MEDICAL IN INDIA: A MODEL FOR THE REST OF THE WORLD?

RESEARCH & ANALYSIS: 2 Tania Boler, Cicely Marston, Nick Corby and Elizabeth Gardiner SECTION HEAD Acknowledgements CORT India (Centre for Operations Research & Training) led on the survey design, carried out the fi eldwork and produced the datasets for analysis by the Research and Metrics Team at Marie Stopes International (MSI). In particular, we would like to thank Sandhya Barge, Seema Narvekar and Anjali Widge for their coordination of the fi eldwork.

The authors would like to thank the following people for their contributions: Jo Burgin, Fiona Carr, Dana Hovig, Erica Nelson, Thoai Ngo and Dhaval Patel.

Acronyms CORT Centre for Operations Research & Training, India ICPD International Conference on Population Development IUD MSI Marie Stopes International MA MBBS Bachelor in Medicine and Bachelor in Surgery MTP Medical Termination of Pregnancy NGO Non Government Organisation OCP Oral Contraceptive Pill PHS Population Health Services WHO World Health Organization

For citation purposes: Boler T, Marston C, Corby N and Gardiner E. Medical : A model for the rest of the world? London: Marie Stopes International, 2009 Cover Photograph Credits © Marie Stopes International 2009 Front: G.M.B. Akash / Panos Pictures Inside: Robert Wallis / Panos Pictures HST/ER (TB/FC 03/09) Back: Stuart Freedman / Panos Pictures 2 SECTION HEAD Contents

Executive summary 6

Methodology 6

Key fi ndings 6

Conclusions and recommendations 8

Chapter One: Background 10

1.1 Medical abortion in India: historical and legal context 11

1.2 Access to medical abortion in India 12

Chapter Two: Methodology 14

2.1 Research questions 14

2.2 Study setting 14

2.3 Study design 14

2.3.1 Household survey design and sampling 14

2.3.2 Purposively sampled healthcare providers 15

2.3.3 Purposively sampled medical abortion users 15

2.4 Data collection instruments 15

2.5 Fieldwork 16

2.6 Data analysis 16

2.6.1 Discrepancies between husbands’ and wives’ accounts of abortion 16

2.7 Background characteristics 17

2.7.1 Women 17

2.7.2 Women: background characteristics associated with self-reported 19

2.7.3 Husbands 20

2.7.4 Background characteristics of practitioners and pharmacists 21

Chapter Three: Attitudes to abortion 22

3.1 Women’s knowledge about and attitudes to abortion, by whether or not they have had an abortion 22

3.1.1 Attitudes: when is abortion acceptable? 22

3.1.2 Important characteristics of abortion providers 24

3.1.3 Perception of dangers of abortion 25

3.1.4 Perceived social support for abortion 26

3.1.5 Perceptions of service availability 28

3 3.2 Medical abortion: knowledge and attitudes 28

Chapter Four: Abortion service provision: practitioners and pharmacists 30

4.1 Healthcare providers’ knowledge and opinions about medical abortion 30

4.2 Service provision practices reported by healthcare providers 32

4.2.1 Assessing suitability for medical abortion and providing information to clients 32

Chapter Five: Experiences of abortion 34

5.1 Provider characteristics 36

5.2 Complications 38

5.3 Post-abortion 38

5.4 Medical abortion: specifi c details 40

Chapter Six: Conclusions and recommendations 42

References 46

Tables

1 Do reports of abortion by women and their husbands match up? 16

2 Demographic characteristics of women, by state, with purposively sampled women also shown for information 17

3 Socioeconomic characteristics of the women, by state, with purposively sampled women also shown for information 18

4 Relationship between education level and women’s report of having had an abortion 19

5 Background characteristics of husbands, by state 20

6 Relationship between husband’s education level and whether or not wife had an abortion 20

7 Pharmacist and practitioner background characteristics, by state 21

8 Knowledge of the legal status of abortion, by state and for the women, by whether or not they had experienced an abortion 22

9 Views of women and men on side effects and dangers of abortion, by state, and by whether or not they themselves have had an abortion 25

