Abortion and methods of reproductive planning: the views of Malta's medical doctor cohort.

Malta is the only EU country where abortion remains illegal in all circumstances. This study aims to assess the previously unexplored views of Malta's medical doctors on the legality of contraception, abortion, assisted reproductive technology and surrogacy. Following ethics approval, 1578 out of a total of 2468 registered medical doctors in Malta were invited for an anonymous survey. The response rate was 28.8% (n = 454), guaranteeing a maximum margin of error of 4.16% assuming a 95% confidence level. Responses consisted of "Yes", "No", and "Not sure". In the abortion section, "Yes" responses were specific to different gestational age limits. A majority supported all contraceptive methods being legal: morning-after pill (59.7%); intra-uterine device (85.9%); surgical sterilisation (>70%). A majority also agreed with in-vitro fertilisation being legal (93.8%). Embryo freezing and surrogacy garnered less support (39.9% and 40.5% respectively). Legalising abortion for "Woman's life in danger" and "Non-viable fetal anomaly" was supported at least up to 12 weeks gestation by 66.8% and 63.0% respectively, and in all stages of pregnancy by 54.2% and 50.2% respectively. Support, at least up to 12 weeks gestation, was less for other circumstances: "Rape or incest" (35.3%); "Preserve a woman's physical health" (30.0%); "Preserve a woman's mental health" (26.8%); "Viable fetal anomaly" (24.6%); "<16 years of age" (23.8%); "Economic/social reasons" (18.9%); "Any circumstance" (14.5%). According to the surveyed respondents, there is at present a clear majority of doctors in Malta who do not agree with the total legal ban on abortion and support its legalisation in limited circumstances.

Introduction

Malta is a southern European country located in the middle of the Mediterranean Sea, and since 2004 has been part of the EU. It is one of the smallest countries in the world, with an area of 316 km2 and a population of under half a million.[1] The constitution of Malta establishes Catholicism as the state religion,[2] with over 90% of the Maltese general population identifying themselves as Catholic.[3] However, over recent years Malta has undergone rapid socio-legal changes. Divorce was legalised following a referendum in 2011,[4] and same-sex marriage and adoption were introduced in 2017.[5, 6]

Contraceptive methods in Malta

The first family planning clinics in Malta were set up in 1962 by the Church to promote only the rhythm method, a natural form of contraception (as other methods of contraception were not approved by the Church).[7] In 1982, the government opened state-managed family planning clinics which provided a service offering various contraceptive methods free-of-charge.[7-9] Such dedicated clinics have not been operational since the late 1980s, and at present there remain no such clinics available as part of community health care. Some of the services were incorporated as part of general health centres around Malta (Prof. Savona-Ventura, personal communication, 4 August 2019). However, these did not continue to provide the same services, and contraception stopped being provided for free by the state. The governmental national health service in Malta does not offer any subsidisation or free contraception (this applies to all forms of contraception).

Awareness about contraception has been increasing, but the subject has been a taboo over the past decades. A national survey[10] on sexual knowledge, attitudes, and behaviour from 2012 shows low rates of contraceptive use. The majority of respondents with multiple partners in the previous 6 months did not use contraception and 30% did not use contraception during their first sexual intercourse.[10] The survey also found that there is a general lack of knowledge on the subject. Research on the use of contraception in Malta is very limited. However, the studies available have suggested that Catholic beliefs permeated to the social aspect of sexuality practised within the Maltese community. Surveys carried out in 1971,[11] 1993,[12] and 2012[13] showed a shift towards the more reliable forms of contraception (primarily barrier methods, hormone manipulation, and sterilisation) and away from unreliable contraceptive methods (natural methods such as coitus interruptus and rhythm method). Changes in sexual behaviour, with more liberal sexual attitudes and changes in contraceptive use, have been attributed to increased secularisation of the Maltese community, which increasingly distances itself from the moral and ethical values of the Roman Catholic Church.[13]

