National Abortion Survey - Brazil, 2021

Abstract The National Abortion Survey 2021 (PNA 2021) utilized face-to-face structured interviews and a self-administered questionnaire placed in a sealed box to collect data on abortions in Brazil. Interviews were held with a nationally representative sample of 2,000 women, randomly selected from among literate women ages 18 to 39 residing in urban areas. We compared some of the results with previous waves of the survey, PNA 2010 and PNA 2016. Findings show that abortion is in decline but remains a major public health issue. Around 10% of the women interviewed in 2021 said they had had at least one abortion in their lives (compared to 15% in 2010). We estimate that nearly one in every seven women (15%) have had an abortion by the age of 40. We identified a decline in the proportion of women who needed to be hospitalized to finalize their abortions (55% in 2010; 43% in 2021; p = 0.003) and in the proportion of women who used medication for the abortion (48% in 2010; 39% in 2021; p = 0.028). Abortion is an event that generally happens early on in women’s reproductive lives: the PNA 2021 found that 52% of women were 19 years old or younger when they had their first abortion. Higher rates were detected among respondents with lower educational levels, Black and Indigenous women, and women residing in poorer regions.


introduction
Abortion is only legal in Brazil if the pregnant person's life is at risk, if the pregnancy is the result of a rape, or in cases of fetal anencephaly.Despite these legal restrictions, data from the National Abortion Survey for 2010 (PNA 2010) and 2016 (PNA 2016), which used self-administered questionnaires deposited in sealed boxes ('ballot boxes') to reduce the rate of false answers, found that abortion is a common event in the reproductive lives of Brazilian women 1,2 .According to PNA 2010 and 2016, approximately one in five women had had at least one abortion by the age of 40, with higher rates detected among respondents with lower educational levels, Black and Indigenous women, and women residing in poorer regions 1,2 .PNA 2019, which was conducted only in Northeast Brazil, corroborates these findings regionally 3 .

Methods
The PNA 2021 household survey was fielded during November 13-21, 2021.Interviews were held with a representative sample of 2,000 women, randomly chosen from among literate women ages 18 to 39 residing in urban areas.The cluster sampling was done in three stages: 125 municipalities were selected using the probability proportional to size (PPS) method; clusters were next selected from census tracts; and, lastly, a fixed number of people were selected within each cluster, controlling for age, educational level, and employment status.The margin of error was ± 2% and the confidence interval was 95%.
Two data collection instruments were used.The first was a face-to-face structured interview consisting of a series of socio-demographic questions, including age, educational level, household income, type and size of municipality, religion, race, marital status, occupation, and number of live births.The second was a self-administered questionnaire which the respondent filled out and then placed in a sealed box ('ballot box'); this questionnaire asked questions about abortion ("Have you ever had an abortion?","How many abortions have you had?", "Age at first abortion, " "Age at last abortion, " "Did you have an abortion in 2020?", "Did you use medication for your last abortion?"and "Did you need to be hospitalized during your last abortion?").The two questionnaires were linked using cryptographic codes to ensure confidentiality.Unlike PNA 2010 and PNA 2016, PNA 2021 included a question about the respondent's age at the time of their first abortion.The three PNA surveys used the same sampling design, interview methods, and self-administered questionnaire design.For purposes of analysis, data from PNA 2021 (n = 2,000) were compared with data from PNA 2010 (n = 2,002) and PNA 2016 (n = 2,002), with the p-values for the difference in proportions presented in brackets.The research project was approved by the Research Ethics Committee of the Institute of Human Sciences at the University of Brasília.
Abortion is a cumulative event; therefore, the age structure of the population may affect the results.In order to control this, we present an estimate of the proportion of women who had had one or more abortions by the age of 40.This estimate is based on the adjustment of a trendline obtained by linear regression of the proportion of abortions by age, from 18 to 39 years, and extrapolating the line to the age of 40 years.This line has a constant = -0.0227,and the parameter for age, = 0.0044 (r² = 0.34).

