Abortion Practice in India a Review of Literature

ABORTION PRACTICE IN INDIA A REVIEW OF LITERATURE

Heidi Bart Johnston

Abortion Assessment Project - India

1 First Published in May 2002

By Centre for Enquiry into Health and Allied Themes (CEHAT) Research Centre of Anusandhan Trust Sai Ashray, Aram Society Road, Vakola Santacruz (East), Mumbai - 400 055 Telefax : 91-22-614 7727/613 2027 Email: [email protected]

Printed at :Chintanakshar Grafics Mumbai - 400 031 The views and opinions expressed in this publication are those of the author alone and do not necessarily reflect the views of the collabo- rating organizations.

2 TECHNICAL ADVISORY COMMITTEE (TAC) ETHICS CONSULTATIVE GROUP (ECG) q Dr. R.N. Gupta, Social Scientist and q Dr. Sudarshan Iyengar, Representing the Researcher, Indian Council of Medical TAC, Gujarat Institute of Development Research, New Delhi Research, Ahmedabad q Dr. Leela Visaria, Coordinator of q Dr. S.V. Joga Rao, National Law School of Healthwatch and Researcher, New Delhi India University, Bangalore q Dr. Saramma Thomas Mathai, Consultant q Dr. Sanjay Gupte, Chairperson, Ethics and in Maternal & Child Health, New Delhi Medico-Legal Committee, FOGSI, Pune q Dr. Thelma Narayan, Epidemiologist - Community Health Cell, Bangalore q Dr Vasantha Muthuswami, Expert on Bio- Medical Ethics DDG (SG), Indian Council q Dr. Padmini Swaminathan, Senior of Medical Research, New Delhi Economist and Researcher, Madras Institute of Development Studies, Chennai q Dr. Ritu Priya, Researcher and q Ms. Manisha Gupte, Health and Women’s Academician Jawaharlal Nehru University, Activist, Mahila Sarvangeen Utkarsha New Delhi Mandal (MASUM), Pune q Ms. Padma Prakash, Deputy Editor, q Dr. Sudarshan Iyengar, Researcher and Economic and Political Weekly, Mumbai Academician, Director of Gujarat Institute q Dr. V.R. Muraleedharan, Researcher and of Development Research, Ahmedabad Academician, Department of Humanities q Ms. Sudha Tewari, Provider of Abortion and Social Sciences Indian Institute of Services, Parivar Seva Sanstha, New Delhi Technology, Chennai q Dr. Kamini Rao, Professional, President q Dr. Amar Jesani, Programme Co-ordinator, Federation of Obstetrician and Gynaeco- Achutha Menon Centre for Health Science logical Societies of India (FOGSI), Studies, Sree Chitra Tirunal Institute for Bangalore Medical Sciences and Technology, q Dr. Narika Namshum, Asst. Commissioner Thiruvananthapuram, Kerala (Maternal Health), Dept. of Family Welfare, Government of India, New Delhi q Ms. Ena Singh, Assistant Representative in UNFPA India Country Office, a member in her personal capacity as an experienced Research Administrator, New Delhi

3 ACKNOWLEDGEMENTS

This paper was developed in coordination with the Abortion Assessment Project - India (AAP-I). The author would like to thank members of the Abortion Assessment Project - India for their comments on an earlier draft of the paper, as well as Ravi Duggal, Bela Ganatra, Saramma Mathai, Manisha Gupte, Malini Karkal, Dale Huntington, Priya Nanda and Robert Pelto for their insightful comments. At Ipas, Jaine Benson, Barbara Crane, Ronnie Johnson and Karen Otsea provided constructive feedback. The Ford Foundation provided financial support for the development of this paper. Inaccuracies in and shortcomings of the paper are the fault of the author alone. Please address comments to the author at [email protected]

4 PREFACE Abortions have been around forever. But V. Dissemination of information and at different points of time in history it has literature widely and development of an received attention for differing reasons, advocacy strategy some in support of it, but often against it. This five pronged approach will, Abortion is primarily a health concern of hopefully, capture the complex situation as women but it is increasingly being governed it is obtained on the ground and also give by patriarchal interests which more often policy makers, administrators and medical than not curb the freedom of women to seek professionals’ valuable insights into abortion abortion as a right. care and what are the areas for public policy In present times with the entire focus of interventions and advocacy. women’s health being on her reproduction, The present publication, the first in the infact preventing or terminating it, abortion AAP-I series evolved along with the develop- practice becomes a critical issue. Given the ment of this project. In that sense it was a official perspective of understanding abortion useful input in that process. Ford Foundation within the context of contraception, it is supported Ipas to undertake this review and important to review abortion and abortion this publication was undertaken through practice in India. that support. While efforts have been made to cover as much ground as possible there The Abortion Assessment Project India may still be gaps in covering some (AAP-I) has evolved precisely with this dimensions of the abortion issue, which we concern and a wide range of studies are being hope to cover in subsequent publications undertaken by a number of institutions and emerging from this project. researchers across the length and breadth of the country. The project has five We look forward to comments and feed- components: back which may be sent to [email protected] Information on this project can be obtained I. Overview paper on policy related issues, by writing to us or accessing it from the series of working papers based on website www.cehat.org existing data / research and workshops to pool existing knowledge and information in order to feed into this _ Ravi Duggal project. Coordinator, CEHAT II. Multicentric facility survey in six states focusing on the numerous dimensions of provision of abortion services in the public and private sectors III. Eight qualitative studies on specific issues to compliment the multicentric studies. These would attempt to understand the abortion and related issues from the women’s perspective. IV. Household studies to estimate incidence of abortion in two states in India.

5 TABLE OF CONTENTS

EXECUTIVE SUMMARY

I. INTRODUCTION ...... 1

II. ABORTION RATES AND ASSOCIATED MORBIDITY AND MORTALITY

A. ABORTION INCIDENCE ...... 1 B. MORBIDITY AND MORTALITY FROM UNSAFE ABORTION ...... 5

III. MEDICAL TERMINATION OF PREGNANCY (MTP) IN INDIA

A. LEGAL STATUS OF ABORTION ...... 6 B. INADEQUATE LEGAL ABORTION SERVICE PROVISION ...... 7 C. ILLEGAL ABORTION – PROVIDERS AND METHODS ...... 9 D. CHARACTERISTICS OF WOMEN WHO TERMINATE UNWANTED PREGNANCIES ...... 10 E. DECISION-MAKING ISSUES ...... 11

IV. POSTABORTION CARE SERVICES

A. MANAGEMENT OF ABORTION-RELATED COMPLICATIONS ...... 12 B. CONTRACEPTIVE COUNSELING AND SERVICES ...... 14 C. LINKAGES WITH OTHER REPRODUCTIVE HEALTH SERVICES ...... 14

V. RECOMMENDATIONS

A. IMPROVING KNOWLEDGE OF ABORTION INCIDENCE ...... 15 B. IMPROVING PREGNANCY TERMINATION SERVICES ...... 15 C. IMPROVING ABORTION CARE ...... 17

