Physician Perceptions on the Prevalence of Illegal Abortions in

Background: Unsafe abortions are performed in countries where abortions are illegal. Preventing unsafe abortions is one of the easiest ways to improve women’s health. Gaining an understanding of the perceptions of physicians to illegal abortions can be used to recommend policy changes that can positively impact on women’s health. Objectives: To determine Grenadian physicians’ perceptions on the prevalence of illegal abortions in Grenada, determine which complications from unsafe abortions are perceived to most negatively impact on Grenadian women’s health, and determine what measures can be taken to prevent unsafe abortions from taking place. Methods: Using an online survey questionnaire, physician perceptions on the prevalence of illegal abortions in Grenada were ascertained as well as determine what they thought were the impacts such unsafe abortions were having on women’s health. Results: Out of 75 physicians registered and licensed to practice medicine in Grenada, 44 (59%) consented to take the online survey. Of these 44 participating physicians, 91% stated that they believed illegal abortions were taking place in Grenada with 66% reporting that they personally knew of illegal abortions cases. Bleeding, infection, and uterine perforation were identified as the three main complications arising from botched abortion procedures. The top three solutions proposed by physicians to curtail illegal abortions in Grenada were health education (91%), encouraging the use of modern contraceptives (77%), and the provision of legalized abortion services (52%). Conclusions: Implementation of sexual health education program to both the general public and kids in high school would garner the greatest support from Grenadian physicians as a potential solution to reducing the high prevalence of illegal abortions allegedly taking place in Grenada.


Introduction
Healthcare professionals' views on abortion vary based on their cultural background and abortion laws of the country in which they practice.Currently, in Grenada the law prohibits abortions unless the mother's life is in danger.As a result of this legal restriction, illegal and unsafe abortions take place throughout the country.
The World Health Organization (WHO) has identified unsafe abortions as a major cause of maternal mortality that can be very easily preventable [1].In 2008, 13% of maternal deaths in the world were attributed to unsafe abortions [2].Unsafe abortions lead to many complications such as hemorrhages, sepsis, and in extreme cases, death [3].Medical methods of inducing abortion, specifically, the combination of mifepristone and misoprostol, are considered to be safer than non-regulated methods, and women prefer these medical methods of abortion [4].
Studies have shown that women prefer abortions in controlled medical setting where they have access to nursing and medical staff in the event of complications [4].Women who have unsafe abortions and need hospital care may need blood products, operating theaters, anesthesia and surgical specialists to treat the problem [1].In order to solve this problem, it is essential to understand the context in which illegal abortions occur in order to understand how to prevent the problems that arise when such procedures are performed without access to appropriate medical care [5].It is particularly important to clearly understand the perceptions healthcare professionals have on this issue, which can have significant public health connotations.
One important step towards improving the health of women within a country where illegal abortions takes place would be to first evaluate how healthcare professional themselves feels about whether legalizing abortion services will be beneficial for women's health.In Ethiopia, abortion was legalized in 2006 with the majority of Ethiopian healthcare providers reporting that they were aware that unsafe abortions caused significant complications for the woman's health [6].In Nepal, after abortion was legalized in 2002, many Nepalese health professionals reported feeling positive about the legalization of this medical procedure [7].Further, a majority of the Nepalese healthcare providers interviewed saw a decline in maternal morbidity and post abortion complications following legalization and noted that now that abortion was women were seeking assistance sooner when they experienced abortion-related complications [7].
Given the prevailing conservative societal views in Nepal, efforts were directed at making policy makers and healthcare professional aware of the implications of continuing to keep abortion illegal [8].Even though legalizing abortion helped improve women's health, Nepal had to deal with the issue of sex selective abortions, a procedure that is illegal in the country [9].Nepalese women who undergo gender selective abortions will often turn to other venues to obtain such illegal abortions and thus can develop complications as a result [9].
In 2007, Mexico legalized abortion despite fears that women would abuse this service [10].A Mexican study found that religious beliefs impacted Mexican health professional's views on the legalization of abortion but not on the willingness of the professional to perform the procedure [11].In Trinidad and Tobago, abortion laws that were written in the 19 th century explicitly ban abortion for any reason [12].In 2006, however, the Ministry of Health in Trinidad and Tobago updated the law to make provisions for abortions if there was a direct threat to the life of the mother.A similar provision has also been incorporated into the Grenadian abortion laws [12].
Perceptions amongst the general population on whether to legalized abortion procedures vary with some being in favor of legalizing all types of abortions while others being in favor of legalizing abortions only under certain circumstances [12].While some of the biggest resistance to the legalization of abortion, especially in countries like Trinidad and Tobago, has reportedly come from religious entities such as the Roman Catholic Church, most self-confessed religious individuals do support legalizing abortion [12].
In India, where abortion has been legal for decades, cultural factors continue to hinder Indian women from accessing safe abortion services and as a result high maternal mortality rates are still being observed [13].Further, attitudes on abortion from medical interns indicate a negative view but these views can be changed through clinical trainings [13].
Prior to this study, there was no information on how Grenadian healthcare providers, and in particular, physicians, feel about abortion and whether they believe legalizing this medical procedure would be beneficial to women.The goal of this study was thus to obtain information on Grenadian physician perceptions and opinions of abortion.The study had three key objectives: (1) To determine Grenadian physicians' perceptions on the prevalence of illegal abortions in Grenada; (2) determine their perceptions on which complications that arise from unsafe abortions most negatively impact Grenadian women's health, and (3) determine what measures Grenadian physicians recommend be taken to prevent unsafe abortions from taking place.

