Original Study

Induced 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 , 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 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 . 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 the randomly select households, and 1 eligible individual from demographic characteristics of participants that answered each household is selected to complete an in-person home and did not answer was performed. We found that the main interview. Questions regarding sexual behavior, mental outcome variables and covariates of sexually active women health, violence, and drugs were applied in a tablet with a who answered the abortion question in CNYS 2015 did not warrant of the confidentiality of the data to the young differ from the sexually active women who did not answer it participant. For this study, from the 9393 participants, 4996 (Supplemental Table 1). female participants were initially included in the sample. Bivariate analysis using Rao-Scott adjustment for c2 test After excluding the ones who did not report onset of sexual on weighted samples was used to examine the association activity (1522) and the ones that did not answer the abor- between SES and covariates with induced abortion. Logistic tion question (981), our analytic sample finally consisted of regression analyses were used to examine the association 2493 participants. between SES and induced abortion while controlling for covariates. Several models were tested. Our final explor- Measures atory model included all of the analyzed covariates. The institutional review board at Clínica Alemana/Universidad The outcome of interest was obtained from the question del Desarrollo determined the study was exempt because “have you ever induced an abortion?” (yes/no). The ques- the data set is anonymized.12 tion did not include the age of the respondent at the time the abortion was performed. Results The key independent variable was SES. SES was defined in the survey according to the World Association Market The age distribution of the sample was 15-18 years: Research classification,11 a composite index on the basis of 25.55%; 19-24 years: 39.46%; and 25-29 years: 35.00%. The A. Huneeus et al. / J Pediatr Adolesc Gynecol xxx (2020) 1e6 3

SES distribution was low: 44.43%; middle: 51.02%; and high: Results of the bivariate unadjusted analysis in which 4.55%. Of all of the participants 87.05% lived in urban set- participants who had an induced abortion was compared tings, 90.09% did not have an indigenous background, with participants who did not is shown in Table 2. 85.36% had public health insurance; 50.08% identified with The full multivariate model of induced abortion accord- a Christian religion; and 74.38% did not have any political ing to SES controlled by covariates is shown in Table 3. identification. As SES increased, participants were less likely Participants with high SES had 4.89 (95% confidence inter- to disagree with abortion in the setting of risk to the val [CI], 1.44-16.51) higher odds of induced abortion mother's life, fatal fetal anomalies, rape, and on demand compared with participants with low SES. Participants with (Table 1). middle SES had 1.8 (95% CI, 1.02-3.24) higher odds of Among the sexually active female participants aged 15- induced abortion compared with participants with low SES. 29 years, 5.15% (n 5 129) reported having induced an That is, a fine social gradient was found in the chance of abortion at some point in the past. having had an induced abortion according to SES in this

Table 1 Sociodemographic, Sexual Behavior, and Cultural Characteristics of 2043 Sexually Active Female Adolescents and Youth According to SES (2015)