Results and discussion
In PNA 2021, the abortion rate dropped in comparison with the 2010 and 2016 surveys.Table 1 shows that around 10% of the women interviewed in 2021 said they had had at least one abortion in their lives, compared with 13% in 2016 and 15% in 2010 (p = 0.014 for 2016-2021; p = 0.000 for 2010-2021).This finding may reflect the worldwide decline in unwanted pregnancies, including rates in developing countries 4 .Data from Latin America and the Caribbean show an upward trend in the use of reversible and long-acting contraceptive methods, although disparities are more prevalent among women who are younger and poorer, have a lower educational level, are Indigenous, or live in rural areas 5 .Despite the increase in contraception, PNA 2021 found a still high proportion of unintended pregnancies.In 2021, two in every three pregnant women (66%) had not planned that pregnancy (not shown in Table 1).
In 2021, the PNA asked for the first time about the total number of abortions that a woman had had in her reproductive life.Among those who have had an abortion, more than ⅕ (21%) have had two or more abortions (67% had the last abortion between 20-39 years old; 74% among Black women; not shown in Table 1).This data reveals a sub-group of women who face height-ened vulnerability in their reproductive lives and are likely exposed to increased negative health outcomes.Studies have shown that offering post-abortion counseling and increasing access to and availability of contraceptive methods are the most efficient mechanisms to prevent repeated unsafe abortions 6 .
Results from PNA 2021 also indicate a decrease in the proportion of women who needed to be hospitalized to finalize their abortions (55% in 2010; 43% in 2021, p = 0.003); the same phenomenon is observed when analyzing the number of hospitalizations at public hospitals over the last ten years that were related to abortion com- it continues plications 7 .The use of safer abortion methods, the falling abortion rate, or both of these factors may explain these findings 4,8 .Little research has been conducted to date on how the COVID-19 pandemic has affected the fall in hospitalizations 9 .
Similarly, PNA 2021 found that the proportion of women who had medical abortions fell, from 48% in 2010 to 39% in 2021 (p = 0.028).
While none of the three surveys asked respondents which specific medication they used to have an abortion, other studies have found that misoprostol is the most common choice in Brazil 10 .One possible explanation to account for the lower rate of medical abortions might be a higher rate of in-clinic abortion care 10,11 , especially among middle-and high-income women; how- ever, this is hard to know given the criminalization of abortion in Brazil.One important finding from PNA 2021 was the age of respondents at the time of their first abortion: half (52%) were adolescents (19 or younger).Since this population is especially vulnerable to the effects of criminalization on abortion needs 12 , the finding demonstrates the critical need for an integrated reproductive justice policy in Brazil, from comprehensive sexual education to the decriminalization of abortion.In gener-al terms, there was no substantial change in the overall profile of women who had abortions: they reflect all age ranges, religions, educational levels, races, social classes, and geographical regions.
Over the last eleven years (2010-2021), evidence shows that abortion remains a common event in women's lives and a large-scale public health issue in Brazil.A linear extrapolation from PNA 2021 data estimates that nearly one in every seven women (13%) has interrupted a pregnancy by the age of 40.

D
Diniz, M Medeiros and A Madeiro participated equally in all stages of preparation of the article.

table 1 .
Characteristics of women who have had abortions in Brazil, 2010, 2016, and 2021.

table 1 .
Question not posed in 2010; b question not posed in 2010 or 2016; c the monthly minimum wage serves as a reference for defining income brackets in Brazil.In 2022, the minimum wage was BRL 1,212, or roughly USD 233.The brackets in the table correspond to ≤ 1; >1 -2; >2 -5; and >5 monthly minimum wages.Source: Pesquisa Nacional de Aborto 2010; Pesquisa Nacional de Aborto 2016; Pesquisa Nacional de Aborto 2021.Characteristics of women who have had abortions in Brazil, 2010, 2016, and 2021. a