Participant recruitment
The target population for this survey study was all current members in good standing of the Grenada Medical Association (GMA) as of 2014.Following Institutional Review Board (IRB) ethics approval, the GMA was contacted and their support solicited to encourage their members to participate in this survey.The survey was made available online and the link sent to all GMA members using their GMA listed email.After two weeks, a reminder email was sent to all physicians who had not yet completed the survey encouraging them to participate.The survey was kept open for four weeks and then closed.

Survey design
The survey questionnaire used in this study was adapted and modified from a study done by [6] to include elements specific to the Grenadian healthcare context.The questionnaire had four parts: physician socio-demographic information, perceptions on abortion, assessment of risks from unsafe abortions, and suggestions for measures on how to prevent illegal and hence unsafe abortions.

Statistical analysis
The data which was originally collected using the online program Survey Monkey, was first exported to Microsoft Excel and then analyzed using the SPSS statistical software program.Descriptive statistics on the following demographic variables were computed: age, marital status, religion, religious beliefs influencing abortion, length of professional career, and primary work place.Descriptive statistics were also calculated for the following: reported prevalence of the occurrence of unsafe abortions, the types of complications thought to arise from such unsafe abortion, solutions to prevent unsafe abortions, motivations of women who seek an abortion, physician views on community acceptability for abortion services to be provided locally, and whether abortion should be legalized.Additionally, logistic regression was used to evaluate whether the physician's religious status affected his or her opinion on whether abortion should be legalized and the social acceptability knew of cases where illegal abortions had taken place in Grenada.
Infection (91%), bleeding (89%), and uterine perforation (86%) were identified as the three most common complications physicians thought arose out of performing such illegal abortions.Twenty-nine (66%) physicians specifically reported that they believe that complications from illegal abortions cause maternal deaths in Grenada.

Opinions on why women seek illegal abortions
The 44 participating physician identified economic constraints (77%), partner pressure (64%), too many children (52%), and school constraints (48%) as the top four main reasons why they thought women sought abortions in Grenada.

Opinions on how to prevent illegal abortions
The top three solutions proposed by physicians to curtail illegal abortions in Grenada were health education (91%), encouraging the use of modern contraceptives (77%), and the creation of legalized abortion services (52%).

Attitudes on abortion services
When asked if they would feel comfortable working in a healthcare facility where abortions were performed, 18 (41%) physicians indicated that they would feel comfortable doing so, 14 (32%) indicated that they would not, and 10 (27%) were undecided.Of the 24 physicians who stated that they would not feel comfortable or were undecided, the top three reasons given were (1) 'It would violate my conscience' (77%), (2) 'It would violate my religious beliefs on abortion' (50%), and (3) it was 'Against personal values' (46%).
Physicians were also asked if they thought performing abortions would cause them to be ostracized by the local community.Only 7 (16%) said 'Yes', whereas 20 (45%) physicians said 'No', with the remaining 17 (39%) stating that they didn't know or were not sure.
Physicians were further asked if abortion was legalized in Grenada it would then be socially acceptable to the Grenadian community to establish an abortion clinic.Only 11 (25%) thought that such would be accepted, with 19 (43%) thinking such a clinic would not be acceptable and 14 (32%) stating that they were not sure.Of the 11 physicians who stated that they felt it would be acceptable to the Grenadian community to open an abortion clinic, only 2 (18%) said that they themselves would be comfortable opening an abortion clinic and providing such a service to the local population.Of the 19 physicians who stated that they felt it would not be acceptable to the Grenadian community to open an abortion clinic, 16 (84%) were not opposed to all abortions.The top three reasons these physicians reported where an abortion would be socially acceptable were of setting up abortion clinics in Grenada if abortion was legalized.In the logistic regressions, the opinions for abortion, motivations for having an abortion, offering of abortion services and other solutions for preventing unsafe abortion are used as dependent variables.Religion, length of career and complications arising from abortions were used as independent variables.Cross-tabulation analysis was also done between the opinions of legalizations and the top three recommended solutions to prevent illegal abortions.

Demographics
Of the 75 physicians registered and licensed to practice medicine in Grenada with the GMA, 46 (61%) responded to the email invitation to take this survey.Of these 46 respondents, 44 (59%) consented to take the survey.Descriptive demographic data on those who took the survey is provided in Table 1.The majority of participating physicians was at least 35-year-olds (77%), married (64%), and professed to belong to a particular religion (86%).