Access to a full range of contraception is regarded as a woman’s right by the World Health Organization (WHO),[14] the Council of Europe (CoE),[15] and the United Nations (UN).[16] At present, there is quite an extensive range of contraceptive products available in Malta, but some are not imported and are therefore unavailable. This includes the female condom, cervical cap and diaphragm, and the contraceptive patch. There are particularly divergent views on certain contraceptives, such as the morning-after pill (MAP), intra-uterine device (IUD), and surgical sterilisation. The MAP has only been approved by the respective medical authorities and made available in Malta since late 2016,[17] following a judicial protest filed by Malta’s Women’s Rights Foundation (WRF).[18] However, it is not stocked in all pharmacies, and pharmacists can act as conscientious objectors. At the time of writing, it is not yet stocked at Malta’s public general hospital (Mater Dei Hospital) and therefore is not available by the national health service for cases of sexual assault[19] (Mater Dei Hospital personnel, personal communication, 3 June 2019). The IUD and surgical sterilisation have been in use for a long period of time.[12,13] In the past, the IUD was provided free-of-charge by the state through family planning clinics, however, this was suspended in 1993 following a local public outcry by anti-choice individuals.[20] Since the national health service does not offer free contraception, methods like IUD and surgical sterilisation can only be provided by government hospitals if there is an underlying medical indication that needs to be managed (e.g. IUD to treat heavy menstrual bleeding, or surgical sterilisation with prophylactic risk-reducing resection of both ovaries and fallopian tubes for patients with a high lifetime risk of developing ovarian and fallopian tube cancer), but not purely as a contraceptive.[19]

The situation regarding abortion in Malta

Within the EU, Malta is the only country where abortion is completely legally banned.[21,22] There are no exceptions for cases such as fatal fetal abnormalities, rape or incest, or even risk to the woman’s life. The current legislation criminalises both the woman and whoever assists her in the abortion. A person found guilty of procuring an abortion risks serving 18 months to 3 years in prison. Medical doctors and other healthcare professionals who do so risk up to 4 years imprisonment as well as being struck off the professional register.[23] Maltese laws condemning and criminalising abortion date back to the time of the Order of the Knights of St John in the 1700s,[24] and in the 1850s they were written and enacted as they remain today,[23] rooted in the nineteenth century. This is in contrast with most other European countries, which allow abortion at least within the first 12 weeks of gestation.[25] Certain countries also allow abortion at later gestational ages either upon the pregnant person’s request or in specific circumstances.

In Malta, discussion about abortion has been gaining momentum in the public sphere over recent years. In 2017, the CoE’s Commissioner for Human Rights stated that Malta needed to reform its abortion laws.[26] He specified that the laws need to be changed on grounds of human rights, right to health, and equality.[27] He urged Malta to bring its legislation in line with “international human rights standards and regional best practices” in the domain of sexual and reproductive health and rights (SRHR).[28], p. 2 According to international and European human rights law, European States have the duty to ensure that women’s SRHR are protected and respected.[15] The UN Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) has also spoken out about the situation in Malta, noting in 2010 that women’s health was an area of concern due to “insufficient access to reproductive health-care services for women”.[29], p. 8 In March 2018, WRF published a position paper on SRHR, taking a public stance in favour of decriminalising and legalising abortion at least in certain circumstances.[30] More recently, in June 2019, the UN’s Committee on the Rights of the Child called on Malta to ensure safe access to abortion and post-abortion services for adolescent girls, and to decriminalise abortion in all circumstances.[31]

Major relevant international health organisations also recognise abortion as a fundamental human right and support universal access to safe and legal abortion. These include the WHO,[32] the International Federation of Gynecology and Obstetrics (FIGO),[33] and the Royal College of Obstetricians and Gynaecologists.[34] According to FIGO, “society has an obligation to tackle this serious public health problem”.[33], p. 128 The Malta College of Obstetricians and Gynaecologists, which is a member of FIGO, has never officially published its position on abortion. Malta is a member state of the WHO and accepts its constitutional description of health as “a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity”.[32], p. 2 It is known that countries with poorly developed health services, and where women are denied the right to control their fertility, have higher rates of unsafe abortion.[33] When properly performed, abortions are actually safer than term deliveries, particularly during the first trimester.[33]