10 Women’s and men’s responses to whether or not the husband would support the wife if she decided to use medical abortion tablets 26

11 Perceptions of the social support around abortion, women and husbands, by state 27

12 Perceived availability of abortion services by women and husbands 28

13 Attitudes to medical abortion, women and husbands, by whether or not they or their wives have previously had an abortion 29 14 Would it be benefi cial to make medical abortion available to the community? Pharmacists’ and practitioners’ responses and reasons by state 31

15 Summary of medical abortion service provision by pharmacists and practitioners, by state 32

16 Questions asked and information given before providing medical abortion: pharmacists and practitioners, by state 33

17 Details of most recent abortion, by state and by type of abortion 34

18 Type of abortion women report having with most recent provider 37

19 Whether or not women used contraception after their abortion, and if not, why not, by abortion type 38

20 Post-abortion contraception adopted, by type of abortion 39

21 Details of post-abortion contraception 39

22 Women’s reports of the questions they were asked before they were given medical abortion 40

23 Process of taking the medical abortion tablets 41

Figures

1 Map of India and study area 15

2 Percentage of women and husbands agreeing that abortion should be allowed under different circumstances, by state 23

3 Women and men’s responses about how important costs are when selecting a provider for abortion 24

4 Pros and cons of promoting medical abortion: women’s spontaneous reasons for saying the method should or should not be promoted* (*as per other fi gures about women able to give multiple responses and we only present those given by at least 10% of them) 29

5 Pharmacist and practitioner knowledge and opinion about medical abortion 31

6 Reasons practitioners gave for not providing medical abortion, by state 33

7 Who decided the pregnancy should be terminated, by abortion type and state* 35

8 Women’s reports of location of most recent and second most recent abortion provider, by state, and by whether or not they report ever having medical abortion 36

9 How much women report paying for their most recent abortions, by state and by type of abortion 37

10 Complications reported by women after their most recent abortion, by type of abortion 38

11 Week of pregnancy and spouse support for termination using medical abortion 40

12 Women’s spontaneously stated reasons for choosing medical abortion* [*disclaimer as per other fi gures] 40

13 Results of medical abortion use and reported satisfaction with the method: women who had had medical abortion 41 SUMMARY

Executive summary

Unsafe abortion continues the two most commonly Methodology used in medical abortion, to be one of the major and , In 2008, MSI undertook a causes of maternal despite strong evidence that cross-sectional randomised medical abortion is safe and household survey in two Indian deaths. Complications effective.2-7 MSI is committed states, Gujarat and Jharkhand. from unsafe abortions to exploring new and feasible In total, 811 women and 403 of ways to increase access to these their husbands were interviewed lead to the hospitalisation potentially life-saving drugs, about a range of issues related of more than fi ve million both within its own clinics and to abortion, including attitudes via other healthcare providers. towards and experiences of women a year around the abortion. To increase the number world.1 The biomedical dimensions of interviewees who had had of the regimen mifepristone a medical abortion, 33 women In the past, safe abortion and misoprostol are well were purposively selected services were mainly restricted documented. However, the through snowballing techniques to clinical settings in urban impact of access to medical and interviewed using the same areas with available skilled abortion via both traditional questionnaire as the other healthcare workers and hospitals and clinics and less women. Finally, 88 pharmacists specialised equipment. Access traditional channels such as and 87 healthcare practitioners was often limited to a minority pharmacies and community were purposively selected and of women who could afford and health workers is not so well interviewed about their attitudes locate services. However, the understood. Of all the countries and experiences in providing introduction of medical abortion that have increased access medical abortion services. involving the use of abortion- to medical abortion, India inducing instead stands out as a country in of surgical intervention has which women (and men) can Key findings radically changed the situation more easily access the drugs.8 over the last 20 years. Medical The government has actively Knowledge and attitudes abortion is an inexpensive, encouraged increased access to simple to use and acceptable safe abortion services and use of The vast majority of women and method of terminating medical abortion is widespread. men in both Indian states unwanted pregnancies with What remains to be investigated support the use of abortion. the potential to revolutionise is how people access medical However, levels of knowledge access to safe abortion. abortion and how men, women differ between men and women and healthcare providers have and between the two states. Marie Stopes International (MSI) responded to the introduction Important gendered differences is a leading global provider of of it, as well as how medical included: reproductive health services, abortion fits into the provision supplying high quality services of broader reproductive  approximately two-thirds to more than five million health care, including post- of women and 85% of clients in over 40 countries in abortion family planning. men erroneously thought 2007. In 2008, MSI provided that abortion was illegal approximately 450,000 safe In response to these questions, surgical abortions as part of a MSI undertook a study to  overall, men are somewhat spectrum of integrated services, examine the views of women, more liberal than women in making it one of the largest non- men and healthcare providers. their views about abortion, profit providers of safe surgical The aim was to understand with more than 95% of abortions worldwide. The the implications of India’s out- men supporting abortion introduction of medical abortion of-clinic provision of medical for a range of reasons. was welcomed by MSI as an abortion and to draw lessons for opportunity for more women to other countries that wish to scale Generally, women and men were access low-cost, safe abortion. up access to medical abortion. more accepting of abortion in Gujarat than their counterparts Some countries have been slow in Jharkhand. Despite these to register and make available differences between the

