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�&�B�B�%�C���������������������������������������������������������������������H &:	@Attitudes Towards Termination of Pregnancy (TOP): Ultra-orthodox and Secular Women in Israel
Abu Rabia, R., Hener, T., Biton, A., Abukrat, Y. & Hendel.T.
Nursing Department, Ashkelon Academic College, Ashkelon, Israel
Abstract
Background: Induced abortion or termination of pregnancy (TOP) is still a controversial issue in all societies because of moral, ethical, legal, emotional and religious questions. The decision to abort is made primarily by mother, couple and family. Studies indicate that abortion can create physical, social and psychological problems both for women and for medical staff. Decisions are influenced by the women's personal values and religious factors thus potentially making it more complicated emotionally, physically and socially.
The aim of the study: To assess attitudes and differences between ultra-orthodox and secular women determining TOP, depending on the cause of the abortion. Methods and Procedure: One hundred ninety-six Jewish women participated in a cross-section study, conducted in 2018. They were evaluated by a questionnaire comprised of two parts. a) Socio-demographic characteristics, b) Attitudes regarding TOP. Data was collected via Google Forms. Data were analyzed by using SPSS, version 25. Results: Orthodox women were found less liberal about abortion than secular women were. Secular women agreed to perform abortions in cases of fetal malformation, albinism, economic distress, unplanned pregnancy, and pregnancy interrupted career goals. There were no differences between the two groups to abort the pregnancy because of fetal gender.  Conclusions: Judaism opposes abortion for both religious and moral reasons. Many religious leaders (rabbis) prohibit abortion in almost every situation. However, there are cases in which they will give permission to perform, mostly if the pregnancy poses a danger to the woman's life. In contrast to this approach, there are various feminist and human rights organizations in Israel, which support the choice of women regarding their bodies.
Keywords: Orthodox Judaism, Values, Termination of pregnancy, Religious, Abortion.

Introduction:
Induced abortion or termination of pregnancy (TOP) is still a controversial issue in all societies because of legal, religious, moral and ethical considerations. Procedures done by medical or surgical intervention depend upon the gestational age of the pregnancy and the institutions' policies. The estimated rate of abortion worldwide is 35 per 1000, in all women of reproductive age (15-44), [1] The decision to abort is usually influenced by women' background: religious belief, values, culture, education, emotional status, women family and partner support is needed, [2]. 
Various reasons women decide to end pregnancy include pregnancy occurring out of wedlock, rape, pregnancy affecting the physical and or mental health of the newborn or mother, economic distress, social considerations, unplanned pregnancy etc. [3,4,5].  Many women who choose TOP are vulnerable to a large number of health problems, including mental and psychological effects like, grief, depression and guilt, [6,7,8].  The State of Israel law maintains the principle of the sanctity of life, that abortion is a criminal offense,[9]. The law establishes and clarifies that a person will not bear criminal responsibility if pregnancy termination is carried out at a recognized medical center.  According to the Israeli Ministry of Health guidelines, every medical center should have an abortion approval committee. The committee may approve termination of pregnancy under various circumstances, specified in the law: 1) Pregnancy under age 17 or above 40, 2) Pregnancy as a result of incest or outside of wedlock, 3) Child is likely to have physical and or sever mental illness; 4) Continuation of pregnancy endangers the mother's life, physically or mentally including social circumstances, [10,11]. The rate of women requesting the committee dropped down through the years 1988-2016, from 18.6% to 9.0% in women reproductive age 16-45. Primary reasons were pregnancy out of wedlock (49.7%) and mental and/or physical disability of the fetus (20.5%). The committees approved 99.3% of requests. According to WHO (2004) lacking legal justification for TOP, women opted for life-threatening unsafe abortions, resulting in roughly 6% of causes of maternal death, [11, 12].

