Emre Yanikkerem  ( Manisa Celal Bayar University, Faculty of Health Science )
Sema Üstgörül  ( Manisa Celal Bayar University, Faculty of Health Science )
Gül Ertem  ( Ege University, Faculty of Nursing, Turkey )
Asli Karakus  ( Manisa Celal Bayar University, Faculty of Health Science )
Ozge Baydar  ( Manisa Celal Bayar University, Faculty of Health Science )
Nicole Esmeray  ( Manisa Celal Bayar University, Faculty of Health Science )

Objective: To evaluate Turkish nursing students\\\' attitudes towards voluntary induced abortion.
Methods: This cross-sectional study was conducted between January and June 2015, comprising students of Ege University Nursing Faculty and Celal Bayar University School of Health, located in two different cities of Turkey. Data was collected with a three-part questionnaire, focussing on students\\\' characteristics, the knowledge of abortion law in Turkey and attitudes towards voluntary induced abortion. SPSS 15 was used for data analysis.
Results: The mean score of students\\\' attitude towards voluntary induced abortion was 39.8±7.9 which shows that nursing students moderately support abortion. Female students, students coming from upper class in society, and students who had higher family income and sexual experiences had more supportiveness attitudes towards voluntary induced abortion (p<0.05). Those who lived in a village before university life, who had extended family, and students of parents with low educational level, had lower score in this regard (p<0.05).
Conclusion: Nursing students should be encouraged to behave non-judgmentally to women who want to have abortion.
Keywords: Abortion, Induced abortion, Nursing students, Voluntary induced abortion. (JPMA 68: 410; 2018)

Introduction

Unintended pregnancies result from the non-use or failure of contraception, rape, incest and forced or unwanted sex.^1,2 Worldwide, 40% of pregnancies were unintended in 2012. Approximately half of all unintended pregnancies ended in voluntary induced abortion (VIA).^3,4 It was estimated that 43.8 million induced abortions occurred in the world.⁵ Induced abortion rate (per 1,000 women aged 15-44 years) was determined 29 in the developing, and 24 in the developed countries in 2008.⁶ In Turkey, the rate of induced abortion was determined as 18%, 11.3% and 4.7% in 1993, 2003 and 2013, respectively.⁷
Unsafe abortion has been linked to numerous maternal and child health problems and is one of the major causes of maternal deaths in countries where abortion is restricted or legally permitted.⁶ Unsafe abortion is estimated to cause 14.5% of maternal deaths in the world. The unsafe abortion mortality rate was found one in Europe, 20 in Asia and Latin America, 10 in the Caribbean and 15 in Romania per 100,000 live births.³
Abortion laws, which prohibit, restrict or regulate the availability of abortion, vary widely among countries. World Abortion Policies published in the United Nations in 2014 stated that the number of governments permitting abortion increased between 1996 and 2013.⁸ In most of the countries (97%) abortion is allowed to save women\\\'s life. Termination of pregnancies is allowed by law only if physical or mental health of women is to be preserved (in about two-third of the countries), if the pregnancy is due to rape or incest, or if foetal impairment is likely to occur (in about half of the countries). Only 29% of all the countries permitted abortion for economic or social reasons or on a woman\\\'s request. It was pointed out that women who could access safe abortion easily and lived in countries with liberal abortion laws had lower abortion rates.^3,6 Abortion in Turkey was legalised in 1983 with the Family Planning Law, and women can obtain abortion on request within the first 10 weeks of pregnancy although that can be extended to the 20th week if the pregnancy threatens the
woman\\\'s health, or if the conception occurs after rape. Moreover, if the woman is married, the consent of the husband is also required. Single women over the age of 18 can choose to have an abortion on their own.⁹
The International Federation of Gynaecology and Obstetrics (FIGO) Committee has pointed out that abortion can be undertaken for medical reasons to protect woman\\\'s health and her right to autonomy in order to prevent unsafe abortion.³ In Turkey and in many countries, VIA has been legal over the past 50 years, but it is still a controversial and highly politicised issue around the world, and healthcare providers have many mixed feelings during the procedure. In some countries, healthcare providers are free to decide whether or not to participate in abortions, depending on their personal moral beliefs. Therefore, it is important to evaluate healthcare providers\\\' attitudes towards abortion because women\\\'s decisions or access to abortion may be affected by their attitudes.^10,11
There are few published studies about nursing students\\\' perception of VIA. Many previous studies have been carried out with medical students in South Africa,¹² Norway and Northern Ireland,¹ the United Kingdom,^13,14 the United States,¹⁵ Malaysia¹⁶and India.¹⁷ Attitude towards abortion was also assessed in earlier studies with medical/nursing students and health professionals in Finland,¹⁸ midwives and gynaecologists in Sweden,¹⁹ medical, nursing and law students in Spain,¹¹ social work students,¹⁰ and nursing students in Italy and Sweden.²⁰
Although the number of nursing schools has increased in Turkey, to the best of our knowledge, only two studies have investigated the attitudes of nursing and midwifery students²¹ and university students²² towards abortion. The aim of this present study was to examine Turkish nursing students\\\' attitudes towards VIA.