While abortion is illegal in Malta, this does not prevent Maltese individuals from travelling abroad in order to secure an abortion.[35,36] Indeed, abortion rates are similar in countries where it is highly restricted and where it is broadly legal.[37] In England and Wales, an average of 57 Maltese women per year were reported to access abortion services between 2011 and 2017,[38] i.e. more than one woman per week. This does not include women who travel to other European countries for this purpose. However, travel to access abortion is contingent on factors such as wealth and mobility. Women also buy medical abortion pills over the internet from organisations such as Women Help Women and Women on Web. Between its inception in 2009 and August 2018, Women on Web alone received 488 requests from Malta (Women on Web, personal communication, 19 August 2018). Estimates suggest that every year around 200 women purchase abortion pills online, whilst around 370 travel abroad for an abortion.[30]

Other methods of reproductive planning in Malta

Like some methods of pregnancy prevention and abortion, techniques of assisted reproductive technology (ART) are also highly contentious. In-vitro fertilisation (IVF) has been available in Malta since January 2013,[39] with amendments made to the respective legal framework in October 2018.[40] Presently, it is available to all individuals between 18 and 48 years of age, regardless of their sexual orientation or relationship status (including those who are not in a relationship). The number of eggs that can be fertilised are two to five and a maximum of two can be transferred into the uterus. The related issue of embryo freezing was heavily debated and changes in the law to facilitate this were met with significant opposition. In May 2018, 100 local academics published a document highlighting their disapproval of embryo freezing.[41] This was followed by 524 doctors signing a declaration against this technique.[42] Embryo freezing is currently legal, but Maltese law does not allow the disposal of embryos under any circumstance. A 5-year permit can be issued allowing the freezing of fertilised eggs. This is renewable until the woman exceeds 48 years of age, and if the frozen embryos remain unclaimed, they must then be given up for adoption.[40]

Surrogacy is illegal in Malta and any doctor who participates in IVF or embryo transfer in this context can be punished by a fine ranging between €5000 and €15,000 and a maximum 3-year prison sentence.[40] According to legal documents, altruistic surrogacy may be allowed with regulations as prescribed by the health minister, who stated that this will be subject to a public consultation exercise.[40,43] However, there have been no further developments on this matter.

Study objectives

Medical doctors have a primary role to play in the provision of all these reproductive healthcare methods. The complete ban of abortion by law also has an impact on their work when caring for patients who wish to access abortion, and in dealing with abortion complications or the after-effects of unsafe abortions. It is therefore imperative that their views on these issues are explored. To our knowledge, this is the first study looking into such data. This study aims to identify the opinions of medical doctors in Malta on whether these methods of reproductive healthcare should be legal.

Methodology

Official ethical approval to conduct the study was obtained from the Malta Health Ethics Committee in June 2018. An online survey involving an anonymous questionnaire was used to record responses from medical doctors registered in Malta on whether they think different methods concerning reproductive health and planning should be legal. As explained above, some of the methods and procedures are already legal and available in Malta, whilst others are not. The questionnaire gathered demographical information including age, sex, nationality, religion, institution where participants obtained their medical degree, medical speciality, and professional grade. This was followed by two main sections (Box 1). The first asked for opinions on which reproductive planning methods should remain or be made legal. The second section asked about circumstances in which abortion should be made legal.

Section 1 – Reproductive planning – should the following methods be legal?

Morning-after pill (MAP)

Intra-uterine device (IUD)

Surgical sterilisation

Female ≥ 18 years in any circumstance

Female ≥ 18 years in case of hereditary genetic conditions

Male ≥ 18 years in any circumstance

Male ≥ 18 years in case of hereditary genetic conditions

In-vitro fertilisation (IVF)

Embryo freezing

Surrogacy

Section 2 – Abortion – should it be legal in the following circumstances?