International human rights organizations believe women should have the rights to comprehensive reproduction health services, including abortion. Many women believe abortion is a human right together with life, health, liberty, privacy, bodily integrity and non-discrimination as well as the law in Israel, [12,13] In contrast, Jewish, Muslim and Christian religious clerics claim that the existence of a fetus in a woman's body does not give her the right to abort, except in cases critical to the mother's safety,[8,14,15]. For orthodox Jews, Halacha (Rabbinic Law) is the only source for definitive answers regarding this subject, depending upon their rabbi's interpretation. The Torah (First Five Books of the Bible) emphasizes the value of life and mandates the saving extension of life. The Torah places great value on the creation of human life whereas abortion is the exact opposite of the extinction of life. According to Jewish Halacha, all orthodox rabbis agree, abortion is permitted only when proven to be a direct threat to the mother's life during pregnancy. In Judaism, there are three approaches to the status of the fetus: 1) the fetus is a separate creature than the mother and it has its own full human rights. Therefore, committing abortion is equated to committing murder, [14]. Two additional reasons forbidding abortion are the prohibition of wasting sperm in vain (Genesis 38:8-10) and "do not destroy" (Deuteronomy 20:19). 2) The fetus is like an internal organ of the mother; therefore, it has no special rights or status. 3) The rights and status of the fetus are fewer than those of a living adult are, however; they exist from its potential to be born and grow into a productive member of society, [16]. Some of the orthodox rabbis adopt the third approach. They feel that one needs to take into consideration the following possible situations: out of wedlock pregnancy, rape, incest, worsening of the mother's health (physical and emotional), and the fetus has a severe and complex abnormality/defect. In these situations, the rabbi should consider whether to allow the TOP, [17]. The earlier the gestational age the easier it is to approve TOP. According to the Halacha, the pregnancy is considered just water up to the 40th day. In addition, up to 90 days, the pregnancy is not visible, thus allowing a more liberal orthodox rabbi to approve TOP, [16]. Some rabbis forbid fetus detection for fetal abnormalities (amniocentesis, for example) as they will not approve TOP. This is why orthodox women refuse to undergo such tests, [17].   Many ultra-orthodox Jewish women believe that God places them on various tests, and therefore they must accept what God gives. These women typically act according to their rabbi's instructions regarding how to accept and raise a sick child in the family, [18]. Secular Jewish women consider TOP from the point of view of a woman's right on her body and that she is the one who decides about her fetus' future, [13].
Islam believes that God creates the fetus and humans have no right to interfere with His creation, [8, 19, 20]. In order to prevent deformation of the Islamic family and community, the mother and community's welfare should be considered cautiously, [21] In Islam, abortion is generally forbidden unless: 1) Pregnancy threatens the mother's life. 2) Proven fetal anomalies resulting in severe handicaps thus decreasing the fetus' viability post birth. 3) Gestational age is less than 120 days, [22, 23] However, various ethical views exist regarding the acceptability of abortion depending upon the gestational age, [24]. A clear explanation about abortion, based upon religious backup (fatwa) helps women to agree to TOP without feeling guilty that they had murdered their fetus, [25]. Christianity believes life is holy, pure and inviolable, and one should respect it as God, the giver of life, should be respected, [20]. The Catholic Church's opinion rarely justifies abortion, considering the fetus as a living human being, having rights and terminating its life is equated as a murder. [26] In fact, the Catholic Church prefers deaths from natural causes over the murder abortion of the fetus. Thus, it is fair to state that the issue of abortion is still controversial within Judaism, Islam, and Christianity, [2].
This study compares attitudes towards TOP between ultra-orthodox and secular women. In addition, it explores relationships between demographic factors such as education, age, marital status and agreement with TOP.