6 SUMMARY

states, more than nine out of procedure and the fact that a In terms of availability, ten men and women thought clinical procedure is not needed. women and men all report that abortion is acceptable in that abortion services are a range of different scenarios. Perceived social support generally available nearby. These state differences were for abortion replicated for attitudes towards Provider experiences abortion. For example: The importance of the husband and attitudes in deciding whether or not a  50% of men in Gujarat strongly woman should have an abortion About eight in ten healthcare disagreed that abortion was a recurring theme in the providers viewed medical leads to major negative side findings. In addition, perceived abortion as effective. Even effects compared with only social support was higher in more said it should be 15% of men in Jharkhand Gujarat than Jharkhand: promoted in the community. (similar pattern for women)  32% of women in Gujarat  78% of pharmacists and 85%  women in Jharkhand who and 40% in Jharkhand stated of practitioners considered had had an abortion were 2.7 that only the man can decide medical abortion to be times more likely to report whether or not a woman somewhat or very effective. that abortions lead to major should have an abortion negative side effects than Overall, pharmacists offered women who had not had  69% of women in Gujarat less information and advice to an abortion. In Gujarat, the and 50% in Jharkhand said medical abortion clients than opposite pattern occurred: they thought their friends and healthcare practitioners, and women who had had an family would support them if there was a greater variety in the abortion were about half (0.46) they used abortion services. advice that they gave, especially times as likely to say that regarding regimens. This abortions were dangerous Comparison of attitudes to suggests gaps in pharmacists’ abortion within married couples knowledge of medical abortion.  more women in Gujarat showed that husband and wife (71% vs. 48% in Jharkhand) agreed with one another in strongly agreed that they only 55% of cases regarding Cost of medical abortion could talk confidentially to whether or not the wife would their doctor about terminating be supported by her husband Obtaining medical abortion an unintended pregnancy if she wanted an abortion. pills from pharmacies is (similar pattern for men). cheaper than going through practitioners. Pharmacists Women, men and healthcare Perceptions about abortion estimate costs below 600 providers were generally very providers rupees ($12) in comparison supportive of medical abortion: with up to 3000 rupees ($60) Overall, both women and amongst practitioners.  65% of women and 57% of men expect quality services men thought that medical and rate privacy, provider abortion should be promoted skill, distance and cost as Specific medical abortion more widely to communities important factors when experiences choosing an abortion provider.  71% of women and 74% Of the 45 women who had had a of men considered medical  in Jharkhand, women who medical abortion, a majority were abortion either very effective had had an abortion placed positive about their experience: or somewhat effective. less importance on privacy (one percent vs. seven per  80% were satisfied with Women who were supportive of cent said privacy was not medical abortion medical abortion had a number important). In Gujarat, women of reasons for being so, including who had had an abortion  56% would recommend the lower price of medical placed less importance medical abortion. abortion, the simplicity of the on cost (67% vs. 52%).

