INTRODUCTION
Abortion is a major public health concern worldwide, with the World Health Organization estimating that approximately 73 million induced abortions occur annually, of which nearly 45% are unsafe, leading to significant maternal morbidity and mortality1,2. In Sri Lanka, abortion is legally permitted only to save a woman’s life under the Penal Code of 1883, making it one of the most restrictive abortion regimes globally3,4. Attempts to reform the law to allow abortion in cases of rape, incest, or fetal abnormality have repeatedly failed5. Despite this, an estimated 658 abortions are performed daily in Sri Lanka, with unsafe abortions accounting for 10–13% of maternal deaths and being the third most common cause of pregnancy-related mortality6,7. Cultural and religious beliefs in Sri Lanka further stigmatize abortion, limiting open discussion and access to reproductive health services8,9. Adolescents are particularly vulnerable due to limited formal sexual and reproductive health education, low contraceptive awareness, and social taboos surrounding sexuality10,11. The 2016 Demographic and Health Survey reported a contraceptive prevalence rate of 64.8% among married women, but knowledge and use among adolescents remain low12. Adolescence is a formative period for shaping long-term sexual and reproductive health behaviors13. The lack of formal sexual and reproductive health education in school curricula, combined with social and religious conservatism, increases adolescents’ vulnerability to misinformation and stigma14,15. Adolescents’ perceptions and attitudes can influence decision-making around pregnancy, contraception, and abortion, yet research on this topic in Sri Lanka is limited, especially among adolescents16,17. This study aims to assess the perceptions and attitudes of adolescents towards abortion in the Colombo District of Sri Lanka, focusing specifically on peri-urban areas. Understanding their knowledge and attitudes towards abortion is vital as it can help address the challenges they face and facilitate the development of targeted interventions.
METHODS
Study design, setting and participants
A descriptive cross-sectional study was conducted from January to March 2024 in four peri-urban MOH divisions (Piliyandala, Homagama, Boralesgamuwa, and Ratmalana) in Colombo District, Sri Lanka. The study included 422 adolescent girls aged 14–16 years, selected from provincial schools in the four MOH divisions. The sample size was calculated using the formula for proportions with a 95% confidence level, 5% margin of error, and an estimated 50% prevalence of positive perception, resulting in a minimum required sample of 384. To account for non-response, 10% was added, yielding a final sample size of 42218. A multistage cluster sampling method was used. Schools were randomly selected from each MOH division, and eligible students were invited to participate.
Data collection tool
Data were collected using a self-administered questionnaire developed based on literature review and expert input. The questionnaire is provided in the Supplementary file. The tool included sections on sociodemographic data, perception of abortion, parent-child sexual communication, knowledge of abortion laws, and attitudes toward abortion. The questionnaire was pre-tested among 30 adolescents in a similar setting and revised for clarity. Content validity was established by a panel of three public health experts. Cronbach’s alpha for the perception and attitude scales was 0.81 and 0.78, respectively, indicating good internal consistency19,20. Responses with regard to perceptions and attitudes were scored on a 5-point Likert scale (1=strongly disagree to 5=strongly agree). Scores were summed and dichotomized at the median to classify as ‘good’ or ‘poor’ perception/attitude. Parent–child communication was assessed using a 5-item scale; scores ≥3 indicated ‘good’ communication.
Ethical considerations
Ethical approval was obtained from the Ethics Review Committee of General Sir John Kotelawala Defence University (RP/S/2023/48, dated 27.09.2023). Written informed consent was obtained from parents/guardians and assent from participants.
Statistical analysis
Data were analyzed using SPSS v25. Descriptive statistics summarized participant characteristics and key variables. Normality of data was assessed using the Kolmogorov-Smirnov test. Associations between sociodemographic factors and perception/attitude scores were assessed using t-tests and ANOVA. Pearson correlation was used to examine relationships between perception, attitude, and communication scores. Statistical significance was set at p<0.05.
RESULTS
Sociodemographic characteristics
Of the 422 participants, the mean age was 15 years (SD=0.8). The majority were Sinhalese (99.8%), Buddhist (98.1%), and from middle-income families. In 67.1% cases only the father was employed (Table 1). Overall, 218 participants (51.7%) had a good perception of abortion, while 204 (48.3%) had a poor perception (Table 2). A total of 360 participants (85.3%) reported good parent–child sexual communication (Table 3). Good communication was associated with higher perception scores (mean=3.9 vs 3.2, p=0.002).
