FACTORS DETERMINING ON-DEMAND ABORTION DECISION-MAKING IN WOMEN

Introduction. Abortion causes problems in reproductive health, relationships in a couple, psychological and social consequences. A woman's decision to have an abortion depends on many factors, whereas in low-income countries, abortion is viewed as a method of family planning. 
Material and methods. A descriptive, quantitative and qualitative sample study was conducted in the Republic of Moldova from December 2021 to February 2022 to identify and evaluate the factors influencing a woman’s decision-making to terminate a pregnancy, as well as to develop recommendations for reducing the number of abortions on demand. The quantitative assessment included a survey carried out on a sample of 399 women who underwent abortions on demand. The qualitative study involved three focus group meetings, where the obstetrician-gynecologists shared their ideas upon the factors determining a woman's decision to terminate a pregnancy. 
Results. Analyzing the data obtained, the present research identified the following factors that determined the decision-making of women to terminate a pregnancy: (i) lack of support and disturbed psycho-emotional state in  women; (ii) social and economic problems, particularly, poverty; (iii) study/career-related conditions; (iv) age; e) difficult relationship with  the partner, particularly, domestic violence; (v) fear of COVID-19 infection. 
Conclusions. Women's reasons for seeking abortions are complex, traced out by circumstantial and systemic realities. 
 


INTRODUCTION
Despite the controversial views regarding abortion, which have become stronger in the modern era, it is increasingly promoted as the women's right to decide upon their sexual and reproductive health, being a fundamental pillar of gender equality that cannot be diminished or violated (1). At the same time, the number of on-demand abortions worldwide is by no means negligible.
Research by the Guttmacher Institute shows that there are about 73 million abortions worldwide each year, of which about 88% occur in developing countries (2).
One of the commonly stated reasons for abortion is an unplanned pregnancy. For example, studies estimate that of the 121 million unplanned pregnancies reported worldwide between 2015 and 2019, about 61% result in abortion (2). However, there are several steps involved in assessing an unplanned pregnancy prior to undergoing abortion and, in fact, a complex of factors that should determine the decision-making (3). Many women with unplanned pregnancies do not think of abortion. Some of them will adjust to the new pregnancy situation and to the new circumstances. Others may initially want to interrupt pregnancy, but change their mind, either because they were initially hesitant and then changed their mind for their own reasons, or under the influence/insistence of other people (family, friends, etc.).
Several international studies show that the reasons that drive women to have an abortion are often more complex than simply not wanting to have children. Among these reasons, social and economic problems are often stated, such as interruption of education or employment, lack of support from the partner, the desire to provide schooling for already existing children, and poverty, unemployment or financial inability to support and educate a child (3). Relationship problems with the partner (4) and the woman's perception that she is too young to become a mother have also been mentioned (5).
Unfortunately, in the Republic of Moldova, abortion is one of the frequently requested methods of birth control. In 2019, there were 33 abortions per 100 live births (6). Experts note that official data do not disclose the total number of abortions, some of which are carried out at home. About 7,000 on-demand abortions are performed annually across the country (7,041 abortions were carried out in 2019). The number of late pregnancy terminations (before 21 weeks of gestation) performed for medical or social reasons remains high (105 in 2019) (7, 8).
The purpose of this study was to identify and assess the determinant factors influencing women's decision-making to terminate a pregnancy, with the aim of developing recommendations to reduce the number of on-demand abortions in the Republic of Moldova.

