Unmarried and pregnant, Ranya gathered up her courage and confided to a friend that she was considering a drastic step: an illegal abortion.
She braced for criticism. But to her surprise, her friend disclosed that she had had one too.
Ranya asked another friend, who also said she'd had an abortion. And another gave her the phone number of a doctor in Beirut who would perform the procedure on the sly. The doctor used no anesthetic. The pain lingered for days, but the guilt engulfed her weeks later.
"It doesn't make me feel guilty because of Islam," said Ranya, 29, a short, brown-haired artist, struggling with her words. "It's a very complicated guilt to explain. I tend to philosophize things. I feel guilty in a weird way. It crosses my mind all the time."
Despite legal and religious restrictions against abortion in much of the Arab world, changing social values and economic realities as well as demographic shifts have contributed to an apparent increase in the number of the procedures in the Middle East.
"There's definitely an increase compared to 10 to 15 years ago," said Mohammed Graigaa, executive director of the Moroccan Assn. for Family Planning. "Abortion is much less of a taboo. It's much more visible. Doctors talk about it. Women talk about it. The moral values of people have changed."
In most Middle East countries, the 15-to-24-year-old age group has grown to make up about a third of the population, but the percentage of early marriages is dropping. In Egypt, only 10% of 15-to-19-year-old females were married in 2003, down from 22% in 1976.
As young people wait longer to marry, they're increasingly engaging in premarital sex.
"I think abortions are going up for just for one reason: Sex is becoming more permissive," said Wissam Ghandour, a Lebanese obstetrician and scholar. "I assure you that the majority of girls getting married now are non-virgins and sexually active."
In addition, Arab youths receive little in the way of birth control or sex education, say family planning experts in the Middle East, many of whom work discreetly to provide reproductive health services in conservative Muslim societies that hold women's maternal roles as sacrosanct.
"If access to contraceptives was widely and freely available, abortion wouldn't be necessary," said an official at a Western family planning organization in Yemen. She spoke on condition of anonymity for fear her organization would be targeted. Abortion, she said, is "a last resort."
According to most interpretations, Islam strictly forbids abortion after the fetus has reached 4 months, and allows it before then only in cases of violent rape or when birth poses an extreme threat to the physical or psychological health of the mother.
Otherwise, abortion is tantamount to killing a living soul, a major sin in Islam, said Abdel Moati Bayoumi, a professor of the fundamentals of Islam at Cairo's Al Azhar University, the world's premier Muslim school of higher education.
"The rise of abortion and its acceptability in the Arab world reflects the decadence of societies in the region and how much people are drifting away from the teachings of Islam," he said in a telephone interview. "Abortion should not be taken lightly, because it involves killing a creature that belongs only to God."
According to a poll released this month by WorldPublicOpinion.org, 53% of Egyptians, 57% of Palestinians and 55% of Iranians oppose their governments' policies of making abortion a crime.
But abortions are often tolerated, with law enforcement officials and prosecutors looking the other way unless a parent or husband files a complaint. Even open-minded clerics give tacit approval for abortions in some cases. They are performed by doctors or back-alley amateurs, many of them midwives.
Statistics are sparse. Family planning experts said they detected a 100% increase in the number of abortions from two decades ago. Graigaa, for example, said the number in Morocco had doubled.
According to the United Nations, about one in 10 pregnancies in the region ends in abortion, half the rate of the United States.
A study by the International Planned Parenthood Federation estimated there were 7 million abortions in the Arab world from 1995 to 2000. A 1993 study showed that 14% of women in one rural Egyptian hamlet had had an abortion.
Researchers estimate that 100,000 abortions are performed a year in Iran, a non- Arab nation that stands out for its relatively progressive sex education and family planning policies.
Moroccan family planning experts estimate that 600 abortions a day are performed in the North African country, most involving unmarried women. Only a small percentage are victims of rape or sexual abuse, they say.
Despite the lack of frank public discussion of volatile issues such as abortion in the Arab world, there are signs that some taboos are slowly crumbling. Women are talking about abortions.
"Things are changing," Graigaa said. "People in Morocco more and more accept abortion as a human right. The subject has become less of a taboo in the past three years. People feel they have the right to be informed about abortion."
But botched procedures are still widespread.
In the spring of 2007, Iraqi obstetrician Donya Taher was on call, roaming her Baghdad hospital, when she was called to the emergency room.
The patient was bleeding heavily, and her blood was turning pinkish. They loaded her up with 10 pints of blood, six pints of plasma and a heavy dose of antibiotics.
"She was dying," Taher recalled. The woman and her husband, both in their early 20s, said she had had a back-alley abortion. They already had two children and couldn't afford a third.
As soon as the woman recovered, the couple slipped away.
"We wanted to know who did this to her," Taher said. "But she wouldn't tell us. Whoever it was should be punished."
Taher was enraged but not surprised. She said that only a few doctors perform relatively safe abortions in Baghdad, a capital city of at least 5 million people. Although she has not detected any noticeable increase in the number of botched abortions, there is a steady stream of injured in the emergency room, she said.
"They use the feces of animals. There are many unscientific methods, herbal medicine," she said. "Sometimes it will cause septic shock."
In some cases, abortion has become a lifestyle choice for Arab women no longer willing or able to care for huge families.
"People are much better informed," Graigaa said. "They have much fewer religious and moral fears about undergoing an abortion."
In the southern Iraqi city of Hillah, a 33-year-old woman named Hind realized this year that she was pregnant with her sixth child. She decided she didn't want any more children.
A friend referred her to a doctor who gave her pills to induce a miscarriage. When that didn't work, she went to a doctor at a private hospital.
With her husband's approval, she obtained an abortion. A Shiite Muslim cleric in the nearby city of Karbala absolved her of guilt and urged the couple to ask God's forgiveness after each prayer.
"I'm too exhausted," she said. "I already have five children. I just didn't want to go through the hassle of having to take care of another one."
Soaring prices for food and housing in the Middle East have put enormous pressure on families with modest incomes. For many couples, an additional child might mean not being able to send the children to school.
"Most families can't afford a sixth or seventh or 10th or 11th child," said the family planning expert in Yemen. "All the women who resort to an abortion already have as many children as they can manage."
Family planning experts say laws and traditions are out of step with reality. They point to the fact that women increasingly are coming to the clinic with their husbands instead of behind their backs. They ask questions about safety, cost and timing.
"Often the husband consents and is usually present with his wife to support her during the operation and in the care period after the abortion," said Graigaa, in Morocco. "The society is more and more permissive to abortions done within the framework of a couple."
Ranya's boyfriend was supportive, and her sorrow eventually waned. Over the last five years, she dived into her career and now shuttles around the region making documentaries. Married to a different man and hoping for a child, she recently confided to a new friend her experience that day at the clinic.
"I never expected it, but she told me, 'Me too,' " Ranya recalled.
"She seemed more conservative," she said. "We talked about it a little. She told me how she felt. But something stops you from going too deep. It's fear of confronting what's really painful."
Special correspondent Raed Rafei in Beirut and a special correspondent in Hillah contributed to this report.