Induced abortion is characterized by the deliberate termination of pregnancy and represents a prevalent reproductive phenomenon, with an annual occurrence exceeding 73 million instances [1]. During the period from 2015 to 2019, it is estimated that approximately 48% (equivalent to 121 million) of all pregnancies globally were unintended. Among these occurrences, induced abortion constituted 61% (equivalent to 73 million) of the cases [2]. In Iran, accurate statistics on abortion are not available due to the sensitive nature of the issue. Nevertheless, there has been a noticeable increase in abortion rates in Iran over the last decade [3].
In Iran, the regulations pertaining to induced abortion are distinguished by stringent guidelines and restricted circumstances under which the procedure is allowed. The general stance is that induced abortion is prohibited unless specific conditions are met. These conditions include situations where there is a substantial threat to the mother's life or when the fetus has been diagnosed with a recognized disease or defect that is considered an exception by the Legal Medical Organization of the country [4]. The exception for cases involving a threat to the woman's life recognizes the importance of safeguarding maternal health and prioritizing life preservation in critical situations. It allows for the termination of the pregnancy when necessary to protect the woman from severe harm or potential loss of life. Another exception applies to cases where the fetus has been diagnosed with a recognized disease or defect. The Legal Medical Organization of Iran evaluates individual cases to determine whether the diagnosed condition qualifies as an exception for induced abortion. This approach acknowledges the complexities of certain medical circumstances and permits the termination of pregnancies when the fetus's health or quality of life is significantly compromised [5]. If these conditions are not met, women seeking to terminate their unwanted pregnancies have no alternative but to resort to clandestine and potentially hazardous abortion methods [4].
Unsafe abortion is a significant factor contributing to maternal mortality globally [6]. However, there is limited information available regarding the extent of maternal mortality and the associated health risks related to unsafe abortions in Iran. A study conducted by Zalvand et al. emphasized the role of abortion as a direct contributor to maternal mortality in Iran [7]. Moreover, according to an indirect estimation, approximately 5% of maternal fatalities associated with pregnancy can be ascribed to complications associated with postabortion interventions [8].
The literature documented the various consequences of unsafe abortion, including physical complications such as sepsis, hemorrhage, and genital trauma [9]. The repercussions of induced abortion extend beyond individual consequences and have wider ramifications for the healthcare system. Addressing these complications necessitates substantial resource allocation, encompassing hospital beds, blood supply, medications, and other essential healthcare services [10]. Furthermore, induced abortion also has implications for the demographic situation of the country; despite Iran's population experiencing an overall increase based on the most recent census conducted in 2016, there has been a decrease in the total fertility rate (TFR) coupled with an increase in life expectancy, leading to rapid growth of the elderly population. Notably, that Iran is undergoing an aging process at a faster pace than other nations [11, 12]. The decision to undergo induced abortion is influenced by a range of factors that are often unique to individuals and can vary significantly. Individual factors encompass aspects such as marital status, experiences of sexual assault or familial abuse, financial self-sufficiency, and level of educational achievement. Interpersonal factors include considerations of the partner's circumstances and the availability of parental support. Societal determinants include social norms, religious beliefs, stigmatization related to premarital and extramarital sexual activity, adolescent status, and societal autonomy. Organizational factors include the quality and accessibility of sex education, the healthcare system, and the legal framework surrounding abortion [13–16].
Although the determination to either terminate or proceed with an unintended pregnancy is commonly regarded as a personal issue, the involvement of spouses in reproductive behaviors and decision-making plays a pivotal role [17]. Men play a key role in matters related to sexual and reproductive health and rights (SRHR) [18]. Research has shown that involving men in reproductive health initiatives is associated with a reduced likelihood of unsafe abortions [19]. Previous studies on decision-making regarding pregnancy termination have focused primarily on women's preferences and perspectives. However, it is important to recognize that decisions concerning pregnancy are often influenced by the male partner, indicating the involvement of distinct fertility motives [20].
To develop effective programs aimed at preventing and reducing induced abortion, it is crucial to gain a deeper understanding of this phenomenon and its underlying factors. Therefore, this study will utilize the I-change model as an integrated framework to enhance our comprehensive understanding of induced abortion and its determinants within couples. The I-Change model is built upon the foundational framework of the Attitude Social Influence-Self-efficacy (ASE) model, which shares similarities with the Theory of Planned Behavior [21]. Nevertheless, the I-Change model incorporates supplementary components, including modeling and social support as influential factors, in addition to subjective norms. By amalgamating the ASE model with the understandings derived from stages of change models and action planning models, the I-change model presents a comprehensive framework for scrutinizing and fostering processes of behavior change [22–25].
The process of behavioral change can be categorized into three distinct phases: premotivational, motivational, and postmotivational. Each phase is characterized by specific determinants that contribute to the overall change process. During the premotivational phase, the key focus lies in creating awareness, where factors such as behavioral cognizance (consciousness of one's own behavior), knowledge (comprehension of the behavior and the associated information that stimulates action), risk perception (evaluation of the probability and severity of a health threat), and cues to action (internal or external prompts that initiate behavior) play significant roles. The motivational phase comprises several key elements, including attitude, social influence, self-efficacy, and intention. Attitude involves the assessment of the benefits and drawbacks associated with a particular behavior, considering its positive and negative aspects. Social influence encompasses the consideration of societal norms and the opinions of individuals closely connected to the behavior, as well as the observation of others who engage in behavior and the response to social pressures exerted by the surrounding environment. Self-efficacy pertains to an individual's belief in her or his own capability to successfully perform or refrain from the behavior in question. Finally, intention denotes the conscious decision and commitment to engage in or avoid behavior based on personal goals and motivations. The postmotivational or action phase represents the stage that is most closely associated with the actual execution of the behavior. This phase encompasses various activities, including the formulation of action plans, the implementation of these plans (plan enactment), and the resolution of personal skills or barriers that may hinder the desired action [26].
The cultural and social contexts in Iran pose distinctive challenges and necessitate careful consideration in regard to the topic of abortion. The attitudes and practices surrounding abortion in the country are significantly influenced by religious and legal factors.
This study acknowledges the importance of bridging the gap between the theoretical knowledge and lived experiences of couples. By exploring the real experiences of couples, this study aimed to identify the significant factors that influence decision-making regarding abortion. It seeks to move beyond theoretical frameworks and gain insights from individuals who face complex choices in their reproductive lives. This approach allows for a deeper understanding of the contextual nuances and challenges that couples encounter when making reproductive decisions. The ultimate objective of this research is to utilize the knowledge gained to develop a program aimed at preventing and reducing abortion.