Variable Low SES Middle SES High SES Total

Weighted percents (%) Age, years 15-18* 28.96 (26.69-31.01) 22.6 (20.88-24-41) 25.32 (19.7-31.91) 25.55 (24.26-26.88) 19-24 41.30 (39.09-43.55) 38.37 (36.40-40.76) 33.57 (26.55-44.14) 39.46 (37.87-41.07) y 25-29*, 29.73 (27.78-31.76) 39.03 (36.51-41.62) 41.10 (33.98-48.62) 35.00 (33.37-36.65) Place of residence y Rural*, 20.92 (19.37-22.56) 6.8 (5.92-7.79) 4.14 (2.42-6.99) 12.95 (12.10-13.86) y Urban*, 79.08 (77.44-80.63) 93.20 (92.21-94.08) 95.86 (93.01-97.58) 87.05 (86.14-87.90) Nationality Chilean 98.81 (98.35-99.15) 98.94 (98.55-99.22) 99.34 (97.54-99.82) 98.90 (98.63-99.12) Other 1.19 (0.8-1.65) 1.06 (0.07-1.4) 0.6 (0.18-2.46) 1.10 (0.88-1.37) Indigenous identification y z Yes*, , 12.32 (10.95-12.84) 8.42 (7.42-9.55) 2.94 (1.71-5.02) 9.91 (9.09-10.79) y z No*, , 87.68 (86.16-89.05) 91.58 (90.45-92.58) 97.06 (94.98-98.29) 90.09 (82.21-90.91) Health insurance y z Public*, , 95.05 (94.10-95.85) 81.83 (79.60-83.87) 34.34 (27.80-41.54) 85.36 (83.98-86.65) y z Private*, , 4.95 (4.15.5.9) 18.17 (16.13-20.4) 65.66 (58.46.72.2) 14.64 (13.35-16.02) Public/charter or private school y Public*, 29.76 (27.54-32.07) 45.12 (42.90-47.96) 49.49 (41.87-57.12) 55.87 (54.16-57.57) y z Charter*, , 68.36 (66.05-70.60) 48.66 (46.10-51.22) 19.11 (14.26-25.12) 38.79 (37.12-40.48) y z Private*, , 1.88 (1.46-2.42) 5.93 (4.92-7.12) 31.4 (24.29-29.51) 5.35 (4.65-6.14) Age of sexual debut, years 7-13* 7.72 (6.22-9.53) 5.08 (4.10-6.27) 4.77 (2.64-8.48) 6.21 (5.35-7.20) 14-17 63.24 (60.40-66.00) 63.59 (60.70-66.37) 54.74 (45.34-63.81) 63.04 (61.06-64.98) y 18-29 29.04 (26.43-31.79) 31.34 (28.67-34.14) 40.49 (31.61-50.05) 30.75 (28.9-32.67) Contraceptive use at sexual debut Yes* 68.09 (65.43-70.63) 73.62 (70.70-76.35) 73.64 (63.87-81.54) 71.22 (69.29-73.08) No* 31.91 (29.37-34.57) 26.38 (23.65-29.30) 26.36 (18.46-36.13) 28.78 (26.92-30.71) Adolescent pregnancy Yes 7.68 (6.73-8.74) 6.06 (5.02-7.31) 3.83 (1.70-8.40) 6.68 (5.97-7.46) No 92.32 (91.26-93.27) 93.94 (92.69-94.98) 96.17 (91.60-98.30) 93.32 (92.54-84.03) Religion y Christian 52.05 (49.78-54.31) 49.12 (46.63-51.62) 41.77 (34.55-49.35) 50.08 (48,42-51.74) y Non-Christian or none 47.95 (45.69-50.22) 50.88 (48.38-52.37) 58.23 (50.65-65.45) 49.92 (48.26-51.58) Political affiliation y z Right , 6.07 (5.21-7.07) 7.41 (6.45-8.51) 16.62 (11.29-23.78) 7.24 (6.54-8.00) y Center*, 2.36 (1.88-2.97) 4.29 (3.53-5.21) 8.40 (4.76-14.4) 3.62 (3.12-4.19) y Left*, 12.35 (10.88-13.99) 16.06 (14.02-18.26) 24.2 (17.64-32.25) 14.77 (13.48-16.15) y z None*, , 79.22 (77.37-80.95) 72.27 (69.93-74.50) 50.78 (43.24-58.29) 74.38 (72.87-75.83) Abortion opinion; disagree with: Life risk of the mother y z Yes*, , 25.16 (23.24-27.17) 16.6 (15.01-18.33) 7.98 (5.01-12.49) 20.71 (18.79-21.29) y z No*, , 74.84 (72.83-76.76) 83.40 (81.67-84.99) 92.02 (87.51-94.99) 79.99 (78.71-81.21) Fetal unviability y z Yes*, , 28.12 (26.19-30.17) 18.85 (17.23-20.57) 12.13 (8.36-17.26) 22.66 (21.42-23.95) y z No*, , 71.86 (69.83-73.81) 81.15 (79.43-82.77) 87.87 (82.74-91.64) 77.34 (76.05-78.58) Rape y Yes*, 29.15 (27.01-31.38) 18.36 (16.89-19.93) 12.17 (8.54-17.07) 22.87 (21.59-24.20) y No*, 70.85 (68.62-72.99) 81.64 (80.07-83.11) 87.83 (82.93-91.46) 77.12 (75.58-78.41) On demand y z Yes*, , 64.35 (62.17-66.47) 57.36 (54.96-59.74) 43.30 (36.1-50.79) 59.83 (58.22-61.41) y z No*, , 35.65 (33.53-37.83) 42.64 (40.26-45.05) 56.70 (49-21-63.90) 40.17 (38.59-41.78) Total 44.43 (42.83-46.04) 51.02 (49.38-52.65) 4.55 (3.93-5.27)

