TX_1~ABS:AT/ADD:TX_2~ABS:AT 74 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2025, 9 (2): 74-79 ReseaRch aRticle Ethical Abortion among Pregnant Women Attending Abortion Decision-making Committee in Erbil Maternity Teaching Hospital Rana S. Khaleel and Parez R. Muhamad Department of Obstetrics and Gynecology, College of Medicine, Hawler Medical University, Kurdistan Region, Iraq ABSTRACT In the Kurdistan Region of Iraq, abortion is legally permitted only to save a woman’s life, requiring approval from a medical committee and spousal consent. This restrictive framework raises public health concerns by pushing women toward unsafe alternatives. The aim of this study is to characterize women applying for legal abortion in Erbil, identify determinants of committee decisions, and document pregnancy outcomes. A descriptive cross-sectional study was conducted on 200 pregnant women who applied to the Ethical Abortion Committee at Erbil Maternity Teaching Hospital (September 2024–August 2025). Data from interviews and records were analyzed using descriptive statistics and Chi-square tests. The results show the committee approved 121 (60.5%) of 200 requests. Decisions were significantly influenced by the indication for termination (P < 0.001). Requests for severe fetal anomalies were frequently approved, whereas requests citing maternal health conditions – the sole legal ground for abortion had a low approval rate (36.6%). Consequently, 116 pregnancies (58.0%) were terminated. Second-trimester requests were significantly more likely to be approved and terminated than first-trimester requests (P < 0.001), reflecting a system driven by the timing of anomaly detection. Under the KRG’s restrictive law, the committee pragmatically expanded its remit to approve terminations for lethal fetal anomalies while being overly cautious in applying the explicit maternal life exception. With nearly 40% of applicants refused care, the findings highlight an urgent need for policy reform, including clearer clinical guidelines for maternal health indications. This study contributes empirical evidence to global debates on the application of abortion law, ethics, and practice in restrictive settings. Keywords: Induced abortion, ethical abortion committee, abortion law, maternal health, fetal anomalies, Kurdistan region, reproductive rights, unsafe abortion INTRODUCTION Induced abortion is a common and essential healthcare procedure performed globally. Each year, approximately 73 million induced abortions take place worldwide, accounting for the termination of three out of every ten pregnancies and six out of every ten unintended pregnancies.[1] A critical distinction exists between safe and unsafe abortion, a dichotomy that carries profound public health consequences. The WHO defines a safe abortion as one carried out using a recommended method appropriate for the gestational age and performed by an individual with the necessary skills. Conversely, when individuals face barriers to such care, they often resort to unsafe methods. Globally, nearly half of all abortions (45%) are classified as unsafe, with a disproportionate burden falling on developing regions in Asia, Africa, and Latin America.[1,3] This practice is a major contributor to preventable maternal mortality and morbidity. A substantial body of evidence demonstrates that legal restrictions do not reduce the incidence of abortion; rather, they directly diminish its safety.[1] In countries with the most prohibitive laws, only one in four abortions is performed safely, a stark contrast to the nearly nine in ten that are safe in countries where the procedure is broadly legal.[4] Islamic jurisprudence allows abortion to save the mother’s life,[5] and this principle underlies abortion laws across the Middle East and North Africa (MENA). However, modern laws in many countries reflect restrictive colonial penal codes rather than classical Islamic thought.[4,6,7] Cihan University-Erbil Scientific Journal (CUESJ) Corresponding Author: Rana S. Khaleel, Department of Obstetrics and Gynecology, College of Medicine, Hawler Medical University, Kurdistan Region, Iraq. E-mail: rana.sardar98@gmail.com Received: August 7, 2025 Accepted: October 2, 2025 Published: October 20, 2025 DOI: 10.24086/cuesj.v9n2y2025.pp74-79 Copyright © 2025 Rana S. Khaleel and Parez R. Muhamad. This is an open- access article distributed under the Creative Commons Attribution License. Cihan University-Erbil Scientific Journal (CUESJ). Khaleel and Muhamad: Ethical Abortion Decisions in Erbil 75 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2025, 9 (2): 74-79 In federal Iraq, abortion is governed by the Penal Code of 1969, which criminalizes the procedure. Article 417 punishes women who procure an abortion and those assisting them, with harsher penalties for medical professionals or if the woman dies. No exception exists for pregnancies resulting from rape or incest.