This study found that most of the women seemed to favour medical abortion due to its convenience, naturalness and cheaper cost compared to surgical abortion. However there were concerns over the long term health effects of medical abortion and this, corroborates the study by Fielding (2002) . Similarly, elsewhere, the acceptance and satisfaction towards medical abortion has also been reported in women [9–12]. Progression in medical technology have given women a safer, cheaper and simpler alternative namely, medical abortion. However, this method was noted to be uncommon in Malaysia as claimed by women in this study.
In Malaysian public hospitals, the main abortion method that is being carried out is still dilatation and curettage which is much less convenient, costlier and most crucially, riskier compared to manual vacuum aspiration (MVA) and medical abortion. The medical abortion regimen combining the use of mifepristone pills and misoprostol pills offers a complete abortion rate up to 95% in early pregnancies . Although misoprostol could be given alone to induce a miscarriage, however, the effectiveness is still low in addition to a higher rate of side effects . While mifepristone and misoprostol is registered in the WHO Model List of Essential Medicines  and is recommended to be used for early pregnancy termination , this is not the case in Malaysia. Mifepristone has yet to be registered while Misoprostol is only registered for use as a treatment for gastric ulcers. In Malaysia, the drug manufacturers need to make the initial move to register their drugs with the Drug Control Authority of Malaysia. This may not be forthcoming as for misoprostol, the manufacturer does not indicate it for O&G uses. Nevertheless, there should be efforts to overcome these difficulties.
The availability of both medical and surgical abortion should be disseminated and made available to women so that they can opt for a method that best suits them and at the same time, this choice would also give women control over their reproductive health matters .
Although the women in the study have undergone abortion, there were still reported fears and uncertainties towards abortion. The fears may have arisen from misperceptions about consequences of abortion and the lack of knowledge and awareness surrounding this issue. Abortion does carry complications such as infections and future sub-fertility and the women were aware of it. However, there were still some serious misperceptions such as: abortion could cause cancer and abortion would lead to birth of an abnormal child in future as reported in this study. This lack of knowledge could be due to the issue of abortion that is minimally discussed in the community. There has not been any provision of legitimate abortion information in the media or the healthcare services in Malaysia. If women were given information and were knowledgeable about the risks and consequences of abortion, perhaps the fears and worries could be avoided and also the misperceptions regarding side effects of abortion could be dispelled.
Access to abortion knowledge/information and services are the major barriers as evidenced from findings of this study. The inaccessibility could be multi-factorial from the clandestine nature of abortion, to cultural, spiritual and social barriers and also to lack of awareness to the abortion laws. In addition, the Medicines (Advertisement & Sale) Act 1956 (revised 1983) Act 290 states that “No person shall take any part in the publication of any advertisement referring to any article, or articles of any description, in terms which are calculated to lead to the use of that article or articles of that description for procure the miscarriage of women” . Hence, abortion services are not widely or openly offered and are not easily accessible. These barriers caused women to” not know where and who to go for abortion” and they could only rely on information from friends or colleagues. In addition, discourse on abortion is rare and is viewed as a taboo. This makes it difficult for women to seek legitimate abortion information and its whereabouts. When women cannot and have difficulties in seeking abortion services, they resort to unsafe, self-induced methods [16, 17] which is also admitted by women in this study. Such a scenario is alarming as self-induced abortion is harmful and could lead to severe complications  and even death .
Malaysian government hospitals do provide abortions but only under specific circumstances as permissible by the law as alluded above. However, this is not known by many women and including health providers themselves . This could be another reason why women faced difficulties to obtain abortion services in Malaysia. It is pertinent that women and health providers must be made to know their rights to have, or to perform an abortion within the permissive provisions of the law so that it is clear to them that they are not committing a crime against the law. To women, they would then know their rights as a patient to have an abortion and would not have to resort to clandestine abortion services to which they could be subjected to harm. To health providers, knowing the abortion law would allow them to conduct their duties without apprehension so that they can provide the best quality care to patients within the law.
In this study, women expressed the difficulties they faced with health providers who disapproved of them having abortions by claiming that it was illegal. Efforts to increase awareness on the abortion law in Malaysia is warranted. In recent studies conducted in Malaysia on medical students and medical officers pertaining to their willingness to carry out medical or surgical abortion services, 41% of medical officers reported that they would not carry out abortion under any circumstances if it is against their personal religious beliefs (Mary Huang, Jegasothy & Lim, 2011. In Medical Officers’ Knowledge, Attitude And Willingness To Provide Abortion Related Service As Reproductive Rights Of Women, 2011; unpublished work), whereas it was less than 20% for medical students (Tey, Low, Yong et al., 2011. Survey on Knowledge and Perception of Medical Students on Abortion; unpublished work). This implies that many current and future health providers are and will not be willing to provide abortion services based on their personal and religious beliefs and this will cause serious repercussions when women are forced to continue an unwanted pregnancy.
