Original Study Induced Abortion According to Socioeconomic Status in Chile Andrea Huneeus MD, MPH 1, Daniela Capella MD 2,*,Baltica Cabieses PhD 3, Gabriel Cavada PhD 4 1 Department of Obstetrics and Gynecology, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile 2 Department of Obstetrics and Gynecology, East Campus, Faculty of Medicine, Universidad de Chile, Santiago, Chile 3 Instituto de Ciencias e Innovacion en Medicina (ICIM), Facultad de Clínica Alemana, Universidad del Desarrollo, Santiago, Chile 4 Department of Statistics, Clínica Alemana de Santiago, Santiago, Chile abstract Study Objective: The Chilean legislation forbids induced abortion, so little is known of the young women who have abortions and what determinants are associated with this practice. In this study we examined the association between adolescents and young women who have had induced abortions and socioeconomic status and compared them with counterparts who reported not having a history of abortion. Design, Setting, Participants, and Main Outcome Measures: Drawing on the 2015 Chilean National Youth Survey, a population-based sample of general community youth aged 15-29 years, we conducted a study on 2439 sexually active females. Bivariate and multiple logistic regression was used to examine the relationship between participants who had induced abortions and participants that had not according to socioeconomic status (low, middle, high), while controlling for demographic, sexual behavior, and cultural covariates. Results: 5.15% (n 5 129) of participants declared having induced an abortion in the past. Participants with high socioeconomic status had 4.89 (95% confidence interval, 1.44-16.51) higher odds of induced abortion compared with participants with low socioeconomic status. Those with middle socioeconomic status had 1.8 (95% confidence interval, 1.02-3.24) higher odds of induced abortion compared with those with low socioeconomic status. Urban or rural residence, indigenous identification, age of sexual debut, con- traceptive use at the time of sexual debut, adolescent pregnancy, and religious and political identification did not correlate with induced abortion rates. Conclusion: In Chile, where induced abortion is legally restricted, a social gradient was found in the chance of having had an induced abortion according to socioeconomic status; adolescent and young women with higher socioeconomic advantage reported more induced abortions compared with those with low socioeconomic status. Key Words: Induced abortion, Youth, Adolescent, Socioeconomic status, Unwanted pregnancy Introduction allowed the termination of pregnancies for therapeutic purposes. However, in 1989, the military dictatorship Induced abortion is the termination of pregnancy after enabled legislation, which forbade any type of abortion. implantation and before the fetus has become indepen- This act made Chile one of few countries where abortion 1 dently viable. One in 4 pregnancies end in an induced was penalized under all circumstances.5,6 Thanks to the abortion worldwide, and yet for 700 million women, rep- advocacy of organized social and political movements, and resenting 41% of women in reproductive age, restrictive after 28 years, in 2017 therapeutic abortion was decrimi- abortion laws in their countries pose multiple barriers for nalized on 3 grounds: vital risk to the mother's life, fatal 2,3 effective and safe access. Adolescent and young women fetal anomalies, and rape of the mother leading to preg- are at risk of unintended pregnancy and abortion because nancy (the so-called “exceptional circumstances”). they often face barriers in access to contraception because A number of elements at different levels have been of limited sexuality education, limited access to health described to influence the decision of having an abortion. At services, and social norms surrounding adolescent sexual the individual level, the decision might be influenced by 4 activity. Evidence suggests that legal restrictions on abor- age, parity, partner support, being a victim of sexual abuse, tion do not result in fewer abortions. Instead they compel socioeconomic status (SES), and educational background. At women to risk their lives and health by seeking out unsafe the interpersonal and social norms level, it is influenced by 3 abortion care. parental, social support, religion, and culture. At the orga- In Latin America, induced abortion on demand is crimi- nizational level, it might be influenced by type of health nalized in every country except for Cuba, French Guyana, care, and abortion laws, as well as cultural beliefs and 3 and Uruguay. In Chile, since 1931, the health code had practices.7 Because the Chilean legislation forbids induced abortion, The authors indicate no conflicts of interest. other than under 3 exceptional circumstances, there is a * Address correspondence to: Daniela Capella, MD, Departamento de Obstetricia y lack of information about who are the women who undergo Ginecología, Campus Oriente, Facultad de Medicina, Universidad de Chile, Cabo induced abortions and which of the multilevel factors are Segundo Julio Pavez Ortiz 5671, Penalol~ en, Santiago, Chile; Phone: þ56999184932 E-mail address: [email protected] (D. Capella). associated with decision-making around abortion. 