[8-10] This legal framework forms the grim baseline for all abortion-related conduct in the country. While in the Kurdistan Region of Iraq (KRG), a major legal change occurred in 2020 with the passage of the Patient’s Rights and Responsibilities Law. Abortion is permitted only when the woman’s life is threatened by a serious health condition and requires her consent, her husband’s consent, and approval by a committee of at least five physicians. The law reinforces its stringent limitations by stating unequivocally, “Other than this case, abortion is categorically prohibited.”[11,12] This unique legal development in the KRG creates a distinct institutional context for abortion decision-making, justifying its selection as a site for focused research. Despite severe criminal penalties, induced abortion is a frequent occurrence. One study conducted in the KRG found that approximately 28% of married women reported having undergone an induced abortion at some point. Gynecologists in the region’s hospitals regularly encounter patients presenting with unwanted pregnancies and, more alarmingly, the life- threatening complications of unsafe abortions, including incomplete procedures, severe hemorrhage, and systemic infection or sepsis.[13] In the absence of safe and legal pathways, women are driven to desperate and dangerous measures, such as obtaining unregulated medications on the black market or seeking services from unqualified and clandestine providers, which can lead to permanent injury or death.[14] At present, legal abortion in both Iraq and the KRG is possible only through a medical expert committee, which interprets vague legal terms such as “serious threat to her life.” In practice, this creates significant ethical and practical challenges. Women must present their case before strangers, sometimes with mandatory spousal consent, raising concerns about bodily autonomy. Physicians on these committees must navigate ambiguous laws, personal morality, and societal pressures.[14-16] Given the complex interplay of legal, religious, and social factors, there is a significant gap in understanding the practical ethics of abortion access in the Kurdistan Region of Iraq. Objectives of the project: • To identify the indications of therapeutic termination of pregnancy. • To investigate the obstetrical background of these patients. • To assess the outcomes of decisions and their relation to patient attitudes. • To describe the mode of termination. METHODOLOGY Study Design and Setting This study was a descriptive cross-sectional analysis conducted at the Ethical Abortion Decision-Making Committee of the Maternity Teaching Hospital in Erbil, KRG. The hospital is a tertiary referral center where pregnancy termination requests are evaluated under legal and ethical regulations. The study covered a 10-month period from September 2024 to August 2025, encompassing all eligible cases presented to the committee during this timeframe. Study Population and Sampling The study population included pregnant women seeking termination of pregnancy who were referred to the Ethical Abortion Committee for evaluation. A consecutive sampling approach was used, whereby all women meeting the inclusion criteria (defined below) and attending the committee between September 2024 and May 2025 were invited to participate. This yielded a final sample of 200 participants who consented and met eligibility requirements. Inclusion and Exclusion Criteria Inclusion criteria (a) Pregnant women seeking termination who appeared before the committee and met the KRG’s legal conditions for abortion (i.e., cases ostensibly falling under the “serious threat to the mother’s life” or severe fetal indication provision); (b) gestational age ≤24 weeks (at or below the legal gestational limit for termination, confirmed by ultrasound dating); and (c) provision of informed consent to participate in the study. All participants had to voluntarily agree to share their information for research, with assurances of confidentiality. Exclusion criteria (a) Ectopic or non-uterine pregnancies – such cases require emergency surgical management and do not go through the committee process, so they were outside the study’s scope; (b) pregnancies resulting from incest or rape – these extraordinary cases are handled separately by special legal provisions and were not included in this study; (c) advanced gestation >24 weeks – any case beyond 24 weeks was ineligible due to legal restrictions on late-term abortion; (d) women who declined to participate in the study (though in practice, none refused). All women who met the inclusion criteria and none of the exclusion criteria were enrolled. In summary, the cohort represents the entire population of legal abortion requests reviewed by the committee in that period, excluding only