sick is low	65 (58.5)
Low possibility of having another baby	24 (21.6)
Not having understood the difficulties they may encounter well	18 (16.2)
Thinking that the diagnosis may be wrong	6 (5.4)

^aMore than one reason was given. Percentage distribution of the groups was calculated within themselves.

Discussion

The results of the study revealed that the educational level of fathers in the group of families who made the decision to have medical abortion was higher (p < .05) (Table 1). These results suggest that fathers with high educational levels had a higher tendency to make the decision to have medical abortion, and fathers with high educational levels were more effective in their family’s decisions. This may be associated with the fact that fathers with high educational levels focused on the life quality of infants after birth instead of focusing on whether or not they would survive. There was no difference between the groups in terms of other demographic and obstetric characteristics (p > .05).

Some of the studies examining the effect of sociodemographic characteristics on family decision have reported that sociodemographic characteristics such as education (Schechtman et al., 2002) and gender (Korenromp et al., 2007; Ahmed et al., 2012) are effective in the family’s decision, while others have reported that they are not (Hjort-Pedersen et al., 2022; Dussel et al., 2009). In the study of Schechtman et al. (2002) to investigate the factors affecting the decision of medical abortion, they reported that parents with high educational levels had higher tendencies for making the decision of medical abortion in severe fetal anomalies (Schechtman et al., 2002).

In a study conducted by Ahmed in Pakistan, it was reported that fathers were more likely to take the decision of medical abortion than mothers. Researchers stated that fathers may be more likely to make a medical abortion decision because they believe that they are responsible for the care of their families or because they experience financial and social pressures (Ahmed et al., 2012). When studies analyzing the correlation between family decisions and sociodemographic and obstetric characteristics were examined, it was found in the study of Korentromp et al. that the husband was effective in the mother’s decision (Korenromp et al., 2007).

When families’ frequencies of medical abortion and birth decision according to diagnosis of fetal anomaly were analyzed, all families diagnosed with chromosomal abnormality and 62% of families diagnosed with CNS anomaly made the decision of medical abortion (Table 2). When the literature was reviewed, it reported that the severity of the anomaly (Graf et al., 2023; Hjort-Pedersen et al., 2022; Alshalan & Alfadhel, 2020; Schechtman et al., 2002) and location of the defect (Hodgson & McClaren, 2018; Allen, 2014) were effective in the family’s decision. In the study conducted by Schechtman et al., it was reported that as the severity of fetal anomalies increased, the rate of abortion decisions increased, and the tendency of abortion decisions was higher in CNS anomalies (Schechtman et al., 2002). In the study conducted by Kose et al., (2015) in Turkey, it was also stated that medical abortion was decided at the highest rate in families to whom medical abortion was recommended due to chromosomal abnormalities (93%), and the rate of decision of medical abortion was 80% in the mental retardation risk group. In parallel with both national and international literature, the results of our study showed that families’ tendency to make the decision to have medical abortion in cases of congenital anomalies and CNS anomalies was higher.

When the groups were compared in terms of the severity of the anomaly, it was observed that in the group making the decision to have medical abortion, the expectation rate of a lethal anomaly was high, whereas the expectation rate of an anomaly not affecting quality of life was significantly low (Table 3). In accordance with the literature, these results made us think that the severity of the fetal anomaly and the infant’s life expectancy were effective in family’s decision to have medical abortion.

When the effective factors on families’ decisions according to their statements were analyzed, it was observed that the families in the medical abortion group reported that the information they received from healthcare personnel, the difficulties they may experience in infant care, and the difficulties the infant may have were effective on their decisions. In a similar vein to the results of the study by Korenromp et al. The results of our study showed that the information received from healthcare personnel motivated parents to make the decision to have medical abortion; on the other hand, thinking of the difficulties that families and infants may experience in their lives after birth was also effective in making the decision to have medical abortion (Korenromp et al., 2007).

In addition, when their reasons for making the birth decision were examined according to the statements of families making this decision, it was observed that religious reasons were the primary factor in their decision. Whereas the information received from healthcare personnel was not effective in their decisions (Table 4). All mothers participating in the study reported that they were Muslims. The rules or some prohibitions brought by religion may affect the lifestyles or life decisions of individuals. It is a common belief in Islam that life is a sort of test, and one should patiently accept the misfortunes they have. Therefore, religious authorities teach that even if the fetus is diagnosed with a fetal anomaly, families should consider it a test in life and accept it, not consider abortion. Moreover, it was also found that family elders were effective in making birth decisions, and trying to convince the parents that the infant may be healthy was frequently made. These results made us think that family decisions were under the influence of family elders due to unique social and familial structures. These results suggest that family elders should be included in the education given to families.

In a study carried out in the Netherlands by Korenromp et al. (2007), one of the reasons for families to be doubtful about the abortion decision was reported to be the fact that this decision contradicted their religious beliefs (Korenromp et al., 2007). It was observed in their study that religion was not at such high rate on the family’s decision as is in our study. Religious reasons were the first factor in making the birth decision in this study think that the religious teachings of Islam were more effective on families’ decisions.

In two studies conducted in a Muslim country, Saudi Arabia, it has been found that religious reasons are the first place for families to avoid medical abortion and to decide on birth (Alshalan & Alfadhel, 2020; Gesser-Edelsburg & Shahbar, 2017). In light of these results, it can be said that in Muslim countries, families who are recommended medical abortion due to fetal anomalies have a higher tendency to decide on birth. Cultural characteristics may also have contributed to these results.

Study Limitations

Conducting the study inat a single center is a limitation. In addition, although the medical abortion recommendation to the families was made with the decision of the ethics committee, the information was given by different doctors. The personal opinions of the doctors about the severity of the malformation and the statements they used in the information may have influenced the decisions of the families. Since the research is a cross-sectional study, it reveals the effects of factors such as sociocultural, religious, and family members at a limited level due to its nature. An interview study is recommended to investigate the possible influence of religious, education, and family characteristics on decision about medical abortion decisions. The strengths of the study are that all women who met the sample selection criteria and agreed to participate in the study were reached during the data collection process (N= 233), and the results reflected the final decisions of the women because the women who were recommended medical abortion were followed up until the postpartum period.

Conclusion and Recommendations

The low life expectancy of the fetus is effective in the decision of the families to have medical abortions. The most effective factor in the motivation of the families who decided to give birth was their religious beliefs, and the most effective factor in the motivation of the families who decided to make a medical abortion was the information received from health professionals.

Within the framework of the results of the research, the cultural awareness of healthcare professionals should be increased, and these cultural characteristics should be taken into consideration while counseling families. It will be useful for healthcare professionals to be aware of the effective factors in families’ decisions and consider the effectiveness of cultural characteristics in these decisions in order to provide families with efficient training and counseling services. Training and counseling services to be provided for families should be provided by taking such religious and cultural characteristics into consideration. For instance, it may be useful to emphasize the short-term and long-term negative effects of the disease on the infant’s and family’s life qualities in more detail and involve family elders in the counseling services to be provided for parents. It may be recommended to conduct qualitative studies, including in-depth interviews, that will reveal the effects of factors such as religion, social cultural characteristics, family, and friends on the decisions of families.

Funding Statement

The authors declared that this study has received no financial support.