Subjects and Methods

This descriptive and cross-sectional study was conducted between January and June, 2015, comprising nursing students of Ege University Nursing Faculty (EUNF) and Celal Bayar University School of Health (CBUSH), located in two different cities of Turkey. No sampling selection was performed and all Ege enrolled students during the 2014-15 academic year were requested to participate in the study which was approved by the ethics committee of Ege University Nursing Faculty. After obtaining permissions from the directors, the purpose of the study was explained to the nursing students in the classroom by the researchers. The questionnaire was distributed during course hours, and written informed consent was obtained from all the subjects.
In accordance with the collected data, a posteriori analysis of the sample was performed based upon the findings gathered by the comparison of the two groups of students. Effect size was found 6.63 according to error probability (a = 0.05) and confidence interval (1-b = 0.95), and obtaining power reached 0.99. It was then decided to publish the research. The analysis was performed using G*Power 3.1.9.
The questionnaire had of three sections. The first section consisted of questions about nursing students\\\' socio-demographic characteristics. The second part comprised of three questions about the knowledge of abortion law in Turkey.
The third part included 12 statements and was developed from previous published studies.^10-12,17 The questionnaire was administered to 10 nursing students, and reviewed by five professors in nursing school to assess the comprehensibility and revised according to students\\\' and professors\\\' suggestions. In the study, the inter-item consistency value (Cronbach\\\'s alpha) was 0.784. A five-point Likert scale ranging from \\\'\\\'strongly agree\\\'\\\' to \\\'\\\'strongly disagree\\\'\\\' was used to assess responses. The items on the questionnaire included both positive and negative statements. The items 1,2,4,6,7 were coded as follows: 1= strongly agree, 2= agree, 3= neither agree nor disagree, 4= disagree and 5= strongly disagree. The items 3,5,8,9,10,11,12 were reversed coded (1= strongly disagree and 5= strongly agree) for statistical analyses. The students\\\' supportiveness about VIA was evaluated by total attitude scores and the total
score ranged from 12 to 60. Higher scores obtained from the questionnaire indicated positive attitudes towards abortion.
SPSS 15 was used to analyse the data. P<0.05 was considered statistically significant. The students\\\' characteristics were analysed descriptively by using frequency, percentage, mean and standard deviation. T test and one-way analysis of variance (ANOVA) were used to analyse the association between the students\\\' characteristics and the scores they obtained from the entire questionnaire and each item of the questionnaire.

Results

Of the 1,089 students, 520(47.8%) were from EUNF and 569(52.2%) were from CBUSH. Besides, 310(28.5%) were in the first year, and 261(24%) in the fourth year of education. In terms of age, 566(52%) students were under 20, with a mean age of 20.7±1.8 (range: 17-36) years. Overall, 866(79.5%) students were female; 908(83.4%) had a nuclear family; 505(46.4%) lived in a city before university; 729(66.9%) came from families having middle income level; and 108(9.9%) had had sexual experience (Table-1).



Overall, 456(41.9%) students gave the correct answer to the statement, \\\'\\\'The VIA is legal within the first 10 weeks in Turkey\\\'\\\', while 883(81.1%) and 898(82.5%) — correctly answered the statements, "Women cannot have VIA without the permission of her husband in Turkey\\\'\\\' and \\\'\\\'If the woman is under the age of 18 and unmarried, family have to give permission for VIA\\\'\\\'.
Besides, 92(8.4%) students strongly agreed that VIA should be banned in Turkey; 214(19.6%) 93(8.5%) strongly agreed and 121(11.1%) agreed that VIA should be legal for unmarried women in case of unwanted pregnancies. Also, 357 (32.8) respondents strongly disagreed that being married is necessary in order to have VIA; 315(28.9%) strongly agreed, and 414(38%) agreed that a married woman should get permission from her husband for VIA; 427(39.2%) supported VIA; 195(17.9%) strongly agreed, and 232(21.3%) agreed that VIA was the right decision — when a foetus was diagnosed as having an abnormality; and 44(4%) strongly agreed and 75(6.9%) agreed with the statement that rape-related
pregnancy should be terminated by VIA. The mean score obtained from the attitude towards VIA questionnaire was 39.8±7.9 (range: 17-58) (Table-2).



Bivariate analysis revealed that female nursing students, students in EUNF in the third or fourth year of education, and students who had sexual experiences had supportive attitudes towards VIA (p<0.05). Students whose family income level was high, obtained a significantly higher total score from the questionnaire (p<0.05). Those who lived in a village before university, who had extended family, and who had parents with low educational level obtained lower scores on the VIA questionnaire and had more negative attitude (p<0.05) (Table-3).