cases outside the committee’s mandate. Data Collection Methods Data were collected using a combination of patient interviews, structured questionnaires, and review of medical records. Upon referral to the committee, each participant was interviewed in a private setting to obtain socio-demographic information (such as age, education, residence, and socio-economic status) and relevant obstetric/medical history. A standardized questionnaire was administered, which covered the indication for abortion request (e.g., fetal anomalies, maternal health conditions), past obstetric history (including previous abortions or known congenital anomalies), and the patient’s knowledge or attitudes regarding abortion. Additional clinical data (gestational age, ultrasound findings, and committee decision outcome) were extracted from the patients’ medical records Khaleel and Muhamad: Ethical Abortion Decisions in Erbil 76 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2025, 9 (2): 74-79 and the committee’s official reports. To ensure accuracy, data collection was performed by trained researchers and validated by cross-checking with hospital records. Ethical Considerations The study protocol was reviewed and approved by the Ethics Committee of Hawler Medical University, Erbil (no = 14 in 2025). Written informed consent was obtained from every participant. Confidentiality was maintained by anonymizing all data. Statistical Analysis After completing data collection, all responses and clinical information were coded and entered into the Statistical Package for the Social Sciences (SPSS) software for analysis. Descriptive statistics were used to summarize the data: categorical variables were presented as frequencies and percentages, and continuous variables (such as maternal age) as means with standard deviation (mean ± standard deviation). For inferential analysis, appropriate statistical tests were applied to explore associations between study variables and outcomes. In particular, comparisons between groups (e.g., cases where the committee approved vs. refused the abortion request) were made using Chi-square tests for categorical variables, with Fisher’s exact test employed when expected cell counts were small. Differences in continuous variables were evaluated using independent-sample t-tests. A P < 0.05 was considered statistically significant for all analyses. All statistical analyses were reviewed by a biostatistician to ensure accuracy and validity of the results. Note: Although cases requiring immediate surgical intervention (like ectopic pregnancies) were excluded by design, a small number of included cases ultimately underwent surgical abortion procedures as the method of pregnancy termination. This typically occurred when a committee-approved case required a dilatation and evacuation (D&E) due to clinical indications (e.g., advanced gestation or failed medical induction). These instances are reported in the outcomes and do not represent a violation of criteria but rather a different method of completing the termination. RESULT AND DISCUSSION Result A total of 200 pregnant women were evaluated, with a mean age of 30.3 ± 7.2 years. The majority of women were multigravida (69.0%), presented in the second trimester (69.0%), and had low educational attainment (36.0% illiterate). Consanguineous marriage was reported by 41.5% of participants. Key sociodemographic and obstetric characteristics are detailed in Table 1. The committee approved termination for 121 (60.5%) women and refused it for 79 (39.5%). The indication for termination was the most significant factor influencing the committee’s decision (P < 0.001). As shown in Table 2, requests for severe fetal anomalies had high approval rates, including for thalassemia (100%), other congenital anomalies (83.3%), and neural tube defects (NTD) or central nervous system abnormalities (80.0%). In contrast, requests based on maternal diseases – the only explicit legal ground – were approved in only 36.6% of cases. Requests for non-lethal genetic or chromosomal anomalies had the lowest approval rate (18.2%). Ultimately, 116 pregnancies (58.0%) were terminated, while 84 (42.0%) were continued. Medical induction was the most common termination method (106 cases). Surgical termination (dilatation and evacuation) was performed in 10 cases, typically following an incomplete or failed medical abortion. The final pregnancy outcome was significantly Table 1: Sociodemographic and obstetric characteristics (n=200) Variable Category n % Age (years) Mean±standard deviation 30.3±7.2 Residence Inside Erbil city 103 51.5 Outside Erbil city 97 48.5 Education Illiterate 72 36.0 Primary 51 25.5 Secondary 22 11.0 University 55 27.5 SES* Low 72 36.0 Medium 85 42.5 High 43 21.5 Gravidity Primigravida 38 19.0 Multigravida 138 69.0 Grand multigravida 24 12.0 Gestation First trimester 62 31.0 Second