1083-3188/$ - see front matter Ó 2020 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. https://doi.org/10.1016/j.jpag.2020.03.003 2 A. Huneeus et al. / J Pediatr Adolesc Gynecol xxx (2020) 1e6 SES is a well described determinant of effective access to the highest level of educational attainment and the type of health services. People from high SES have better access to employment of the main provider of the household, as well quality health services, lower environmental exposures, as the total family income. This classification divides Chil- healthier individual behaviors, fewer health problems, and ean SES in 5 groups; A, B, and C1 that correspond to high longer life.8,9 The relationship between SES and abortion SES, C2 and C3 that correspond to middle SES, and D and E access in young women in a context of restrictive laws has that correspond to low SES. Control variables were de- not been previously explored in Chile. mographic, health care provision, sexual behavior, and The Chilean National Youth Survey (CNYS) done in cultural characteristics. The demographic characteristics 201510 was the first population-based survey that included examined were age, urban/rural residence, immigrant sta- a question about induced abortion in a confidential manner tus (yes/no), having an indigenous status (yes/no), and type to its responders. Drawing on this survey, the objective of of schooling. Chile has 3 types of schools; free public schools this study was to characterize the adolescent and young that serve mostly the poor and lower middle class, charter Chilean women who have had induced abortions and schools that are privately run and share limited financing compare them with their counterparts who reported not with families and serve middle and upper middle class having a history of abortion according to SES, crude as well students, and private schools that charge high tuition. as adjusted by a number of potentially significant cova- Health care provision was either private or public. The riates. Establishing a baseline for abortion prevalence and sexual behavior characteristics analyzed were age at the factors determining its use according to SES before the time of sexual debut, contraceptive use at the time of sexual relaxation of these laws in 2017 could be useful for future debut, and adolescent pregnancy. Cultural variables refer to public health monitoring in Chile. Also, from an exploratory religious identification (Christian, non-Christian, or none), perspective, it could inform other Latin American countries political identification (right, central, left, or none), and with similar sociopolitical contexts on additional de- personal opinion about abortion. That is, whether induced terminants of induced abortion in adolescents and young abortion should be available on demand, only when the life women. of the women is at risk, when fatal fetal anomalies preclude the viability of the fetus, or in rape-related pregnancy. The Materials and Methods question regarding abortion approval was answered with a 5-point Likert scale that ranged for level of agreement: (1) Sample strongly disagree; (2) disagree; (3) neither agree nor disagree; (4) agree; or (5) strongly agree. It was categorized Data were drawn from the 2015 CNYS.10 This survey is as abortion disagree: yes (1 and 2), or no (3-5). done in Chile by the Chilean Youth Institute, a governmental agency, and seeks to update the available knowledge that Statistical Analyses exists on youth, contributing to the design of public policies aimed at the young population. It uses a probabilistic All analyses were weighted to reflect a nationally strategy designed to select participants who are represen- representative sample using survey estimation commands tative of Chilean youth aged 15-29 years. Census estimates in Stata version 12.1 (StataCorp LP) that account for complex indicated that there were 4,283,245 adolescents and youth study design. Because 981 (28.68%) of the sexually active in 2015. After stratifying according to region and urban/ female participants did not answer the induced abortion rural residence, a multistage sampling approach is used to question, a deterministic sensitivity analysis between