MATERIAL AND METHODS
To achieve this goal, a selective descriptive, quantitative and qualitative study was conducted. Several methods were used to collect and process the obtained data, systematize the facts and present them as scientific categories and trends to confirm or refute the hypotheses stated. The historical, sociological, comparative and biostatistical methods were applied within this research. The quantitative study involved 399 pregnant women up to 12 weeks of age, who were interviewed on their decision to follow an abortion within the advisory departments of specialized medical institutions of Cahul, Chisinau and Balti municipalities. The sample size was calculated based on the number of on-demand abortions up to 12 weeks in 2020, which is 4987 cases (N is the size of the general population: women who applied for an abortion up to 12 weeks).
The study included only those women who expressed a desire and voluntary consent to complete the printed questionnaires distributed within the Perinatal Centers of the Republic of Moldova authorized to perform abortions. 450 questionnaires were distributed to a sample of 392 respondents. 450 questionnaires were collected, of which 399 were validated. The questionnaires were used within the Level III Perinatal Center: IMPH Institute of Mother and Child and within three Level II Perinatal Centers, namely, George Paladi Municipal Clinical Hospital, Balti Perinatology Center, and Cahul Perinatology Center. The questionnaires were developed by the authors of the study on the basis of the relevant international researches and were tested to define the questions on a small group of respondents, as well as considering the scientific requirements and objectives of the study. The questionnaire consists of 32 questions with main-2020 ly closed answers, divided into 4 compartments, viz. (i) Socio-demographic data; (ii) Decisionmaking factors; (iii) Consequences of abortion; (iv) Contraception. Data was collected between December 2021 and February 2022.
The qualitative study included the opinions of obstetrician-gynecologists regarding their own experience and cases from practice, which give ideas about the determining decision-making factors in women who requested abortion. There were 3 focus group (FG) sessions (each 8-12 participants). The study selected doctors providing safe abortion services who expressed their willingness to participate in discussions. The focus group guide focused on several key topics, including questions on factors that determine a woman's decision to terminate a pregnancy; the role of the partner in decision-making; the doctor's role in a woman's decision to have an abortion, women's perceptions or knowledge about the consequences of abortion and contraception, etc. The major purpose of the subsequent analysis was focused mainly not on the respondents, but rather on understanding their attitudes or gaps found. Besides the questions prepared in advance that were included in the interview grid, the interviewees were also encouraged to speak up openly in order to clarify some specific aspects. Study participants were guaranteed complete confidentiality. Incomplete questionnaires were not included in the study.
The obtained data were stored, processed and analyzed using Microsoft Excel and SPSS programs.
The study collected a range of socio-demographic data on the quantitative study sample, such as age, place of residence, occupational status and family composition, etc. Thus, the study involved women aged 20 to 29 years (41.8%); women 30-40 years old (38.8%); women aged 16-19 (10.2%); and women over 41 (9.2%). More than 2/3 of the participants indicated urban environment as place of residence. Regarding the occupational status, most women under study (68.8%) were employed; 12.2% -on parental leave; 13.0% -female students; about 6% were unemployed. In terms of education, 39.8% of participants had higher education; 39.0% -vocational secondary education, high school education -11.4%; postgraduate studies -5.8%; secondary education -4.0%. The proportion of married women was 64.2%; living together -16.2%; sin-gle -12.3%; those whose marriage ended in divorce or spouse death -7.3%. The proportion of primigravidas who requested an abortion was 19.3%; about 36.6% already have a child, every third (33.6%) have 2 children, and 10.5% of them have 3 or more children.
Women's attitudes towards abortion. The study found that women from the Republic of Moldova have different perceptions regarding abortion. About 35% of women who applied for abortion fully or partially claimed that every child conceived has the right to be born, about 17.8% agree that a pregnant woman is obliged to give birth, and about 37% consider abortion a crime. Every fourth woman included in the study (24.3%) admitted that it was very difficult for her to decide on an abortion, and the majority of respondents (70.9%) indicated that it was difficult for them to make such a decision. Only a few women (4.8%) admitted that their decision was an easy one. Thus, many women's perception of abortion continues to have a negative connotation that is not accepted but requested for certain reasons.
One of the priority factors influencing the abortion decision-making, mentioned in numerous international studies, is the socioeconomic status of a woman. This reason seems to be true for women from the Republic of Moldova. Thus, even if about 2/3 of women are employed, almost every third woman surveyed (34.3%) indicated poverty and material difficulties in raising a child; and more than a third (37.3%) indicated housing shortage. A large number of women interviewed mentioned as determining factors, the impossibility of leaving the job (44.6%) and the concern that the pregnancy/child will affect their career (40.1%); 9.3% of women stated the impossibility of maintaining pregnancy due to emigration planning ( fig. 1).
Moreover, economic problems and poverty were assessed as a priority in a woman's decision to terminate a pregnancy among the focus group. However, other opinions were also mentioned during the discussions. Some physicians argue that a woman's economic profile is irrelevant, and the same determining factors cannot be assessed in the same way. "You can't say that only poor women or only rich women request abortions! It's something completely different!" (FG 3).
Age has also been found as a factor influencing the decision-making on abortion in about 10.3% of the women who participated in the study, particu-larly in 16-19 age group or in women over 41 years old ( fig. 1). Of the arguments given, the young women stated: "I'm too young", "I'm not married", "I should continue my studies". Whereas in over 41 age group "the fear of giving birth to a disabled child" and "I have already few born children" were mentioned. In this context, it is worth mentioning the opinions of gynaecologists from the focus groups, who believe that most women over 41 years old do not dare to give birth due to fear of being stigmatized. "In our society, stereotypes and prejudices are very strong, which make women over 41 feel ashamed to give birth ... they are afraid of what the world will say" (FG 2). Another assessed factor was the involvement of the partner in the decision to terminate the pregnancy. According to the data, every fourth woman (25.3%) preferred not to tell her partner about her pregnancy. At the same time, in 1.5% of cases the partner had no opinion, leaving the decision to the woman. This is probably due to cultural peculiarity, whereby some men believe that childbearing is entirely the responsibility of the woman.
At the same time, a significant number of women (44.6%) admitted that their partner insisted on an abortion. However, 18.8% of women indicated that their partner insisted on maintaining the pregnancy and was against abortion; nevertheless, they decided to terminate it. In 9.8% cases the death of a partner was recorded. Probably, a psychological counseling would be useful in such cases.
One of the reasons claimed by women in decisionmaking was domestic partner violence, which was reported in 6% of cases. Women who apply for abortion after being raped is also an alarming factor: the study revealed 4 such cases (1.0%). It should be noted that about 2/3 of women (68.0%) stated that it was an unwanted pregnancy, and among the reasons given (12.0%) was that it came from a wrong man. At the same time, about 1/3 of women indicated that this was a desired pregnancy. Among the factors that influenced the change in the woman's decision were the partner' death, separation, and financial changes.
Physicians who participated in the focus group discussions often emphasized the important role of the partner in a woman's decision to terminate a pregnancy. Some of the relevant opinions stated were as follows: "The role of the partner should not be underestimated! It often makes a big difference!" (FG 2); "The reason for an abortion is often a difficult relationship with a partner -family fights, infidelity, divorce, and violence. Thus, a woman decides to have an abortion even in cases where the pregnancy was initially desired! (FG1); "If there were love and understanding, a woman would not have an abortion, even if she lives in poor conditions" (FG 3).
The study shows that the decision to have an abortion was also significantly influenced by a number of other society actors, even though there is a high percentage of women who made this decision on their own (65.2%), without any support from the others. Thus, every third respondent claimed that different people influenced their decision: parents (13.8%), friends (6.5%), and in unique cases -by the doctor or the village priest. 2020 A factor that may contribute to unwanted pregnancies (which were reported in ⅔ of cases under the study) and, consequently, to requests for abortion, is the availability of contraceptive methods. When being asked to rate the affordability and geographic accessibility of contraceptives, the majority of respondents (60.7%) stated the fact that, in most cases, contraceptives are available whenever they need them; at the same time, every 5th woman indicated that she could afford to buy contraceptives to a lesser extent; and more than 1/3 of women reported that they can only sometimes buy contraceptives. There was also a lack of access to information in more than 80% of women, who admitted that they would like to know more about contraceptive methods. It was an interesting fact found, showing that more than half of the respondents had previously had abortions, of which about 39% women had a second abortion, for 10% that was their third abortion, and 12 women (3%) indicated that they already had had more than 3 abortions before.
Among the reasons influencing the decision to have an abortion were the fears for the health of the unborn child; consumption of harmful substances (alcohol, smoking) was found in 21 women (5.3%); using teratogenic drugs -44 women (11.0%). One of the aggravating circumstances was the period of the COVID-19 pandemic. Every third woman (34.8%) indicated the fear of the COVID-19 infection as one of the factors that prompted them to have an abortion, and 18.3% of those surveyed indicated that they had had SARS-Cov-2 infection during pregnancy ( fig. 2).
During focus group discussions, doctors confirmed that the number of unplanned pregnancies increased during the pandemic.