Perceptions on prevalence of abortions
For the 44 participating physicians, 40 (91%) stated that they believed illegal abortions were taking place in Grenada.Further, 29 (66%) stated that they personally Bleeding, infections, and uterine perforation were identified by Grenadian physicians as the three main complications arising out of illegally performed abortions.Death, however, was not listed in the top five complications, possibly indicating that illegal abortions may not be a major determinant of maternal deaths in Grenada.Local physicians indicated that the prime motivations for women to seek an abortion in Grenada were economic constraints, partner's pressure, and already having too many children.Partner pressure and too many children create pressures within the home environment, a key factor that has been shown in other studies to have an adverse effect on a woman's health.

Limitations of study
Of those physicians who are registered and licensed to practice medicine in Grenada, only 46 (61%) participated in this cross-sectional survey.Given the topic of this study being a very sensitive one, it is possible that several physicians might have had concerns regarding the anonymity of their responses.Of the two physicians who responded to the email invitation to take the survey but ultimately did not consent to do so, one reason offered was that they did not feel comfortable having their views on this issue documented in spite of assurances that their responses would be kept confidential.Several other physicians who did not respond to the email invitation to participate in this survey shared in personal communications with one of the researchers of this study that in a small island country such as Grenada, which has a population of approximately 105,000, they felt that while anonymity was promised, it could not be guaranteed.Given that there are less than 100 registered physicians on the island, there is a genuine fear among Grenadian physicians that they will suffer either strong peer pressure or a backlash from the medical community if their views on such a sensitive topic were to be revealed.If more time was available to conduct this survey, an alternative approach that could have been implemented would have been to send out anonymous surveys via regular mail that included a return addressed envelope to send back their responses.Alternatively, data could have been collected from hard copies of the survey given to all GMA physicians at one of their monthly meeting.It is still quite likely, however, even if such alternative data collection approaches were used that some physicians would still have felt uncomfortable and uncertain that the documenting their views could not eventually be linked back to them.

Conclusions
Based on an evaluation of physician reports collected in this study, it is clear that unsafe abortions are being performed in Grenada.As for what potential strategies exists to tackle this problem, these physicians recommended improved health education, the use of modern contraception, and the use of legalized and regulated abortion services as their top three solutions.cases of ectopic pregnancy (84%), rape (84%), and sexual abuse (74%).

Attitudes on legalization of abortion services
Of the 44 physicians who participated in this study, while 19 (43%) stated that abortion should be made legal in Grenada, 10 (23%) said 'No', with 15 (34%) presently undecided.

Analyzes of physician's religious status and opinion on abortion legalization and acceptability of abortion clinics
Nineteen (43%) and 11 (26%) physicians reported that their religious beliefs influence their views on abortion 'Somewhat' or 'A lot' respectively.Only 8 (18%) physicians indicated that their religious beliefs had no effect on their view of abortion.
No statistically significant relationship was found between a physician's religious identification and their opinion on abortion legalization (p = 0.901).Further, no statistical significance was found between a physician's religion and their views on whether they thought opening an abortion clinic would be socially acceptable in Grenada (p = 0.444).

Discussion
This study expands the current literature regarding abortion perceptions among physicians, especially those who practice in the Caribbean.The findings clearly indicate physician approval for the use of sexual health education programs as a prime tool to help improve the status of women's health.Other studies have shown that sexual health education programs implemented in schools can promote healthy sexual behaviors, such as use of contraceptives, increase condom usage, and reduce the incidence of unprotected sex [14].In the Bahamas, a school-based intervention for sixth grade students who were experiencing high rates of teenage pregnancy and HIV, called Focus on Youths in the Caribbean, was found to significantly improve knowledge, condom-use skills, perceptions and intentions regarding condoms, and condom use behaviors [15].The Focus on Youths in the Caribbean initiative also included a parental component.Such schoolbased interventions on sexual health can be an effective strategy employed to reduce the number of unsafe abortions.
In countries where abortions are illegal performed, these procedures have been found to be invariably unsafe and the cause of major medical complications that adversely impact on the state of women's health, as well as place an increased burden on already limited healthcare resources.In Ethiopia, studies on the perception of healthcare providers found that they recognized that unsafe abortions were a major risk to a woman's health [6].Following the legalization of abortion in Nepal, Nepalese doctors saw a decline in not only post abortion complications but also maternal morbidity [7].

Implications for Practice and/or Policy
The findings from this study indicates that Grenadian physicians, irrespective of their views on whether abortion should be legalizing or not, overwhelming support the use of sexual health education programs as a key tool to help reduce the reported high prevalence of illegal abortions taking place on the island.A schoolbased curriculum that clearly incorporates sexual health education would most likely receive the strong support of the medical community and general public at large.School-based sexual health education programs can reduce the increased pressure complications from illegal abortions place on the public health system, allowing for scarce resources to be allocated to other pressing public health problems.Finally, these findings can be used to help advice those entrusted with developing policies to formulate policies and programs that better address and promote that wellbeing and health of women living in this country.

Table 1 :
Demographic data for Grenadian physicians.