Politics, policies, pronatalism, and practice: availability and accessibility of abortion and reproductive health services in Turkey

Abstract

Turkey has maintained liberal contraception and abortion policies since the 1980s. In 2012, the government proposed to restrict abortion; a bill limiting abortion was later drafted but never passed into law. Since the proposed restriction, women have reported difficulty accessing abortion services across Turkey. We aimed to better understand the current availability of abortion and reproductive health services in Istanbul and explore whether access to services has changed since 2012. In 2015, we completed 14 in-depth interviews with women and 11 semi-structured interviews with key informants. We transcribed all interviews and completed content and thematic analyses of the data. Key informants had good knowledge about the political discourse and the current abortion law. In contrast, women were familiar with the political discourse but had mixed information about the current status of abortion and were unsure about the legality of their own abortions. There was consensus that access to services has become more limited in the last five years due to the political climate, thus advocacy to prioritize reproductive health services, and abortion care in particular, in the public health system are needed.

Resumé

Depuis les années 80, la Turquie a maintenu des politiques libérales de contraception et d’avortement. En 2012, le Gouvernement a proposé de restreindre l’avortement ; un projet de loi limitant l’avortement a été préparé, mais n’a jamais été adopté. Depuis, les femmes ont signalé des difficultés pour avoir accès aux services d’avortement dans l’ensemble du pays. Nous souhaitions mieux comprendre la disponibilité actuelle de services d’avortement et de santé génésique à Istanbul et déterminer si l’accès aux services avait changé depuis 2012. En 2015, nous avons complété 14 entretiens approfondis avec des femmes et 11 entretiens semi-structurés avec des informateurs clés. Nous avons transcrit tous les entretiens et complété des analyses thématiques et de contenu des données. Les informateurs clés connaissaient bien le discours politique et la législation actuelle sur l’avortement. Par contre, les femmes étaient familiarisées avec le discours politique, mais possédaient des informations contradictoires sur la situation actuelle de l’avortement et elles n’étaient pas sûres de la légalité de leurs interruptions de grossesse. Tous s’accordaient à penser que le climat politique avait restreint l’accès aux services ces cinq dernières années. Des activités de plaidoyer pour donner la priorité aux services de santé génésique, et en particulier aux soins en cas d’avortement, dans le système de santé publique sont donc nécessaires.

Resumen

Turquía ha mantenido políticas liberales referentes a la anticoncepción y el aborto desde la década de los ochenta. En el año 2012, el gobierno propuso restringir el aborto; posteriormente se formuló un proyecto de ley para limitar el aborto, pero nunca fue promulgado como ley. Desde la restricción propuesta, las mujeres han informado dificultad para acceder a los servicios de aborto en toda Turquía. Nuestro objetivo fue entender mejor la disponibilidad actual de los servicios de aborto y slaud reproductiva en Istanbul y explorar si el acceso a los servicios ha cambiado desde 2012. En 2015, realizamos 14 entrevistas a profundidad con mujeres y 11 entrevistas semiestructuradas con informantes clave. Transcribimos todas las entrevistas y concluimos análisis de contenido y temáticos de los datos. Los informantes clave tenían buenos conocimientos del discurso político y la ley vigente referente al aborto. En cambio, las mujeres estaban familiarizadas con el discurso político pero tenían información divesa sobre el estado actual del aborto y no estaban seguras de la legalidad de sus propios abortos. Hubo consenso de que el acceso a los servicios se ha vuelto más limitado en los últimos cinco años debido al clima político; por lo tanto, se necesitan actividades de promoción y defensa para priorizar los servicios de salud reproductiva, y de aborto en particular, en el sistema de salud pública.

