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Abortion and Unintended Pregnancy in Six Indian States

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Abortion and Unintended Pregnancy in Six Indian States ABORTION & UNINTENDED PREGNANCY IN SIX INDIAN Findings and STATES Implications for Policies and Programs ABORTION & UNINTENDED PREGNANCY IN SIX INDIAN Findings and STATES Implications for Policies and Programs Susheela Singh Rubina Hussain Chander Shekhar Rajib Acharya Ann M. Moore Melissa Stillman Manas R. Pradhan Jennifer J. Frost Harihar Sahoo Manoj Alagarajan Aparna Sundaram Shveta Kalyanwala Haley Ball Preface “No woman can call herself free until she can choose consciously whether she will or will not be a mother.”—MARGARET SANGER ccording to a 2016 study published in The tertiary—of public- and private-sector health ALancet by the Guttmacher Institute and the facilities and also estimates the incidence of World Health Organization, an estimated 56 million unintended pregnancy, the precursor to abortions took place globally each year between most abortions. 2010 and 2014. These numbers make a strong case that abortion is a vital part of health care and I would like to commend and congratulate the should be easily available when needed. International Institute for Population Science, Mumbai; the Population Council, New Delhi; and It was a proud moment for India when its proactive the Guttmacher Institute, New York, for working parliamentarians legalized abortion with the historic closely with the Ministry of Health and Family Medical Termination of Pregnancy Act of 1971, Welfare to bring these valuable data to the public. creating a framework meant to protect women from Findings from the study will provide vital evidence the grave risks of unsafe abortion. Unfortunately, in to support the government’s current efforts—and, spite of this legislative protection, unsafe abortion I hope, will inform many other such efforts—to remains the third leading cause of maternal make this legal reproductive health service safe mortality in India, and close to eight women die and accessible and, thus, prevent morbidity and from causes related to unsafe abortion each day. mortality due to unsafe abortion and improve the well-being of women and families across the This is why the provision of safe, effective and country. And while the accessibility and availabil- accessible abortion services is a priority in the ity of safe, legal abortion is a major public health Government of India’s current Reproductive, necessity, providing a safe abortion is also about Maternal, Newborn, Child and Adolescent Health reproductive choice and entitlement, rights and (RMNCH+A) programme. This and other govern- justice. Hopefully this study will enable all those mental initiatives need reliable information for involved with the improvement of women’s health their planning and implementation, and yet to take safe abortion in India to the next level. comprehensive data on abortion incidence and service provision has been limited. Dr. Nozer Sheriar Chair, Scientific Programme Committee, International The Incidence of Abortion and Unintended Pregnancy Federation of Gynecology and Obstetrics in Six Indian States: Findings and Implications for Former Secretary General, Federation of Obstetric Policy and Programs provides such data for six states and Gynaecological Societies of India from each region of the country: Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Member, South East Asia Region Technical Advisory Pradesh. This major new body of evidence covers Group, World Health Organization abortion provision at all levels—primary to 2 GUTTMACHER INSTITUTE Acknowledgments his report is part of a larger study titled The following colleagues provided much- TUnintended Pregnancy and Abortion in India appreciated guidance, information or external (UPAI), which was conducted to provide much- data along the way: Kalpana Apte, Family Planning needed information on the incidence of abortion Association of India (FPAI); Alok Banerjee and and pregnancy, as well as access to and quality of Sudha Tewari, Parivar Seva Santha; Amit Bhanot safe abortion services, in six Indian states. and Mahesh Kalra, Hindustan Latex Family Planning Promotion Trust (HLFPPT); Todd Callahan, The authors thank the technical advisory commit- Christopher Purdy and Michele Thorburn, all of DKT tee that provided guidance throughout the project. International; V.S. Chandrashekhar, Foundation for It was chaired by Purushottam Kulkarni, formerly Reproductive Health Services India; Kathryn Church of Jawaharlal Nehru University, and its members and Barbara Reichwein, Marie Stopes International, were Dinesh Agrawal, independent consultant; London; Altaf Hossain, Bangladesh Association for Sushanta Banerjee, Ipas Development Foundation the Prevention of Septic Abortion; Vivek Malhotra (IDF); Manju Chhugani, Jamia Hamdard University; and Sunitha Bhat, Population Health Service India; Kurus Coyaji, King Edward Memorial Hospital; Hanimi Reddy Modugu, formerly of HLFPPT; Armin Ravi Duggal, International Budget Partnership; Neogi, formerly of FPAI; Ram Parker, Janani; Mahesh Sharad Iyengar, Action Research and Training Puri, Center for Research on Environment Health for Health; Sunitha Krishnan, St. John’s National and Population Activities, Nepal; Faujdar Ram, Academy of Health Sciences; Mala Ramanathan, formerly of the International Institute for Sree Chitra Tirunal Institute for Medical Sciences Population Sciences (IIPS); and Usha Ram and and Technology; T.K. Roy, independent consultant; L. Ladusingh, IIPS. Nozer Sheriar, Hinduja Healthcare Surgical and Holy Family Hospitals; Leela Visaria, Gujarat Institute In addition, the authors are grateful to the follow- of Development Research; and Ministry of Health ing colleagues who reviewed one or more drafts of and Family Welfare representatives Rakesh Kumar, the report: Sushanta Banerjee, Vinoj Manning and Manisha Malhotra, Dinesh Biswal, Sumita Ghosh Ritu Raj, all of IDF; Medha Gandhi, formerly of IDF; and Veena Dhawan. Sharad Iyengar; Shireen Jejeebhoy, independent consultant; and Nozer Sheriar. The authors are grateful to the data collection agencies that fielded the Health Facilities Survey The report was written by Susheela Singh, Rubina in the six states and to the field investigators who Hussain, Ann M. Moore, Melissa Stillman, Jennifer conducted the interviews. They also thank the J. Frost, Aparna Sundaram and Haley Ball, all of the survey respondents, who contributed their time Guttmacher Institute; Chander Shekhar, Manas R. and expertise in providing essential information Pradhan, Harihar Sahoo and Manoj Alagarajan, all on abortion services in their facilities. of IIPS; Rajib Acharya of Population Council–India; and Shveta Kalyanwala, independent consultant. ABORTION IN SIX INDIAN STATES 3 It was edited by Haley Ball. The authors also thank Guttmacher colleagues Gustavo Suarez and Colette Rose (for reviewing a draft of the report) and Alyssa Browne, Marjorie Crowell and Shivani Kochhar (for research support). The UPAI project, including this report, was made possible by grants to the Guttmacher Institute from the Government of UK Department for International Development (until 2015), the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, the Ford Foundation and the Dutch Ministry of Foreign Affairs. The Guttmacher Institute gratefully acknowledges the unrestricted funding it receives from individuals and foundations—including major grants from the William and Flora Hewlett Foundation and the David and Lucile Packard Foundation—which undergird all of the Institute’s work. The views expressed do not necessarily reflect the positions or policies of the donors. 4 GUTTMACHER INSTITUTE Table of Contents Preface 2 Acknowledgments 3 1 Context of Abortion in India 6 2 Incidence of Induced Abortion 8 3 Abortion Provision in Health Facilities 10 4 Provision of Postabortion Care 13 5 Incidence of Unintended Pregnancy 15 6 Implications of Findings for Policies and Practice 18 Data and Methodology Appendix 22 References 25 ABORTION IN SIX INDIAN STATES 5 1 Context of Abortion In India nduced abortion has been legally permitted In addition to presenting estimates of the incidence Iin India on broad grounds since 1971,1 yet of abortion, pregnancy and unintended pregnancy, representative information on access to abortion this report also highlights findings on service pro- services and abortion incidence has remained scarce. vision that are relevant for informing policies and The lack of comprehensive estimates of abortion programs. The sources and methodologies used to incidence has in turn prevented the accurate calculate the estimates are detailed in the Data and estimation of the incidence of total pregnancy and Methodology Appendix on page 22, and in-depth of unintended pregnancy because abortion is a key analysis of data for each state can be found in component of these indicators. Reliable measures individual state reports.2–7 of abortion and unintended pregnancy are vital to obtaining a clear picture of how successfully Past research on abortion incidence women and couples are able to achieve their A few previous studies have provided state-level fertility goals, and gaps in such knowledge have estimates of abortion incidence, but most have limited the ability of government at the state and relied on incomplete sources of data. Statistics national levels to design policies and programs that compiled by the government are known to greatly ensure equitable access to safe and legal abortion, underestimate abortion incidence, both because postabortion care and contraceptive services. reporting on facility-based
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