The aim of our study was to identify the rate of women seeking repeated abortions in the region of Monastir (Tunisia) and associated factors. The relationship between CMD and women characteristics was also investigated.
In Tunisia, voluntary abortion is a public health issue. In fact, since the legalization of the abortion low (1973), the number of abortions in the public sector had increased from 342 in 1973 to 14699 in 2009 . Data about the profile of women seeking repeat abortion are scarce. Data on psychological impact of abortion were also scarce.
Our results found that 42.2 % of women seeking abortion had experienced one, two or subsequent abortions. This rate is similar to those noted in developed countries such as Sweden , USA  and England .
Repeat abortion was associated with some baseline social and obstetrical factors. Our cross-sectional study identifies 5 characteristics that are independently correlated to repeat abortion; some of them are in agreement and others are in contradiction with previous studies.
We found an association between repeat induced abortion and increased age. Compared with first-time abortion patients, repeat-abortion patients were significantly older than those, like in the USA and Canada [9, 10]. Aged women are often those who have a sufficient number of children so they undergo an abortion in case of unintended pregnancy. There is marked shift in age of multiple time abortion seekers; the most relevant age-group is 15–29 years in previous studies . The fact that women seeking one abortion are younger than women seeking multiple abortions confirms that women undergoing an abortion are at high risk of repeat unintended pregnancy . Thus, interventions that improve women’s knowledge and practice in order to better manage their lives and reduce induced abortions are needed.
Recurrent abortion seekers were less educated than first-time abortion seekers, and higher per cent of them were single. It suggests that repeaters have less stable family relations compared to the first time abortion seekers, which is in accordance with previous studies [8, 14, 15]. In a Danish study, single women were more likely to seek repeat abortions compared to first abortions ones (ORa = 39.1) . The same facts were reported in Scotland and Filand [17, 18].
Repeat abortions seem to be closely related to the lack of knowledge about birth control methods in our study. Our results were also in accordance with results of studies in many developed and developing countries [19, 20]. Consultations providing information’s about contraception methods and their availability free of charge especially for lower educated women are needed. It is not a matter of use rather than a problem of knowledge. Women did not know how to deal with missing a pill and had very little awareness of forms of contraception and emergency contraception [21, 22]. According to Serrano et al.  failure of contraceptive use was reported by 77 % of those using condoms and by 84 % of those using hormonal contraception. In fact, a rise in contraceptive use must be combined to effectiveness of use to obtain a decline in induced abortion.
Actually, it is well recognized that induced abortion was associated with CMD mainly anxiety and depression during the post-abortal period [24, 25]. Our findings suggested a relationship between repeat abortion and history of conflicts or violence (physical/sexual abuse by a male partner) suggest serious effects of these factors on women's health outcomes . In fact, these women were more likely to develop CMD as suggested by our results and others studies. History of conflicts, physical and sexual abuse was closely related with social problems, request for a termination of pregnancy and a higher risk of anxiety, depression and sleep disturbances .
According to literature, a relationship exists between pregnancy loss and CMD (anxiety and depression) and drug use during the subsequent year [28, 29]. Giannandrea et al.  showed that pregnancy loss type was not related to depression, although the losses’ number was related to the presence of depression and anxiety.
The main limitation of our study is its cross sectional design carried out over a short period. In this case we cannot draw conclusions about a causal relationship between repeat abortions and the occurrence of CMD. Nevertheless, CMD and partner violence have not been studied yet in women seeking abortions in Tunisia. So, this study can be a first step in assessing these aspects. Another limitation was the use of women seeking first abortion as a control group which does not allow us the comparison to women without a history of abortion. However, the estimation of CMD in women seeking first abortion allows us to assess the situation of a woman requesting one abortion even though it may perform other abortions in the future.