Abstract

The National Abortion Survey 2021 (PNA 2021) utilized face-to-face structured interviews and a self-administered questionnaire placed in a sealed box to collect data on abortions in Brazil. Interviews were held with a nationally representative sample of 2,000 women, randomly selected from among literate women ages 18 to 39 residing in urban areas. We compared some of the results with previous waves of the survey, PNA 2010 and PNA 2016. Findings show that abortion is in decline but remains a major public health issue. Around 10% of the women interviewed in 2021 said they had had at least one abortion in their lives (compared to 15% in 2010). We estimate that nearly one in every seven women (15%) have had an abortion by the age of 40. We identified a decline in the proportion of women who needed to be hospitalized to finalize their abortions (55% in 2010; 43% in 2021; p = 0.003) and in the proportion of women who used medication for the abortion (48% in 2010; 39% in 2021; p = 0.028). Abortion is an event that generally happens early on in women’s reproductive lives: the PNA 2021 found that 52% of women were 19 years old or younger when they had their first abortion. Higher rates were detected among respondents with lower educational levels, Black and Indigenous women, and women residing in poorer regions.

Palavras-chave:
Aborto induzido; Inquéritos epidemiológicos; Brasil

Resumo

A Pesquisa Nacional de Aborto 2021 (PNA 2021) empregou questionários estruturados face a face e um questionário autoadministrado depositado em uma urna para coletar informações sobre aborto no Brasil. As entrevistas foram realizadas em uma amostra representativa de 2.000 mulheres selecionadas aleatoriamente com idades entre 18 e 39 anos e residentes em áreas urbanas. Comparamos alguns dos resultados com ondas anteriores da pesquisa, PNA 2010 e PNA 2016. O aborto está em declínio, porém segue como importante questão de saúde pública. Cerca de 10% das mulheres em 2021 disseram ter feito ao menos um aborto na vida (15% em 2010). Estimamos que aproximadamente uma em cada sete mulheres (15%) teve um aborto aos 40 anos. Houve declínio na proporção de mulheres que foram hospitalizadas para finalizar o aborto (55% em 2010; 43% em 2021; p = 0,003) e na proporção de mulheres que usaram medicamentos para o aborto (48% em 2010; 39% em 2021; p = 0,028). O aborto é um evento que ocorre no início na vida reprodutiva das mulheres: a PNA 2021 constatou que 52% tinham 19 anos ou menos quando fizeram o primeiro aborto. Taxas mais altas foram detectadas entre as entrevistadas com menor escolaridade, negras e indígenas e residentes em regiões mais pobres.

Palavras-chave:
Aborto induzido; Inquéritos epidemiológicos; Brasil

Introduction

Abortion is only legal in Brazil if the pregnant person’s life is at risk, if the pregnancy is the result of a rape, or in cases of fetal anencephaly. Despite these legal restrictions, data from the National Abortion Survey for 2010 (PNA 2010) and 2016 (PNA 2016), which used self-administered questionnaires deposited in sealed boxes (‘ballot boxes’) to reduce the rate of false answers, found that abortion is a common event in the reproductive lives of Brazilian women¹1 Diniz D, Medeiros M. Abortion in Brazil: a household survey using ballot box technique. Cien Saude Colet 2010; 15(Suppl. 1):959-966.^,22 Diniz D, Medeiros M, Madeiro A. National Abortion Survey 2016. Cien Saude Colet 2017; 22(2):653-660.. According to PNA 2010 and 2016, approximately one in five women had had at least one abortion by the age of 40, with higher rates detected among respondents with lower educational levels, Black and Indigenous women, and women residing in poorer regions¹1 Diniz D, Medeiros M. Abortion in Brazil: a household survey using ballot box technique. Cien Saude Colet 2010; 15(Suppl. 1):959-966.^,22 Diniz D, Medeiros M, Madeiro A. National Abortion Survey 2016. Cien Saude Colet 2017; 22(2):653-660.. PNA 2019, which was conducted only in Northeast Brazil, corroborates these findings regionally³3 Diniz D, Medeiros M, Madeiro A. Brazilian women avoiding pregnancy during Zika epidemic. J Fam Plann Reprod Health Care 2017; 43(1):80..

Methods

The PNA 2021 household survey was fielded during November 13-21, 2021. Interviews were held with a representative sample of 2,000 women, randomly chosen from among literate women ages 18 to 39 residing in urban areas. The cluster sampling was done in three stages: 125 municipalities were selected using the probability proportional to size (PPS) method; clusters were next selected from census tracts; and, lastly, a fixed number of people were selected within each cluster, controlling for age, educational level, and employment status. The margin of error was ± 2% and the confidence interval was 95%.

Two data collection instruments were used. The first was a face-to-face structured interview consisting of a series of socio-demographic questions, including age, educational level, household income, type and size of municipality, religion, race, marital status, occupation, and number of live births. The second was a self-administered questionnaire which the respondent filled out and then placed in a sealed box (‘ballot box’); this questionnaire asked questions about abortion (“Have you ever had an abortion?”, “How many abortions have you had?”, “Age at first abortion,” “Age at last abortion,” “Did you have an abortion in 2020?”, “Did you use medication for your last abortion?” and “Did you need to be hospitalized during your last abortion?”). The two questionnaires were linked using cryptographic codes to ensure confidentiality. Unlike PNA 2010 and PNA 2016, PNA 2021 included a question about the respondent’s age at the time of their first abortion. The three PNA surveys used the same sampling design, interview methods, and self-administered questionnaire design. For purposes of analysis, data from PNA 2021 (n = 2,000) were compared with data from PNA 2010 (n = 2,002) and PNA 2016 (n = 2,002), with the p-values for the difference in proportions presented in brackets. The research project was approved by the Research Ethics Committee of the Institute of Human Sciences at the University of Brasília.