VI. CONCLUSIONS

REFERENCES ...... 19 APPENDIX

TECHNIQUES USED TO ESTIMATE ABORTION RATES PRESENTED IN THIS REVIEW ...... 23

6 EXECUTIVE SUMMARY

The Medical Termination of Pregnancy tion care, including postabortion care. Act of 1971 greatly liberalised the indications for which abortion is legal in India. The Gov- Results of the studies reviewed suggest ernment intended for this Act to reduce the that reducing recourse to unsafe abortion incidence of illegal abortion and consequent will be a complex multi-step process that maternal morbidity and mortality. However, includes increasing women’s access through 30 years after the groundbreaking legisla- improve-ments in service delivery and tion, the majority of women seeking abor- addresses the more complicated issues of tion still turn to uncertified providers for abor- rights and gender power inequities. tion services because of the barriers to legal Strategies to make safe and legal abortion abortion. While some uncertified providers services more attractive to women and offer safe services, many provide unsafe decision makers include: increasing abortions that result in complications or geographic accessibility; increasing death. Women with access to fewer re- affordability; providing high quality abortion sources, for example low-income rural care and prioritising confidentiality of women and adolescents, are among those services. Addressing the system of barriers most likely to turn to unsafe abortion and limiting women’s access to safe abortion have complications. Studies suggest that the services may require review and revision of choice of specific provider is most often not the MTP Act, 1971 and associated rules and made by the woman inducing abortion but regulations. with or by her husband or other family mem- This review suggests a need for expanded bers. community-based education to address While the incidence of abortion in India specific issues of women’s reproductive is unknown, the most widely cited figure sug- health and the broader issues of women’s gests that around 6.7 million abortions take right to high quality health care services. place annually. According to government Household decision-makers, men and data, only about one million of these are per- women, would benefit from awareness formed legally. The remaining abortions are raising about the dangers of unsafe abortion performed by medical and non-medical prac- and the availability of safe abortion services. titioners. Levels of unsafe abortion are very Women with reduced access to reproductive high in India, especially given that abortion health resources, such as adolescents and is legal for a broad range of indications, and rural poor, should be a priority focus in com- available in the public and private health munity-based education. sector. This review of the current literature of In the current situation abortion services abortion in India suggests that abortion and are not adequately decentralized, and regu- latory reform will have to take place before decentralization of legal services will hap- pen in a meaningful way. To reduce morbidity and mortality from unsafe abortion in this context, several broad activities require strengthening: decreasing unwanted pregnancies; increasing access to safe abortion services; and increasing the quality of abor- 7 qualified practitioners to attend MTP training Clearly a great deal is known about courses; reviewing MTP Act and associated provision of and access to safe and unsafe rules and regulations to determine how the abortion services in India and the need to law can be revised to decentralize abortion improve safe abortion and contraceptive services and otherwise better meet the choices to more adequately meet the needs needs of women; upgrading facilities that of women experiencing unwanted pregnan- currently offer MTP services; orienting MTP cies. Still, a great deal more needs to be services to meet the needs of women most known before programs are implemented to at risk of accessing unsafe abortion; ensure low-resource Indian women can increasing awareness among women and readily access safe abortion services. The men of reproductive age of the availability of cost in terms of women’s health and lives safe abortion services and the dangers of emphasizes the need to efficiently and unsafe abortion; involving communities and effectively pursue efforts to make abortion providers at all levels to improve reproductive safer and more accessible for Indian women. health care; and improving adolescent reproductive health services in general. Innovative interventions need to be developed, implemented, monitored and scaled up as appropriate.

8 About the Author

Heidi Bart Johnston, Ph.D. Dr. Johnston is a specialist in demography and reproductive health. Her research includes testing methods of quantifying induced abortion rates and identifying perceptions and practices of abortion clients and providers in rural communities. Her current work focuses on exploring means of increasing the demand for high-quality reproductive health care among rural women and decision-makers. She contributes research expertise to Ipas’s Asia program.

9 ABORTION PRACTICE IN INDIA A REVIEW OF LITERATURE

I. INTRODUCTION have on women’s health and lives? Complications of unsafe abortion are a Recognizing the high estimated incidence major public health issue facing women in of abortion-related mortality and morbidity developing countries. In India, abortion is in parts of India this paper reviews the legal for a broad range of medical and social literature on safe and unsafe abortion reasons. Officially, women can access safe services, abortion facilities and providers, abortion services by trained medical complications of unsafe abortion, and personnel in registered facilities, and minors availability of postabortion care in India. The need consent from their husband or father. review aims to synthesize what is known In practice, limited access to authorized about abortion in India and identify steps abortion providers, the threat of forced that need to be taken to develop abortion contraceptive acceptance, the financial costs related services that more closely meet associated with legal abortion, the stigma Indian women’s needs. associated with induced abortion, and low levels of awareness regarding the legality of II.ABORTION RATES AND ASSOCIATED the procedure bar women from safe abortion MORBIDITY AND MORTALITY services (Khan et al. 1999; Sinha et al. 1998). As a result, women often resort to untrained A. ABORTION I NCIDENCE clandestine practitioners operating under Induced abortion incidence is extremely unsafe conditions. The consequences of difficult to measure in most countries and abortions performed under such India is no exception. Data quality is an circumstances range from life threatening important consideration in studying abortion. to chronic reproductive tract morbidity such Abortion procedures, whether performed as infections, chronic disability and legally by trained professionals using modern infertility (Chhabra and Nuna 1994). technology or illegaly using “traditional” In India each year an estimated 453 methods are subject to substantial women die due to maternal causes for every underreporting (Huntington et al. 1993). 100,000 live births (UNFPA 1997). This Abortion data typically come from one of two statistic masks the vast variation among sources: clinic or hospital records or states. While national and state estimates individual surveys of women. Clinic or are imprecise, they are able to represent hospital sources tend to be of poor quality certain trends. Orissa and Madhya Pradesh where abortion is illegal, highly stigmatized had approximately 738 and 711 maternal or difficult to obtain (Baretto et al. 1992; deaths per 100,000 births in 1992. Among Frejka 1985; Paxman et al. 1993; Remez the large states, Kerala has a singularly low 1995). Individual surveys underestimate the ratio of 87 maternal deaths reported per incidence of induced abortion even where 100,000 births. On an average, roughly abortion is legal (Anderson et al. 1994; Jones fifteen percent of maternal deaths in India and Forrest 1992). are thought to result from unsafe abortion No valid data exist on the incidence of (Chhabra and Nuna 1994). In what abortion in India (Mathai 1997). Clinic data conditions are these abortions provided? are published as government statistics but What impact do these unwanted pregnancies these reflect only reported medical termination of pregnancy (MTP) cases conducted in the five states of Haryana, Orissa, in clinics recognized by the government Rajasthan, Tamil Nadu and Uttar Pradesh (Khan, et al n.d.). These abortion statistics in 1983-84. According to ICMR findings, for show an increase in MTP since the the five states combined, 19 per 1000 liberalization of abortion laws in 1972 until pregnancies were terminated. Six per the early 1980s (Khan et al. 1999 from Family thousand were terminated legally, and 13 per Welfare of India Year Book, Government of 1000 pregnancies were terminated illegally. India, 1993). Since 1982-83 there has been Applying these proportions to 1990 national an increase in MTP centers, but no corres- abortion data implies that the approximately ponding increase in the reported numbers 600,000 legal abortions reported in 1990 of MTP performed. Underreporting of MTP indicate that in total 1.3 million illegal could be a reason for this (Mathai 1997). abortions were performed nationwide (Indian Council of Medical Research 1988; World Illegal and thus unreported abortions are Bank 1996). The ICMR national abortion estimated to outnumber legal abortions by a estimate is substantially lower than factor of between three and eight (Gupte n.d.; Chhabra and Nuna’s widely cited indirect Karkal 1991, as cited in Chhabra and Nuna estimate of 6.7 million induced abortions 1994). Surveys like the National Family annually (Chhabra and Nuna 1994). Health Survey collect abortion data (Inter- national Institute for Population Sciences Because available direct estimates of 1995). These data report a very low incidence abortion rates from clinic and survey data of abortion among Indian women and are also are generally acknowledged to be under- considered gross underestimates (Arnold estimates, various indirect estimation 1999; International Institute for Population techniques have been used to measure Sciences 1995; Mishra et al. 1998). In abortion incidence and relative rates general, large scale DHS-like surveys are (Chhabra and Nuna 1994; Johnston and Hill inadequate tools for investigating socially 1996; Mishra et al. 1998; Shah 1966). Each stigmatized topics such as induced abortion of the indirect estimation techniques used (Huntington et al. 1996). employ assumptions that affect the resulting estimates. Estimated rates of induced The Indian Council of Medical Research abortion are presented by state in Table 1. (ICMR) conducted induced abortion research See Appendix 1 for details on the calculation of these estimates.