Keywords:

• Turkey
• abortion
• contraception
• Middle East and North Africa

Introduction

The Republic of Turkey has a longstanding legacy of progressive reproductive health policies. Despite restrictions on contraception and abortion at the outset of the Republic, Turkey implemented a robust family planning program in the 1960s that introduced reproductive health clinics, reduced pronatalist propaganda, and promoted the use of traditional and modern contraceptive methods. ¹ At that time, abortion was permitted if the woman’s health was at risk or in cases of foetal anomaly but remained restricted in most circumstances ²; thus the practice of illegal, unsafe abortion was exceedingly common throughout the 1960s and 1970s. ¹ In 1983, Turkey took another step in advancing maternal and women’s health when the government legalized abortion without restriction as to reason. ² As part of Population Planning Law No. 2827, abortion is permitted through 10 weeks’ gestation without restriction as to reason. Married women and minors must obtain consent for the abortion from the spouse or parent, respectively. ² In the Middle East and North Africa context, Turkey’s reforms were historic; Tunisia was and remains the only country in the region with a more liberal abortion law. ³

Legalization of abortion in Turkey was followed by a dramatic reduction in the maternal mortality ratio, from 251 deaths per 100,000 live births in 1980 to 121 deaths per 100,000 live births in 1990. ⁴ The abortion ratio has steadily decreased from 1990 to 2008, when the number of reported induced abortions per 100 pregnancies went from 20.6 to 10.0. ^5,6 The decrease in the abortion ratio has coincided with increased use of modern contraceptive methods and more effective use of traditional methods. ⁷ Nonetheless, abortion remains a vital component of maternal and reproductive health services in Turkey; the 2013 Turkish Demographic Health Survey estimated that 14% of ever-married women have had at least one induced abortion. ⁸

Despite the essential role of abortion in comprehensive reproductive health, the current Turkish government initiated a vocal anti-abortion campaign in 2012. On May 25, 2012, then-Prime Minister Erdoğan announced his opposition to abortion and the Ministry of Health soon after publicised plans to restrict the existing abortion law. ⁹ Immediate public outcry stalled the proposed legislation thus leaving the 1983 law intact. However, since mid-2012 activists and women have reported that abortion has become more difficult to obtain. In 2014, the Turkish Society of Obstetrics and Gynecology reported that the code for induced abortion had been removed from the electronic record system in public hospitals across Turkey, thus preventing the scheduling of abortion procedures. ¹⁰ A 2015 report found that only three public hospitals in Istanbul provide abortion without restriction as to reason and only one of these provides through 10 weeks’ gestation. ¹¹ This lack of public sector availability has been echoed in research documenting women’s experiences obtaining abortion services in Istanbul. ¹² Since 2012, access to misoprostol, the only form of medication abortion available in Turkey, has also been limited. ¹³

The Turkish government has also endorsed pronatalist population planning to encourage women to bear a minimum of three children. ¹⁴ As a result, abortion is only one of the reproductive health services targeted. In 2012, the Turkish government equated both abortion and caesarean sections with murder and later legally restricted the provision of caesarean sections to cases of medical necessity. ¹⁵ Proponents of this ban have argued that the procedure impedes women from having three or more children. ¹⁵ Progestin-only emergency contraceptive pills were removed from pharmacies and made briefly unavailable in 2014 only to later be replaced by ulipristal acetate, which is significantly more expensive. ¹⁶ Given this politically charged context, we wanted to explore both key informants’ and women’s perspectives on the availability and accessibility of reproductive health services, in general, and abortion, in particular, in Turkey.

Methods

In the summer of 2015, we completed a multi-methods qualitative study that included key informant interviews and in-depth interviews with women who had obtained an abortion. For the key informant component, we aimed to elicit the perspectives of a range of professionals, ¹⁷ including academics and researchers, representatives from women’s rights, human rights, and other non-governmental organizations, clinicians, government officials, and religious and community leaders. We identified participants through publicly available information, study team networks, and early participant referral. Once an invitee accepted our invitation to participate, we tailored our interview guide for that individual and used open-ended questions to explore the participant’s career and professional activities, experiences in the sexual and reproductive health arena, knowledge of and perspectives on the changing political attitudes toward abortion and reproductive health and the consequences for service accessibility and availability, and ideas about how policies and services could be improved in Turkey. We audio-recorded interviews, which lasted 45-60 minutes.

As detailed elsewhere, ¹² to be eligible for the second component of our project, women had to be aged 18 or older at the time of the interview, have obtained at least one abortion in Istanbul on/after January 1, 2009, and be sufficiently fluent in English or Turkish to answer questions. Our multi-modal recruitment strategy included social media posts, outreach through gender and women’s organizations, and participant referrals. Our interview guide began with questions about the participant’s background and reproductive health history, circumstances surrounding the terminated pregnancy, and the abortion process. We then asked questions about how abortion and reproductive health services could be improved. We closed by asking women their opinions about the current government and its stance on reproductive rights and health. Audio-recorded interviews lasted 60-90 minutes.