7 SUMMARY

Nearly one-third of the women  of those women who took up uptake and less medical abortion had obtained the pills directly post-abortion family planning, counselling. However, many from a pharmacy, with nearly 53% of surgical abortion of these issues could easily be all of them (96%) receiving users took up long-acting addressed through training to instructions. Just over half and permanent methods increase the knowledge and the women failed to return compared with only 25% skills levels of pharmacists. for follow-up advice. of medical abortion users Rather, the overarching lesson is that, in spite of A large proportion of women  43% of medical abortion these challenges, out-of-clinic reported complications following users who did not take up provision of medical abortion has their abortion: 40% of surgical contraception following succeeded in making medical abortion users and nearly 66% of their abortions cited lack of abortion more accessible. medical abortion users. However, information as the reason on closer inspection it appears (compared with only 12% of Our research suggests that, that these women did not surgical abortion users). in order to reach public health actually suffer from complications goals and improve reproductive but rather from some of Four women reported that they health and choices, access the known and expected were forced to be sterilised to and awareness of medical physical effects of an abortion. as a pre-condition of having abortion should be increased Nonetheless, the findings reveal a surgical abortion, which is dramatically, including in out-of- a perceived concern about a matter of grave concern. clinic settings. Reasons include: these effects that perhaps were not well explained to the  high social, community and clients when receiving the pills. Conclusions and clinical support to increase recommendations access to medical abortion Compared with medical abortion users, women who had had Main conclusions  high client satisfaction a surgical abortion were more and high success rates than twice as likely to have Medical abortion in the two been hospitalised as a result states is easily accessible,  cost effectiveness, with of the abortion, suggesting popular and associated with medical abortion up to five that major complications fewer serious complications times less expensive than associated with medical abortion than surgical abortion - even surgical alternatives were relatively uncommon. in the context of low levels of knowledge and training.  less serious and fewer India’s model of liberalised complications and Post-abortion family access to medical abortion reduced need for costly planning has, on the whole, gained hospitalisation compared high levels of acceptability to surgical procedures Post-abortion family planning is from both women and men an important aspect of abortion- (demand side) and healthcare  women using “backstreet” related counselling and reduces providers (supply side). clinical settings are open to the likelihood of repeated exploitation, for example, in unintended pregnancies.9 Although the law does not terms of the price charged Worryingly, post-abortion allow for pharmacists to provide and forced sterilisation as a contraception use was not very medical abortion drugs without determinant for surgery. high in either state and was prescription, it is apparent particularly low for women who that over-the-counter sales India’s model of liberalised had had a medical abortion: without prescriptions are fairly access to medical abortion widespread. Clearly, over-the- is a lesson to the many other  56% of surgical abortion counter sales can be associated countries that struggle with high users took up contraception with some potentially negative rates of and following their abortion, consequences, such as the consequent unacceptably compared with only 46% inaccurate medical abortion high levels of maternal of medical abortion users regime prescriptions, lower rates morbidity and mortality. of post-abortion family planning

8 SUMMARY

Main recommendations

Access to medical abortion needs to be urgently scaled up through as many cost- effective and simple approaches as possible. Key recommendations to improve access to medical abortion include:

 rolling out the provision of medical abortion into urban slums, rural and under- served areas through out-of-clinic settings such as pharmacies and via mid-level healthcare professionals

 providing basic training to providers of medical abortion on the regimen, correct prescription, side effects, post-abortion family planning, counselling and follow-up

 educating women and men about their reproductive health rights and family planning in general; and specifi cally about the legality and availability of mifepristone and misoprostol for safe abortion

 ensuring medical abortion pills that meet the highest standards of quality and effi cacy.