 Methods & Materials: 
Design, procedure and the study sample:
Cross-sectional study carried out amongst 196 Jewish Israeli women during 2018. Of these, 48.4% were ultra-orthodox and 51.6% were secular. A self- answering questionnaire was distributed via social media, Google Forms. 
Data collection and description of variables:
 The participants completed a questionnaire consisting of two parts, examining: a) Participant's socio-demographic data, including religious status, age, origin, level of education by years, family status, number of children and income status. b) Attitudes towards termination of pregnancy (TOP); Includes six items regarding agreement or disagreement relating to artificial abortion. The answers were given on a Likert type scale, from one (completely disagree) to seven (completely agree.) In our study, the internal consistency of the questionnaire was confirmed, with Cronbach's alpha equaling 0.80.
Statistical analyses: 
 Descriptive statistics of demographic data, using SPSS version 25, produced frequencies for nominal variables and means and standard deviations for numerical variables. In addition, 95% confidence intervals were calculated. Univariate analyses included t-tests for comparison of means (or Mann-Whitney tests as appropriate) for numerical variables and chi-square tests for nominal variables. The significance level was 5%. An average score was calculated for each item, so it reflects the outcome agreement towards abortion.
Ethical issue: The Ashkelon College Research Committee approved the study.
Results:
Table 1 presents subjects' socio-demographic characteristics, of 196 Jewish women, 48.4% ultra-orthodox and 51.6% secular. The mean age of the participants was 27.7 and 31.7, respectively. Most of the Orthodox women were of Sephardic (North Africa & Asia) origin (64.2%) and the majority defined themselves as earning below the average income (69.5%).
Most of the women were unmarried (67.4% orthodox and 70.3% secular). Mean years of education in orthodox women was 14.3 vs 13.7 in secular women. Orthodox women had more children than the secular mean, 1.6 vs 1.1. Regarding decisions made for termination of pregnancy; about 63.1% of the orthodox women reported the couple's parents or a religious leader decided. In contrast, among secular women, the couples themselves made 80.2% of decisions regarding TOP.  
Table 2 presents the differences in attitudes toward TOP between orthodox and secular women. The study reveals that secular women were more willing to abort, than the orthodox women, in cases of fetal malformation, albinism, economic distress, unplanned pregnancy, and pregnancy interrupted career goals (p=0.00).  Both secular and orthodox women disagree with abortion because of fetal gender (p=0.94). 
Table 3 presents a univariate analysis association between demographic variables and attitudes towards TOP, within the study group.  It was found that women 36 years and older, agreed with TOP because of unplanned pregnancy (p=0.03) and fetus that has albinism (p=0.00). Differences related to origin were noticed between Ashkenazi (of European & North American origin) and Sephardic women. The Ashkenazi agreed to end the pregnancy if it was unplanned and fetus had malformation (p=0.02). Women who defined themselves as earning below the average income accepted TOP more in case of fetus malformation compared to women with better economic status. The latter group accepted TOP in cases fetus' albinism, socioeconomic distress and unplanned pregnancy (p=0.00).
Women who had no children tend more for TOP in cases of economic distress (p<0.05), unplanned pregnancy (p<0.02) and whether pregnancy interrupted career goals p<0.0(5). No relation has been found between attitudes toward TOP and women's level of education and family status.



Table 1. Socio-demographic characteristics of the subjects
CharacteristicOrthodox women
(n=95)
N (%)Secular women
(n=101)
N (%)p-valueAge
Mean, mode, minimum- maximum
27.7,24, 18-52
31.7,27, 18-62Family status
Married
Single
31(32.6)
64(67.4)
30(29.7)
71(70.3).51Years of education
Mean, mode, minimum- maximum
14.3,12.0,3-24
13.7,12.0,3-19Number of children
Mean, mode, minimum- maximum
1.6,0, 0-12

1.1, 0, 0-4Origin
Sephardic
Ashkenazi
mixed

61(64.2)
23(24.2)
11(11.6)
35(34.7)
44(43.6)
22(21.7).00Average income
Below average
Similar to average
Above average
66(69.5)
21(22.1)
8(8.4)
56(55.4)
32(31.7)
13(12.9).12Decision made by
Couple
Couple's parents
Religious leader
35(36.8)
50(52.6)
10(10.5)
81(80.2)
4(4.0)
16(15.8).00