KM conducted all in-person or telephone/Skype interviews for both components with the aid of a Turkish interpreter (including DT and EÇ) as necessary. A Canadian master’s student in Interdisciplinary Health Sciences at the University of Ottawa, KM received training in qualitative research from her supervisor (AF), a medical anthropologist with extensive abortion-related research experience, and guidance during her fieldwork from gender studies specialist MO. KM took detailed notes during and debriefed with members of the study team after each interview. She also engaged in formal memoing to reflect on the interviewer-interviewee-interpreter interactions, explore her reactions to interview content, and initiate the analytic process. ¹⁸

We transcribed and translated into English all interviews. BB, a Turkish graduate student at the University of Ottawa, reviewed and verified all translated transcripts for accuracy. We used a multi-phased, iterative analytic plan centred on content and themes and used ATLAS.ti to manage our data. In the first phase, KM led the development of a codebook of a priori codes based on the interview guide, notes, and memos. In the second phase, we developed and added new codes to address emergent content. ¹⁸ The third phase focused on interpretation and drawing connections between ideas, a process guided by regular meetings between KM and AF. We analysed each component of the project separately and in the final phase we combined the results paying close attention to convergence and divergence.

We received ethics approval from the Research Ethics Board at the University of Ottawa (File #02-15-05) and the Gender and Women’s Studies Research Center at Kadir Has University in Istanbul reviewed the study protocol to ensure it adhered to local research standards and determined that additional approval was not requried. All participants verbally consented prior to the interview and gave us permission to use quotes. We have masked or redacted all personally-identifying information and use pseudonyms for the women who participated throughout.

Results

Participant characteristics

We interviewed 11 key informants (seven women and four men) and 14 women during this study. Key informants consisted of three Ob/Gyns who were also abortion providers, three NGO representatives, two academics, two pharmacists, and one lawyer, all of whom were working in Istanbul at the time of the interview. Women participants ranged in age from 21 to 44; seven women were unmarried, six were married, and one was divorced. Ten women identified as Turkish citizens, while four were expatriates currently residing in Istanbul. Eleven of our participants, including all of the expatriates, had completed or were completing a bachelor’s degree. The women we interviewed had received 19 abortions since January 2009. Most abortions were obtained in the private sector – eight in clinics and eight in hospitals – and three were obtained in a public hospital. Five abortions took place prior to May 2012 and fourteen took place after May 2012.

Knowledge of and opinions about Turkey’s abortion law

“I didn’t really have very many arguments with myself about it. What I did have was a huge dose of fear because when I realized I was pregnant, I didn’t know how far along I was…and I thought that I was very close to the [cut off], and that scared the shit out of me.”

(Mia, age 44)

Overall, our key informants evinced accurate knowledge about the legal status of abortion in Turkey. The majority (n = 9) correctly described the spousal consent requirement, although only one noted that failure to obtain this consent is not a criminal offense. The majority (n = 9) referenced the 10 week gestational age limit but only two key informants correctly explained abortion is legally permissible through 20 weeks in cases of sexual assault and one correctly noted that there is no gestational limit in cases of foetal anomaly or if the woman’s life/health is at risk, provided state authorities are notified. Only five key informants described the parental consent requirements for minors. Women’s knowledge of the law at the time of the interview was highly dependent on their individual experience. Several women were unaware of the 10-week gestational age limit and others were uncertain if husband or partner consent was legally required.

Most of our key informants (n = 10) raised concerns about one or more aspects of Turkey’s current abortion law. A number specifically referenced that the 10-week limit was too low and that the spousal consent requirement should be eliminated. As one lawyer argued,

“We think that this time period should be extended, it is very minimal and there are examples of longer periods in other countries.”

An Ob/Gyn working in Istanbul echoed this sentiment:

“[10 weeks] is not long enough. I don’t think there should be any restrictions on abortion. It’s a woman’s body and she should be able to decide about everything herself. She shouldn’t need her husband’s consent either…if she decides not to have the baby, it’s her choice, it’s a private situation.”