Woman’s life in danger

Rape or incest

Under 16 years of age

Non-viable fetal anomaly (e.g. anencephaly)

Viable fetal anomaly (e.g. Down’s syndrome)

To preserve a woman’s physical health

To preserve a woman’s mental health

For economic or social reasons

Any circumstance

For each method of reproductive planning, the participants answered “Yes”, “No”, or “Not sure”. For abortion, in each case where participants agreed with legalisation, they needed to specify up to which gestational age they thought this should be allowed: “In all stages” of pregnancy, “Up to 24 weeks”, or “Up to 12 weeks”. The other options were “No” or “Not sure”. These gestational age limits were selected for the purpose of the survey on the basis that in EU countries, 12 weeks is the upper limit in most circumstances and 24 weeks is the highest limit. In other specific circumstances, abortion is legal at any stage in the pregnancy within some EU countries (e.g. to preserve physical health, in cases of fetal impairment).[25]

The study was targeted at all the medical doctors registered in Malta in 2018, which included 2114 doctors on the principal register, 244 doctors on the provisional register, and 110 of newly recruited first year foundation doctors (who were not yet listed on the publicly available 2018 provisional register). Medical doctors in any one of these groups were eligible to participate. An electronic invitation for participation was successfully sent to 1578 out of the total of 2468 doctors. The other doctors were not contactable either due to missing contact details or fault with email. Data was collected between 14th August 2018 and 13th October 2018.

The quantitative data collected was evaluated using descriptive statistical analyses. A Chi-squared test was also used to analyse the responses on abortion for statistically significant differences controlled for sex, age, and religion.

Results

A total of 454 questionnaires were completed and returned, with a response rate of 28.8% (n = 454/1578). This is equivalent to 18.4% (n = 454/2468) of the total medical doctor cohort registered in Malta. A sample of 454 participants from a target population of 2468 registered doctors guarantees a maximum margin of error of 4.16% assuming a 95% confidence level. All the respondents were practising doctors.

Description of participants

Table 1 shows demographic details of the participants. There was a good response from both female and male doctors (0.2% did not specify their sex). Just over 50% of the participants were under 35 years of age. Most participants were Maltese and others included Italian, British, Hungarian, American, Canadian, Nigerian, Serbian, and Vietnamese nationals. 7.7.% of participants trained in foreign universities including England, Ireland, Hungary, Poland, and former Yugoslavia.

Table 1.

Participants' demographic details

Age	Under 35 years	35–50 years	51–65 years	Over 65
	50.9%	23.8%	24.7%	0.7%
Sex	Female	Male	Other/Not specified
	53.5%	46.3%	0.2%
Nationality	Maltese		Other
	94.9%		5.1%
Religion	Christian	No religion	Muslim	Other
	83.0%	16.3%	0.2%	0.4%
Medical degree	University of Malta		Other
	92.3%		7.7%
Grade	Specialists67.0%Consultants, n = 141Residents, n = 31Trainees, n = 132Total, n = 304	General Practitioners17.4%Qualified, n = 66Trainees, n = 14Total, n = 80	Foundation Doctors14.8%Total, n = 67	Other/Not specified0.9%Total, n = 3

As expected in a country where Roman Catholicism is the predominant religion, less than 18% of participants were of religions other than Christianity or not affiliated to any religion. At least 52.4% of participants (n = 238/454) had finished their postgraduate training (i.e. consultant specialists, resident specialists, and qualified general practitioners), whereas the others were primarily specialist trainees and foundation doctors (i.e. newly qualified medical doctors, within 2 years from qualification, who rotate through different specialities). Figure 1 shows the speciality distribution of all the participants.

Figure 1.

Number of participants by speciality

Contraception

Figure 2 shows participants’ responses on reproductive planning methods. For contraceptive methods, the majority of participants were in favour of the legal use of all the surveyed methods: MAP, IUD, and female and male surgical sterilisation (both in cases of hereditary genetic conditions and in any circumstance). IUD was the contraceptive that gained the most support (85.9%), while MAP the least (59.7%).

Figure 2.

The views of Malta’s doctors on specific methods of reproductive planning

Abortion

The results for this section are summarised in Figure 3. In the case of abortion, there are two circumstances in which the majority of participants agreed with legalisation, even “In all stages” of pregnancy: “Woman’s life in danger” and “Non-viable fetal anomaly”. Legalisation of abortion in all other circumstances was opposed by the majority of participants.

Figure 3.

