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An Enquiry Into Provision of Abortion Services in Madhya Pradesh Dr An Enquiry into Provision of Abortion Services in Madhya Pradesh March 2004 Dr. Alex George Manasa, Bangalore Research Study Supported by CEHAT Mumbai For Limited Circulation Only An Enquiry into provision of Abortion Services in Madhya Pradesh Research Team Dr. Alex George, Principal Investigator Mr. K.C. Jaymon, Junior Research Officer Mr. Kishore Babu, Junior Research Officer Research Study Supported by CEHAT Mumbai For Limited Circulation Only Page 2 of 118 Contents Acknowledgement List of Tables Executive Summary I. Introduction II. Policy and Legal Issues III. Facility, Infrastructure, Human Power and Equipment IV. Constellation of Available Services and Their Performance V. Technical Quality: Performance Standards of Facilities and Providers VI. Accessibility of Services VII. Provision of Abortion by Informal Providers VIII. Conclusion Appendix: I District wise Status of Prenatal Diagnostic Test Appendix: II Quality of Care Index References Page 3 of 118 Acknowledgment We are particularly grateful to Dr. Yogiraj Sharma, Director, Health and Family Welfare, and Dr. Bhushan Shrivasthava, Deputy Director, Family Welfare M.P. for providing us necessary secondary data and issuing direction to the CMOs of Ujjain and Sidhi districts to co-operate with the study. We also thank Dr. RL Chauhan CMO Ujjain and Dr. Shukla and Dr. SB Singh CMOs of Sidhi during various periods. Dr. R.N. Gupta of Indian Council of Medical research has helped in streamlining the study with officials in MP which we thankfully acknowledge. We are thankful to Dr. Asha Mishra, State Secretary, Bharat Gyan Vigyan Samithi (BGVS), Bhopal who generously provided us with several contacts in Bhopal and the Districts. We express our thanks to Dr. Mahalakshmi Govinda Raghavan MD for imparting training on medical and technical aspects of abortion to our fieldworkers and Dr. (Mrs) Bharadwaj MS. Superintendent, Sultania Ladies Hospital for permitting our investigators to see the Operation Theatre and equipment as part of our training programme. The research team also thank the Block Medical Officer, Tarana Civil Hospital, Ujjain and Civil Engineer PWD in Churahat for providing accommodation facilities in Makdone in Ujjain District and Churahat in Sidhi district respectively. The team has benefited from the accommodation and training facilities provided by Pastoral Centre, and Asha Niketan at Bhopal and from the accommodation provided by Kripa Social Welfare Society at Ujjain. We also thank all the members of our fieldwork team, namely Mr. Haleem and Hassan who are BGVS activists, Mr. Rangen Humne, Mr. Bhupender Mainway, Mr. Rauth and Mr. Paresh Yadav from Nagpur, and our nurse- investigators: Ms. Padmavathi Negi, Ms. Sujitha Minz, Ms. Sangeetha Sachan and Ms. Bharathi from Bhopal. Finally the research team thankfully acknowledges the support and guidance from CEHAT Mumbai and appreciates the peer reviewers who reviewed the draft report. Page 4 of 118 List of Tables Table 1: No. of Govt. and registered private Institutions Providing MTP Services in M.P Table 2: Medical Termination of Pregnancy Training Centres in M.P Table 3: No. of M.T.Ps Conducted in Govt. facilities from 1998-to August 2002 Table 4: M.P. District Level Ranking (Arranged in Descending Order) Table 5: Blocks in Ujjain District –Some Indicators Table 6: Blocks in Sidhi District – Some Indicators Table 7: Participated Facilities by Type and District/Block Table 8: Public Facilities Providing / Not Providing Abortion Table 9: Data Collection tools used Table 10: Certification Status of Private Facilities Table 11: Difficulties Faced in the Registration Process: Already Certified Facilities Table 12: Difficulties faced in the Registration Process: Uncertified Facilities Table 13: Facilities and their Reporting of MTPs Table 14: Consent Requirements at Public and Private Sector Facilities Table 15: Observation of Consent Form Table 16: Proportion of Facilities with listed Physical Facilities Table 16.A: Place in Hospitals where MTP was done Table 17: Facilities where Actual Observation of Equipment and Supplies was Possible Table 18: Availability of Basic Equipment for Abortion Procedure Table 19: Availability of Anaesthesia Related Equipment Table 20: Availability of Sterilization /Infection Prevention Equipment and Consumables Table 21: Drugs and Other Consumables Table 22: Maintenance of Equipment Table 23: Availability of Abortion Service Providers at Different facilities Table 24: Availability of Anaesthetist (MD or diploma) at Different Facilities Table 25: Availability of Nursing and Support Staff at Different Facilities Table 26: Profile of Interviewed Abortion Providers Table 27: Place of M.T.P. Training Table 28: Types of Procedures Trained in Table 