11 Table 1. Total Abortion Rate Estimates from Three Indirect Estimation Techniques TAR TPIAR TAR Abortion:Birth Potential Induced Residual Technique Ratio Abortion Rate __ India 0.97 2.65 North India __ Delhi 1.72 2.08 Haryana 1.72 0.94 1.37 __ Himachal Pradesh 1.68 0.59 __ __ Jammu (J&K) 2.25 Punjab 1.91 0.53 1.61 Rajasthan 1.62 0.57 5.35 Central India Madhya Pradesh 1.60 0.73 5.29 Uttar Pradesh 1.64 1.39 5.77 East India Bihar 1.53 1.13 6.24 Orissa 1.70 0.88 3.88 West Bengal 1.74 1.22 2.39 Northeast India __ Arunachal Pradesh 1.81 4.89 Assam 1.91 1.20 2.53 __ Manipur 2.16 2.00 __ Meghalaya 1.93 5.55 __ Mizoram 0.70 __ Nagaland 2.35 6.23 __ Tripura 1.87 3.13 West India __ Goa 1.95 2.02 Gujarat 1.68 0.27 1.25 Maharashtra 1.66 0.68 1.73 South India Andhra Pradesh 1.55 0.43 3.78 Karnataka 1.72 1.08 2.24 Kerala 1.91 0.42 0.88 Tamil Nadu 1.66 0.79 3.13 Sources: Chhabra and Nuna 1994; Mishra et al. 1998; and original data generated for this report: Please see Appendix 1 for brief descriptions of the three estimation techniques. Data for Sikkim and Union territories not available. Chattisgarh, Uttaranchal and Jharkhand are included in MP, UP and Bihar respectively.

12 The data presented in Table 1 show that Various alternative estimation different methods of estimating abortion techniques also yield wide variations in generate vastly different rates and relative estimates of the number of abortions rates. Rates vary substantially by state. The occurring annually in India, as shown in potential induced abortion and residual Table 3. In 1966 the Shah Committee estimation techniques take into account estimated that 3.9 million induced abortions variations in reproductive behavior by state took place annually in India (Chhabra and and are thought to more accurately reflect Nuna 1994). In 1970 IPPF assumed that 200 relative rates. For the entire country the abortions occurred per 1000 births, and number of abortions a woman will have on suggested the national figure was close to an average throughout her reproductive 6.5 million (Mishra et al. 1998). [Goyal et al. years is estimated to be between (1976) presented a range of four to six million approximately 1.0 and 2.6. in 1976 (Khan et al. n.d.).] UNICEF reports that roughly five million induced abortions Table 2 makes some sense of the indirect occur annually in India. Four and a half estimates by showing agreement between million of these are said to be performed the different estimation techniques illegally, and only one-half million are according to states ranked among those performed within the health services having highest abortion rates in the country. network (Jejeebhoy 1996; UNICEF/India States in one or more ranking systems are 1991). Based on clinical records, which are marked in bold. The states that have high recognized to undercount the incidence of rates of induced abortion in more than one abortion, the Government of India reported ranking system are Nagaland, Meghalaya, the total number of induced abortions in Uttar Pradesh, West Bengal, Assam, Bihar, India in 1991-92 at 0.63 million. Chhabra Arunachal Pradesh, Orissa, Madhya Pradesh, and Nuna (1994) used the same technique and Tripura. This suggests that abortion as the Shah Committee to estimate that 6.7 rates are highest in Northeast and Central million induced abortions occur in India India. Not all states were included in each annually. This comparison of the same analysis. However, the larger states were. technique suggests that the number of abortions has increased over time. Table 2. Abortion Rates by Three Different Indirect Estimation Methods

Abortion:Birth Ratio Abortion Potential Residual Estimation

1 Nagaland 2.35 Uttar Pradesh 1.39 Bihar 6.24 2 Manipur 2.16 West Bengal 1.22 Nagaland 6.23 3 Meghalaya 1.93 Assam 1.20 Uttar Pradesh 5.77 4 Punjab 1.91 Bihar 1.13 Meghalaya 5.55 5 Assam 1.91 Karnataka 1.08 Rajasthan 5.35 6 Kerala 1.91 Haryana 0.94 Madhya Pradesh 5.29 7 Tripura 1.87 Orissa 0.88 Arunachal Pradesh 4.89 8 Arunachal Pradesh 1.81 Tamil Nadu 0.79 Orissa 3.88 9 West Bengal 1.74 Madhya Pradesh 0.73 Andhra Pradesh 3.78 10 Delhi 1.72 Maharashtra 0.68 Tripura 3.13

Sources: Chhabra and Nuna, 1994; Mishra et al. 1998; and original data generated for this report.

13 Table 3. Estimates of number of induced Table 4. Maternal Mortality Attributable abortions nationwide annually to Abortion