The views of Malta’s medical doctors on legalising abortion in different circumstances

Woman’s life in danger: In case of a “Woman’s life in danger”, a majority of 54.2% of the respondents were in favour of legalisation “In all stages” of pregnancy. The other responses in favour included a further 5.1% “Up to 24 weeks” and 7.5% “Up to 12 weeks”. This means that a majority of 66.8% favoured the legalisation of abortion at least up to 12 weeks gestation in this circumstance. “Woman’s life in danger” had the greatest majority favouring its legalisation, when compared with all the other circumstances questioned in this survey.

Non-viable fetal anomaly: 50.2% of the respondents were in favour of legalisation “In all stages” of pregnancy in the case of a non-viable fetal anomaly. The other responses in favour included a further 6.2% “Up to 24 weeks” and 6.6% “Up to 12 weeks”. This means that a majority of 63.0% favoured the legalisation of abortion at least up to 12 weeks gestation in this circumstance.

Rape or incest: The percentage of participants who disagreed with legalisation of abortion in the case of “Rape or incest” was 51.8%.

To preserve a woman’s physical and mental health: With regards to a pregnant woman’s health, 50.4% disagreed with legalisation “To preserve a woman’s physical health”, and 56.2% disagreed with legalisation “To preserve a woman’s mental health”.

Viable fetal anomaly: A majority of 67.4% of participants disagreed with legalisation in the case of a “Viable fetal anomaly”.

Under 16 years of age: A majority of 68.7% of participants in the study disagreed with legalisation of abortion in the case of a person who is aged under 16 years.

Economic and social circumstances: 74.0% of participants disagreed with legalisation of abortion in this circumstance. Out of all the specific circumstances in question, socio-economic reasons garnered the greatest opposition.

Any circumstance: The percentage of participants who disagreed with legal abortion in “Any circumstance” was 78.0%. As expected, abortion without circumstantial restrictions (i.e. upon the pregnant person’s request) had the largest opposition.

Assisted reproductive technology and surrogacy

The results for this section are depicted in Figure 2. IVF appears to be largely accepted by Malta’s medical doctor cohort with a majority of 93.8% saying that it should be legal. Embryo freezing and surrogacy garnered more divergent responses, with a slightly higher percentage of participants in disagreement.

Comparative analyses for abortion based on sex, age, and religion

Analyses of all the responses on abortion (for all circumstances) were performed using a Chi-squared test controlled for sex, age, and religion. Any statistically significant differences observed are included below.

Female vs. Male: There was no statistically significant difference between female and male doctors in their views on legalising abortion in any of the circumstances.

< 35 years vs. 35–50 years vs. ≥ 51 years: In case of “Woman’s life in danger”, there was a clear majority agreement (at least “Up to 12 weeks” gestation) with legalisation in all age groups, and a statistically significant polarisation to agree in the youngest age group when comparing <35 year olds with ≥51 year olds (p < 0.01). In case of “Non-viable fetal anomaly”, there is also a clear majority agreement with legalisation (at least “Up to 12 weeks” gestation) in all age groups. The differences between the three age brackets were statistically significant, with younger age groups agreeing more to legalisation in this circumstance (p < 0.01). There are statistically significant more “Not sure” answers by those ≥51 years when compared to the younger age groups, which reflects a greater degree of uncertainty in this age group (p < 0.01). Those under 35 years are statistically more likely to agree with legalisation of abortion in case of “Rape or incest” and “To preserve a woman’s physical health” (at least “Up to 12 weeks” gestation) when compared to older age groups (p < 0.01 and p < 0.05 respectively). No statistically significant differences were identified for the other circumstances: pregnant person “Under 16 years of age”, “Viable fetal anomaly”, “To preserve a woman’s mental health”, “For economic or social reasons”, and “Any circumstance”.

Religion vs. No religion: With the exception of two circumstances, “Woman’s life in danger” and “Non-viable fetal anomaly”, those who are not religious are more in favour of legalisation and those who are religious are more opposed to legalisation (p < 0.01). In case of “Woman’s life in danger” and “Non-viable fetal anomaly” there is no statistically significant difference, with the majority of both religious and non-religious respondents agreeing with legalisation in both cases. In case of “Any circumstance” there is a strong opposition from religious respondents and only weak support for legalisation from non-religious respondents.

