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Abortion Practice in India a Review of Literature

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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] © CEHAT/HEALTHWATCH Printed at :Chintanakshar Grafics Mumbai - 400 031 The views and opinions expressed in this pub- lication 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
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