FIGO WORKING GROUP ON PREVENTION OF UNSAFE ABORTION
TURKEY SITUATIONAL ANALYSIS
Dr Berna Bernar-Dilbaz
UNWANTED PREGNANCIES

Incidence of unwanted pregnancies
According to 2003 Turkish Demographic Health Survey (TDHS-2003)
results 1 780 556 pregnancies per year is expected and 201 203 of these
pregnancies are terminated (voluntary termination of pregnancy).
According to the same survey (2003) the percentage of married women
who do not want to have any more children is 69.2%.
The percentage of voluntary termination of pregnancy is 11.3 per 100
pregnancies according to TDHS-2003, remarkably lower then the figure
reported in TDHS-1998 which is 14.5 per 100 pregnancies .
Regional distribution of women who do not want
to have any more children (%)
Turkey: DHS 1998 : 66,3
DHS 2003 : 69,2
80,0
70,0
70 68,6 71,7 72,8
60,0
50,0
65,2 63,9 69,7 69,8 64,5
62,6
40,0
30,0
20,0
10,0
1998
West
South
2003
Central
North
East
.

Vulnerable groups (refugees, internally displaced populations, youth, HIV
positive women, rural population, etc)

Rural population, internally displaced populations and youth
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
Determinants of unwanted pregnancies (including access to contraceptive
and contraceptive and user failure, violence against women, and lack of
social support of pregnant women).
According to TDHS-2003; 24.4 % of the women who had voluntary
termination of pregnancy used no contraceptive method one month
prior to thie unwanted pregnancy whilst 46.1% used coitus interruptus.
Only 23% of these unwanted pregnancies that ended up with
termination of pregnancy occured while using a modern contraceptive
method.

Characteristics of women with unwanted pregnancies(health, poverty, etc)

The risk factors for voluntary termination of pregnancy are using a
traditional method, especially coitus interruptus and having a
previous pregnancy just before having this unwanted pregnancy.
Uneducated women, women living in rural areas, adolescents are at
higher risk for unwanted pregnancies due to the difficulties in
reaching family planning methods and FP services.

Consequences of unwanted pregnancies

The total fertility rate is 2.2 whereas the desired fertility rate is 1.6
This figures show that some of the unwanted pregnancies end up
with abortion while some of the babies are delivered. The difference
between the total fertility rate and desired fertility rate is higher
among uneducated women and women living in rural areas.

Barriers to certain methods (providers and health system barriers)
It is hard for women living in rural areas to reach the health services.
For women who have immigrated to the cities reaching the health
service delivery system is difficult.
INTERVENTIONS TO PREVENT UNWANTED PREGNANCIES AND INDUCED
ABORTIONS
Contraceptive information and services including EC

Overall and method specific prevalence rate
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According to the Turkish Demographic Health Survey (2003) 71% of the
married women are using a contraceptive method. Modern methods are
used by 43% of the married women while 29% are using a traditional
method such as withdrawal, vaginal douching etc..
The odds ratio of traditional method use vs modern methods is
increased by:
1. increasing age of woman
2. decreasing educational status(man and woman)
3. husband’s disapproval of FP
4. having no child or only one child
Distribution of contraceptive methods among married women:
IUD
20.2%
Condom
10.8%
Female sterilization
5.7%
COC
4.7%
Diaphram
0.6%
Injectables
0.4%
Vasectomy
0.1%
Modern
methods:42.5%
Withdrawal (coitus interruptus)
26.4%
Calendar
1.1%
Lactational amenorrhea
0.6%
Other traditional methods
0.4%
Traditional
methods
28.5%
Percentage of married women who are not using any contraceptive
method: 29%
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Changing trends in Turkey:
Total fertility rates
6,00
5,00
4,00
3,00
TFR(%)
2,00
1,00
0,00
1970
1993
1998
2003
Changing trends in
contraceptive use in Turkey
80,00
70,00
60,00
50,00
40,00
Modern
30,00
Traditional
71%
20,00
10,00
0,00
1988
1993
1998
2003
There is not a wide difference between the geographic regions in terms
of the rate of the women who do not want to have any more children but
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there is a remarkable difference between the prevalance of modern
method use from one region to another one and urban to rural areas
Regional differences in
contraceptive use, Turkey (%)
80
70
60
50
Contraceptive use
40
30
Modern methods
20
10
0
East
South
West Central North
Regional Distribution of FP Method use
1998-2003
80
74
74
71
72
70
58
60
50
40
30
20
10
0
West
South
1988