Table 2. Differences in attitudes towards (TOP) between orthodox and secular women
AttitudesOrthodox women (n=95)
M (SD)Secular women(n=101)
M (SD)t-test
t(df)p valueFetal malformation3.0(1.8)5.2(1.7)-8.2(194)0.00Fetal albinism1.6(1.3)3.2(1.9)-6.7(194)0.00Fetal gender1.0(0.5)1.1(0.5)-0.0(193)0.94Economic status1.3(1.0)2.6(1.9)-5.5(193)0.00Unplanned pregnancy1.3(1.0)3.1(2.2)-6.9(194)0.00Pregnancy interrupts career goals1.3(1.0)2.6(2.1)-5.4(194)0.00Unknown reason4.2(2.1)5.1(1.9)-3.0(194)0.05


   






Table 3. Univariate analysis association between demographic variables and attitudes towards TOP
VariableN (%)Fetus malformation
M (SD)Fetal albinism
M (SD)Fetal gender
M (SD)Economic status
M (SD)Unplanned pregnancy
M (SD)Pregnancy interrupts career
M (SD)
Unknown reason
M (SD)Age
18-35 years
Over 36
152(77.5)
44(22.5)
4.0(2.0)
4.6(2.2)
2.2(1.7)
3.1(2.0)*
1.1(0.6)
1.0(0.1)
1.9(1.60)
2.2(1.8)

2.1(1.8)
2.8(2.3)*
2.1(1.8)
2.8(2.3)
4.6(2.0)
4.8(2.2)Origin
Sephardic
Ashkenazi
96(59)
67(41)
3.8(2.1)
4.6(1.9)*
2.4(1.8)
2.4(1.7)
1.0(0.5)
1.0(0.3)
1.9(1.6)
2.1(1.7)
1.9(1.7)
2.5(2.0)*
1.8(1.7)
2.2(1.8)
4.5(2.0)
4.6(2.1)Years of education
12 years
Over 12 years
80(41)
116(59)
4.0(2.2)
4.3(2.0)
2.5(1.8)
2.4)1.8)
1.1(0.7)
1.0(0.3)
2.0(1.7)
2.0(1.6)
2.3(2.0)
2.2(1.9)
2.1(1.9)
1.9(1.7)
4.8(2.0)
4.6(2.0)Family status
Married
Single
61(31.1)
135(68.9)
4.0(2.0)
4.2(2.1)
2.2(1.7)
2.5(1.8)
1.1(0.6)
1.0(0.4)
2.1(1.6)
2.0(1.6)
2.0(1.8)
2.4(2.0)
2.2(2.0)
1.9(1.7)
5.0(2.0)
4.5(2.1)Women have children
No children
Have children

82(41.8)
114(58.2)

4.4(2.0)
4.0(2.1)

2.5(1.8)
2.3(1.8)

1.1(0.6)
1.0(0.4)

2.4(1.9)*
1.7(1.4)

2.7(2.1)*
2.0(1.8)

2.5(2.1)*
1.6(1.4)