The issues raised by key informants were reflected in the lived experiences of half the women in the study. One woman described the age of consent as being a source of difficulty and additional women, like Mia, expressed significant concerns about exceeding the 10-week gestational limit, obtaining spousal consent, or both. As Kathleen explained,

“[My husband] wasn’t gonna give me consent so I went to a private clinic and the doctor was a friend of a friend of mine, and he did it for me and was really nice about it and everything. But yeah...it was a problem.”

Knowledge of abortion- and reproductive health-related policy changes

“I think it’s about excluding women from social life and public space. It’s about occupying women with three children and using that as an excuse to exclude them.”

(Yasemin, age 21)

Almost all of the participants in both components of the study were aware of the Turkish government’s attempt to restrict abortion in 2012. In general, key informants understood that the bill had been drafted but not introduced and that no legal changes impacting abortion had been enacted. None of the key informants had seen a copy of the 2012 bill or heard of any efforts to introduce new abortion legislation. In contrast, women in our study were confused as to whether or not restrictive provisions had been enacted in 2012; four women believed gestational age limits or consent provisions had been recently imposed.

All participants in both components of the project expressed awareness of the Turkish government’s pronatalist efforts. Key informants and women repeatedly described the aim of the government as trying to promote a certain number of children per woman and explained that a number of incentives, including awarding money to families with multiple children and extending maternity leave, had been implemented in support of this effort. As Funda, age 28, explained:

“The government’s new incentive of giving money after pregnancies and deliveries is manipulating and confusing women’s minds…I see women like that in my neighbourhood, just for the incentive they get pregnant. The government imposes this for women to have more children. I see women like that around me.”

Participants, particularly key informants, discussed other types of policy changes, including the prohibition on non-medically indicated caesarean sections, the upregulation of misoprostol, and the lack of mifepristone registration as part of this overarching effort. Well-positioned key informants also reported that policy efforts were underway to remove reproductive health content from textbooks and change the status of oral contraception pills such that presentation of a prescription at a pharmacy would be required and recorded.

Participants suggested a range of political and economic motivations for the pronatalist efforts. Notably, both key informants and women believe that the government’s ideology revolves around conservative, often religious, values and building traditional families with the consequence of seriously compromising both women’s rights and human rights. As 30-year-old Esin explained:

“[The ruling party has] this thing about making at least three children…They don’t have a stand on women’s rights, they are trying to implement their ideologies and ideas [which are] based on the value of family, the sacred nature of motherhood. They are trying to limit access to abortions, birth control, and free health services for women. It reflects the idea of the role they think women should have in a society. They don’t want women to be independent and free, so they think by limiting all these things, they can prevent that.”

The influence of the anti-abortion political climate on practices and access

“It’s incredibly difficult to fight these secret, underlying restrictions which they [the government] do through health reform…There is no legal restriction, it’s still the old reproductive health law…But there have been non-legal changes…Although abortion was not banned, although there was actually no written policy change, a lot of abortion was de facto restricted.”

(NGO representative)

Key informants and women consistently described the anti-abortion and pronatalist government rhetoric as far-reaching and significant. Participants in both components of the project explained that even in the absence of policy change, Erdoğan and other leaders of the Justice and Development Party (AKP) have tremendous impact at the individual, institutional, and systems levels. Jeanine, age 36, commented:

“Oh yeah my husband is very pro-Erdoğan, he’s like ‘We will have three children, one for us, one for the country and one for’ whatever the saying is. Yeah my husband is very much that we will have three children 'cause that’s what Erdoğan says to do.”

Most of our participants felt that access to abortion care had diminished in the previous five years. Informants and women spoke at length about how the government resorted to “secret” or “backdoor” measures to restrict service availability. The reduction in the number of public hospitals providing abortion in Turkey, in general, ¹⁹ and Istanbul, in particular, has been well documented. ^11,12 However, our key informants also reported that some private facilities that are financially supported by the AKP or prominent leaders within the party have also stopped providing services. One NGO representative offered an explanation for the relationship between the political rhetoric and provision,

“Erdoğan says that abortion is a crime…once he says something, even if it’s very illogical or against the party, a lot of people in the state and in this government and in the party start claiming it. They just repeat it…[W]hen he says something, a lot of people, his followers, start implementing it, even if there’s no law.”