Central
1993
1998
North
East
2003
Which methods are approved and sold in the country?
Modern family planning methods available in Turkey are:
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1. Intrauterine device
2. Combined oral contraceptives
3. Injectables
4. Implant (Implanon- Organon)
5. Condom
6. Spermicides
7. Intrauterine system (LNG-IUS, Mirena)
8. Tubal ligation and vasectomy
9. Emergency contraception

Which methods are distributed for free or at subsidized price through
public or private health networks in the country?

Intrauterine devices, combined oral contraceptives, condoms and
injectables are available for the women either free or at a subsidized
price through the public health networks. Tubal ligation and
vasectomy is covered by the national social security system.
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The sources of modern family
planning methods
6% 3%
MCHC
9%
State hospital
32%
Other public
Pharmacy
Private doctor
25%
14%
Other private
11%
Others

Sources of most widely used FP
methods (%) (Turkish DHS, 2003)

Tubal
ligation
Oral
contraceptives
IUD
Condom
Public
82.0
30.6
71.3
34.1
Private
16.3
67.5
27.6
59.3
Other
1.7
1.9
1.1
6.6
Which is the real availability of methods in the public health services
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
All the methods are available in the public health services but the
social security system does not cover Implanon or Mirena, the
clients have to pay for tem.

What data are available on access to methods by young people,
unmarried women and other marginalized groups (rural people,
indigenous groups, refugees IDPs). [L]

All of the Mother and Child Health Care Units (Ministry of Health)
keep records about family planning method use and characteristics
of the clients. There are “Youth Centers” (MOH) and “Medicosocial
Departments” (Universities) that aim to serve young people.
Unmarried women can apply for counseling and get family planning
method, there is no legal or regulatory obstacle for this.
Comprehensive Sexuality Education

What is the current situation of knowledge among women and men on
sexuality education?

Knowledge abou reproductive health is given in the 7th grade
onwards.

Are there governmental programs for comprehensive sex education?

No

How comprehensive is the coverage of sexuality education programs? Out
of school youth?

No, but the counseling sessions provide by Mother and Child Health
Care Centers partially covers sexual health issues.

How comprehensive and adequate is the training of teachers to provide
sexuality education?

No specific training

Which is the technical orientation (scope and content) of the existing
programs?

There are some EU projects that aim to improve the sexual health
issues on certain targeted populations.
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Social protection of pregnant women and mothers of small children

Is employment of pregnant women protected by law during pregnancy and
after delivery and for how long?

No.

Is the law enforced?

How long is the legal parental leave? Is it paid? Is it the same for all
populations within the country?

The legal maternal leave is 8 weeks before delivery and 8 weeks after
delivery. The antenatal leave is 10 weeks for mothers with multiple
pregnancies.

Is maternal breast feeding effectively protected for working women?

The postpartum patients can apply for payless maternity leave for 1
year after their maternal leave without losing their job. The women
who return to work after their 8 weeks maternity leave are entitled to
use one hour maternity brake per day for one year after delivery for
breast feeding

How is the compliance with the law on parental leave and maternal breast
feeding?

The compliance is high but there is no law to protect the employment
of pregnant women during pregnancy in the private sector.

Are there sufficient whole day nurseries, preschool and school for the
children of working women?

Yes, there are kindergardens, preschools in most parts of the
country for working women but nurseries are not that widely
available.
Adoption

Is there support for women who wish to give baby to adoption?

The babies who are not wanted by their families have to be accepted
by the “Social Services” and then a family for adoption is arranged .

Is there an effective procedure for adoption in the country?
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
There is an effective procedure for adoption but the waiting list is
very long. There are also some families who want to leave their
children to “Social Services” and refuse adoption; these children are
raised by the government orphanages. The children in the
orphanages can have “protector families” who will partially take care
of these children without actually adapting them.
ABORTION

Incidence
According to 2003 Turkish Demographic Health Survey (TDHS-2003)
results 1 780 556 pregnancies per year is expected and 201 203 of these
pregnancies are terminated (voluntary termination of pregnancy).

