Attitudes of medical students towards the ethical and legal aspects of abortion: a cross-sectional study from Saudi Arabia

Study design

This is a descriptive cross-sectional questionnaire-based study that was conducted by distributing an electronic survey among medical students at Imam Abdulrahman Bin Faisal University in Saudi Arabia. The target population was male and female medical students aged 18 and above who were enrolled at the university and were willing to participate. 1227 medical students were studying at the College of Medicine of the Imam Abdulrahman Bin Faisal University at the time when the study was conducted. The sample size was calculated using the population proportion-sample size calculator. A sample size of 293 was estimated with a 95% confidence level and 5% marginal error. Ethical approval was obtained from the Institutional Review Board (IRB) of the university (IRB-UGS-2021-01-398; 03-November-2021). Information pertaining to the introduction and objectives of the present study was provided to the participants on the first page of the online questionnaire survey and if they proceeded to complete the questionnaire, it was considered as the participants’ consent for participation. Moreover, student participation was anonymous and voluntary with the purpose of respecting their right of choice to participate in the present study.

Instrument

An online self-administered questionnaire was developed based on previously published studies.^3,4 This questionnaire was reviewed by two experts with experience in research methodology and knowledge on this specific research topic. The questionnaire was also piloted on a sample of 20 students and based on their comments the questionnaire was finalized. The finalized questionnaire was distributed through social media platforms to all medical students at the university during the months of November and December in 2021. The response rate was 25%.

The questionnaire contained 20 items categorized into four sections. The first section included student demographic data (age, sex, year of study, and marital status). In the second section, the participants were asked to evaluate eight statements related to the general support of abortion. An additional seven statements in the third section were related to abortion decision support in specific conditions based on their opinion, asking whether they strongly agreed/agreed/disagreed/strongly disagreed/were neutral. Finally, in the fourth section, students’ attitudes toward abortion were assessed through five different clinical circumstances, to evaluate their intentions to act based on their attitudes.

Data analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp., Armonk, New York). Normality was assessed by the Shapiro-Wilk Test. Descriptive statistics were used to report frequencies and proportions for the categorical responses. The association between categorical variables was checked using the Chi-square test. A p-value of <0.05 was considered significant in all cases. All the underlying data for the present study is available without restriction.

Demographics

A total of 308 participants took part in our study (Table 1). The mean age was 21 years, with female participants constituting over two-thirds of the population (70.1%). The majority of the population was unmarried (91.5%). Approximately one-third of the medical students were in the sixth year (36.8%). Second and third-year students were categorized as pre-clinical year students (38.1%) while fourth to sixth year students were categorized as clinical year students (61.9%).

General support for abortion provision

Participant responses regarding general support for abortion provision are detailed in Table 2. Almost two-thirds of students believed that abortion did not fall in the category of murder (n=192, 62.5%). This belief was more common in female students than in males (66.6% vs 52.2% respectively; p=0.03). A similar proportion of single and married participants believed that abortion should not be considered murder (62.6% vs 61.5%; p=0.99). Furthermore, a significantly greater number of clinical year students, compared with pre-clinical students, also believed abortion did not fall in the category of murder (72.6% clinical and 46.2% pre-clinical; p<0.001).

Over half of the participants believed that abortion decisions should not be made individually by the mother herself (n=161, 52.4%). This belief was more common amongst male medical students than female (70.4% vs 45.2% respectively; p <0.01). There was no significant difference in responses between married and unmarried individuals (61.5% vs 52%; p=0.63).

Overall, more than 50% of the students believed that medical education provides enough information regarding ethical issues surrounding abortion (n=158, 51.4%). The proportion of female students (n=118, 53.8%) and male students (n=40, 45.4%) with this belief was similar (p=0.06). Although a numerically higher proportion of married participants believed this, the difference between married and single individuals was not statistically significant (53.3% vs 30.7% respectively; p=0.17).

About half of the medical students asserted that medical education provided sufficient information regarding ethical issues surrounding abortion (n=158, 51.4%). A similar number of pre-clinical year and clinical year students were found to believe this (53.8% and 50% respectively; p=0.72).

Conditional support for abortion provision

The overall response of the sample population towards conditional support of provision of abortion is detailed in Table 3. When asked whether abortion should be provided in case of congenital anomalies not compatible with life, the majority of participants responded in favor of the provision (n=248, 80.8%). Female medical students were more likely to be in favor of abortion in this scenario (85.8% vs 68.1% respectively; p=0.002). The proportion of single and married participants with this belief was similar (80.8% vs 80.7% respectively; p=0.86). More than half of participants felt that abortion should not be provided to parents who are not financially capable (n=216, 70.4%;). Male medical students were more likely to believe this than female students (80.6% vs 66.2% respectively; p=0.07). A similar proportion of married and single participants also held this belief (80.7% vs 85.9% respectively; p=0.67).