29: Providers who have Received Training in Support Areas Table 30: Facilities that are Functional Table 31: Gestation of Pregnancy for which Services are Offered Table 32: District wise data on Gestation of Pregnancy for which Abortions Services are offered Table 33: Number of MTPs Conducted per Month Table 34: District wise data on Number of MTPs Conducted per Month Table 35: Need to postpone / refuse service provision because of logistic reasons Table 36: Ability of facility to function for Emergency cases / non routine hours Table 37: Management of Abortion Complications Table 38: Actual No. of Emergency Cases Seen Page 5 of 118 Table 39: Facilities Offering Other Types of RH services Table 40: Referral Linkages Table 41: Referral Patterns Table 42: Availability of Service Guidelines Table 43: Techniques Used by Providers for Ist Trimester Abortions Table 44: Techniques Used by Providers for 2ndTrimester Abortions Table 45: Pain Control Methods Used for 1st Trimester Abortions Table 46: Pain Control Methods Used for 2nd Trimester Abortions Table 47: Pre discharge Examination Table 48: Drugs Routinely Prescribed after MTP Table 49: Pre Abortion Counselling Table 50: Post Abortion Counselling Table 51: Information given on Follow up Visits Table 52: Contraceptive Counselling Table 52.A: Providers Response to Repeat Abortion Seekers Table 53: Methods Ranked by Providers as being most Popular Table 54: Sterilization /Infection Prevention (specified by criteria) Table 55: Waste Disposal Methods Table 56: Physical Accessibility Table 57: Cost of Services by Sector and Trimester of Pregnancy Table 58: Inclusion of Ancillary Services in Cost of Service Table 59: District wise data on Cost of Services by Sector and Trimester of Pregnancy Table 60: Providers who are able to Communicate in the Local Language Table 61: Facilities with Female Abortion Service Provider Table 62: Facilities Providing Service on same day as Woman’s First Visit Table 63: Circumstances Under which Facilities Provide Abortion Table 64: Profile of Informal Providers Interviewed Table 65: Treatment for Delayed Periods by Informal Providers Table 66: Instrumental Intervention to bring on an Abortion Table 67: Average Amount Charged For abortion Table 68: Place from where Providers Learned Table 69: Other Services Provided by Informal Providers Page 6 of 118 EXECUTIVE SUMMARY An Enquiry into Provision of Abortion Services in Madhya Pradesh Rationale The state of MP was selected for Though the MTP Act 1971 has the study based on an analysis of the legalised abortions with the consent of women’s health and related indicators of only the woman, the necessary facilities states of India and MP’s score in it. The for conducting abortions are not indicators selected for this ranking adequately available in the public or the included institutional deliveries, maternal private sector. While in the public sector mortality ratio, neonatal mortality rate, several facilities, which are supposed to female infant mortality rate, couple provide the service, are not providing it, protection rate, total fertility rate and the availability of providers with the female literacy rate. The indicators of the necessary training and institutions with the pre-divided state of MP before the passage required registration under the Act is very of the Chattisgarh formation Bill was limited. The training facilities for taken into consideration. The scores of imparting training in MTP are also limited different states were aggregated under four in number. This has given rise to a lack clusters. The combined state of MP was adequate facilities and providers for ranked along with UP and Rajasthan as conducting safe abortions and to the Fourth category state i.e. in the lowest mushrooming of unregistered facilities and category. untrained providers who conduct abortions, causing concerns of quality and Objectives safety. In addition to unregistered The study intends to understand providers with formal qualification in one and analyse issues related to the provision or other stream of medicine who are of abortion services in public and private conducting abortions, the informal sectors with the following objectives: providers who do not have any formal 9 Management of abortion services qualifications are also conducting including management of abortions. The study intends to look into complications. the provision of abortion services in detail 9 Technologies used. and to come up with findings which would 9 Registration, training and certification. facilitate making necessary changes in the 9 Availability, technical competence, registration, training, quality of abortion training needs and current training service and to improve the provision of the facilities/ programmes for abortion service in such a way that it
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