SES, socioeconomic status. Data are presented as weighted percentage (95% confidence interval). y z Significant differences P less than .05 in comparisons of: * low vs middle SES; low vs high SES; and middle vs high SES. 4 A. Huneeus et al. / J Pediatr Adolesc Gynecol xxx (2020) 1e6

Table 2 Table 3 Unadjusted Comparison of Participants Who Had Induced Abortion with Those Who Odds of Induced Abortion According to Socioeconomic Status of Chilean 15- to 29- Did Not According to Sociodemographic, Sexual Behavior, and Cultural Variables Year-Old Sexually Active Female Adolescents and Youth in the Fully Adjusted Lo- (2015) gistic Regression Model Controlled by Covariates (2015)

Variable Induced No Induced OR 95% CI P Abortion (Weighted %) Abortion Socioeconomic status (reference Low) Age, years* Medium 1.8 1.02-3.24 .01 15-18 2.56 97.44 High 4.89 1.44-16.51 .04 19-24 5.58 94.42 Age, years (reference 15-18) e 25-29 5.65 94.39 19-24 2.13 0.87-5.23 .09 Socioeconomic status* 25-29 1.30 0.52-3.28 .57 Low 4.24 95.76 Place of residence (reference Rural) Medium 5.74 94.26 Urban 1.71 0.76-3.86 .19 High 10.01 89.99 Nationality (reference Chilean) Place of residence Other 6.95 1.66-29.14 .01 Urban 5.34 94.66 Indigenous status (reference Yes) Rural 4.24 95.76 No 0.57 00.27-1.22 .15 Nationality Health insurance (reference Public) Chilean 5.12 94.88 Private 0.24 0.07-0.91 .04 Other 13.97 86.03 Type of school (reference Public) Indigenous identification Charter 0.91 0.27-3.07 .88 Yes 6.70 93.30 Private 1.16 0.33-4.01 .82 No 5.02 94.98 Age of sexual debut, years Health insurance (reference 7-13 years) Public 5.27 94.73 14-18 0.58 0.23-1.46 .25 Private 4.28 95.72 19-29 0.61 0.24-1.57 .30 Public/charter or private Contraceptive use at sexual debut elementary school (reference yes) Public 4.73 95.27 No 1.39 0.78-2.47 .26 Charter 5.44 95.56 Adolescent pregnancy (reference yes) Private 8.00 92.00 No 0.84 0.41-1.75 .65 Age of sexual debut, years Christian religion (reference yes) 7-13 6.48 93.52 Non-Christian or none 1.4 0.84-2.8 .19 14-17 5.11 94.89 Political identification (reference Right) 18-29 4.91 95.09 Center 0.74 0.19-2.86 .67 Contraceptive use at Left 0.82 0.29-2.27 .70 sexual debut None 0.72 0.28-1.80 .48 Yes 5.25 94.75 Abortion opinion, disagree with: No 5.13 94.87 Life risk of the mother (reference Yes) Adolescent pregnancy No 1.14 0.37-3.54 .80 Yes 4.43 95.57 Fetal unfeasibility (reference Yes) No 5.11 94.89 No 0.93 0.33-2.62 .9 Christian religion Rape (reference Yes) Yes 4.63 95.37 No 1.57 0.60-4.13 .92 Non-Christian or none 6.00 94.00 On demand (reference Yes) Political identification No 3.12 1.83-5.33 .00 Right 7.65 92.35 CI, confidence interval; OR, odds ratio. Center 6.01 93.99 Left 5.91 94.09 None 4.76 95.24 Abortion opinion, 5.33) higher odds of induced abortion compared with par- disagree with: ticipants who disagreed with on demand abortion. No other Life risk of the mother* Yes 2.99 97.01 demographic, sexual behavior, or cultural characteristics No 5.74 94.26 were associated with a markedly higher or lower odds of Fetal unfeasibility* induced abortion. Yes 3.05 96.95 No 5.79 94.21 Rape* Discussion Yes 2.98 97.02 No 5.88 94.12 fi On demand* In this rst nationally representative study of induced Yes 3.06 96.94 abortion among adolescents and young adults in Chile, a No 8.50 91.50 country with highly restrictive abortion laws, we found that Data are provided as weighted percentages. women with high and middle SES reported more induced * P less than .05 in comparison of participants with and without abortion. abortions than those with low SES. In the literature, the relationship between SES and abortion varies according to e the regional context.13 17 In countries where abortion is country among adolescent and young women. Also, immi- legal, lower SES women are the ones who tend to have more e grant participants had 6.95 (95% CI, 1.66-29.14) higher odds induced abortions.15,17 19 In countries where abortion is of induced abortion than Chilean participants. Participants restricted, a clear pattern associated with SES has not been with