trimester 138 69.0 Consanguinity Yes 83 41.5 No 117 58.5 Previous abortion Yes 66 33.0 No 134 67.0 Previous child with anomaly Yes 31 15.5 No 169 84.5 *SES: Socioeconomic status Table 2: Committee decision by indication for termination (n=200) Indication for termination Approved n (%) Refused n (%) Total n (%) P-value NTD and CNS abnormalities 44 (80.0) 11 (20.0) 55 (100) <0.001 Maternal diseases 15 (36.6) 26 (63.4) 41 (100) Hydrops fetalis 16 (66.7) 8 (33.3) 24 (100) Congenital anomalies 35 (83.3) 7 (16.7) 42 (100) Thalassemia 5 (100.0) 0 (0.0) 5 (100) Genetic/ chromosomal anomalies 6 (18.2) 27 (81.8) 33 (100) NTD: Neural tube defect, CNS: Central nervous system Khaleel and Muhamad: Ethical Abortion Decisions in Erbil 77 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2025, 9 (2): 74-79 associated with gestational age and parity (P < 0.05) but not with the woman’s personal belief about abortion [Table 3]. Only 25.8% of first-trimester pregnancies were terminated, compared to 72.5% of second-trimester pregnancies. Notably, the fetal gender was unknown in 54.5% of cases, likely because many referrals were based on anomaly scans performed before 18 weeks of gestation, when sex determination is less accurate.[8] In addition, 5.5% of women did not know their blood group, suggesting potential gaps in prior antenatal care. Discussion This study provides a critical insight into the functioning of the Ethical Abortion Decision-Making Committee in Erbil, revealing a significant divergence between the strict letter of the law and its practical application. The findings highlight three key themes: the committee’s creation of an ethical hierarchy, the paradoxical refusal of maternal health cases, and the broader public health implications of this system. The most striking finding is the committee’s de facto policy of approving terminations for severe fetal anomalies, an indication not explicitly covered by KRG law. Approval rates of 80% or higher for conditions like NTDs and other congenital anomalies suggest a pragmatic reinterpretation of the law.[16,17] This practice aligns with contemporary Islamic jurisprudence, which increasingly considers preventing “extreme hardship” (haraj) for the family and avoiding a life of severe suffering for the child, particularly before ensoulment (nafkh al-ruh), often cited at 120 days of gestation.[18,19] As 69% of women presented in the second trimester, most decisions fell within a timeframe where termination for severe anomalies finds justification in modern Islamic legal thought.[20] The Kurdish population is predominantly of the Shafi’i school, which can be restrictive; however, the committee’s practice suggests an adoption of the more widely accepted 120-day threshold.[21,22] Paradoxically, while showing flexibility on fetal grounds, the committee was exceptionally stringent when applying the law’s explicit “life of the mother” exception, refusing 63.4% of such requests. This is troubling, as saving the pregnant woman’s life is the single point of unequivocal consensus across all schools of Islamic thought and the legal basis for abortion in nearly every MENA country.[6] This high refusal rate suggests a “chilling effect,” where physicians in a punitive legal environment fear liability for a subjective judgment about maternal risk.[23] Without clear clinical guidelines, the committee appears to require a near-certain risk of death, creating an inverted ethical hierarchy where a non-viable fetus is prioritized over a sick mother.[24,25] Finally, the committee’s caseload reflects upstream public health challenges. The high rate of consanguineous marriage (41.5%) is strongly linked to the genetic and congenital anomalies that constituted 79.5% of all cases.[26,27] Compounded by low educational attainment (36% illiterate), these factors show that the committee is a downstream bottleneck for a population-level genetic risk profile.[28] It functions as a reactive mechanism in the absence of a proactive public health strategy, such as widespread genetic screening and counseling. The high termination rate in the second trimester (72.5%) further illustrates this; it is not medically intuitive but reflects a selection bias, as severe anomalies are typically detected at the mid-trimester scan.[29] This “filter effect” masks a cohort of women denied a wanted abortion in the first trimester, likely for unapproved reasons, pushing them toward unsafe alternatives.