Photograph: G.M.B. Akash / Panos Pictures

9 BACKGROUND

Chapter One: Background

Unsafe abortion continues to be one of the major causes of maternal deaths. Complications from unsafe abortions lead to the hospitalisation of more than fi ve million women a year around the world. An unsafe abortion represents one of the greatest indicators of inequity between rich and poor women: in rich countries, up to eight percent of abortions are unsafe compared with more than 95% in Latin America and Africa and 60% in Asia.1

Access to safe and affordable When taken within the first nine that have registered medical abortion services is hampered weeks of pregnancy, these abortion drugs, uptake has been by restrictive legal environments drugs are associated with a high. Over three million women and weak underlying health 98% success rate.2, 3, 10 (See were estimated to have taken the infrastructure. Traditionally, Box 1 for more information on drugs successfully by 1999.14 the provision of safe abortion misoprostol and mifepristone.) services has required the training Marie Stopes International (MSI) of specialised medical staff Despite the proven effectiveness is a leading global provider of as well as relatively expensive of medical abortion, only a reproductive health services, equipment. However, since minority of countries (35) supplying high quality services 1988, a new and easier have registered mifepristone.1 to more than five million clients alternative has existed in the Misoprostol is more widely in over 40 counties in 2007. MSI form of medical abortion.4 available, as it is registered in provides access to safe abortion Medical abortion involves numerous countries for services as part of a spectrum taking two drugs known as non-abortion-related purposes. of integrated services. The mifepristone and misoprostol. However, within those countries introduction of medical abortion was therefore welcomed by MSI as an opportunity for Box 1: mifepristone and misoprostol more women to access safe abortion in a simple, low-cost The term “medical abortion” refers to pregnancy termination with abortion- and client-oriented manner. inducing in the place of surgical intervention.

By the 1980s, medical abortion had become a safe and effective alternative MSI is committed to exploring for pregnancy termination in the fi rst trimester. This was made possible with new and feasible ways to the availability of in the 1970s and of anti-progesterones increase access to these in the 1980s. potentially life-saving drugs. Various drugs and combinations have been used for fi rst trimester abortion. MSI’s research in the United The most widely researched drugs and combinations are prostaglandins Kingdom shows that women (PGs) alone, mifepristone alone, alone, mifepristone with would prefer more flexibility in prostaglandins and methotrexate with prostaglandins. The combined use where they take medical abortion of mifepristone and misoprostol has become the standard medical drugs, with many preferring the regimen for early medical abortion recommended by the World Health comfort of their own home to a Organization (WHO).11 clinic setting. Anecdotal evidence Mifepristone is an antiprogestin that is licensed for pregnancy termination suggests that medical abortion in many countries. Taken orally during pregnancy, mifepristone blocks drugs are now freely available progesterone receptors, making the endometrium unable to sustain a as both legally registered growing embryo. Mifepristone also triggers an increase in levels drugs and on the black market and dilates the cervix, facilitating abortion.12 in many countries, including Prostaglandins soften the cervix and cause uterine contractions. They are large swathes of Africa, Latin administered orally or vaginally to ripen the cervix before surgical or medical America and Asia. It is important 13 termination of pregnancy. The most commonly used prostaglandin is to understand how these new misoprostol (administered orally or vaginally), a approaches have increased originally developed to prevent and treat gastric ulcers. access to medical abortion The reported complete abortion rate for misoprostol alone varies between and what the effects are. 61% for single use and 93% for repeat doses.

