- A cross-sectional study among outpatients of a selected tertiary care hospital in SL
Abortion remains a sensitive public health and ethical issue in Sri Lanka, where it is legally permitted only to save the life of the mother. At present, expanding legal indications for abortion, particularly in cases such as foetal abnormalities remain a controversial topic in national policy discussions. Limited awareness of legal provisions, persistent stigma, and the occurrence of unsafe abortions highlight the importance of understanding public perceptions toward abortion legalisation and the factors influencing these attitudes.
Methodology
A descriptive cross-sectionally-designed study was conducted among 371 adult outpatients attending the tertiary care Colombo South Teaching Hospital in Kalubowila (an urban setting), selected using systematic sampling, to explore perceptions towards the legalisation of abortion and the factors associated with these perceptions. The participants represented individuals from diverse social backgrounds including a wide range of age groups, educational backgrounds, employment statuses, and religious affiliations. Data were collected using a pre-tested, structured, validated interviewer-administered questionnaire.
Results
The majority was female (233/62.8 per cent), married (226/60.9%), Buddhist (281/75.7%) and educated up to the General Certificate of Education Advanced Level (236/63.6%). Overall, 321/86.5% showed a supportive, though conditional perception towards the legalisation of abortion in Sri Lanka. Among the participants who indicated that abortion should be legalised in certain circumstances (263/70.89%), most supported legalisation in situations such as there being risk to the mother’s life (170/70.1%), foetal abnormalities (139/57.4%) and rape/incest (121/50.1%), while support for unwanted pregnancy/failed contraception (38/15.9%) and socio-economic reasons (26/10.8%) remained low. A total of 210/56.5% of the participants had good knowledge regarding abortion. Significant associations with supportive perception were observed among those of a younger age, of the Buddhist faith, being employed and a higher education level.
Discussion
The study demonstrated that perceptions towards the legalisation of abortion among the study population were generally favourable, with a large majority of the participants demonstrating a supportive overall perception (86.5%). More than half had good knowledge regarding abortion (56.5%). Acceptance of abortion legalisation was largely conditional, with approximately 70.9% supporting legalisation only under specific circumstances rather than unrestricted legalisation.
Perception towards abortion legalisation varied across several sociodemographic factors. Statistically significant differences were observed with respect to age, religion, the employment status and the school education level.
Perception towards the legalisation of abortion
The high proportion of participants demonstrating a supportive perception towards abortion legalisation (86.5%) suggests the increasing recognition of abortion as an important public health issue. This finding was anticipated, considering the emphasis placed on unsafe abortion and maternal health in both local and global literature. However, support for legalisation was predominantly conditional. Acceptance was the highest for medically justified situations, particularly when there was a risk to the mother’s life (70.1%), in cases of foetal abnormalities (57.4%), and in rape/incest (50.1%), while support for unwanted pregnancy or contraception failure (15.9%) and socio-economic reasons remained low (10.8%). A substantial proportion believed that legalisation would reduce unsafe or illegal abortions (67.9%) and maternal deaths (63.6%). This perception aligns with established public health evidence showing that restrictive abortion laws are associated with higher rates of unsafe abortion.
Several studies report findings compatible with the supportive perception observed. A systematic review and meta-analysis on attitudes toward safe abortion care among healthcare providers in Ethiopia reported an overall pooled prevalence of 56% of favourable attitudes. A descriptive cross-sectional study among university students in Nigeria reported that 70.4% demonstrated a supportive perception towards abortion. Similarly, a cross-sectional study among health workers in Ghana found that 64.27% demonstrated a favourable perception, while a qualitative study among healthcare workers in Nepal reported generally positive perceptions toward abortion legalisation (65.7%). A community-based cross-sectional study conducted in Ethiopia also reported that 56% preferred abortion legalisation. Furthermore, a mixed-methods study conducted in the United States (US) reported increasingly supportive perceptions toward abortion legalisation over time, reflecting evolving social attitudes. Within the Sri Lankan context, a community-based study conducted in Colombo reported a high overall supportive perception of 89%, mainly due to the study population being of reproductive age. These findings collectively support the overall trend of the favourable perception observed.
However, some studies report contrasting findings with lower levels of supportive perception toward abortion legalisation. A descriptive cross-sectional study assessing attitudes among youth aged 18–30 years in Namibia reported that a substantial proportion (60%) disagreed with abortion legalisation, with less than half (40%) expressing agreement which may be related to the stronger influence of sociocultural norms among adolescents and young adults. Additionally, the Family Planning Association of Sri Lanka reported that only 28% of community leaders demonstrated a positive perception toward abortion legalization, reflecting the more conservative viewpoints typically held by community leadership groups influenced by cultural and religious values. Compared to these findings, the present study indicates a substantially higher level of supportive perception (86.5%). These differences may be explained by variations in study populations, the sociocultural context, and exposure to healthcare settings, as the present study was conducted among adults attending a tertiary care Hospital where awareness of maternal health issues may be greater.