Table 1
Sociodemographic characteristics of participants, descriptive cross-sectional study, peri-urban MOH areas, Colombo District, Sri Lanka, 2024 (N=422)
Table 2
Perception regarding abortion among adolescents, descriptive cross-sectional study, selected peri-urban MOH areas, Colombo District, Sri Lanka, 2024 (N=422)
Table 3
Perception regarding parent–child sexual communication among adolescents, descriptive cross-sectional study, selected peri-urban MOH areas, Colombo District, Sri Lanka, 2024 (N=422)
Only 173 participants (41.0%) had a good perception of abortion laws, while 249 (59.0%) had poor knowledge (Table 4). Positive attitudes toward abortion were observed in 360 participants (85.3%), with 62 (14.7%) expressing negative attitudes (Table 5). Overall, there was a significant positive correlation between perception and attitude scores (r=0.62, p<0.001), and between parent–child communication and perception (r=0.41, p=0.002).
Table 4
Perception on abortion laws in Sri Lanka among adolescents, descriptive cross-sectional study, selected peri-urban MOH areas, Colombo District, Sri Lanka, 2024 (N=422)
Table 5
Attitudes towards abortion among adolescents, descriptive cross-sectional study, selected peri-urban MOH areas, Colombo District, Sri Lanka, 2024 (N=422)
DISCUSSION
This study found that just over half of adolescent girls in peri-urban Colombo had a good perception of abortion, and the majority held positive attitudes toward abortion. However, knowledge of abortion laws was limited, and nearly 60% had poor understanding of the legal context. Parent–child sexual communication was predominantly positive and was associated with better perception and attitudes toward abortion.
The moderate perception and high positive attitude toward abortion may reflect increasing access to information through media and peer networks, even in the absence of formal education21,22. The high rate of positive parent–child communication could be due to recent public health campaigns encouraging open discussion of reproductive health23. However, the persistent knowledge gap regarding abortion laws suggests that legal and policy information is not reaching adolescents effectively, possibly due to cultural taboos and lack of curriculum content24,25.
The proportion of adolescents with good perception and positive attitudes is higher than reported in previous Sri Lankan studies, where adolescent abortion seekers comprised only 3% of clinic attendees26.
The high rate of positive parent–child communication (85.3%) contrasts with national data indicating low levels of reproductive health awareness among adolescents27. Studies in other South Asian countries, such as Nepal, have shown better awareness of abortion laws among youth, likely due to more liberal legal frameworks and targeted education28. In contrast, research from the Democratic Republic of Congo and Lao PDR has highlighted similar gaps in knowledge and attitudes, emphasizing the influence of cultural and legal environments29,30. Internationally, studies have shown that adolescents’ attitudes toward abortion are shaped by a combination of personal, familial, societal, and religious factors31,32. In countries with restrictive abortion laws, stigma and misinformation are more prevalent, leading to negative perceptions and unsafe practices33,34. The positive correlation between parent–child communication and favorable attitudes toward abortion in our study aligns with findings from other contexts, where open family dialogue is associated with healthier sexual and reproductive health outcomes35,36.
The findings underscore the urgent need for comprehensive sexual and reproductive health education in Sri Lankan schools. Improved family communication may foster informed attitudes and reduce the risks associated with unsafe abortion. Policymakers should consider integrating accurate, age-appropriate information about reproductive rights and legal frameworks into the school curriculum. Community-based interventions that engage parents and adolescents together could further enhance communication and understanding.
Implementing school-based sexual and reproductive health education programs is essential. These programs should include information on abortion, contraception, and legal rights to provide young people with comprehensive and accurate knowledge. Promoting open parent–child communication on sexual and reproductive health topics is also crucial. This can be achieved through community workshops and the distribution of parental guidance materials that facilitate discussions within families. Advocating for policy reform to improve access to safe abortion and post-abortion care is another key recommendation. Such reform should also aim to reduce the stigma associated with abortion, ensuring that individuals can make health decisions freely and safely. Additionally, further research is necessary to explore the perspectives of out-of-school adolescents and assess the long-term impact of educational interventions on young people’s sexual and reproductive health.
Strengths and limitations
The study has several strengths. It utilized a large, representative sample drawn from multiple peri-urban settings within Colombo District, enhancing the generalizability of the findings. The use of a validated, pre-tested questionnaire with good internal consistency ensures the reliability of the data collected. However, there are limitations to consider. The cross-sectional design of the study limits the ability to draw causal inferences. Additionally, the reliance on self-reported data may introduce social desirability and recall biases, potentially affecting the accuracy of responses. The study did not include out-of-school adolescents or boys, which limits the generalizability of the findings to these groups. Finally, the findings may not apply to rural or urban populations outside the selected MOH areas, reducing the applicability of the results to other regions.
CONCLUSIONS
This study demonstrates that adolescent girls in peri-urban Colombo District, Sri Lanka, have moderate perceptions and predominantly positive attitudes toward abortion, but limited knowledge of abortion laws. Positive parent–child sexual communication is associated with better perceptions and attitudes. These findings highlight the need for targeted educational interventions, both in schools and at the community level, to address knowledge gaps and promote informed, safe reproductive health choices among Sri Lankan adolescents. Expanding access to accurate information and fostering open family dialogue are essential steps toward reducing the risks associated with unsafe abortion and improving adolescent reproductive health outcomes.