10 BACKGROUND

Given the lack of understanding significantly by adopting can provide medical abortion in of how medical abortion is the Medical Termination of any clinic, not necessarily one being used outside of the Pregnancy (MTP) Act. Until certified under the 1971 MTP clinical setting, MSI undertook then, the Indian penal code Act, provided that they have research into the attitudes and only permitted abortion if it access to a certified site with experiences of women and was required to save the life capacity to perform a surgical their husbands and healthcare of the woman. Anyone caught abortion, should the need arise. providers in two states of India performing an illegal abortion - a country where medical was liable to three years In 2002, the Drugs Controller abortion drugs are widely imprisonment and a fine. Women of India duly approved a license available and some level of terminating their pregnancy for mifepristone; misoprostol provider training has taken faced up to seven years in prison had already been available in place. The aim was to see how and a fine. Whilst this did not India to treat gastric ulcers. accepted the Indian model of deter many women from seeking Upon doing so, the Controller medical abortion has become. a termination, it did mean recommended the use of 600mg abortions were often carried of mifepristone coupled with out by unskilled practitioners in 400 µg of misoprostol orally, 1.1 Medical abortion unsafe conditions. The resulting albeit only in the first 49 days in India: historical high maternal mortality rate of pregnancy. Since then, a and legal context prompted the government- National Consortium of medical appointed Shah Committee experts developed consensus Although abortion is illegal in to recommend legalising protocols and guidelinesi many developing countries, abortion in 1966 to encourage suggesting a lower dose of abortion in India is legal. women to seek terminations 200mg of mifepristone (in line Official figures suggest that in legal and safe settings.18 with WHO recommendations). approximately one million abortions are performed each The MTP Act allows any In developing countries, the year in India,15 although various government-run hospital or combination of mifepristone studies suggest there are actually certified private facility in India and misoprostol has proved six times as many abortions.16 to perform abortions up until highly successful at terminating The biomedical dimensions of 20 weeks of pregnancy. Under pregnancies, with an average the regimen mifepristone and the original Act, an abortion success rate of 95%.12 This misoprostol are well documented could only be performed by an success rate has been replicated (see Box 1). However, what is obstetrician-gynaecologist or in a number of studies in less understood is the impact another medical practitioner India. For example, one study of access to medical abortion who has undergone sufficient in 2000 found that 96-98% via both traditional hospitals training and has been certified. of medical abortions in three and clinics and less traditional different settings - a research channels such as pharmacies In 2002 and 2003, the hospital, a family planning and community health workers. Indian Parliament passed clinic and a rural healthcare India is an important country to the Medical Termination of clinic - were successful.19 analyse because of its relatively Pregnancy (Amendment) Act This finding was repeated liberal approach to medical and the amended Rules and in several other studies.20 abortion and the ease with Regulations to strengthen which women and men can the MTP Act and improve Few women report any serious buy the drugs outside of the the availability of abortion side effects of medical abortion. clinical setting.8 It should be services. Most significantly, Mundle et al.20 studied the noted that it is still illegal in India the amended MTP Rules medical abortions of 149 women to acquire medical abortion sanctioned medical abortion. in a government-run primary drugs without a prescription, They allow an obstetrician- health centre in a village in the although studies suggest that gynaecologist or another Nagpur district, Maharashtra over-the-counter sales of the certified medical practitioner in India. No woman involved in drugs is common practice.8, 17 to provide mifepristone and the study reported any serious misoprostol in a clinic setting complications. All women In 1971, the Indian Government until the seventh week of reported bleeding - 8.6 days on liberalised its abortion laws pregnancy. Furthermore, they average - but this is expected i See http://www.aiims.edu/aiims/events/Gynaewebsite/ma_finalsite/report/2_1_7.html. 11 BACKGROUND