Comparative analyses of “No” responses to all methods based on sex, age, and religion

Separate observations considering only the “No” responses to all methods (contraception, abortion, ART and surrogacy) are depicted in Figure 4 (sex), Figure 5 (age), and Figure 6 (religion). Figure 4 shows that there is very little discrepancy between males and females in opposing legalisation of these methods. On the other hand, within the group of respondents there was a greater opposition to all the methods by older age groups (Figure 5) and those who are religious (Figure 6) when compared to younger age groups and those who are not religious respectively.

Figure 4.

“No” to legality – female vs. male

Figure 5.

“No” to legality – age comparison

Figure 6.

“No” to legality – religious vs. no religious affiliation

Discussion

This study looked into the opinions of medical doctors in Malta on whether they believed different methods of reproductive healthcare (contraceptive methods, abortion, ART and surrogacy) should remain or become legal in the country.

The vast majority of the Maltese population identify themselves as Roman Catholic, a religion which is enshrined in the Maltese constitution. The official national ethics and regulations for medical professionals also specify that “in all matters bearing on faith or moral the Catholic member of the profession shall abide by the tenets of the Roman Catholic Apostolic Religion”.[44], p. 15 The same regulations also specify “the importance of preserving human life from the time of conception until death”.[44], p. 16 Given that over 80% of participants identified themselves as Christians, religion is an important aspect to keep in mind when looking into the results of this study. As the comparative analyses show, religion (as well as age) appears to have an impact on the agreement or disagreement of participants with the various reproductive healthcare methods questioned in this study.

Considering that the MAP had already been available in Malta for close to two years at time of data collection, there was still substantial opposition by the medical doctor cohort to it being legally available. A potential explanation as to the disparity between the support for the IUD and the MAP is that the IUD has been available for a much longer period of time in Malta, whereas the MAP is a newer addition to available methods of contraception in the country. In addition, more of the participants may accept and support the use of IUD (but not MAP) due to its application in the treatment of gynaecological medical conditions.

With regards to surgical sterilisation, as expected a higher percentage of participants agreed with it in case of a hereditary genetic condition (i.e. when a medical condition could be passed on to the offspring) than in any circumstance (i.e. without a medical reason). A small-scale survey conducted in Malta in 2012 reported female sterilisation in 2.4% and male sterilisation in 3.3% of the sampled population.[13]

When interpreting the results on abortion, it is important to bear in mind that gestational age limits may have greater consequences in certain circumstances over others. In practice, new developments and complications (such as a threat to life, physical and mental health problems) can arise throughout pregnancy, at times beyond certain gestational age limits. As affirmed by the WHO, “saving a woman's life might be necessary at any point in the pregnancy and, when required, abortion should be undertaken as promptly as possible to minimize risks to a woman’s health”.[32], p. 2 In the case of fetal anomalies, dedicated anomaly scans are routinely performed between 18 and 22 weeks in Malta,[45] and even this has its limitations, with some anomalies being detected at a later stage.[46,47]

Whilst abortion is always illegal in Malta, even when a woman’s life is in danger, current medical practice generally applies the ethical principal of double-effect, where possible, in order to protect the woman.[48,49] However, this can only be applied to specific medical scenarios. The ethical principle stipulates that it is permissible to do something “morally good” that has a “morally bad” side-effect, providing the latter was not the intention, even if it was foreseen. By applying this principle (in the context of Maltese law which considers Catholic teaching as the normative value), doctors can only save the woman when the life of the fetus is terminated indirectly (e.g. surgical removal of an ectopic pregnancy). Importantly, this remains an ethical principle and not a law. Its main flaws in practice are that it is not clear what constitutes “direct” or “indirect” termination, and that the law as it stands does not make this distinction, condemning any form of induced termination of a pregnancy. As expected, “Woman’s life in danger” had the greatest majority favouring its legalisation, when compared with all the other circumstances questioned in this survey. Nonetheless, there was still a considerable percentage of participants (21.8%) who opposed legalislation in this circumstance.