Maternal Source Number of Induced Mortality Abortions Location Attributable Source Nationwide (millions) to Abortion (percent) Shah, 1966 3.9 India, 1982-1983 18.1 ICMR IPPF, 1970 6.5 India, Rural, 1989 10.8 Office of the Registrar General 1991* Goyal et al., 1976 4.6 India, Rural, 1993 11.7 Office of the Registrar General 1993* UNICEF, 1991 5.0 India, 1992-1994 11.1 Bhatt 1997@ India, 1993-1994 12.6 ICMR task force GOI, 1991-92 0.6 1998@ India, 1994 12.6 GOI 1998@ Chhabra and Nuna, 1994 6.7 India, 1991-1995 18.0 Office of the Registrar General of India n.d.# The gap between reported legal abortion Sources : * Mathai 1998 and total abortion estimates suggests that # World Bank 1996; less than 10 percent of the abortions that @ Ganatra 2001: take place in India are conducted legally Each abortion related death represents (Khan et al. n.d.). In the 1983-84 ICMR many more abortion related complications. abortion study, of the 55 percent of abortions In India, the most frequently recognized com- conducted in the first trimester, only about plications from unsafe abortion are: pelvic 25 percent were conducted by certified infection, incomplete abortion, hemorrhage, doctors or other health staff (Indian Council uterine injury and cervical injury (Barge et of Medical Research 1988; World Bank 1996). al. 1997; Kerrigan et al. 1995). Mathai (1998) Abortions conducted in the second trimester found Indian women are presenting to medi- are more difficult to access, requiring the cal facilities with grade III sepsis, including authorization of two physicians (United sepsis associated with generalized perito- Nations 1993). As such they are more likely nitis, septicemia, septic shock, acute renal to be performed by uncertified providers. failure and disseminated intravascular co- While abortion services from some agulation (Sharma et al. 1992; Sood et al. uncertified providers can be completely safe 1995 as cited in Mathai 1998). Gas gangrene, many uncertified providers perform tetanus, severe adhesions and renal failure dangerous abortion procedures that result in associated with the use of Fetex Paste are morbidity and death. also reported (Mathai 1998). Women presenting at clinics in Uttar Pradesh with abortion B. Morbidity and Mortality from Unsafe complications were reported to have at- Abortion tempted to abort using insertion of a foreign Limited data exist on the number of ma- body such as a stick or a root; orally ingested ternal deaths from abortion in India. The drugs; improper dilation and curettage and Survey of Causes of Death reports that nearly other less common means (Barge et al. 1997). 18 percent of maternal deaths result from Second trimester abortions are a parti- abortion (Office of the Registrar General of cular health concern. Women who delay India n.d.). Data from other sources suggest accessing abortion or MTP until the second that the percent of maternal mortality re- trimester place themselves at a greater risk sulting from unsafe abortion ranges from 4.5 of complications and death, particularly if the to 16.9 percent (See Table 4). abortion provider is untrained (Jones 1991; 14 Kerrigan et al. 1995). Studies show that performed by a registered physician in a unmarried adolescents and women hospital established or maintained by the undergoing sex selective abortion are the government or in a facility approved for the groups most likely to attempt second purpose by the government (Mathai 1998). trimester abortion (Ganatra et al. 2000; Rao For abortions taking place between twelve and Rao 1990, Aras et al. 1987). and twenty weeks of pregnancy, a second opinion is required except in urgent cases. Adolescents are particularly prone to Women must grant consent prior to the abortion related morbidity and mortality. In performance of the abortion. In the case of 1995 almost 50 percent of deaths among minors (defined as under age 18) and women age 15-19 were abortion related. This mentally retarded women, written consent implies that around twenty percent of of guardian is necessary (United Nations abortion-related deaths occur among adole- 1993). scents (Government of India n.d. as found in Mathai 1998). Adolescents, particularly Critics of the abortion law admit that unmarried adolescents, face fear, anxiety, when it was introduced it was a great and the social implications of having a achievement for women’s health. Nearly 30 pregnancy. These make unmarried years later, the law and associated rules and adolescents as a group particularly at risk of regulations are considered overly delaying obtaining abortion services and of medicalised and bureaucratic, and as such, obtaining services from untrained but more not oriented torward women’s right to access confidential providers. Thus adolescents are safe and legal abortion services. The law more vulnerable to suffering complications offers substantial protection for medical of second trimester abortions. Of adolescents providers. Chhabra and Nuna (1947) note who sought abortion in the second trimester that “doctors . . . receive blanket indemnity almost one in four suffered complications, under the MTP Act – instead of functioning compared to only one percent of those who as for other surgical procedures and taking underwent abortion in the first trimester the consequences of any default or neglect”. (Aras 1987). Jesani and Iyer (1995) state “[C]learly the MTP Act does NOT encompass a fundamental III. MEDICAL TERMINATION OF right to induced abortion but is limited to the PREGNANCY (MTP) IN INDIA liberalisation of the conditions under which women may have access to abortion services A. Legal Status of Abortion provided by approved medical practitioners”. The Medical Termination of Pregnancy The law constrains women’s access to legal Act, approved in India in 1971 and enacted abortion services by requiring providers in 1972, permits abortion (or MTP) for a broad receive a level of training that is difficult to range of social and medical reasons, achieve given the shortage of training including: to save the life of the woman; to facilities in the country and the absence of preserve physical health; to preserve mental incentives to receive formal training (Khan health; to terminate a pregnancy resulting et al. 1999). from rape or incest and in cases of fetal Bureaucracy associated with registering impairment. Contraceptive failure also is MTP facilities with the government and with sufficient ground for legal abortion (United reporting and recording MTP procedures, Nations 1993). further contributes to the end result that Barring medical emergencies, legal many physicians provide abortion illegally abortions must be performed within the first (Chhabra and Nuna 1994). When a physician 20 weeks of pregnancy and must be performs abortion without registering the 15 procedure, the physician can avoid the provider and the necessary equipment to extensive paperwork associated with re- provide safe abortion services. Many doctors porting MTP (Barge et al. 1994; Chhabra and who are authorized to provide MTP feel Nuna 1994; Kerrigan et al. 1995). inadequately trained to provide the service safely. In addition, many women do not know B. Inadequate Legal Abortion Service Pro- MTP is legally available at government vision facilities. Unfortunately, many government Despite the broad range of indications for facilities that are supposed to provide MTP legal abortion, illegal and unsafe abortions services free of charge actually charge are common in India for many reasons. clients for MTP services, placing another Women access care from uncertified barrier to women’s access of safe abortion providers because certified providers are from the formal health care system (Khan et geographically inconvenient; staff at al. 1999; Khan et al. 1998). Furthermore, certified facilities tend to not respect evidence suggests that contraceptive women’s confidentiality; because women are acceptance can be a precondition to the unaware of certified facilities; because abortion (Ganatra et al., 2000; Lakshmi and registered facilities often do not have a Pelto, 1999; Gupte et al. 1997, as cited in trained provider and/or the necessary Ganatra 2001). equipment to provide safe abortion services; Table 5 shows that on an average, MTP fa- and many women are unaware that abortion cilities do not perform high numbers of MTPs is legal and publicly available. Cost, coercion, annually. Still, there is significant variation moral dilemma, late knowledge of pregnancy among the states in terms of average num- and unmarried status are addi-tional reasons ber of MTPs performed per MTP facility. women seek abortion from illegal providers. Assam has the highest number of MTP per- Some providers do not approve of elective formed per institution, followed by West Ben- abortion and scold the client as they provide gal, Orissa, Madhya Pradesh, and Haryana. treatment; the pressure to accept Gujarat and Karnataka have the fewest num- sterilization or other long-term ber of MTP performed per facility. It is not contraception after an abortion discourages clear whether states with higher levels of women from using registered facilities. MTP per facilities better meet women’s needs When the reason a woman elects to abort a and thus attract more clientele or have in- pregnancy is not legally sanctioned, for sufficient number of clinics and thus a example for a sex-selective procedure; or heavier client load. Likewise states with when the procedure is highly socially stig- fewer MTP per facility may have more ad- matized, for example to terminate an equate number of facilities or may run in- extramarital pregnancy, women must access adequate facilities that prevent clients from the more confidential services of uncertified presenting. abortion providers (Barge et al. 1997; Barge, et al. 1994; Chhabra and Nuna 1994; Gupte More telling statistics are the number of 1997; Kerrigan et al. 1995; Khan et al. 1999; MTPs per 1000 people and the number of MTP Khan et al. 1998; Ravindran and Sen 1994; facilities per population by state in Table 5. World Bank 1996). Uttar Pradesh and Bihar have the lowest ratios of MTP per 1000 person yet are ranked Government facilities are acknowledged to have among the highest levels of total to be inadequate providers of abortion abortion (see Table 1). This combination in- services. MTP facilities are most often located dicates that more abortions are performed in urban areas while the vast majority of outside certified facilities in Uttar Pradesh Indian women live in rural areas. Only about and Bihar than in any other Indian states ten percent of the clinics that are registered and suggests that the level of unsafe abor- to provide MTP actually have a trained 16 Table 5: Ratios of MTPs, Government Approved MTP Facilities and Population by State

State No. of No. of State MTP: MTP: 1000 Population MTPs Facilities Population Facility Population Facility ratio (1993-94) (1993-94) (1996) ratio ratio Andhra Pradesh 13719 373 72,155,000 37 0.19 193,445 Assam 21372 100 24,726,000 214 0.86 247,260 Bihar 11060 209 93,005,000 53 0.12 445,000 Gujarat 10263 700 45,548,000 15 0.23 65,069 Haryana 22438 228 18,553,000 98 1.21 81,373 Karnataka 9077 471 49,344,000 19 0.18 104,764 Kerala 34433 559 30,965,000 62 1.11 55,394 Madhya Pradesh 33086 295 74,185,000 112 0.45 251,475 Maharashtra 97079 1775 86,587,000 55 1.12 48,781 Orissa 19510 169 34,440,000 115 0.57 203,787 Punjab 19436 242 22,367,000 80 0.87 92,426 Rajasthan 29023 316 49,724,000 92 0.58 157,354 Tamil Nadu 42364 623 59,452,000 68 0.71 95,429 Uttar Pradesh 12103 425 156,692,000 29 0.08 368,687 West Bengal 64273 452 74,601,000 142 0.86 165,047 India 609915 9271 934,218,000 63 0.65 100,768 Sources: Number of MTP: Government of India. Ministry of Health and Family Welfare. Family Welfare Program in India: Year Book (1993-94). Number of MTP Facilities: Nirman Bhavan, New Delhi: Ministry of Health and Family Welfare, [n.d.]; State Populations: (UNFPA 1997). tion may be higher in Uttar Pradesh and This further suggests that MTP facilities Bihar than elsewhere in India. could explore means of improving services to the population the facilities are meant to The population per MTP facility ratios in serve. This would includePrimary exploringHealth Centre means Table 5 show that Bihar has one MTP center of making MTP more accessible to the 100 Community Health for every 445,000 people. In Uttar Pradesh, women meant to be served by the facilities. Madhya Pradesh, Assam and Orissa MTP fa- Centre cilities are more prevalent but still each fa- 90 Figure 1. Percent of PHCs and CHCs cility serves an average of over 200,000 80 offering MTP services by state people. The six states that have the highest number of abortions (Assam, Bihar, Madhya 70 Pradesh, Orissa, Uttar Pradesh and West Bengal according to results of three indirect 60 estimation techniques presented in Table 1) mirror the states with fewest facilities per 50 population. This suggests the population 40 most needing access to MTP facilities are also the population least likely to have ac- 30 cess to MTP facilities. 20 The data presented in Table 5 together with the incidence data presented in Table Gujarat Maharashtra Tamil Nadu Uttar Pradesh 1 suggest that though MTP facilities are inadequate to meet the needs of the population, the available facilities are underused.