Informants also discussed how the recent overarching health reform initiative has curtailed sexual and reproductive health services in Turkey. First, the transition to a family medicine model of care has resulted in the closure of dedicated maternal-child health and family planning centres (AÇSAP). These closures directly impacted at least two women in our study. Damla, age 39, explained:

“There used to be mother’s health centres, that’s where I learnt [information about reproductive health]. In the past, it was more accessible.”

Since the closure of AÇSAP clinics key informants reported that women have had to travel greater distances to reach family planning and abortion care because family medicine clinics do not consistently provide these services.

Second, the health reform initiative removed family planning services, including abortion and contraceptive counselling, from the public sector funding scheme. As one Ob/Gyn explained:

“The Ministry of Health has said that menstrual regulation is not a disease so it should not have ICD [billing] code…but if you don’t have an ICD code, you don’t get paid for it. The hospital is not paid for it, neither by the government nor by the social security system…so the others [doctors] say that ‘There is no code for it, so I don’t provide abortion’…not because they are against abortion, because they are not paid for it. It’s very simple.”

Similarly, contraceptive services appear to have been removed from the performance scale for physicians, thereby impacting compensation. The same Ob/Gyn elaborated:

“To provide an IUD has less points than examining a patient. [Other reproductive health services] have no performance system scores. If you do it, you don’t get any points, you don’t earn anything. It is legal but it’s not reimbursed.”

Women also repeatedly commented on the costs of obtaining reproductive health services. In addition to discussing the challenges with obtaining fee-for-service abortion care in the private sector, several women also specifically referenced the increased price of emergency contraception as a barrier to access. A pharmacist also described the challenge:

“[NorLevo] was 17 Lira [USD6] but this [Ella] is 50, 49 Lira [USD17.40]…it’s very expensive for, especially for youth…I saw that many young lady or young man collecting from their friends some money to buy it.”

Women expressed significant concern about abortion documentation and familial notification

“I got the fear because our government doesn’t want women to get an abortion…if you have an abortion in the government hospital, they may even write your name and inform your parents without your knowledge. So I didn’t want [to be worried] that my mother would learn…I told my doctor at school [and] he said that maybe [I could] get a private abortion.”

(Sevda, age 22)

Women in our study were highly concerned about the documentation surrounding their abortion procedure. Half of our participants wanted to avoid having their abortion on their medical record, mainly because they were worried that their abortion would be disclosed to the government or their family members. As Mia explained,

“That was another reason why I went into a private clinic rather than a hospital…Because I have a feeling that the records at the private clinic are not accessible [to the government] in the same way that they are from a hospital.”

Women spoke at great length about avoiding “the wrong hospital” or “conservative hospitals” because they believed their abortion could be disclosed without their consent. Further, women believed the government intentionally established this culture of fear to deter women from seeking services. Esin explained,

“And then, the issue of needing your husband’s consent and sending letters to the parents stating that the daughter got an abortion. That’s how they [the government] are scaring woman away and preventing it, by invading their privacy.”

Notably, key informants did not raise this as an issue nor did they discuss government initiatives designed to track abortion patients or impose punitive systems of disclosure.

Although almost all of our participants had to show identification and sign a general consent form while obtaining their abortion care, some women still described the procedure as “undocumented” because it was understood that the abortion would not be recorded in their medical record. Esin’s consent form did not specify the type of medical procedure:

“And my abortion wasn’t registered or documented, so it was easy for me to access…Only when I left the hospital, I had to sign something. But that only stated that I had an operation with the doctor.”

Consequently, several women seemed unsure of the legality of their abortions and used language that reflected this ambiguity. Women consistently described obtaining abortion as “a little bit illegal”, “a legal grey area”, or as “black market.” Interestingly, women viewed this lack of documentation as highly desirable and several preferentially sought care in the private sector, especially private clinics, for this reason.