Despite the overall supportive perception observed, the pattern of conditional acceptance closely resembles findings from other Sri Lankan studies. A 2016 study reported that acceptance was the highest when the mother’s life was in danger (89%), in cases of rape (65%), incest (55%), and foetal abnormalities (53%), while support for contraceptive failure (6%) and adverse economic conditions (7%) remained notably low. Similarly, a 2023 study reported that approximately half of the respondents supported legalisation in cases of rape (49.6%) and incest (45.6%), with higher support for lethal foetal abnormalities (75.2%), while support remained limited for contraceptive failure (13.7%) and economic hardship (9.1%), and only 5.3% agreed with abortion on request. The present study reflects a comparable pattern where acceptance is largely confined to severe medical or morally compelling circumstances rather than unrestricted personal choice. Both studies therefore demonstrate that abortion legalisation in Sri Lanka continues to be viewed within restrictive ethical boundaries. Findings from healthcare professionals also demonstrate similar trends. A descriptive cross-sectional study among doctors in Sri Lanka reported almost universal agreement (97%) to perform abortion when the mother’s life was in danger and 76% when the mother’s health was at risk. Additionally, 57% agreed in special medical conditions such as anencephaly, Down syndrome, thalassemia major, and haemophilia, while 68% supported abortion in cases of rape and incest. The present study similarly indicates that support is the strongest under medically justified circumstances, although the magnitude of approval among doctors appears greater, possibly reflecting the professional prioritisation of maternal safety and clinical responsibility.
Factors associated with the perception towards the legalisation of abortion
In the present study, age was a statistically significant factor associated with perception. Participants aged 18–35 years demonstrated the highest proportion of supportive perception (90.3%), followed by those aged 36–55 years (87.4%), while participants aged 56 years or above demonstrated the lowest level of favourable perception (73.8%).
Several studies report findings compatible with the present study. A descriptive cross-sectional study conducted among university students in Nigeria reported increasing positive perception with age among adolescents, although the overall level of support remained lower, with only 36.1% demonstrating positive perception toward abortion legalisation. Similarly, evidence from Ghana indicated that health workers aged 26–35 years were 2.71 times more likely to demonstrate favourable attitudes compared to younger cohorts aged 18–25 years. Within Sri Lanka, a community-based study in Colombo reported that respondents younger than 25 years were more likely to accept legalisation for “soft reasons” such as contraceptive failure or economic hardship. These findings support the trend observed in the present study, where younger adults demonstrate a more favourable perception toward abortion legalisation.
Conversely, some findings differ from the present study. A vignette-based experiment conducted in rural Sri Lanka revealed that acceptability depended more on the age of the woman seeking abortion rather than the age of the respondent, with higher acceptance for a 15-year-old compared to a 25-year-old, possibly reflecting the stronger influence of contextual and cultural considerations in rural communities when evaluating abortion scenarios. Gender was not found to be a statistically significant factor in the present study, with 87.1% of females and 85.5% of males demonstrating supportive perception toward abortion legalisation. This finding is compatible with a cross-sectional study among health workers in Ghana where gender did not significantly influence perceptions or attitudes toward abortion. However, contrasting findings have been reported in other settings. A descriptive cross-sectional study among youth in Namibia reported a noticeable gender gap, with 34% of females supporting abortion legalisation on demand compared to 22% of males, which may reflect gender differences in reproductive health experiences and decision-making autonomy among young populations. Similarly, a community-based study conducted in Colombo found that females were significantly more likely to support legalisation for economic hardship and contraceptive failure, although there was no gender difference for “hard reasons” such as rape or incest, possibly because women are more directly affected by the physical and social consequences of unintended pregnancy. These variations may reflect sociocultural differences and population characteristics.
Religion emerged as a highly significant determinant in the present study. Buddhists demonstrated the highest level of supportive perception (90%), while non-Buddhist participants demonstrated lower levels (75.6%), with Catholic participants showing the highest proportion of poor perception (31.71%).
Similar patterns have been observed internationally. A quantitative study among Asian Americans in the US reported that frequent religious worship was strongly associated with opposition to abortion legalisation. Within Sri Lanka, a study conducted among doctors at the same Hospital reported significantly lower acceptance among Muslim doctors for abortion following rape compared to Sinhalese and Tamil doctors. These findings reinforce the strong influence of religious beliefs on abortion perception.
Ethnicity was not significantly associated with perception in the present study. Sinhala participants demonstrated a slightly higher proportion of favourable perception (87.7%) compared to non-Sinhala participants (77.8%), although the difference was not statistically significant.
