Introduction

Abortion refers to the end of a pregnancy before the 20^th week of gestation, which can be spontaneous or induced [1]. Induced abortion refers to the medical or surgical termination of pregnancy, which can be done for various reasons and contexts [2]. The issue of induced abortion has long been disputed in various moral and religious schools and remains one of the most challenging issues in the field of medical ethics and policymaking. Currently, various countries have different approaches to abortion. Some countries, such as England, Netherlands, and Turkey, legally permit abortion up to the 24^th week of pregnancy on request. However, in many other countries, it is permitted only to save the life of the mother [3,4].

In the Islamic Republic of Iran, abortion law has seen some twists and turns. With the victory of the Islamic revolution in 1979, the legislators, emphasizing the religious teachings on the prohibition of induced abortion, enacted stricter laws on abortion access, and people who directly or indirectly participated in abortion faced criminal penalties. However, after 15 years, according to the Population Control Law of 1993, medical abortion in situations where the fetus has certain diseases that make the continuation of the fetus difficult or the mother has difficulties in keeping the fetus, or she has a disease that makes the pregnancy dangerous for her before the “soul enters the fetus” (16^th weeks of gestation due to Shiite scholars) was legally authorized by a specialist [5]. Contraceptive use in Iran rose high, and fertility declined to low levels. In the law of 2021, which was promulgated by the conservative government to increase the population, in addition to the restrictions in the field of prenatal screening, more restrictions were also placed on abortion, and the authorization of medical abortion was placed under the responsibility of a council consisting of a judge and a specialist doctor. In this way, the legislatures made the condition of medical abortion more stringent along with prenatal screening, and the lawbreakers have faced more severe criminal penalties [6].

Students in health domains, including medical, nursery, and midwifery, will gradually enter the country’s healthcare system in the next decade and will implement the health policies of the country. Therefore, ascertaining the attitudes of this group is necessary for the implementation of existing policies and for enacting more appropriate policies in the field of medical education. For example, A study in Jordan showed that medical students had a conservative approach to induced abortion [7], while a study in Bosnia and Herzegovina found that 81% of medical students supported abortion under certain conditions [8].

Induced abortion remains a highly debated and sensitive issue worldwide, with varying legal, ethical, and cultural perspectives. Understanding the attitudes of future healthcare providers, such as medical students, obstetrics and gynecology residents, and nursing and midwifery students, is crucial as they will play a pivotal role in reproductive health services. In this study, we aim to assess the attitudes of medical students, obstetrics and gynecology residents, and nursing and midwifery students toward induced abortion and compare it with the legal processes of the country and the current law of the population. We also ascertain the differentials in attitudes by background characteristics of respondents, such as age and marital status. By identifying these attitudes and their differentials based on background characteristics, the study aims to inform policymakers and educational institutions, ultimately contributing to more informed and empathetic healthcare practices.

Method and materials

Results

The participation rate in this study was 59.25%, with 237 out of 400 students who were approached completing and submitting eligible questionnaires with median age of 25 years (min:18, max:45 years). Among the participants, 168 (70.9%) were medical students, 63 (26.6%) were preclinical, and 105 (44.3%) were clinical. In addition, 34 (14.3%) were obstetrics and gynecology residents, 16 (6.8%) were nursery students, and 19 (8.0%) were midwifery students. Among participants, 31 (13.1%) participants were above 30 years old, 37 (15.6%) were married, and 222 (93.7%) declared their religion as Shia. Moreover, 103 (43.5%) lived in the dormitory, and 82 (34.6%) lived with their family in Tehran. When the participants were asked about the Rejuvenation of the Population and Protection of Family Law, 106 (44.7%) knew the law, 52 (49.1%) of them were against the law, while 31 (29.2.9%) participants were neutral. The background characteristics are shown in Table 1. The scattering of answers to each question in detail is shown in Table 2.