Stigma attached to abortion is another challenge for women to have safe abortions and this is particularly for young, unmarried single women who are faced with an unwanted pregnancy . This study found that the abortion stigma appeared at both individual and community level as the women revealed that they were embarrassed to ask for abortion information and also to go back to the same clinic for abortion because they felt shameful of letting people know they are doing a ‘wrong’ thing. In Malaysia, abortion is still considered a taboo and is culturally unacceptable for single or married women but more so for the former. These cultural beliefs hinder women from obtaining abortion information and services and drive women to have self-induced abortion or resort to unsafe clandestine abortion providers. Removal of stigma attached to abortion should be done so that women can get an unbiased, safe and quality medical treatment and care.
It is also found in this study that when women are determined to end their pregnancy, they are willing to pay whatever the cost. Such a situation would enable unscrupulous health providers to charge exorbitant prices for abortion services that is unaffordable by women from the lower socio-economic classes. For those who can’t afford to pay for the service, they will turn to cheaper alternatives such as traditional methods or seek illegitimate abortion services that are harmful which are usually available at a lower cost. Monitoring and regulation of abortion services is needed to avoid such events from occurring. However, for this to be done, clinics/healthcare centers which offer abortion services would need to come forward and make themselves known.
In terms of abortion decision making and support, the women in this study claimed to receive support from family members, friends and particularly from husband/partner. Men play a significant role in abortion as they have influence on the women’s abortion decision and emotional outcomes. Among the roles they play are as instigators, facilitators, collaborators, transporters, advisors, informers, supporters or punishment givers . In terms of abortion decision making, although majority of the women in this study claimed to make the abortion decision by themselves but they had also sought their partner’s agreement or support and took considerations of their relationship with the partner before proceeding to have abortions. Kimport (2011) revealed that women felt the need to have control over their abortion decision and if the decision is not primarily theirs, they would experience emotional difficulties, however, it was further highlighted that support from partner, family and close friends were needed in order to validate their abortion decision making . Other studies have shown similar findings where, when it comes to making abortion decisions, women had discussions with their partners, mothers and friends and were influenced by childhood experiences as well as their economic situation and future planning [24, 25]. In the current study, husbands/male partners were also found to play a supportive role to the women in terms of providing moral support and help in accessing abortion services especially in terms of transportation and locating the service and financial assistance. Similar findings has also been found in other studies [26, 27]. Support for women during pre and post abortion is crucial to avoid adverse physical and psychological effects [23, 28] and attention is needed to be given to include men’s involvement in female reproductive and health matters.
Women’s needs with regards to abortion information and services are clearly highlighted in this study. Many of them are in favor for abortion information and services to be disseminated to the public. The lack of abortion information and services has prompted the call for increased availability and access to such services. Although there was favour for increasing and dissemination of abortion information and services to the public partly because the women themselves have had to use the service, another factor could be due to escalating incidences of baby dumping that is s a rising issue in the country at the time of data collection which indirectly influenced the women to feel the need for abortion services in the country. Perhaps, future studies can be conducted to determine the needs for abortion services in Malaysia in the general population and look into factors that lead to such a need, such as unmet contraception needs. The needs of women with regard to abortion uncovered in this study provided insights on the gaps that are existing in the current abortion services provided in the country and such needs should be addressed so that an accessible, comprehensive, safe abortion service can be provided.
Strengths and limitations of study
This study has some strengths that should be noted. Firstly, based on the literature, it has been found that there is only limited research on abortion experiences and needs that have been carried out in the Malaysian context and none of these studies looked into women’s experiences with medical abortion and their needs with regard to abortion [29, 30]. Hence, this study adds to the existing body of evidence for this topic in the country and to the internationally body of literature as a whole. Secondly, this study provided perspectives and empirical evidence into the topic of abortion which is often not talked about and discussed in Malaysia. Thirdly, the issues highlighted in this study will be of considerable importance for the understanding of the experiences and needs of women with regard to abortion in Malaysia and it is hoped that the findings can serve as a guide for developing policies and programmes to promote safe abortion which could potentially help to reduce dangerous clandestine abortion and ultimately reduce mortality of women.
We acknowledge that our study has limitations. Firstly, due to the qualitative nature of the study, the findings of this study cannot be generalized to the wider population. Secondly, the data gathered in this study required respondents to recall past experiences where recall bias was likely to occur. However, most of the participants had their last abortion less than one year from the period of data collection, thus the chances or recall bias were reduced. Thirdly, the respondents were recruited from only one urban clinic. Perhaps future studies could recruit women from various places (etc. clinics, healthcare centers, hospitals) from both rural and urban areas so that the understanding of the current abortion scenario in Malaysia could be captured from experiences of women from different settings.