17 Source: Khan et al. 1999 Methods In the Seventh Five-Year Plan (1985- Because of the barriers preventing 1990) the Government of India stated the women from accessing MTP, women access intention to equip all primary health cen- abortion from unregistered, uncertified tres1 with staff and supplies to conduct abor- providers. Abortion services from tion services. Khan et al. (1999) relay that unregistered providers range from “according to the national norm, all commu- completely safe – provided by trained medical nity health centres2 , postpartum centres, doctors in appropriate facilities – to life- and similar higher level facilities are ex- threatening – provided by a range of providers pected to provide abortion services”. Figure in various settings (Mathai 1998; Kerrigan 1 shows this goal remains unrealised. et al. 1995; Johnston et al. 2001). Uncertified Around one-quarter of primary health cen- abortion providers can include trained ters in Uttar Pradesh and Maharashtra pro- medical doctors and nurses in hospitals, vide abortion services. One-third and almost Auxiliary Nurse Midwives (ANM), ayurvedics, two-thirds provide these services in Gujarat homeopaths, dais or traditional birth and Tamil Nadu, respectively. Among com- attendants, family health workers, village munity health centres only 59 percent in health practitioners, pharmacy shop-keepers Uttar Pradesh and 78 percent in Gujarat pro- and village women (Bandewar n.d.; Mathai vide abortion services. Eighty-nine percent 1998; Johnston et al. 2001). of community health centres provide MTP in Common methods of inducing abortion Maharashtra. In Tamil Nadu, 95 percent of include vaginal and oral methods. Dais use community health centers and sub-district methods such as inserting sticks, herbs, hospitals provide MTP. However, in Tamil roots, and foreign bodies into the uterus to Nadu abortions are offered primarily on ster- induce abortion. Other vaginal methods ilization days and according to several stud- include pins, laminaria tents, and Fetex ies abortion providers pressure abortion cli- Paste3 . Rural Medical Providers (RMPs or ents to accept sterilization (Khan et al. 1999). “quacks”) sell medicines for oral use to Information presented in this section sug- induce abortion. ANMs (Auxiliary Nurse/ gests that abortion services from PHCs are Midwives) and ISMPs (Indian System of inadequate, yet underutilised. This corrobo- Medical Practitioners) use intramniotic rates data from other sources suggesting injections such as intramniotic saline and that women often turn to certified and intramniotic glycerine with iodine to induce uncertified providers at private facilities for abortion. Orally ingested abortificants abortion services. For example, in include indigenous and homeopathic Maharashtra, over two-thirds of the approved medicines, chloroquine tablets, MTP centers are in the private sector (Barge prostoglandins, high dose progesterones and and Rajagopal 1996). estrogens, papaya seeds with high dose progesterones and estrogens, liquor before C. Illegal Abortion – Providers and distillation, seeds of custard apple and carrots, etc. (Mathai 1998; Johnston et al.

1 Primary health centres (PHCs) cover a population of about 30,000, staffed by a medical officer, associated facility staff and field supervisors (World Bank 1996) 2 Community health centres (CHCs) serve as “first referral units” and cover a population of approximately 100,000 staffed by specialists in pediatrics, surgery and obstetrics and gynecology (World Bank 1996).

3 Fetex Paste (brand name) contains benzoin, iodine, thymol, potassium iodide and saponified vegetable oil paste. It is introduced vaginally as an abortificant (Marathi 1998). 18 2001). Chloroquine is applied contraception is generally high, lack of intramuscularly as an abortificant. Abdo- availability of spacing methods, minal massage, witchcraft, dilation and misinformation and apprehension about the curettage, vacuum aspiration and heat appli- different contraceptive options prevents cations are also used to induce abortion widespread contraceptive use and abortion (Indian Council of Medical Research 1989; is used as an alternative to contraception Kamalajayaram and Parameswari 1988; (Parivar Seva Sanstha 1998). Maitra 1998; Meenakshi, et al 1995; Rani et Indian women access abortion through- al. 1996; Sood 1995, as found in Mathai 1998). out their reproductive years. A 1990-91 study D. Characteristics of women who termi- shows that more than 80 percent of women nate unwanted pregnancies who obtain MTP are in the 20-34 age group (Chhabra and Nuna 1994). Adolescents, both The reasons Indian women terminate married and unmarried, also obtain abortion unwanted pregnancies are many and varied. services in significant numbers. According Conditions that can lead to a pregnancy to Chhabra, 27 percent of the 2755 abortions being unwanted include: financial reasons; conducted in a clinic in rural Maharashtra already having too many children or having in the period 1976-87 were for adolescents too many female children; becoming (Chhabra 1988) and as many as 30 percent pregnant after too short a birth interval; of 1684 abortions conducted in an urban experiencing health problems during hospital setting were for adolescents pregnancy; becoming pregnant at an older (Solapurkar and Sangam 1985). A substantial age; becoming pregnant soon after marriage; number of unwanted pregnancies among suspecting husband’s infidelity; having an adolescents result from forced sexual extra-marital pregnancy and becoming intercourse. A Bombay study published in pregnant as a result of rape are all conditions the late 1970s showed that around 20 percent that can lead to a pregnancy being unwanted of pregnancies of adolescents obtaining (Barge et al. 1997; Jejeebhoy 1998; Sinha et abortion were reported to have resulted from al. 1998). rape (Divekar et al. 1979, as cited in For most of these conditions, a more Jejeebhoy 1996). proximate determinant of unwanted As adolescents have less access to pregnancy is lack of access to appropriate reproductive health information and contraception. For some women, contracep- services compared to older married tion is not an option because of family counterparts, they are more likely to delay pressure. Other women can not access a recognising pregnancy, to delay obtaining contraceptive method appropriate for them. care, and to access care from unsafe For unmarried adolescents, contraception is providers (Jejeebhoy 1996; Mathai 1998). generally not available. In such cases, Seventy two percent of the unmarried abortion may be the predominant means of women who sought abortion at a rural clinical birth control (Gupte et al. 1997). facility, most of whom were under age 20, Contraceptive failure and user failure sought MTP in the second trimester can lead to unwanted pregnancies that can (Chhabra 1988). In a clinic-based study be aborted legitimately in the Indian medical conducted in the mid 1980s, a majority (59 system. Reasons for contraceptive failure percent) of unmarried adolescents presented should be explored and addressed and for second trimester abortions, while a contraceptive options should be made more minority (26 percent) of married adolescents adequate. Though awareness of came in during their second trimester of