private health insurance had 0.24 (95% CI, 0.07-0.91) identified. This can be related to the difficulty of obtaining lower odds of induced abortion compared with participants information because of the illegality and a shortage of sci- with public health insurance. Participants who did not entific studies.20 Chae et al state that in some countries of disagree with on demand abortion had a 3.12 (95% CI, 1.83- low and medium income, women with higher SES have A. Huneeus et al. / J Pediatr Adolesc Gynecol xxx (2020) 1e6 5 more access to abortions.20 This could be explained by a rapid modernization and globalization of Chilean society better access to information on how to have a safe abortion, norms are changing fast and the young are adopting freer better access to clinical services including across the border sexual mores. If we consider that religious and political abortion, and more empowerment to act according to their preference are culturally related,25 it is not surprising that fertility preferences compared with women who have a these variables behave similarly and do not affect abortion lower SES.20 In Chile, low SES adolescent delivery rates are 8 decisions in these young women. times higher than the high SES adolescent delivery rates, Our study presents limitations. We did not have the in- suggesting that sexual activity leads to very different life formation on the age of the responders at the moment of course trajectories between these groups.10 Higher rates of having the abortion. Because only 35% of our participants contraceptive and condom use at the time of sexual debut were aged 25-30 years, we believe a large proportion of the has been previously reported in high and middle SES Chil- abortions in this sample were performed during adoles- ean youth compared with lower SES youth.21 Chilean teen cence and youth. We do not know if SES and other de- pregnancy disparity could be explained by contraceptive mographic covariates answered during the survey could use disparity and also by unequal access to restricted have changed from the moment the respondent had the abortion. induced abortion. Chilean longitudinal studies on socio- Immigration is currently growing in Chile, but in 2015 economic differences show that mobility between SES is only 1% of youth were not Chilean. The higher rates of minimal.27 Therefore, this bias unlikely changes our find- induced abortion for immigrants could reflect the legal ings. Despite that there were no differences between those status of abortion at their country of origin. More studies on who answered the abortion question and those who did a focused sample should be done to understand induced not, we do not know why 28.68% of the sample did not abortion rates on immigrants. answer it. Women who had performed abortions might The fact that privately insured youth had lower rates of have not answered the question because of social desir- induced abortion was an unexpected finding but could be ability. This could mean that abortion rates were under- explained because in Chile, public health insurance is reported. further stratified in 4 categories according to income that Variables that are taken into account at the moment of were not captured in this survey. The categories are A, having an abortion depend on individual and interpersonal lowest income, B and C in the middle, and D, highest in- factors, institutional, and other determinants, which might come.22 Only 37% of our high SES youth that reported differ in different countries and different historical pe- induced abortions had private insurance, the other 62.5% riods.7,19 The results of this study represent the context of had public insurance, most likely category D. Future studies young Chilean women in 2015 and cannot be generalized. that include all possible categories of health insurance are The public health implications of this study is than if needed to understand health care system inequalities on induced abortion is more accessible to socioeconomically induced abortion. advantaged women in conditions where abortion is