Discussion

Turkey’s 1983 Population Planning Law guarantees that safe abortion should be available “for every woman who needed the service.” ⁶ However, recent accounts suggest the law is not being consistently implemented. The Turkish media has reported that some public hospitals are unwilling to provide through 10 weeks’ gestation, ¹¹ are disclosing a woman’s pregnancy status to her family, ²⁰ withholding anaesthesia, ²¹ turning away unmarried women, ²² and incorrectly informing women that abortion is illegal. ²³ These profound inconsistencies are reflective of overarching changes in reproductive health policy, practice, and rhetoric in Turkey.

Against this backdrop, our key informants report that political discourse has impacted service delivery at the institutional and systems levels. Policy changes associated with health reform and the heightened stigma surrounding abortion have effectively shifted the practices of hospitals and clinicians. The experiences of participants in both components of our study are consistent with a recent study that indicates that family planning counselling and IUD insertions have been “virtually abandoned” as a result of the health reform initiative. ²⁴ Our results suggest that public sector abortion provision has become more limited and funding for abortion and family planning has been undermined in the last five years. Future advocacy efforts from clinicians and community-based organizations to call for reform within the public sector is critical. Efforts should focus on (re)incorporating family planning and abortion services into the performance scale for physicians and the list of reimbursed services.

Our results also suggest that the negative political discourse has created a culture around abortion-seeking in Turkey that is ambiguous and terrifying for some women to navigate. That women in our study lacked clarity regarding the abortion law is hardly surprising. Studies have demonstrated that, even when liberal abortion laws are in place, lack of knowledge among women about the abortion law creates barriers to accessing safe abortion services. ^25,26 Based on the reports of both groups of participants, it appears that the Turkish leadership has successfully created what the World Health Organization refers to as a “chilling effect”; that is, policies and practices that may ultimately deter women from seeking abortion care and dissuade clinicians from providing them because they are fearful of penalty. ²⁵ Proactive approaches to disseminate accurate information to women about the abortion law appear warranted. Even if the existing law was uniformly implemented, informants commented on the unreasonable limits placed on abortion care, especially the gestational age limit and requirement for spousal consent. Such restrictions may hinder women from accessing safe abortion care, ²⁷ therefore resources should be mobilized not only to protect the current law, but to push for reform of non-evidence based regulations.

Limitations

As is true of all qualitative research, our study does not offer findings that are generalizable or representative. Although our key informants had experiences working in and/or were able to reflect on access issues throughout the country, all of the women who participated obtained their abortion care in Istanbul. Thus, our project does not offer insight into the lived experiences of women in other regions. Further, we only interviewed women who obtained abortion care; the experiences of women who were unable to navigate the public health system or afford a procedure in the private sector are not reflected in our study. Unfortunately, despite our attempts, we were unable to interview members of the AKP, current government officials, or religious leaders and thus these perspectives are not reflected in our findings. The positionality of our research team members also influenced researcher-participant interactions and the interpretation of the data, dynamics that we reflected on through team meetings and memoing.

Conclusion

In 2014, Health Minister Müezzinoğlu defended the public defunding of abortion in Turkey by asking, “Is abortion a disease? No. Why should the government pay for it? The laws have not changed.” ²⁸ Our results support the argument that the unique intersection of neo-conservative and neo-liberal values under the AKP has led to a resulting “politics of the intimate” that overemphasizes the importance of motherhood, and procreation, while undermining the importance of women’s choices and lives. ²⁹ Although abortion remains legal, the Turkish leadership has successfully created a climate that hinders abortion provision and stigmatizes the procedure, in turn impacting women’s lived experiences obtaining services.

Conflicts of interest

The authors declare that they have no conflicts of interest, financial or otherwise.

Acknowledgements

The authors would like to acknowledge the funding received for this project from the University of Ottawa Centre for Global and Community Engagement and the Mitacs Globalink Research Award. Dr. Foster’s Endowed Chair in Women’s Health Research is funded by the Ministry of Health and Long-Term Care in Ontario and we appreciate the support for her time that made this project possible. We would also like to thank Drs. Kathryn Trevenen and Raywat Deonandan for their input on this project. Finally, we would like to express our gratitude to the Kadir Has Gender and Women’s Studies Research Center in Istanbul for hosting KM during her fieldwork. The conclusions and opinions expressed in this article are those of the authors and do not necessarily represent the views of the organizations with which the authors are affiliated or the funders.