19 pregnancy (Aras 1987; Jejeebhoy 1996). Data National Family Health Survey (1992-93) from the 1970s suggest that eighty percent reports the sex ratio at birth to have been of adolescents receiving abortion sought almost constant at 106.3-106.6 for five-year abortion in the second trimester (Bhatt 1978; periods since 19724 , offering no support to Purandare and Krishna 1994). This compares arguments that sex selective abortion is to 34 percent of older women who sought skewing sex ratios at birth at the national abortion in their second trimester. level. As a comparison, in China and South Korea, where sex selective abortion is India’s second trimester abortion rate is reportedly common, sex ratios at birth were thought to be among the highest in the world 119 and 114 respectively in 1992 and increasing (Chhabra and Nuna 1994). (International Institute for Population Of women accessing legal abortion services Sciences 1995). at specific teaching hospitals in 1981, a range of between ten and forty percent were While women from all socio-economic in their second trimester (Indian Council of groups access abortion, there is a class Medical Research 1981). Second trimester differential in where women from different abortions increase risks to women in two socio-economic groups obtain abortions. ways. First, women are more likely to go to Women who obtain abortions at safe facilities an uncertified provider because the tend to be the women who can afford to pay procedure is more difficult to obtain legally the transport costs and additional associated than first trimester abortion (Kerrigan, et al. fees (Barge et al. 1997). Because legal 1995; Ravindran and Sen 1994). Second, in abortion is not an option for most Indian the second trimester the risk of women from lower socio-economic classes, complications is higher for physiological these women tend to obtain abortion services reasons (Jones 1991). from less trained, but more accessible providers (Jejeebhoy 1998). Sex selective abortions and delay of accessing abortion services for an unwanted E. Decision-making issues pregnancy are the two most common reasons Making the decision to abort a pregnancy for second trimester abortions (Mathai 1997). can be difficult and cause delays in abortion A strong son preference and the availability seeking. Factors that cause delays in acces- of prenatal diagnostic techniques have sing abortion services include not initially resulted in an increased use of prenatal sex recognizing the pregnancy, postponing tests, even among rural poor. Some private communicating the news of an unwanted clinics provide prenatal sex tests and offer pregnancy to a decision maker, lack of abortion services (United Nations 1993). awareness of available abortion services, While this practice was outlawed in 1994, lack of resources (financial, transport etc.) it apparently remains widespread and to access available services and fear of social impossible to accurately quantify. In 1989, stigmatization. For adolescents and eleven percent of abortions were thought to unmarried women, the confidentiality of the be to abort a female fetus (Indian Council abortion service is particularly crucial and of Medical Research 1989). Indian non- delays in accessing abortion are more likely governmental organizations suggest that (Ganatra 1997; Indian Council of Medical over 2 million sex selective abortions are Research 1989 as found in Mathai 1998). reported every year, representing only the tip of the iceberg, according to a recent A woman may make the decision to abort newspaper article-Reuters 1999. The a pregnancy but often the decision-making

4 The typical sex ratio at birth is 104-107 males to 100 females (Shryock and Siegel 1976) 20 role is taken by husbands, mothers-in-law reportedly do not maintain client confi- or other household members or community- dentiality; can be expensive5 ; and tend to be level health care providers. Decision makers far from where women live and thus difficult may support a woman’s choice, pressure her to access (Barge et al. 1997; Indian Council into having an abortion or object to her of Medical Research 1989). having an abortion. Sinha et al. (1998) report In Uttar Pradesh, a study of women who women turn to a range of confidants to help sought abortion from either legal public or make the abortion decision. In a study of 132 private sector clinics found that the most women conducted in Uttar Pradesh, the important priority of women accessing majority of women (32 out of 49) who wanted abortion services from private clinics was to abort their unplanned pregnancy first the clinic’s reputation for providing high discussed the prospect with their husband. quality care. In contrast, the most important Many husbands were supportive of the priority for women who sought care from decision to abort and actually facilitated the public clinics was the convenience of the abortion process. Mothers-in-law, sisters-in- location of the clinic. Other reasons for law, health workers, neighbours and other choosing clinics that were much less relatives were also consulted (Sinha et al. important to the respondents included 1998). On the other hand, fear of disapproval, knowing the doctor, family members’ opposition or violence can result in women suggestions, cooperative behavior of staff and hiding the abortion from her family (Ganatra doctor and confi-dentiality of services (Barge 2001; Gupte et al. 1996). et al. 1997). Choosing an abortion provider can be influenced by multiple factors. Study results IV. POSTABORTION CARE SERVICES show that people who obtain abortion from legal and unregistered facilities generally A. Management of Abortion-related have different characteristics and priorities. Complications Low-income women and women who live in Issue of comlications related to abortion rural areas are severely limited in choices will exit while, safe abortion services are for abortion services, causing such women eccessible to all whomen. Clearly activities to be more likely to access abortion from should address decreasing unwanted providers of unsafe abortion. In rural areas, pregnancies and increasing women’s access uncertified providers thrive because they can to safe abortion services. However, the need offer abortion services at an affordable price, to address ongoing complications from and are often located closer to women’s unsafe abortion services cannot be ignored. residences than legal providers (Parivar Seva Sanstha 1998). As a result of limited access The majority of morbidity and deaths to safe providers in rural areas, rates of from unsafe abortion are preventable. unsafe abortion are thought to be Recognizing abortion complications and significantly higher in rural than in urban accessing appropriate medical care promptly areas (Kerrigan et al. 1995). can reduce the risks of chronic morbidity and mortality from complications of unsafe Women who have the choice between abortion (Greenslade et al. 1994; Johnson et public and private providers report feeling al. 1992; Salter et al. 1997; World Health more satisfied with the services of private Organization 1994). The successful providers. Care in government facilities is treatment of abortion-related complications reportedly inadequate; such facilities