According to the Malta Congenital Anomalies Registry, the total number of registered births with a congenital anomaly between 1993 and 2016 was 103,331.[50] These include fatal and non-fatal fetal anomalies and involved a combination of live and stillbirths.[50] Non-viable fetal anomalies refer to severe anomalies for which there are no known medical treatments and that are not compatible with life. These include severe anomalies of the central nervous system, such as anencephaly, which results in stillbirth or death shortly after birth.[51] Viable fetal anomalies are those thought to be compatible with life. These include some of the chromosomal abnormalities (aneuploidies) such as Down’s syndrome, single gene conditions, and birth defects. The national health service, based on the current law, does not offer abortion for any fetal anomaly. Therefore, women in Malta in such a circumstance must proceed with the pregnancy, unless they travel abroad at their own expense (if they can afford it). Between 1993 and 2016 the total number of registered anencephaly births alone in Malta was 30.[50] However, there are of course other anomalies that are fatal. Comparing neonatal mortality reported from European countries, Malta has a high rate most marked for deaths due to congenital anomalies.[52] As expected, we found that support for legalislation in the case of “Non-viable fetal anomaly” was much higher among participants than for “Viable fetal anomaly”, with a 41.6% higher opposition in the latter circumstance. In fact, following “Woman’s life in danger”, “Non-viable fetal anomaly” garnered the second highest support for legalisation.

When it comes to a woman’s health, legalisation of abortion to preserve mental health garnered a 5.8% higher opposition than legalisation to preserve physical health, which reflects on how physical and mental health are regarded differently within the group of respondents. This may suggest that mental health is yet to be elevated to the same status as physical health.

Over the past 11 years, from 2008 to 2018, there were a total of 176 cases of female rape reported to the police in Malta (Malta Police Force, personal communication, 7 May 2019). This is an average of 16 cases per year. 37 of these cases involved females under 18 years of age. It is important to note that there is a very significant under-reporting phenomenon pertaining to sex offences. Formosa Pace[53] conducted a crime victimisation survey in Malta which clearly indicated that people are highly unlikely to report sexual offences – as attested by the figure of 85%. Therefore, a potentially large number of victims remains unknown. Also recall that (at the time of writing) the MAP is as yet unavailable in the Malta public general hospital for potential rape victims. Even when considering conception through rape or incest, which involves a criminal act, there were still over half of the respondents who disagreed with legalising abortion.

The age of consent in Malta is 16 years.[54] Over a 10-year period, from 2008 to 2017, there were a total of 104 registered pregnancies delivered by under 16-year-olds in Malta (an average of 10.4 per year), with the youngest being 13 years old at delivery (Directorate for Health Information and Research, personal communication, 11 April 2019). Worldwide, pregnancy is the leading cause of death among those aged 15–19 years due to childbirth complications and unsafe abortion.[33] Yet the majority of respondents disagree with abortion in underage pregnancies.

In questioning the Malta medical doctor cohort about the legalisation of abortion in a total of eight specific circumstances and in “Any circumstance”, we conclude that according to the surveyed respondents, there is at present a clear majority of doctors who do not agree with Malta’s total legal ban on abortion. A definite majority are in favour of legalisation, for at least up to 12 weeks gestation, in case of “Woman’s life in danger” (66.8%) and “Non-viable fetal anomaly” (63.0%). These two circumstances also gained a narrow majority in favour of abortion being legal at all stages in the pregnancy (no gestational age limit), at 54.2% and 50.2% respectively. The other circumstances did not have a majority in favour of legalisation, but still garnered variable degrees of support. Only a narrow majority was against the legalisation of abortion “To preserve a woman’s physical health” and in case of “Rape or incest”. The other four circumstances garnered greater opposition, with a majority of respondents opposing legalisation. Legalisation of abortion in “Any circumstance” had the greatest opposition.

Both IVF and embryo freezing are legal in Malta. However, participants’ response to the two methods varied greatly. Although the vast majority of participants were in favour of fertility assistance by IVF remaining legally available, we did not find a majority in favour of the associated method of embryo freezing. There was actually a higher percentage of participants who opposed embryo freezing than supported it. This highlights the fact that the freezing of embryos is still a contentious issue in Malta, as reflected by the debates in recent years. This might relate to the Catholic belief that life starts from the moment of conception.