This contrasts with findings among Asian Americans in the US where support for abortion legalisation varied widely across ethnic subgroups, possibly due to the diverse cultural and religious backgrounds present within those populations. Ethiopian studies have also reported ethnicity as a significant determinant of abortion knowledge, which may reflect differences in educational access and sociocultural norms across ethnic groups.
Income did not significantly influence perception in the present study. Participants earning Rs. 100,000 or above demonstrated 91% supportive perception compared to 85.3% among those earning less, although this difference was not statistically significant.
In contrast, international studies have reported that higher income levels predict greater support for abortion legalisation, possibly because individuals with a higher socioeconomic status may have greater access to education and health information.
The employment status was significantly associated with perception, with 90.4% of employed participants demonstrating a favourable perception compared to 82.9% of unemployed participants. Evidence from Ghana supports this association, where increased work experience significantly increased the likelihood of favourable attitudes. However, a Sri Lankan study among female factory workers reported higher acceptance among workers with fewer years of work experience, possibly reflecting generational differences in attitudes toward reproductive rights within the workforce. Educational attainment demonstrated a strong association with perception in the present study.
Participants with higher school education demonstrated markedly greater supportive perception. While this finding aligns with much of the international literature, Ethiopian studies have reported higher acceptance among women with only primary education, suggesting contextual differences, which may be influenced by differences in cultural norms and the local awareness of reproductive health services.
The marital status, the parental status, and the number of children were not statistically significant in the present study. This differs from studies conducted in Ghana and Ethiopia where the marital status and the number of children influenced abortion attitudes and knowledge, possibly because personal reproductive experiences may shape perceptions in certain cultural contexts. However, the trend toward lower acceptance among participants with more children resembles findings from the US.
The knowledge level was not significantly associated with perception in the present study, although participants with a higher knowledge demonstrated somewhat greater favourable perception. This contrasts with findings from Nigeria where greater knowledge was negatively associated with support for legalisation, which may be related to differences in sociocultural or religious attitudes influencing the interpretation of abortion-related information. However, the present findings align with Sri Lankan studies demonstrating a poor awareness of legal provisions despite varying levels of acceptance.
Public health relevance
The findings of this study have important implications for public health in Sri Lanka. The observed support for abortion legalisation under specific circumstances suggests a gradual shift towards a more health-focused perspective among the public. This provides an opportunity for informed policy discussions aimed at reducing unsafe abortions and associated maternal morbidity and mortality by legalising abortion in Sri Lanka.
The participants’ perception that legalisation could reduce unsafe and illegal abortions is consistent with global public health evidence. The association between supportive perceptions and higher educational levels further highlights the importance of strengthening reproductive health education. Targeted awareness programs, particularly for older adults and individuals with lower educational attainment, may help address misconceptions and promote informed decision-making.
Limitations
The descriptive cross-sectional design restricts causal inference and the Hospital setting may have resulted in the inclusion of participants with a greater health awareness.
Choosing non-substantive responses to certain questions may have affected the findings. Furthermore, given the sensitive nature of abortion as a topic, some may have provided socially acceptable responses despite assurances of confidentiality contributing to the social desirability bias.
Ideally, multivariable analysis should have been conducted to control for potential confounding factors when assessing associations between socio-demographic characteristics and perception towards abortion legalisation. However, this was not performed in the present study, which may have limited the ability to determine independent predictors of supportive perception.
Conclusions and Recommendations
In summary, this study demonstrates a largely supportive perception towards the legalisation of abortion under specific circumstances among adults attending a tertiary care Hospital in Sri Lanka. Perception was significantly associated with age, religion, the employment status, and the educational level. Despite its limitations, the study provides useful insights into public attitudes that may inform future reproductive health policies, educational initiatives, and further research.
Adults attending a tertiary care Hospital in Sri Lanka held largely supportive but conditional perceptions toward abortion legalisation, with support the highest for a risk to maternal life, foetal abnormalities, and rape/incest, and the lowest for unwanted pregnancy and socio-economic circumstances. Supportive perception was significantly associated with being of a younger age, being of the Buddhist faith, having employment, and a higher educational attainment, highlighting subgroups where awareness and attitudes differ. These findings underscore the need to strengthen reproductive health education and public awareness of unsafe abortion and its consequences, particularly among older adults and those with lower educational attainment. Given the conditional nature of the support, an informed policy dialogue on expanding legal indications for abortion in specific circumstances is warranted, with the potential to reduce unsafe abortions and related maternal morbidity and mortality.
Mendis, Felician, Hansanee, Sateha and Tissera are attached to the Sri Jayewardenepura University’s Medical Sciences Faculty. Ubeysekara is attached to the Health Ministry’s Youth, Elderly and Disabled Unit. Seneviwickrama is attached to the same Faculty’s Community Medicine Department
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The views and opinions expressed in this column are those of the authors, and do not necessarily reflect those of this publication