[23,30,31] CONCLUSION This study reveals that the Ethical Abortion Decision-Making Committee in Erbil operates not as a simple enforcer of the law, but as a site of pragmatic negotiation between legal text, medical necessity, and Islamic ethical principles. It has established a de facto policy of approving terminations for severe fetal anomalies while paradoxically applying an exceedingly strict interpretation of the law’s explicit “life of the mother” exception. The committee’s substantial refusal rate of nearly 40% channels a significant number of women toward the dual risks of unsafe clandestine abortion or the adverse consequences of carrying an unwanted or high-risk pregnancy to term. This research provides crucial, context- specific data that contribute to global scholarly debates on the real-world application of abortion law and its profound impact on women’s health and rights in legally restrictive settings. Recommendations Based on the findings, the following evidence-based recommendations are proposed: For Policymakers and the Ministry of Health: Develop and disseminate standardized clinical guidelines to provide objective criteria for interpreting the “serious threat to her life” clause. This would reduce subjectivity, protect clinicians from legal ambiguity, and ensure women with serious maternal health conditions receive legally entitled care. For Public Health Authorities: Implement an upstream public health strategy to address the high prevalence of congenital anomalies. This should include integrating voluntary, confidential, and culturally sensitive preconception and prenatal genetic counseling and screening services into Table 3: Final pregnancy outcome by gestation, parity, and patient belief Variable Terminated n (%) Continued n (%) Total n (%) P-value Gestation <0.001 First trimester 16 (25.8) 46 (74.2) 62 (100) Second trimester 100 (72.5) 38 (27.5) 138 (100) Parity 0.032 Primigravida 28 (73.7) 10 (26.3) 38 (100) Multigravida 72 (52.2) 66 (47.8) 138 (100) Grand multigravida 8 (33.3) 16 (66.7) 24 (100) Idea about abortion 0.249 Against 8 (42.1) 11 (57.9) 19 (100) Not Against 108 (59.7) 73 (40.3) 181 (100) Khaleel and Muhamad: Ethical Abortion Decisions in Erbil 78 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2025, 9 (2): 74-79 primary healthcare, particularly for couples in consanguineous unions. For Healthcare Institutions: Establish a formal psychosocial support pathway for all women referred to the committee. There is an ethical duty of care for the nearly 40% of women whose requests are denied. A mandatory referral to professional counseling and social support services must be integrated to mitigate the adverse mental and physical health outcomes associated with being denied a wanted abortion. For the Research Community: Conduct further research to build on these findings. In-depth qualitative studies are needed to explore the decision-making calculus of committee members and the lived experiences of women. A prospective cohort study is also essential to track the health and socioeconomic outcomes of women who are denied a legal abortion in the Iraqi context to strengthen the case for evidence-based legal reform. Study Limitations and Future Research Directions This study has several limitations that should be acknowledged. As a descriptive, cross-sectional study conducted at a single tertiary hospital, its findings may not be generalizable to the entire KRG or other parts of the country. The quantitative design captures the “what” of the committee’s decisions but not the “why”; it cannot explain the reasoning of the committee members or the lived experiences and perceptions of the women who appear before them. The study also does not follow women who were refused termination, so the discussion of their outcomes is based on inference from international literature. These limitations point to critical directions for future research: First, qualitative studies are urgently needed. Interviews with committee members would illuminate the ethical, legal, and personal factors that shape their decision-making. Interviews with women who have been both approved and refused by the committee would provide invaluable insight into their experiences, coping mechanisms, and the impact of the process on their lives. Second, a prospective cohort study, modeled on the Turnaway Study, is essential to track the health, psychological, and socioeconomic outcomes of women who are denied a legal abortion in the Iraqi context. This would provide local, context-specific data to either validate or nuance the findings from Western settings and strengthen the case for legal reform. Finally, a larger, multi-center or population- based survey is needed to more accurately estimate the true incidence of requests for legal abortion, the prevalence of unsafe abortion, and the associated morbidity and mortality across the region. REFERENCES 1. World Health Organization. Abortion. Geneva: World Health Organization, 2021. Available from: https://www.who.int/ news-room/fact-sheets/detail/abortion [Last accessed on 2024 Mar 06]. 2. World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: World Health Organization, 2003. 3. C. Calvert, O. O. Owolabi, F. Yeung, R. Pittrof, B. 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