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Table 1. The Background Characteristic of Students in Tehran University of Medical Sciences, 2023.

https://doi.org/10.1371/journal.pone.0320302.t001

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Table 2. The Scattering of Answers to Each Question of The Questionnaire among Students in Tehran University of Medical Sciences, 2023.

https://doi.org/10.1371/journal.pone.0320302.t002

The median (min, max) of the total score of the attitude toward induced abortion among participants was ‒5.0 (‒12,10). The score associated with participants aged above 30 years was ‒4.0 (‒12,10), while it was ‒5.0 (‒12,10) for those below 30 years (P-value = 0.043). The score for females and males was, respectively, ‒4.0 (‒12,10) and ‒6.0 (‒12,10) (P-value = 0.062). The total score among married participants was 0.0 (‒12,10), compared to ‒6.0 (‒12,10) among single participants (P-value < 0.001). The total score for participants without any children was ‒5.0 (‒12,10) and 0.0 (‒4,8) among participants with one child as compared to the score of ‒4.5 (‒12,10) for participants with more than two children (P-value = 0.047). Moreover, the scores of participants living in the dormitory, with family, with a partner, and alone were ‒6.0 (‒12,10), ‒5.0 (‒12,9), ‒1.0 (‒9,10), ‒6.0 (‒12,10) respectively (P-value = 0.004). Furthermore, the total score among participants agreeing with The Rejuvenation of the Population and Protection of the Family Law was 0.0 (‒12,10), whereas it was ‒7.0 (‒12,9) for participants disagreeing with the law and ‒5.0 (‒12,10) for those with no opinion about the law (P-value = 0.001). The score of attitude toward abortion is shown in Table 3.

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Table 3. The Attitude Toward Abortion Based on Total Score of Students in Tehran University of Medical Sciences, 2023.

https://doi.org/10.1371/journal.pone.0320302.t003

Discussion

The results of this survey show that the general attitude toward induced abortion before 16 weeks of gestation among medical students, obstetrics and gynecology residents, midwifery, and nursing students is positive and pro-choice. However, married people, those who live with their spouse, and those who agree with the Rejuvenation of the Population Law are less supportive of induced abortion. These results indicate that Iranian medical students who are supportive of abortion and will be responsible for health care in the future might face challenges regarding the implementation of the Rejuvenation of the Population Law, which restricts the provision of abortion and contraception to the general population.

While the study sheds light on the current state of attitudes toward abortion among healthcare students in Iran, it is important to consider the underlying causes and factors that may influence these perspectives. The cultural context in Iran, which places a strong emphasis on family values and childbearing, may also contribute to the more conservative stance on abortion observed among certain demographic groups in the study, such as married students and those with children. The influence of medical education, clinical experience, and exposure to ethical discussions in the field of reproductive health may also shape students’ opinions, particularly as they prepare to become healthcare providers responsible for making decisions about reproductive healthcare [13].

The main reasons for restricting abortion historically were to protect women from the dangers of illegal abortion and the unskilled abortionists who can harm them, to enforce moral standards and discourage abortion as a sin, and to safeguard fetal life in some or all cases [5,14,15]. United Nations reported that in 2017, almost every country in the world permitted abortion to protect a woman’s life; however, those involved in an unlawful abortion can face criminal charges according to explicit provisions in most countries [14]. Iran had a fluctuating history regarding abortion. After the establishment of the modern legal system, the act of abortion was criminalized in 1926 and had heavy punishments except for saving the mother’s life. The first decriminalization of the act of abortion was done in 1969, which justified abortion not only in the time of preserving a mother’s life but also in cases of preserving the mother’s health. Later, in 1976, the law permitted unrestrictive abortion before 12 weeks of gestation based on the parents’ decision and by providing sufficient reasons. Also, therapeutic abortion was permitted without any restriction based on the parent’s request and physicians’ judgments, and only the mother’s decision was required. After the 1979 revolution, abortion was again criminalized in 1982 due to Shia jurisprudence, with the punishment of paying blood money [5]. Islamic scholars permit induced abortion just before the point of ensoulment (120 days); however, there are controversies and disagreements about the permitted situations before 120 days of gestation [16]. Until 1998, only abortion for saving a mother’s life was legally permitted. After 2005, the Therapeutic Abortion Act and induced abortion were permitted only in case of problematic fetuses and major anomalies [5]. In 2021, after The Rejuvenation of the Population and Protection of the Family (RPPF) law, different types of contraceptives were previously restricted, with access limited to certain individuals based on health conditions and previous children, such as vasectomy and obtaining an abortion became more difficult than before. A team of Muslim doctors, a forensic medicine expert, and a judge must approve a pregnant woman’s abortion request, and judges have the final authority. They can allow the abortion if the fetus is under four months old, the mother or the fetus has a life-threatening condition or a severe disability, and there is no other reason to permit abortion before the point of ensoulment [6].