5 While abortion services are supposed to be free in public sector clinics, clients report having to pay for doctor’s fee, hospital room fee, medicine, transport and food (Barge et al. 1997). 21 is highly dependent on the availability of are not giving women appropriate care after some degree of treatment at all levels of the abortions are provided. For example health care system. The elements of abdominal pain and prolonged bleeding postabortion care (PAC) services that can be following abortion are often ignored by integrated into a comprehensive abortion providers after providing abortions (Indian care program include: emergency treatment Council of Medical Research 1989). of incomplete abortion and potentially life- Even when women access facilities that threatening complications; abortion have the basic skills and technology to contraceptive counseling and services and provide emergency care, women may get links to other emergency services and inappropriate care. In Uttar Pradesh Potts et reproductive health care services al. (1998) noted a tendency of registered (Greenslade et al. 1994). The studies and providers to scold patients when they present information gathered on abortion in India with complications of abortion from an unsafe suggest that both the availability and quality of such aspects of abortion care are in- provider. Some clinicians feel the scolding adequate. attitude discourages women from having repeat unsafe abortions. There are Emergency treatment of a complication indications that emergency treatment can is an essential aspect of abortion care. The be painful, even when pain control is applied first step for a woman seeking care is re- (Potts et al. 1998). cognising that she needs care. Then frontline health providers at the community Delays in receiving appropriate level must be able to recognise what is treatment may occur for a number of needed and treat or refer the woman. reasons, including: delay in identifying the symptoms of a com-plication; inability on the The care a woman receives when a com- part of the community-level health care plication is first recognised is crucial. provider to diagnose, manage or stabilise Typically, the woman is first cared for in her patients; lack of awareness or concern of own home by the female head of household potential compli-cations; lack of awareness (Potts et al. 1998). Women with complications of an appropriate higher level facility that tend to play a peripheral role in making the accepts referrals for complications of decision of whether or not they should obtain abortion; and lack of transport to higher level care (Ganatra, et al. 1998). If obtaining care facilities and inability to pay for care and is determined necessary, the woman may associated costs at higher-level facilities go to a traditional birth attendant, trained (Ganatra, et al. 1998; Maitra 1998; Potts et midwife, a range of community level al. 1998). Furthermore, women with severe providers or a qualified allopathic doctor. complications have reportedly been sent away There is a general lack of information in rural from private clinics because the clinic does community about the type of treatment and not want the reputation that women die at the providers accused by women for abortion their clinic (Kerrigan, et al. 1995). care. If the women who require emergency care following an abortion complication are Ensuring the appropriate referral of not obtaining it in the health care system, patients for clinical care is crucial for im- this serivce-delivery gap needs to be better proving emergency care for complications of understood and addressed (Potts et al. 1998; abortion. Components of appropriate referral include: accurate clinical assessment of the Johnston et al. 2001). woman; appropriate stabilization; accurate Accessing appropriate facilities is a com- diagnosis; complete written record of her plex issue. Research suggests that providers presenting and referral condition; communi- 22 cation between the initiating center and the also noted that women obtaining second referral center; and assistance with trimester abortion at a rural Maharashtra transport to the referral center (Potts et al. clinic often would agree initially to accept 1998; Salter et al. 1997). IUD contra-ception, only to refuse the IUD Women with abortion complications need after the procedure and leave the clinic care immediately. Too few resources are without any method of contraception. A study available to women who experience abortion conducted in rural Uttar Pradesh shows that complications. The missing resources unregistered abortion providers rarely offer include knowledge, authority, transport, contraceptive services (Johnston et al. 2001). close appro-priate medical care and others. Where postabortion contraceptive At the level of District Hospitals and counseling exists, it is reportedly inadequate Medical College Hospitals, service-delivery and not based on the principle of informed challenges include improving provider choice. In Uttar Pradesh only one-third of attitudes toward abortion patients; ensuring acceptors were counseled about how the that facility-based policies and management method works, the possible side-effects, and activities support immediate and high- steps to take if side-effects are experienced quality emergency postabortion care; (Barge et al. 1997). Issues such as increasing ensuring availability of blood products and contraceptive method mix and maintaining medicines essential for clinical treatment; a stable supply of contraceptives are working to minimize problems of diagnosis longstanding in India. Major logistical issues and referral; improving providers’ attitudes need to be addressed before the toward women experiencing abortion contraceptive needs of Indian couples will be complications; main-taining equipment and met. expertise for suction machines for the Negative attitudes toward MTP clients by treatment of incomplete abortion; promptly providers and insufficient contraceptive treating women with complications and knowledge and counseling skills among MTP ensuring that patients are not lost to follow- providers are thought to be major reasons up; recognizing and treating women’s postabortion contraception is not widely reproductive health and other health needs; accepted (Kerrigan et al. 1995). Other issues and identifying women who have been in that may limit the extent to which contra- abusive situations and referring these ception is accepted after an abortion include: women to appropriate resources (Potts et al. fear of contraceptive side-effects; husband 1998). or other family members may be against B. Contraceptive counseling and contraceptive use; ignorance of the woman services and the provider of the immediate return to fertility after an abortion; a lack of knowledge Another critical element of abortion care about appropriate contraceptive methods to is contraceptive counseling and services. use; and an inadequate supply of equipment Several studies report that the majority of and contraceptive commodities. Additio- abortion clients accept contraception after nally, weak referral networks may limit the an MTP procedure (Barge et al. 1997; range of contraceptive method available Chhabra et al. 1988). However, acceptors (Barge et al. 1997; Potts et al. 1998). report that accepting the method can be a precondition for getting an MTP (Barge et al. C. Linkages with other reproductive 1997). Chhabra et al. (1988) report that many women obtaining MTP have to be motivated to accept contraception by clinic staff. They 23 health services thorough review of MTP policy and service- delivery guidelines may be beneficial. The third critical aspect of abortion care, linking women to other reproductive health A. Improving knowledge of abortion in- services suffers from a lack of information cidence and appropriate facilities in most countries including India. Several studies conducted There is an identified absence of verifi- in Uttar Pradesh have documented a lack of able abortion incidence data in India. Sug- awareness among medical providers of the gested rates of abortion and unsafe abortion risk of sexually transmitted diseases (STDs) vary widely. Methods of collecting acceptable or reproductive tract infections (RTIs) contri- abortion incidence data are intensive, use buting to the spread of HIV or morbidity such multiple methods of data collection and in- as secondary infertility and thus a lack of struments must be designed based on local concern for postabortion reproductive health cultural norms (Anderson et al. 1994; Hun- care such as screening for and treating STDs tington et al. 1996). These fundamental re- and RTIs (Barge et al. 1997; Potts et al. 1998). quirements necessitate medium-scale stud- In addition, women who experience repeat ies (several districts or statewide). Intensive spontaneous abortion deserve appropriate studies of the incidence of abortion and abor- counseling and the option of fertility tion complications would be informative and treatment. would yield valuable information particularly Women who obtain abortions and post- as baseline measures and guides for inter- abortion care may have experienced rape or vention studies. domestic violence. Jejeebhoy (1998) reports B. Improving pregnancy termination ser- that an alarming proportion of adolescent vices abortion seekers became pregnant as a Results of the literature reviewed point result of rape. In a study conducted in rural to areas that need to be addressed to improve Maha-rashtra, Ganatra et al. (1988) found abortion care in India. Operations research that domestic violence was the second most could be conducted to test the effectiveness common cause of deaths during pregnancy, of innovative interventions. A thorough representing additional morbidity associated review of MTP policy and service-delivery with pregnancy. The concept of identifying guidelines may be required. In addition a women with additional reproductive health review of MTP policy and service-delivery and other needs and effectively linking with guidelines could suggest means of increasing appropriate reproductive health services is women’s access to safe abortion services. clearly an area where additional research and training is necessary. Training: Motivate qualified practitioners to attend MTP training courses. The pro- V. RECOMMENDATIONS cedures for training and licensing providers Results of the research studies reviewed and licensing abortion facilities need to be in this paper suggest that abortion and adapted to current situations. MTP training associated morbidity and mortality from should include training in the various forms unsafe abortion are common and should be of providing MTP (manual vacuum a top priority safe motherhood issue in India aspiration, electric vacuum aspiration, and and point to areas that need to be explored to dilation and curettage), emergency improve abortion care. Operations research postabortion care, postabortion contraceptive could be conducted to test the effectiveness services and counseling and linking women of innovative interventions. In addition a to additional reproductive health services 24 (Khan et al. 1999). women accessing abortion services. Women report scolding attitudes Review the MTP Act to determine means among pro-viders when presenting in which the Act can be revised to better for abortion services. Counseling improve abortion services for women. Each training for providers is essential in recom-mendation presented here represents terms of providing high quality care multiple steps of reviewing and improving in service provision, by interacting services to better meet the needs of women with women in a positive manner, and men at the community level. Some providing them with the information recommendations to improve health care go they need and helping them to make beyond current MTP Act, indicating that the informed choices (Mathai 1998). current MTP policy needs to better meet the z Increasing geographical accessibility reproductive health needs of women. Experts of safe abortion services for women have recommended reviewing the criteria of reproductive age in general, and for certifying providers and considering for adolescents in particular. One key including additional care of providers for MR reason women turn to untrained pro- and MTP service delivery; reviewing provider viders is that untrained providers are training required; reviewing procedures for more accessible at the community licensing facilities and reconsidering MTP level compared to trained providers, rules and regulations in light of medical which tend to require additional methods for terminating pregnancies travel time and associated costs. To (Chhabra and Nuna 1994; Mathai 1998; Khan increase accessibility of safe abortion et al. 1999). services, additional providers could