DISCUSSONS
The data analysis revealed the fact that married women (64.4%), employed women (70.0%), living in urban areas (78%), those aged 20-40 years old (80.8%), those who have a professional or higher education (80.0%) and who have already given birth to children (79.6%) are among the women who decide to terminate a pregnancy. Among the factors that determined the women from the Republic of Moldova to terminate a pregnancy are the following: (i) lack of support; (ii) socio-economic problems, particularly, poverty; (iii) study/career-related issues; (iv) age; (v) difficult relationship with a partner, particularly, domestic violence; (vi) fear of contracting COVID-19; (vii) substance use (alcohol, tobacco). The partner plays an important role in a woman's de cision to have an abortion. Even if the proportion of married women prevails (64.4%), about 44% of respondents did not tell their partner about it. However, in 44.6% of cases, the partner insisted upon having abortion. Based on the fact that ⅔ of the respondents reported that the pregnancy was unwanted, whereas some women had already had three abortions before, we concluded that abortion is mostly perceived as a method of family planning by a significant part of the population. According to the 2018-2022 National Program for Health and Sexual and Reproductive Rights of the Republic of Moldova, Article 20, the state together with the National Health Insurance Company covers 80% of the contraceptive costs for population groups as low-income people, adolescents, HIV-infected people, sexual assault victims (8). A previous study with comparable objectives and results, conducted at the district level (Cahul district) on a sample of 950 women revealed that common factors that lead women to seek abortion on demand are as follows: socioeconomic status (26%), status of a modern woman (22%), marital status (single/divorced) 19%, unstable relationship with a partner (15%), no desire to have more children 12%) or having already small children in the family (6%). At the same time, it was found that most 19-30 aged women seek for abortion, particularly the married ones (59%).
The rate of rural women under the study was higher (63%), and only 50% of respondents had higher education and specialized secondary education. Most of the interviewed women think that abortion is an acceptable way to avoid unwanted childbirth, despite the fact that it may threaten their health. Nevertheless, the World Health Organization (WHO) promotes women's universal access to abortion through quality services and without stigmatization, carried out in accordance with the international standards.

CONCLUSIONS
1. The woman's decision to interrupt a pregnancy is commonly a complex process, combining several factors. Thus, preventive actions should cover several areas, such as education and information, psychological support, financial support, fighting stereotypes and prejudices, access to sexual and reproductive health services, etc.
2. According to the data presented, the partner 'decision, the fear of SARS-CoV-2 infection and the use of teratogenic drugs are paramount in abortion decision-making process.