Abortion is a cumulative event; therefore, the age structure of the population may affect the results. In order to control this, we present an estimate of the proportion of women who had had one or more abortions by the age of 40. This estimate is based on the adjustment of a trendline obtained by linear regression of the proportion of abortions by age, from 18 to 39 years, and extrapolating the line to the age of 40 years. This line has a constant = - 0.0227, and the parameter for age, = 0.0044 (r² = 0.34).

Results and discussion

In PNA 2021, the abortion rate dropped in comparison with the 2010 and 2016 surveys. Table 1 shows that around 10% of the women interviewed in 2021 said they had had at least one abortion in their lives, compared with 13% in 2016 and 15% in 2010 (p = 0.014 for 2016-2021; p = 0.000 for 2010-2021). This finding may reflect the worldwide decline in unwanted pregnancies, including rates in developing countries⁴4 Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model. Lancet Glob Health 2018; 6(4):e380-e389.. Data from Latin America and the Caribbean show an upward trend in the use of reversible and long-acting contraceptive methods, although disparities are more prevalent among women who are younger and poorer, have a lower educational level, are Indigenous, or live in rural areas⁵5 Ponce de Leon RG, Ewerling F, Serruya SJ, Silveira MF, Sanhueza A, Moazzam A, Becerra-Posada F, Coll CVN, Hellwig F, Victora CG, Barros AJD. Contraceptive use in Latin American and Caribbean with a focus on long-time reversible contraceptives: prevalence and inequalities in 23 countries. Lancet Glob Health 2019; 7(2):e227-e235.. Despite the increase in contraception, PNA 2021 found a still high proportion of unintended pregnancies. In 2021, two in every three pregnant women (66%) had not planned that pregnancy (not shown in Table 1).

In 2021, the PNA asked for the first time about the total number of abortions that a woman had had in her reproductive life. Among those who have had an abortion, more than ⅕ (21%) have had two or more abortions (67% had the last abortion between 20-39 years old; 74% among Black women; not shown in Table 1). This data reveals a sub-group of women who face heightened vulnerability in their reproductive lives and are likely exposed to increased negative health outcomes. Studies have shown that offering post-abortion counseling and increasing access to and availability of contraceptive methods are the most efficient mechanisms to prevent repeated unsafe abortions⁶6 Huber D, Curtis C, Irani L, Pappa S, Arrington L. Postabortion care: 20 years of strong evidence on emergency treatment, family planning, and other programming components. Glob Health Sci Pract 2016; 4(3):481-494..

Results from PNA 2021 also indicate a decrease in the proportion of women who needed to be hospitalized to finalize their abortions (55% in 2010; 43% in 2021, p = 0.003); the same phenomenon is observed when analyzing the number of hospitalizations at public hospitals over the last ten years that were related to abortion complications⁷7 Uliana MD, Marin DFD, Silva MBD, Giugliani C, Iser BM. Hospitalization due to abortion in Brazil, 2008-2018: an eco-logical time-series study. Epidemiol Serv Saude 2022; 31(1):e2021341.. The use of safer abortion methods, the falling abortion rate, or both of these factors may explain these findings⁴4 Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model. Lancet Glob Health 2018; 6(4):e380-e389.^,88 Gomperts R, van der Vleuten K, Jelinska K, Costa CV, Gemzell-Danielsson K, Kleiverda G. Provision of medical abor-tion using telemedicine in Brazil. Contraception 2014; 89(2):129-133.. Little research has been conducted to date on how the COVID-19 pandemic has affected the fall in hospitalizations⁹9 Fulcher IR, Onwuzurike C, Goldberg AB, Cottrill AA, Fortin J, Janiak E. The impact of COVID-19 pandemic on abor-tion care utilization and disparities by age. Am J Obstet Gynecol 2022; 226(6):819.e1-819.e15..

Similarly, PNA 2021 found that the proportion of women who had medical abortions fell, from 48% in 2010 to 39% in 2021 (p = 0.028). While none of the three surveys asked respondents which specific medication they used to have an abortion, other studies have found that misoprostol is the most common choice in Brazil¹⁰10 Diniz D, Medeiros M. Itineraries and methods of illegal abortion in five Brazilian state capitals. Cien Saude Colet 2012; 17(7):1671-1681.. One possible explanation to account for the lower rate of medical abortions might be a higher rate of in-clinic abortion care¹⁰10 Diniz D, Medeiros M. Itineraries and methods of illegal abortion in five Brazilian state capitals. Cien Saude Colet 2012; 17(7):1671-1681.^,1111 Silveira P, McCallum C, Menezes G. Personal experiences with induced abortions in private clinics in Northeast Brazil. Cad Saude Publica 2016; 32(2):e00004815., especially among middle- and high-income women; however, this is hard to know given the criminalization of abortion in Brazil.

One important finding from PNA 2021 was the age of respondents at the time of their first abortion: half (52%) were adolescents (19 or younger). Since this population is especially vulnerable to the effects of criminalization on abortion needs¹²12 Sedgh G, Finer LB, Bankole A, Eilers MA. Adolescent pregnancy, birth, and abortion rates across countries: levels and recent trends. J Adolesc Health 2015; 56(2):223-230., the finding demonstrates the critical need for an integrated reproductive justice policy in Brazil, from comprehensive sexual education to the decriminalization of abortion. In general terms, there was no substantial change in the overall profile of women who had abortions: they reflect all age ranges, religions, educational levels, races, social classes, and geographical regions.

Over the last eleven years (2010-2021), evidence shows that abortion remains a common event in women’s lives and a large-scale public health issue in Brazil. A linear extrapolation from PNA 2021 data estimates that nearly one in every seven women (13%) has interrupted a pregnancy by the age of 40.

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