The percentage of voluntary termination of pregnancy is 11.3 per 100
pregnancies according to TDHS-2003

Reliability of data

TDHS is a reliable source and these figures about abortion are not
official data ontained from the Ministry but actually from the women
interviewed.

Sources of data

Ministry of Health General directorate of Mother and Child Health
Care keeps records of all voluntary termination of pregnancies. The
records of the procedures carried out at public sector can be
missing.
UNSAFE ABORTION

Incidence

No national statistics are available

What data are available on the magnitude and severity of the problem of
unsafe abortion?

The records of Ministry of health show 35 115 voluntary of
terminations in 2007 but none of them were recorded as unsafe
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abortion. Tukish Society of Obstetrics and Gynecology will ask the
reported casesof unsafe abortions from the maternity hospitals.


Source of data

Characteristics of women who come for abortion (age, place of residence,
marital status, income)

Characteristic of providers of unsafe abortion and method used

Availability of misoprostol, is it registered/approved, what indications?
Distribution channels, cost?

Misoprostol is available in Turkey but it is registered for
nonobstetrical indications.
Quality of the care of women consulting for complications of abortion

Which methods are used in the country for incomplete abortion? Who can
provide these methods?

D&C, MVA are available but these services are not given at the
primary health care facilities, so the patients need to apply to a
hospital at the state sector. These services are also avaliabe at the
private sector.

Which is the real availability of those methods in the public health
services, and how much they cost?

For women under social security cover, these procedures are free of
charge.

How is the access to treatment of incomplete abortion services by young
people, unmarried women and other marginalized groups (rural people,
indigenous groups, refugees, IDPs)?

There are no national statistics on this matter.

Is physicians and other health professionals training following WHO
recommended methods for treatment of incomplete abortion?

The obstetrician are entitled to handle the incomplete abortion
cases.
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
Is the country implementing WHO guidance?

Ministry of health is working on protocols for emergency obstetric
care and these protocols are implementing WHO guidance.
Consequences of Unsafe Abortion

The abortion related maternal mortality [C]

All the cases of maternal mortality is evaluated by a committee under
Ministry of Health’s Mother and Child Care Divison. The results will be
obtained from them.

Magnitude and severity of complications of unsafe abortion

Is there an established national level mechanism for monitoring and
evaluation of maternal mortality and morbidity resulting from unsafe
abortion?

All the maternal mortalities are recorded and analyzed by Ministry of
Health .

Cost of unsafe abortion to the health system, women and families
LEGAL SITUATION OF ABORTION AND REGULATORY FRAMEWORK
International standards
National Laws

To save the women’s life

To preserve women’s physical health

To preserve women’s mental health

To preserve women’s health (no specification)

Pregnancy resulting from rape

Severe fetal malformation

Socioeconomic reasons

Women’s choice
Regulatory framework-key elements
Provision of Legal Abortion Services
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
Is the law being complied with for each legal indication?

Yes, abortion on voulantary basis –up to 10 weeks of pregnancy has
been legal in Turkey since 1983

Which methods are used in the country for legal abortion?

MVA and D&C

Which is the real availability of those methods for legal abortion services in
the public health services, and how much they cost?

How is the access to legal abortion services by young people, unmarried
women and other marginalized groups (rural people, indigenous groups,
refugees).

Is the physician and mid level provider training following the WHO
recommended methods for legal abortion?

Is the country implementing the WHO recommended list of essential
medicines that includes mife/miso and essential commodities list of WHO
and UNFPA that includes MVA? Are these being used?

Are FIGO Ethics Committee Recommendations recognized and followed
by the OBGYN society? Extend this point.
In situations of restrictive laws:

Are women being prosecuted and jailed after induced abortion?

No, induced abortion is legal up to 10 weeks of pregnancy. Induced
abortion after 10 weeks can only be performed in the presence of a
maternal disease worsened by pregnancy or a fetal abnormality
incompatable with life.

Are health providers/facilities following the ethical principle of
confidentiality of health records in the care of women with induced
abortion?

Yes

What are the consequences for physicians and other health
professionals?
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
Are professionals being prosecuted and jailed for providing induced
abortion?

No, if the abortions are carried out within legal limits and conditions.
Page 14 of 14