Discussion

The findings of this study are important because it was conducted with large-size samples in two universities of Turkey. The topic of the study is a very critical and important issue in terms of women\\\'s health. Health providers, especially nurses who come into direct contact with women having an unplanned pregnancy in abortion services, play an important role for women\\\'s reproductive health.
In the study, it was found that nursing students moderately support abortion. Similar findings reported with medical students.¹² Findings from different countries found that abortion on demand was supported by 10.5% of the students in Northern Ireland,1 78.2% in Norway,1 65.5% in Spain11 and 62% in the UK.¹³ Attitudes towards VIA can greatly vary from country to country. Moreover, political, religious, cultural and educational factors affect the attitudes towards abortion.
In the current study, 60.7% of the students indicated that VIA should be legal. The findings are parallel to those of the previous studies carried out in Spain and in South Africa.^11,12 In one study in Turkey, 52.1% of the students agreed that deliberate abortion was morally wrong.²¹
In that study, 56.5% of the students believed that being married is necessary to have VIA. In India, 20% of the medical students disagreed with that \\\'\\\'Abortion among unmarried women is acceptable in the case of an unplanned pregnancy\\\'\\\'.¹⁷ Pre-marital sexual relationships have been on the rise in Turkey, and women can face unplanned pregnancies. Students should realize
the importance of legal access to safe abortion care. It is important that students should consider women\\\' rights and decisions about their reproductive health when providing care for them. The number of induced abortions can be reduced through education, and nurses have an important role in giving information about contraception methods — especially to unmarried women.
In this study, the students supported abortion if a woman had a child with a mental disease or Down syndrome. In Turkey, a woman is allowed to undergo an abortion after the 10th gestational week if she has a foetus with Down syndrome. As can be seen in the present and earlier studies\\\' findings, foetus\\\' condition during pregnancy plays a very important role in making a decision of abortion on mother\\\'s request. According to the results of studies, 76.3% of the Norwegian and 10.7% of the Irish students thought that abortion should be allowed if a foetus had Down syndrome.¹ In South Africa, according to 65% of the medical students, abortion should be made legal if the foetus showed the signs of a serious congenital defect or malformation.¹² Moreover, in the UK, 15.8% of the medical students stated that they would not perform abortion for congenital anomalies before the 24th week of pregnancy.¹⁴
In this study, one out of ten students stated that a married woman should not get permission from her husband for VIA. The finding was in contrast to those of studies from Spain, South Africa and Sweden in which the decision to end pregnancy is the responsibility of women.^11,12,19
Most of the Swedish and Italian nursing students believed that women and men together should make a decision for abortion.²⁰ In India, one fourth of the medical students agreed with the statement that \\\'\\\'A woman needs to have her partner\\\'s or spouse\\\'s approval to have an abortion.¹⁷ In our study, a small group of students agreed that a woman did not need her husband\\\'s approval for the decision of abortion, which may be due to the laws in Turkey giving a right to the husband to be involved in the decision of abortion.
Majority of the students in the present study believed that undergoing VIA was a sin for a woman. This is probably due to the fact that the majority of the nursing students were Muslim, and codes of Islam prohibit performing abortion for non-medical reasons. In the literature, it was stated that religious beliefs is the most important factor leading to the development of negative attitudes toward
abortion.^1,10 Previous studies suggested that general practitioners of Christianity were more pro-life than were non-religious people.²³In the UK, medical students who hold a religious belief were more pro-life than were non-religious students.< sup>13 Many women can face an unplanned pregnancy and VIA, and nurses should be able to set aside their own moral belief or attitudes while giving care to women, especially when they undergo VIA.¹¹
In the current study, the students living in extended families and students with lower family income levels had a negative attitude towards VIA. The differences between the attitudes of different families are probably related to family culture in Turkey.
Having sexual experience was another factor which appeared to affect the students\\\' attitudes towards VIA. The students who had experienced sexual intercourse made a more supportive approach towards VIA. This is probably because the students, who had sexual experience previously, may have had an unintended pregnancy, which may have affected their attitudes towards abortions positively. The findings are consistent with a study in South Africa.¹² A study on medical students in USA pointed out that education intervention is essential to develop positive attitudes towards VIA.¹⁵ The present study had some limitations. First, findings are not generalisable to all nursing students in Turkey. Second, the participants were not asked about what their religion was because in Turkey many students are Muslim. Last, in Turkey there was not a validated scale about attitudes towards abortion and we tried to develop a questionnaire appropriate to Turkish culture.

Conclusion

Clinical practices and courses during nursing education should include topics like ethics and abortion care to ensure that nurses and all other healthcare providers
were more tolerant towards and respectful of people\\\'s abortion-related decisions. Displaying supportive and non-judgmental attitudes are very important while health professionals provide care for women.

Disclaimer: The study was presented as Oral Presentation at the 4th World Conference on Health Sciences, April 28-30, 2017, Antalya, Turkey.
Conflict of Interest: None.
Source of Funding: None.

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