Objective:

To identify the barriers in accessing formal abortion services in Turkey and understand the motivating factors for requesting a telemedicine-mediated medical abortion

Background:

Since 1983, the Population Planning Law 2827 allows abortion to be performed until the end of the tenth week of gestation. However, it requires spousal consent for married women and parental consent for minors.1 Furthermore, the Turkish Penal Code permits abortion up to the twentieth week of gestation if the conception occurred as a result of a criminal act.2 Despite the legal framework, many studies have shown that abortion services have been gradually discarded by hospitals and the number of medical doctors who are willing to provide abortion services are low. 3,4

Design:

The Women on Web (WoW) is an international organisation that provides telemedicine-mediated medical abortion service. Women who sought medical abortion via the WoW website filled a consultation survey that consisted of 25 questions. On the survey, they were also asked for their consent to partake in research. The data from all consented users were collected. Following the survey, all participants were also given user-initiated follow-up option to engage in discussion about their experiences in formal abortion services or expectations from medical abortion. The qualitative data from the correspondents who initiated this track were collected for content analysis.

Methodology:

Between 1 January 2013 and 12 October 2020, 620 women who were over the age of eighteen, lived in Turkey and consented to partake in research were included in this study. A cross-sectional analysis of the surveys was conducted with SAS 9.4. Consecutively, correspondence from 138 women who engaged with user-initiated follow-up were subjected to content analysis until overarching themes were saturated.

Results:

• 75% of  the surveyors were under the age of thirty. The mean age was 26.55 with a range of 18 to 54. 

• 74.87% of the participants have never undergone an abortion.

• 83.31% of the participants had at least one previous pregnancy.

• 32.57% of surveyors had at least one child. 

• 97.53 % of  the participants reported their pregnancy to be either unwanted (excess of ideal number of children) or mistimed at the time of survey.

• 74.19% of participants requested an abortion within the first seven-week of the gestation. Only 2.2% of pregnancies were beyond 10 weeks.

• 58.39% of the surveyors were not using any contraceptives at the time of conception.  

• 219 women stated that their contraceptive method did not work (more than 35%).

• 97.74% of them reported having a hospital within 60 minutes of distance.

• The barriers to formal abortion care were reported as cost (31.62%), need to keep the abortion secret from partner or family (27.94%).

• 16.91% of the participants reported abusive partners as barrier to the formal services. 

• While 7.35% of them highlighted being an immigrant as an obstacle.

• Decreasing availability of abortion services in public and private sectors, de-facto privatisation of abortion, spousal permit requirement and concerns over physicians’ approach to confidentiality and medical ethics of abortion were frequently cited barriers. (Box 1)

• Dissatisfaction with available abortion methods and potential of medical abortion for autonomy were mentioned as main  motivators  for medical abortion. (Box 1)

   

Correspondences (Box 1):

 

“Yes, I called public hospitals and asked for abortion services, but they told me that abortion is illegal in Turkey.”

 

“Hospitals charge 2000- 3000 Turkish Liras for abortion. I don’t have any money.”

 

“I was raped, and I will be killed if my family learns. If I go to the doctor, my pregnancy will be documented, and my family physician will call my house.”

 

“The ministry of health monitors all pregnancies, and every gynecologist is obliged to report pregnancies. If my husband and I do it formally, we will be tagged.”

 

“I am subjected to violence and harassment by my husband. I left the house, but a spousal permit is sought to terminate this pregnancy.”

 

“I do not want to undergo curettage for my first pregnancy. I want to have a medical abortion with my husband’s help at home.”

Conclusion:

 

Despite relatively liberal regulations in Turkey, this study demonstrated that access to formal abortion services remains tenuous for many women due to limited availability of abortion providers, de-facto privatisation of abortion and arbitrary pricing strategies, practitioners’ approach to confidentiality and the requirement for spousal permit.

Further research into the mismatch between abortion regulations and services should be considered to explore the factors behind this phenomenon at macro (institution) and micro (practitioner) levels.