Population politics, reproductive governance and access to abortion in Turkey.

Turkey currently pursues an aggressive pronatalist population politics which has created wide-reaching reproductive governance regulating reproductive health care and family planning choices. One aspect of this orientation centres on restricting access to abortion services despite the fact that abortion is legal through ten weeks of pregnancy. This article uses nationwide data collected from mystery patient surveys administered to all public (in 2016 and 2020), and all private (2021) hospitals in the country to determine the availability of abortion services in Turkey. Less than half of all hospitals responding provided abortions to the full extent provided by law. Abortion without restriction as to reason was largely unavailable at public hospitals and the cost of care at private hospitals remained prohibitive for many. Among those hospitals we reached, in four provinces, there was no public or private hospital providing any type of abortion care. The most frequent explanation for the lack of abortion services was that abortion is illegal. This was particularly the case for public hospitals. Despite a 10-week cutoff for abortions, 39% of private hospitals responding to the survey invoked even earlier time limits creating further restrictions. The extreme pronatal orientation of the reproductive governance currently in place has created a state of reproductive injustice that makes enhanced access to abortion of vital importance.

The availability of emergency contraception from family health centers in Turkey.

Reproductive health care, including contraception, is a fundamental aspect of any public health care system and it is important to reduce barriers to access to all forms of contraception, including emergency contraception. In recent years, the rhetoric of pronatalism in Turkey has come to dominate and raises questions about the availability of reproductive health care services, in particular contraception, from state run facilities. This study aimed to determine the availability of dedicated emergency contraception (EC) from government run Family Health Centers (FHCs) in Turkey. In 2019, a team of trained researchers called a random sample of 583 FHCs located in the largest cities in twelve regions across Turkey asking for dedicated EC. Dedicated EC is largely unavailable from government supported FHCs. Only 6.1% stated that they provided EC while 53.8% stated that it was not available and that they could provide no alternative. A further 28.3% declared that they could provide an alternative to dedicated EC that almost always consisted of oral contraceptives. We found statistically significant variations in response rate and availability among cities as well as the rate of referral to pharmacies. There is little access to EC from government sponsored health clinics designated to provide family planning services, which hinders access to an essential reproductive health care service that should be available to women everywhere.

Abortion services at hospitals in Istanbul.

OBJECTIVE: Despite the existence of a liberal law on abortion in Turkey, there is growing evidence that actually securing an abortion in Istanbul may prove difficult. This study aimed to determine whether or not state hospitals and private hospitals that accept state health insurance in Istanbul are providing abortion services and for what indications. METHOD: Between October and December 2015, a mystery patient telephone survey of 154 hospitals, 43 public and 111 private, in Istanbul was conducted. RESULTS: 14% of the state hospitals in Istanbul perform abortions without restriction as to reason provided in the current law while 60% provide the service if there is a medical necessity. A quarter of state hospitals in Istanbul do not provide abortion services at all. 48.6% of private hospitals that accept the state health insurance also provide for abortion without restriction while 10% do not provide abortion services under any circumstances. KEY CONCLUSIONS: State and private hospitals in Istanbul are not providing abortion services to the full extent allowed under the law. The low numbers of state hospitals offering abortions without restriction indicates a de facto privatization of the service. This same trend is also visible in many private hospitals partnering with the state that do not provide abortion care. While many women may choose a private provider, the lack of provision of abortion care at state hospitals and those private hospitals working with the state leaves women little option but to purchase these services from private providers at some times subtantial costs.

The availability of abortion at state hospitals in Turkey: A national study.

INTRODUCTION: Abortion in Turkey has been legal since 1983 and remains so today. Despite this, in 2012 the Prime Minister declared that, in his opinion, abortion was murder. Since then, there has been growing evidence that abortion access particularly in state hospitals is being restricted, although no new legislation has been offered. OBJECTIVES: The study aimed to determine the number of state hospitals in Turkey that provide abortions. STUDY DESIGN: The study employed a telephone survey in 2015-2016 where 431 state hospitals were contacted and asked a set of questions by a mystery patient. If possible, information was obtained directly from the obstetrics/gynecology department. I removed specialist hospitals from the data set and the remaining data were analyzed for frequency and cross-tabulations were performed. RESULTS: Only 7.8% of state hospitals provide abortion services without regard to reason which is provided for by the current law, while 78% provide abortions when there is a medical necessity. Of the 58 teaching and research hospitals in Turkey, 9 (15.5%) provide abortion care without restriction to reason, 38 (65.5%) will do the procedure if there is a medical necessity and 11 (11.4%) of these hospitals refuse to provide abortion services under any circumstances. There are two regions, encompassing 1.5 million women of childbearing age, where no state hospital provides for abortion without restriction as to reason. CONCLUSION: The vast majority of state hospitals only provide abortions in the narrow context of a medical necessity, and thus are not implementing the law to its full extent. It is clear that although no new legislation restricting abortion has been enacted, state hospitals are reducing the provision of abortion services without restriction as to reason. IMPLICATIONS: This is the only nationwide study to focus on abortion provision at state hospitals.

"It was as if society didn't want a woman to get an abortion": a qualitative study in Istanbul, Turkey.

INTRODUCTION: In 1983, abortion without restriction as to reason was legalized in Turkey. However, at an international conference in 2012, the Prime Minister condemned abortion and announced his intent to draft restrictive abortion legislation. As a result of public outcry and protests, the law was not enacted, but media reports suggest that barriers to abortion access have since worsened. OBJECTIVES: We aimed to conduct a qualitative study exploring women's recent abortion experiences in Istanbul, Turkey. STUDY DESIGN: In 2015, we conducted 14 semi-structured in-depth interviews with women aged 18 or older who had obtained abortion care in Istanbul on/after January 1, 2009. We employed a multimodal recruitment strategy and analyzed these interviews for content and themes using deductive and inductive techniques. RESULTS: Women reported on a total of 19 abortions. Although abortion care is available in private facilities, only one public hospital provides abortion services without restriction as to reason. Women who had multiple abortions in different facility types described quality of care more positively in the private sector. Unmarried women considered their marital status when making the decision to seek an abortion and reported challenges obtaining comprehensive sexual and reproductive health services. All participants were familiar with the Turkish government's antiabortion discourse and believed that this was reflective of an overarching desire to restrict women's rights. CONCLUSION: Public abortion services in Istanbul are currently limited, and private abortion services are accessible but relatively expensive to obtain. Recent antiabortion political rhetoric appears to have negatively impacted access and service quality. IMPLICATIONS: This is the first qualitative study exploring women's experiences obtaining abortion services in Turkey since the proposed abortion restriction in 2012. Further research exploring the experiences of unmarried women and abortion accessibility in other regions of the country is warranted.

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

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.