Attitudes to induced abortion are different in countries due to many factors like socio-economic situations, religion, political ideology, and the reasons under which abortion is legally permitted. While most people are in favor of therapeutic abortion, there is less support for elective abortion, where the woman chooses to end the pregnancy. A study in the United States and New Zealand found that while support for elective abortion has gradually increased over the past few decades, a considerable minority of the public remains opposed to it [17]. This gradual shift is in contrast to the more static views on abortion in Iran, where restrictive policies such as the Rejuvenation of the Population and Protection of the Family (RPPF) Law continue to shape public opinion. Despite this, our study found that medical students in Iran, who will play a pivotal role in future healthcare policies, are more supportive of abortion than the general public, possibly indicating a generational divide. This mirrors trends observed in Western countries, where younger generations tend to favor reproductive rights more than older generations.

It is difficult to access the exact data on abortion in Iran because of the challenge of reaching all the different groups of people and the delicate nature of the issue. The study by Mahdavi et al. indicated that no abortion permission was granted for non-medical cases, which likely reflects the restrictive nature of abortion laws in Iran. [18]. However, this study did not assess the attitudes of medical students or healthcare providers toward such laws, a gap our study aims to address. In contrast to our study’s focus on medical students, the study by Hosseini et al. looked at a broader female population, showing that 3.8% of women aged 15–49 had an induced abortion. The difference may arise from the broader societal factors affecting abortion, such as cultural norms and policies [19]. However, a survey by Ranji has shown that 17% of women had experienced at least one illegal induced abortion, and having an abortion was mainly due to the desire to prevent or defer childbearing and the economic problems of the family. Non-medical providers unsafely do a considerable amount of these abortions [20]. Abortion complications are much lower in safe abortions than in unsafe abortions [21]. The RPPF law, which limits access to abortion, may inadvertently lead to an increase in illegal abortions. Policymakers must consider these public health risks when shaping future legislation, ensuring that the legal framework protects women’s health and reduces the potential harms of unsafe abortion practices.

Studies around the world have shown different attitudes toward induced abortion in medical students. A study conducted among Jordanian medical and health sciences students found that abortion was largely viewed negatively, except in cases where the mother’s life was at risk or the pregnancy was a result of rape. This is consistent with the more conservative stance observed in many Middle Eastern countries, where cultural and religious factors heavily influence attitudes toward abortion [7]. Our findings, however, suggest a more pro-choice attitude among Iranian medical students, which may reflect a generational shift or differing regional attitudes, though factors such as marital status and legal constraints still play a significant role. These differences highlight the complex intersection between individual beliefs, societal norms, and national policies on abortion.. In Bosnia and Herzegovina, 87.8% of medical students who participated in the study agreed that abortion is “murder,” and only a few of them would perform an abortion on request. However, medical conditions were acceptable reasons for many students to perform an abortion [8]. In South Africa, a study revealed that while most medical students held positive attitudes toward medical abortion, only a small percentage (12.5%) would perform or refer for abortion on request. [22]. This finding is consistent with our own results, where medical students expressed support for abortion in certain circumstances, such as to preserve the mother’s health or in the case of fetal anomalies. However, like South African students, Iranian medical students showed reluctance to support elective abortion on demand. This may be partly due to the religious and legal framework in Iran, where abortion is heavily restricted by law, influencing the views of even future healthcare providers.