The majority of the students were in favor of abortion being made available to rape victims (n=192, 62.5%), with female students significantly more likely to believe this than male students (68.9% vs 46.6% respectively; p=0.04). Furthermore, single participants (63.3%) were significantly more likely to be advocates of this belief than married individuals (53.8%; p<0.01).

Intention to act on attitudes

The attitude of medical students towards abortion as future physicians was also assessed. The overall response is detailed in Table 4. More than two-thirds of the participants disagreed when asked if they would not perform an abortion at any cost (206, 67.1%). A nearly equal response in favor was observed between female and male medical students (69.8% vs 60.2% respectively; p=0.32). Marital status did not influence the response (single: 67.2% disagreed vs married: 61.5% disagreed; p=0.68).

About half of the medical students preferred to advise the patient not to go through the procedure (n=154, 50.2%). Male students (59.1%) were more in favor of this than female students (46.5%; p=0.04). This response was similar between single and married students (50.5% vs 46.2% respectively; p=0.97).

A significant number of participants disagreed with stopping other physicians from performing abortions (n=140,45.6%;). Female students (52.5%) were more in favor of this than male medical students (28.4%; p <0.01). There was no significant difference in responses between married and single participants (53.8% vs 44.8% respectively; p=0.56).

The independent-sample t-test to compare Likert scale score for attitude towards abortion as future physicians revealed no significant difference between male (n=14.9, SD=2.9) and female (n=13.8, SD=3.3) respondents (p=0.08).

General support for abortion provision

The results of this study showed that 62.5% of the students believed that abortion did not fall in the category of murder, female students were more likely than males to hold this belief (p=0.03). In a comparable survey among Turkish university students, the percentage of male participants who agreed with the statement “abortion shouldn’t be allowed anyway” was higher than that of female participants, and the difference was statistically significant (p<0.001). In addition, Turkish students had a more conservative attitude toward abortion, with approximately 80% of the participants either having no opinion or being opposed to abortion, and 70% believing that eliminating a life is the only right of Allah.³ A similar conclusion was made in Jordan, where around 53% of students believed that abortion should be considered a form of murder.⁵ However, medical students’ attitudes toward abortion may change as they progress in their academic levels. In our study, most clinical-year students (72.6%) agreed that abortion isn’t considered a type of murder which was significantly higher than pre-clinical-year students (46.2%). Similar results were reported in a study that assessed midwifery students’ attitudes towards abortion in Poland. There was a significant difference between the first and the final year students’ attitudes toward abortion, where a higher number of the final year students were willing to participate in abortion under different circumstances than first-year students (71.9% vs 57.3%); their willingness to participate in abortion cases shows that they don’t believe that abortion is murder as well.⁶ Gleeson et al. encountered consistent results in their study, which found that second-year medical students in the United Kingdom were more pro-choice than first-year students.⁷ Similarly, significant differences in attitudes regarding abortion were observed between first- and fourth-year medical students in Papua New Guinea, indicating that acceptance of abortion grew with years of study.⁸

Most of the students who participated in our study believed that abortion decisions should be determined by law and religion. This may reflect Saudi Arabia being an Islamic country that regulates most of its laws by the religion of Islam. Consequently, 74.3 % of the participants in the present study believed that abortion decisions should be determined by religion. A similar finding was reported in a systemic literature review of health care providers’ perceptions and attitudes towards abortion in sub-Saharan Africa and Southeast Asia. Most of the respondents of the studies included in the systemic review believe that only God can make decisions about life and death. Additionally, abortion was viewed as a sin.¹ A study that assessed the attitudes towards abortion among the Muslim minority and non-Muslim majority in western Europe countries showed that Muslim’s negative attitude towards abortion was significantly influenced by religion.⁹

In addition to laws and religion, participants in the present study believed that spousal consent is required in making the abortion decision since 52.4% of them disagreed that a woman should have the right to decide for herself whether to have an abortion. This finding is inconsistent with the results of a study conducted among medical students in South Africa where most of the participants (70%) agreed that a woman should have the right to decide for herself whether to have an abortion or not.⁴ Similar results were found in a study conducted among physicians who provided clinical reproductive health care in the United States, where many participants strongly opposed that spousal notification (81.3%), and consent (86.6%) should be required for married women. Fewer strongly disagreed that parental notification (57.6%) and parental approval (66.9%) should be required for minors.¹⁰ Our findings suggest that male students in Saudi Arabia are more likely to disagree with the statement “abortion decision should be determined individually by the pregnant woman” than females and it is statistically significant. Similarly, male students were more likely to agree with the statement “spousal consent is essential to make abortion decisions” and this difference was also found to be statistically significant.