be Upgrade facilities that currently offer based in rural areas. Certainly more abortion services. Monitoring of safe abortion medical providers, particularly service providers may be necessary to women pro-viders, could be trained in ensure that providers are at their sites abortion provision to staff rural during clinic hours, that charges do not clinics. As many medical providers exceed a set standard, that high quality care are unwilling to be based in rural is provided from the patient’s entry into the areas, the strategy of training clinic throughout service provision and Bachelor of Science Nurses, Lady contra-ceptive counseling. Public and private Health Visitors (LHV) and Auxiliary medical officers could provide monitoring Nurse Midwives (ANM), to provide services (Mathai 1998; Khan et al. 1999; safe abortion services with manual Bandewar 2000). vacuum aspiration equip-ment might Orient abortion services to meet the be considered (Khan et al. 1999). needs of women by: z Increasing affordability of safe z Prioritizing confidentiality of abortion abortion services. Costs associated services at public facilities. Confiden- with publicly and privately provided tiality of abortion services is a priority safe abortion services prompt women for many women obtaining abortion to access abortion services from less services. When safe services are not expensive and untrained providers. confidential many women will turn Addi-tionally, costs associated with to unsafe but more confidential travel and overnight stays prevent services (Mathai 1998). women from obtaining care from trained providers who are often z Providing high quality care for 25 located at substantial distances from cation. Many women turn to their husbands women’s residences and increase for decision-making about reproductive the likelihood women will obtain health issues. In addition to being informed abortion services from an untrained about the importance of safe abortion but more accessible local provider services and signs of abortion complications, (Johnston et al. 2001). men should be addressed in reproductive health campaigns that promote small Increase awareness among women and families and educate about temporary or men of reproductive age of the availability of permanent contraceptive use (Khan et al. safe abortion services and the dangers of 1999; Mathai 1998; Johnston et al. 2001). unsafe abortion. Household decision-makers are often husbands and mothers-in-law as Improve adolescent reproductive health well as pregnant women. All could be the services in general. Adolescents are particu- focus of campaigns that educate about the larly at risk of serious morbidity and mortality from unsafe abortion. Family Life Educa- availability of safe abortion facilities and tion programs that target unmarried and methods and the dangers of unsafe abortion married male and female adolescents need services. Safe abortion services need to to address issues such as preventing un- become a priority for women accessing wanted pregnancy and recognising and safely abortion and those who decide from whom managing unwanted pregnancy. Statistics women will access abortion care. The stage showing increasing rates of unwanted preg- of gestation at which a woman can safely nancies and unsafe abortion among unmar- abort a fetus is an important component of ried adolescents demonstrate a need for ado- any campaign to increase awareness (Khan lescents to be included in reproductive health et al. 1999; Mathai 1998). education and to be able to access reproduc- Involve communities and providers at all tive health services, including abortion and levels to improve reproductive health care. contraception, without the consent of a par- In implementing activities to make health ent or guardian (Jejeebhoy 1998; Mathai and medical facilities more responsive to the 1998). populations served, important roles can be C. Improving abortion care played by community-level women’s, men’s and adolescents’ organizations. Private, Sparse literature on the care surround- public and NGO medical providers, including ing abortion service delivery demonstrates paramedics and unregistered practitioners that this is a target area for additional re- at the community level, the government from search. From the available evidence, the fol- the national level to the village level and the lowing recommendations have been made. press and other media groups can all be Develop demand for quality emergency included in campaigns to help women access abortion care. Women and key decision-mak- improved reproductive health services, in- ers need to be advised of the need to access cluding safe abortion and a wide array of high-quality abortion care services imme- voluntary contraceptive services (Khan et al. diately if having complications of induced or 1999). This multi-sector involvement is spontaneous abortion. Women and decision- particularly relevant as states are actively makers should know that care for abortion decentralizing health systems and local complications includes stabilization and re- panchayats become increasingly involved in ferral to appropriate service facilities; emer- health care delivery. gency treatment as necessary; high quality Involve men in reproductive health edu- care, including contraceptive counseling and services and referral to other health facili- 26 ties as necessary (Maitra 1998; Johnston et be reliably available at the community level al. 2001). to ensure easy access (Maitra 1998; Johnston et al. 2001). Decentralise abortion care services at public and private facilities. Emergency care Provide comprehensive abortion care. capabilities should be expanded to lower lev- Health care providers in general, and par- els of the formal health care system. Com- ticularly those at the referral level, need to munity members and providers should be able be aware that the interface between the to recognize symptoms of emergency com- woman with the complication and the for- plications that require treatment or referral mal medical system typically represents a and be able to get women with these compli- rare opportunity to assess other aspects of cations to appropriate referral facilities. the patient’s reproductive health and provide Higher level facilities should be prepared to treatment or refer her to appropriate care. effectively and efficiently manage cases of Providers need to be trained in this largely emergency complications and provide appro- unrecognized aspect of abortion-related care priate postabortion contraceptive counseling (Johnston et al. 2001; Potts et al. 1998). and services (Kerrigan et al. 1995; Maitra 1998). Involve communities and providers at all levels to improve abortion care. In imple- The concept of integrating midlevel pro- menting abortion care activities to make viders into emergency treatment raises health and medical facilities more some policy questions. To what degree can responsive to the population they serve, ANMs and other midlevel providers and TBAs important roles can be played by community or dais be included in the abortion care sys- level women’s, men’s and adolescents tem? Can ANMs receive training to provide organizations, LHVs and ANMs, and public elements of abortion care, including diagnos- and private and NGO medical communities. ing, stabilizing and referral when necessary, Community level providers, including ANMs, aspirating the uterus, providing postabortion PHC nurses, Anganwadi workers and local contraceptive counseling and linking women doctors, need to be included as much as to other reproductive health services? What possible in pro-viding a wide array of incentives can be introduced to encourage voluntary contra-ceptive services (Johnston providers to refer patients when appropriate et al. 2001; Kerrigan et al. 1995). instead of providing treatment for a profit? VI. CONCLUSIONS Offer informed contraceptive choice. While postabortion contraceptive counseling This review of literature shows that and services are not being offered at many morbidity and mortality from unsafe abortion abortion service sites, postabortion contra- remains a serious problem for Indian women; 30 years after the indications for ception is sometimes imposed coercively legal abortion were greatly liberalized in (Rajagopal et al. 1996). Identifying determi- India. Research results show that unsafe nants of voluntary postabortion contraceptive abortions are common; adolescents and acceptance will be key to introducing suc- unmarried women are most at risk of cessful postabortion contraception programs. morbidity and mortality from unsafe abortion. Postabortion contraceptive counseling Furthermore, studies show that for a number should include information about the correct of reasons current legal abortion services are use of the various available methods, poten- not meeting the needs of Indian women, tial side effects associated with available con- particularly rural women. In four states, a traceptive methods, and means of maintain- large sample of registered facilities and ing a steady supply of the selected method. certified providers have been intensively Post-abortion contraceptive services should studied and from those four state studies, 27 REFERENCES means of improving services have been Baretto, T., O. M. R. Campbell, J. L. identified. 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TECHNIQUES USED TO ESTIMATE ABORTION RATES PRESENTED IN THIS REVIEW Chhabra and Nuna revised an estimate proportion of women reporting ill-timed or from a study conducted in 1966 by the unwanted pregnancy. The method of Committee to Study the Question of calculating total induced-abortion potential Legalisation of Abortion or the Shah is similar to the method of calculating Total Committee. The Shah Committee’s Fertility Rates with age-specific potential estimates were based on India’s 1966 induced abortion rates used in place of age- population of 500 million and crude birth rate specific fertility rates. The author of 39 and the assumption of a constant ratio acknowledges that these rates could easily of 15 induced abortions per 73 live births. be underestimates as once a child is born, a The committee derived this ratio from woman is much less likely to think of the community studies in Tamil Nadu and associated pregnancy as unwanted or ill-timed. hospital studies in Delhi. Chhabra and The indirect estimation technique is a Nuna’s estimates were based on 1991 birth residual method based on Bongaarts’ rates and population figures, using the same proximate determinants of fertility model Shah Committee ratio of abortions to live (Bongaarts and Potter 1983), using data births and suggested 6.7 million legal and available in the NFHS 1992-93. A standard illegal induced abortions take place annually maximum potential fertility rate is reduced in India (Chhabra and Nuna 1994). This is by delayed marriage, contraceptive use, the most widely cited estimate of numbers postpartum infecundability and actual of induced abortion in India. The estimation observed fertility. The residual represents technique is based on the questionable fertility reduced by the remaining proximate assumption that 15 abortions occur per 73 determinant of fertility and induced abortion. live births. By assu-ming a constant ratio of This residual can be translated into a total abortions per live births, the variations in abortion rate, which represents the average abortion rates by state are masked. total number of abortions a woman will have Mishra et al. (1988) developed an throughout her reproductive years. A key “induced abortion potential” based on questionable assumption behind this tech- information recorded on ill-timed and nique is that the minor proximate deter- unwanted pregnan-cies by the National minants, fecundability (frequency of sexual Family Health Survey 1992-93. Age-specific intercourse), intrauterine mortality and pregnancy rates (ASPR) are derived from sterility, which are included as constants in pregnancies resulting in live births by age the proximate determinants of fertility model, and age specific fertility rates and represent do not have a varying influence on residual the number of women in 1000 in a given age fertility (Johnston and Hill 1996). The category who will conceive in a specified average maximum total potential fertility year. Out of the number of women at risk of rate per woman is thought to be 15.3 births pregnancy, the number of pregnancies per woman. If Indian women experience reported as ill-timed or un-wanted are those lower maximum total potential fertility rates, considered to be potentially aborted. The as has been proposed, the rates presented number of potential abortions in the given here will reflect overestimates. However, the age categories is the ASPR multiplied by the relative rate of abortion will still be representative. 32