illegal, Although we found a significant tendency for women reducing legal restrictions could potentially make abortion who had abortions on approving abortion on demand, it is access more equal across SES. The reduction of socioeco- interesting that some of them did not approve of it. This nomic inequalities in health and health care are an impor- might indicate that feelings of shame and stigma about tant challenge for health policies.9 their personal reproductive decisions did not allow them to In conclusion, adolescent and young women with higher share opinions publicly. The finding that less restrictive socioeconomic advantage reported more induced abortions opinion on abortion was associated with higher SES could compared with poor during a time when be one of the multiple variables related to the social abortions were illegal and criminalized in all cases. Since gradient of abortion rate. the decriminalization of therapeutic abortion in 2017 in Identification with religious groups or political parties Chile a social movement in favor of free abortion has gained was not associated with abortion among the responders in strength. It is important to carry out follow-up studies to our study. Although most religions disapprove abortion, monitor abortion patterns and the associated determinants studies have reported that its role is not conclusive for of women who have an induced abortion.28 A deeper un- women at the moment of deciding whether to have one or derstanding can help us adopt the best strategies for pre- not.23 Previous studies have described that Catholic women venting unwanted pregnancy and abortion. show the same amount of abortions as the rest of the women, which is in agreement with the results obtained in References our analysis.24 However, women who belong to a religion and have had an abortion could be conflicted about their 1. Faundes A, Miranda L: . In: Quah S, editor. International Encyclopedia of Public Health, (2nd ed.). Birmingham, AL, Academic Press, decision and even if they had an abortion, they could ex- 2017, pp 301e310 press disagreement with it. 2. Sedgh G, Bearak J, Singh S, et al: Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet 2016; 388:10041 In terms of politics, identification with the conservative 3. Center for : The World’s Abortion Laws. Available: https:// right showed a tendency to disapproveabortion.25,26 In this reproductiverights.org/worldabortionlaws. Accessed September 27, 2019. 4. Munakampe M, Zulu J, Michelo C: Contraception and abortion knowledge, study, identifying with the right wing was not associated attitudes and practices among adolescents from low and middle-income with lower rates of induced abortion. This might suggest countries: a systematic review. BMC Health Serv Res 2018; 18:390 5. Rodríguez A: La ilicitud del aborto consentido en el derecho chileno [The that general political preferences did not correlate with the illegality of inducced abortion in Chilean law]. Derecho Humanidades 2004; personal decisions of sexual health in young women. 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Appendix

Supplemental Table 1 Sociodemographic Variables of Sexually Active Women Who Did and Did Not Answer the Induced Abortion Question (2015)

Variable Answered Question of Abortion Did Not Answer Question of Abortion P (n 5 2493; 71.76%) (n 5 981; 28.68%)

Weighted percents (%) Age, years 15-18 13.83 15.78 .08 19-24 45.94 40.16 25-29 40.23 44.07 Socioeconomic status High 4.09 3.14 .11 Medium 47.84 53.17 Low 48.07 43.06 Place of residence Urban 86.72 86.2 .75 Rural 13.28 13.8 Nationality Chilean 99.00 98.63 .42 Other 1.00 1.37 Indigenous identification Yes 9.96 11.25 .41 No 90.04 88.75 Health insurance Public 89.74 89.46 .87 Private 10.26 10.54 Public/charter or private elementary school Public 56.83 57.62 .24 Charter 37.71 38.9 Private 5.46 3.48 Religion Christian 53.39 53.81 .81 Non-Cristian or none 46.61 46.19 Political identification Right 7.86 7.00 .64 Center 2.96 3.44 Left 14.23 15.32 None 74.94 74.25

Data are weighted percentages except where otherwise noted.