Conditional support for abortion provision

Most of the students believed that abortion is warranted when a woman’s health is at risk, when serious fetal congenital defects are suspected, and in the case of rape. This is consistent with the results of other studies.^4,5,11–16 Our study also showed that most of the participants were against permitting abortion in the case of financially incapable parents (70.3%), and in the case of unplanned pregnancy (82%).

Intention to act on attitudes

In the present study, around 67% of the participants were against refusing to perform an abortion at any cost and 45.6% were against stopping other physicians from performing abortions. The percentage of participants in our study who agreed to refer patients to other physicians in situations where they would not perform abortion was much less than those reported in a South African study (47.2% vs 70%).⁴ However, a similar finding was concluded from a study assessing the attitudes of abortion objectors towards physician referral for abortion services in Colombia. Most of the moderate Colombian objectors felt comfortable referring patients to other physicians who would provide the required service for the patients as requested.¹⁷

Abortion education and training

Sanitya et al. discovered that health care providers’ positive attitudes about unplanned pregnancies and unsafe abortions increased dramatically after a training program to prevent unsafe abortion was implemented in Thailand.¹⁸ This emphasizes the value of training programs in raising awareness about unsafe abortion and providing safe abortion services. Overall, most participants (51.4%) in our study were satisfied with the current medical education regarding the ethical considerations surrounding abortion. Likewise, in a study from the United Kingdom, 57% of medical students believed that they received the appropriate amount of education on abortion.¹⁹ In contrast, a Malaysian study reported that more than 90% of medical students believed that there should be more education and training about the legal aspects of abortion, as well as increased knowledge about this.²⁰

The number of studies showing the effect of abortion laws on women’s physical and mental health in the Middle East and North Africa is insufficient and there is no reliable data about unsafe abortion in this region.

In 2008, the World Health Organization reported that there were about 830,000 unsafe abortions in West Asia that caused 600 maternal deaths and 900,000 unsafe abortions in North Africa leading to 1500 annual maternal deaths.²¹ Therefore, abortion is considered a serious medical issue because of increased maternal mortality in cases of unsafe abortion.²¹ The results of the present study showed that the attitudes of medical students toward abortion are mostly positive, which is reassuring because medical students will play a major role in managing abortion and its complications in the future and raising awareness about such issues. Moreover, it is important to assess how future physicians will act toward abortion cases so that we can have an estimation of the possible ways of managing unsafe abortion cases in the future.

Strengths and Limitations

A positive aspect of the present study is that it is one of the first studies to be conducted in Saudi Arabia to assess medical students’ attitudes towards abortion. An anonymous questionnaire was used to collect data. This made it suitable for the participants to possibly provide honest opinions about abortion, a very sensitive topic.

However, the present study is not without limitations. Our study was conducted in a single center. Thus, the results of our study cannot be generalized to the entire medical student community in Saudi Arabia and aren’t applicable on a global scale. Moreover, this study included the current opinions of medical students which might change in the future as they qualify to practice as physicians. On the other hand, assessing physicians’ attitudes would provide a better understanding of abortion safety measures being considered. In addition, the study included more single students than married students and this might have led to an interpretive bias in results. Finally, the participants were asked to report their biological sex only. While social factors such as gender identification were not taken into account because it is not culturally an accepted phenomenon in Saudi Arabia.

Recommendations

For future research

A nationwide study involving the entire medical student community in Saudi Arabia is recommended for a broader picture of the attitudes of medical students, the future physicians, towards abortion. Such a study should be a multi-centered one with a larger sample size. Similar studies should be conducted to learn about the attitudes and practices of the present physicians toward abortion not just in Saudi Arabia, but in the rest of the Middle East as well.²²

For policy and law makers

The laws of abortion are based on Islam. Thus, it is not amenable to changes. However, the policy and law makers need to provide clearer guidelines for abortion practices that can be easily accessible to those genuinely requiring these services in Saudi Arabia.

For medical students

Provision of sufficient medical and legal education regarding abortion and the proper way to act in challenging situations is recommended, as unsafe abortion practices are known to increase maternal mortality. Lastly, raising the community’s awareness level of this sensitive topic via varied ways of communicating information such as public health campaigns with the involvement of medical students could be considered.