Apart from abortion, surrogacy is the only other surveyed method that is currently illegal in Malta. Like embryo freezing, responses to surrogacy were polarised, and the method had slightly more opposition than support. The particular type of surrogacy (e.g. traditional vs. gestational or commercial/compensated vs. altruistic) was not specified in the questionnaire. Results might have differed if the various types of surrogacy had been questioned.

Comparative analyses

Older age groups and/or religious doctors are evidently in greater disagreement with the legalisation of abortion and with all the methods of reproductive planning questioned in this survey, when compared with younger and/or non-religious doctors. On the other hand, there is no evidence of a significant difference between the views of male and female doctors. It appears that religious affiliation and age have an influence on the opinions of Malta’s medical doctor cohort questioned in this study. This implies that further socio-cultural changes and expansion of secularisation within the Maltese community might lead to a shift in Malta’s doctors’ views on methods of reproductive healthcare.

Limitations

The lack of availability of a reliable detailed database of the entire Malta medical doctor cohort demographic profile creates a limitation when it comes to making sure that the responding cohort matches the actual demographic distribution for different demographic variables (i.e. age, sex, religion, etc.). However, the sampled cohort is still very likely to be representative of the studied population since: (1) it is well balanced between male and female respondents (and there do not seem to be any statistically significant differences in their responses, according to our comparative results); (2) most respondents are Christian (as one would expect in a country where this is the predominant religion); and (3) the sample has a widely varied age distribution.

The Malta Medical Council (MMC) was also unable to provide information about the number of doctors on the 2018 medical register who were retired. Therefore, the entire registered cohort was included as target population. Of these we managed to contact 63.9% (n = 1578), as the other doctors were not contactable either due to missing contact details or fault with email. Since the invitation for participation was sent via electronic mail to work email addresses, it may not have reached retired doctors who are still registered with the MMC. In fact, all the respondents were practising doctors. Consequently, the results are more likely to be reflective of the 2018 practising doctor cohort than the entire registered cohort. This is not regarded negatively since ultimately it is the practising doctors who influence current and future practice. There are no other recognised biases from this limitation as this did not favour or exclude any demographic or specific speciality doctors. Our response rate of 28.8% still provided a large enough sample size allowing reliable inferences to be made about the views of the entire medical doctor cohort registered in Malta.

Another limitation is the narrow scope of our survey. However, this study was exploratory in nature, with its focus being purposely limited to (1) medical doctors in Malta and (2) specific methods of reproductive healthcare. We recognise the importance of other influencers on SRHR, such as health professionals other than doctors, and politicians. Additionally, there are further key topics, such as post-abortion care, that are also vital to the overall discourse on reproductive healthcare in Malta, which we did not examine in this current study.

Conclusion

There has been a dearth of empirical research on abortion in Malta. Research on contraceptive use and other methods of reproductive planning has also been limited. This survey provides the first ever data on the views of doctors in Malta about different aspects of reproductive health methods. According to the surveyed respondents, the majority of doctors in Malta do not agree with a total legal ban on abortion. We hope that this information, as well as results on other reproductive health methods, will inform and further enable the discussion around the topic in Malta. This study should serve as a baseline for repeat future studies to assess changes in the position and views of Malta’s medical doctor cohort.

Since data collection, there have been a number of local developments which triggered further discussion and campaigning on abortion. In February 2019, Abortion Support Network extended its services to Malta, providing logistic and financial assistance for Maltese residents to access abortion abroad.[55] March 2019 saw the launch of the very first Maltese pro-choice coalition, Voice for Choice,[56] which advocates for changes in the law and elimination of social stigma. In May 2019, Doctors for Choice Malta also launched their campaign[57] supporting complete evidence-based reproductive healthcare, and have since become a member of Voice for Choice.

Recommendations for further research, some of which we hope to address in future studies, include an update on the current use of contraception methods in Malta and research on the following topics: views on decriminalisation (rather than legalisation) of abortion and post-abortion care; opinions of allied healthcare professionals (such as nurses, midwives, mental health professionals, etc.); implications of the complete ban on abortion; and conscientious objection.