5.0(2.0)
4.4(2.1)Monthly income
Below average
Above average
122(62.2)
74(37.8)
3.8(1.9)*
4.7(2.2)
2.0(1.5)
3.0(2.1)*
1.0(0.5)
1.1(0.5)
1.8(1.5)
2.3(1.8)*
1.9(1.7)
2.8(2.3)*
1.8(1.6)
2.3(2.0)
4.6(2.0)
4.8(2.1)Religious status
Orthodox women
Secular women
95(48.4)
101(51.6)
3.0(1.8)
5.2(1.7)*
1.6(1.3)
3.2(1.9)*
1.0(0.5)
1.1(0.5)
1.3(1.0)
2.6(1.9)*
1.3(1.0)
3.1(2.2)*
1.3(1.0)
2.6(2.1)*
4.2(2.1)
5.1(1.9)*                    *p <0.05
Discussion:
The issue of abortion is much more complicated today than in the past. In the modern era, it is simpler for the early diagnosis of fetal malformation. In addition, advanced abortion options rarely endanger a woman's health. The ethical and moral discussion surrounding abortion has existed for many years and shall likely continue. The current study compared attitudes towards termination of pregnancy (TOP) in ultra-orthodox and secular Jewish women. About half of the women were orthodox, most of them from Sephardic origin and earned below the average level. Our findings show that secular women agreed more to abortion than the orthodox women, in cases of fetal malformation, albinism, economic distress, unplanned pregnancy and pregnancy interrupted career goals. Both, orthodox and secular women, agreed not to abort because of fetal gender. Orthodox women agreed less to TOP because the religious believe the fetus is considered as a human being and thus has the right to life. Therefore, induced abortion, while the fetus is alive, is likened to murder. Similar findings were clearly noticed in Muslim women as well; refusing to undergo TOP due to religious considerations, [27]. In the case of fetal malformation, our finding related to secular women is similar to the finding of Hourieh (2010), [28], In contrast, a study conducted in Chinese women which examined attitudes towards TOP, found no relation between religiosity and TOP,[29]. Differences were noticed between Ashkenazi women and Sephardic women, with Ashkenazi women agreeing more to TOP if the fetus had malformation and if it was an unplanned pregnancy. In contrast to Iranian women found that, the majority of subjects disagree with TOP in cases of unplanned pregnancy, [28].
 Women who defined themselves as earning below the average wage accepted TOP only in case of fetus malformation, in comparison to women with better economic status, the latter group agreed to terminate pregnancy also in cases of fetal albinism, socioeconomic distress, unplanned pregnancy, and pregnancy interrupted career goals. A study established in the UK found similar results. Women who had good socioeconomic status agreed more to TOP in case of pregnancy malformation, unplanned pregnancy or pregnancy interfering with career, [5, 29] also found a positive correlation between socioeconomic status and the decision about TOP. Women who suffer from economic distress and poverty were more inclined to TOP, according to other studies. [30]. Mostly the couple made the decision about TOP, in secular women, while orthodox women counseled more with the couple of parents and religious leaders. Women above 36 years old agreed more than younger women to abort in cases of fetal albinism and unplanned pregnancy, [5]. Expanded the data we have about women's age. They found that women 20 years old and younger agreed more to TOP. Our study found the level of education did not influence attitudes toward TOP. This in contrast with others, which indicated pregnancy interrupting education and career as the main reason for TOP, [5]. Some healthcare providers face ethical and moral issues when their religious backgrounds differ from their patients, for reasons of religiosity, demonstrated different attitudes towards TOP, [31]. Medical staff who believed abortion is a murder tended not to participate in this procedure, [22, 32]. Health care providers should be sensitive and aware of both the cultural and religious backgrounds of their patients in order to plan tailored treatments for them. The mothers should not be judged, and they need to be well informed about the procedure, including emotional support. 
Conclusions and Recommendations:
Health policy makers and religious clerics should discuss the many issues of abortion in order to agree on guidelines to TOP and to reduce mother's suffering. Clear guidelines will ease decision making for the health care providers, as well as for the women needing to abort. 
Religiosity is the main factor in decisions made regarding TOP. This study examined only Jewish women, but it has implications for Muslim and Christian women, thus for the entire Israeli population. 
Study limitation: Our study performed via a social media questionnaire, therefore, excluding women with no access to the Internet. We advise expanding the study to more women, including those without internet access and include men's point of view.








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32. Karimi M, Bonyadi M, Galehdari M, et al. (2008). Termination of pregnancy due to thalassemia major, hemophilia, and Down's syndrome: The views of Iranian physicians. BMC Med Eth.2008; doi: 10.1186/1472-6939-9-19.


	









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