However, few medical students at the University of Washington thought that 1st-trimester abortion should not be accessible, and the overall attitudes toward 1st-trimester abortion were more positive than 2nd-trimester abortion [23]. Furthermore, 62% of medical students in the United Kingdom had pro-choice attitudes [24], and it is believed that medical education should train students to be skilled practitioners, with clinical placements and non-stigmatizing abortion care as critical components. They proposed that teaching should be for everyone, even those who object to abortion on conscience grounds [25].

In this study, marriage status and living with a spouse were factors associated significantly with more pro-choice abortion attitudes. Ranj has found that education level, religion, family income, ethnicity, number of children, and age at marriage are related to having an induced abortion [20]. The study by Rosenblatt et al. found that older students were more supportive of abortion, which aligns with our finding that participants over 30 years old were more likely to oppose abortion [23]; also, Osborne et al. demonstrated that abortion support for women and men is more among men and is influenced by both their religiosity and their intimate partners’ religiosity [17]. Meanwhile, there was no statistical evidence of the effect of medical education length and sex on abortion attitudes among Bosnia and Herzegovina students [8]. In our study, men were more supportive of induced abortion, while it was not statistically significant. Moreover, in our study, people aged more than 30 years are more against induced abortion compared to younger. Most of the population in our study were Shia, and data could not demonstrate the comparison between religious declaration and abortion attitudes.

This study was a rare investigation of the induced abortion attitude in Iran. The respondents were young people who were responsible for health decisions. The study shows how the laws and policies are at variance with the perspectives and attitudes of medical students who are future healthcare providers in Iran. The study has some limitations. First, the lack of students with other religions besides Shia did not allow us to compare students’ attitudes with varying religions. Future research that includes participants from a wider variety of religious backgrounds will be essential to provide a more comprehensive understanding of how religious diversity influences attitudes toward abortion in Iran.

Secondly, some students refused to participate due to sociopolitical situations. We emphasized confidentiality and ethical consideration of privacy and informed consent, which helped to improve the response rate. The findings are limited to students of the Tehran University of Medical Science and may not be generalizable to students of other medical science universities in Iran, and the results might be influenced by the specific practices, culture, and environment of that particular institution, We did not investigate the different types and causes of induced abortion; which is another limitation in this study. Furthermore, one of the limitations of this study is the use of convenience sampling, which may introduce selection bias. This sampling method may not fully represent the broader population, potentially limiting the generalizability of the findings, and the findings may not be directly applicable to other populations or settings. Future studies employing random sampling methods may help mitigate selection bias and improve the external validity of the results. Finally,

Conclusion

In conclusion, this study has highlighted that medical and health science students in Iran generally exhibit positive attitudes toward induced abortion. However, factors such as marital status, having children, and cohabitation with a partner seem to contribute to a more conservative stance on the issue. These findings are significant in the context of Iran, where abortion laws are heavily influenced by Islamic principles and are limited to specific medical circumstances. The disconnect between students’ attitudes and the national policies outlined in the RPPF law poses a substantial challenge for the future implementation of abortion-related policies. Specifically, the younger generation of future healthcare providers, who may be responsible for enforcing these laws, shows a trend toward more progressive views on reproductive rights. Aligning public health initiatives with the evolving views of medical students and professionals is essential for developing more effective and socially acceptable healthcare policies related to reproductive rights in Iran. These findings suggest that incorporating broader ethical discussions, clinical experiences, and education on reproductive health into medical training could help reconcile these differing views and improve the overall healthcare framework.

Supporting information