and was reported by many than surgery.21 The Indian NGO abortion services in more than women as similar to or less Parivar Seva Sanstha found half of the public health facilities. than that experienced during a that some women preferred These primary health centres normal menstrual cycle. Three- medical abortion because they commonly cite as barriers quarters of the women involved were afraid of surgery or pain.22 the absence of a provider in the study mentioned nausea trained in surgical methods or and 65% reported abdominal Participants from focus group the lack of equipment and/or cramping for three days on discussions in one study also felt infrastructure required to provide average. However, women that medical abortion provides surgical abortion services, reported low levels of pain. greater privacy (especially if including water and electricity. multiple doctor visits were not The side effects reported in required). They also thought that This limited availability of this study largely reflect the it would be of great use when surgical abortion should mean prevalence and severity of side secrecy was important, especially that medical abortion provides effects reported in other studies for unmarried women.17 a key option for many Indian from India.21 For example, women seeking to terminate a review of 239 medical Notably though, some studies their pregnancy. However, abortions between April 2002 have found that women because providers must at least and February 2003 by Parivar who chose surgical abortion have access to a certified site Seva Sanstha, a registered cited many of the same with the capacity to perform a non government organisation reasons for doing so; such surgical abortion, the availability (NGO) in India, found that whilst as its convenience and being of medical abortion is also women complained of nausea, faster, easier, simpler and limited. This restriction may have abdominal cramps, bleeding compatible with their lifestyle.7 contributed to a mushrooming and vomiting after taking of over-the-counter sales of misoprostol, very few women Given the supportive policy mifepristone and misoprostol in required medication. The same environment and extensive response to increasing demand study found that, after taking evidence in support of medical and willingness to pay.8 misoprostol, 89% of women had abortion, demand for the vaginal bleeding and 84% had procedure has grown quickly Surgical abortion is more abdominal pain, the majority of in India. However, government expensive than medical abortion which was moderate or mild.22 implementation of the MTP and it is therefore typically Act has been slower and as educated, married women from In addition to the few side the following section shows, an urban middle-income family effects associated with medical services on the ground do not rather than lower income women abortion, in several studies always conform to national who access surgical abortion.15 Indian women have identified legislation or guidelines. Given that not all public facilities a number of other positive are yet offering medical abortion features. For example, almost services, it is poorer women half of the women involved 1.2 Access to medical who are more likely to resort to in the study by Mundle et al. abortion in India unsafe abortions or over-the- liked the ease and speed of counter purchases because they medical abortion, whilst a fifth Implementation of the MTP cannot afford the higher costs appreciated that the abortion Act has been slow and associated with surgical abortion. was done in an outpatient setting geographically uneven. For and/or that no anaesthesia was example, the Act stipulates Under the MTP (Amendment) required.20 This is reflected in a that all public sector facilities Act, pharmacists are only number of other studies.7, 23, 22 from primary health care supposed to sell mifepristone In fact, the perceived ease and level upwards must provide and misoprostol by prescription. availability of medical abortion abortion services. However, However, sales of the pills led women in some studies to according to Khan et al., by without prescription are widely prefer medical abortion because 2001 just a quarter of primary reported. In one study, three it was compatible with their health centres in Uttar Pradesh chemists admitted to some lifestyle, duties or tasks.21 A provided abortion services.24 over-the-counter sales.8 In number of women also view Furthermore, only one of the another study, most chemists medical abortion as less painful four reviewed states provided interviewed reported that the

12 BACKGROUND

majority of clients that requested In 1997, a study concluded tablets for medical abortion that women could safely and did not have a prescription.17 effectively use mifepristone and misoprostol with less medical Chemists emerge from various supervision than was typically studies as the primary source recommended.26 The study of mifepristone and misoprostol collected data from 799 medical for many women because these abortions in six urban health drugs are not widely available in centres in China, Cuba and public sector health services.8, 17 India between 1991 and 1993. For example, a study of medical It found that women could abortion in 2005 in an area of correctly determine pregnancy northern Tamil Nadu found most in nearly all cases and that chemists in the district stocked the majority of women could mifepristone or misoprostol, correctly calculate whether whilst only larger clinics and or not the duration of their private hospitals typically had pregnancy was short enough their own stocks. As a result, for medical abortion to be doctors in smaller, public facilities possible. It also found that no often sent patients to buy the woman incorrectly thought her pills from a chemist.8 Where local abortion was complete during pharmacies do not exist, pills the course of a medical abortion. for medical abortion are often available at local grocery shops.17 Liberalising the protocols on how medical abortion is administered In some cases, pharmacists would improve privacy and have replaced doctors reduce many of the difficulties altogether, advising clients women face in addressing about which drugs to take for their sexual and reproductive medical abortion and how to health needs. However, further take them. What is not clear is evidence about the impact and how effective and acceptable efficacy of taking mifepristone this model has become. and misoprostol outside a clinic setting is essential. For Although it is not legal for example, will women be able pharmacists to provide to access adequate care in an medical abortion pills without emergency? It is also unclear a prescription, the reality is whether women correctly follow that this is a fairly common the appropriate medical abortion occurrence in India. Not only has regimen outside clinics. this happened in response to low government provision but also With these gaps in knowledge in response to women wanting in mind, MSI undertook a study to demedicalise the procedure. of attitudes and practices with In one study by Mundle et al., respect to medical abortion. 19% of women who had had Unlike some of the studies a medical abortion indicated described above, MSI’s they would prefer home study included a randomised administration of misoprostol in household survey of both the future.20 Another study found women and their husbands that, whilst 87% of medical (allowing for a comparison within abortion users preferred taking couples), as well as a survey of the drugs in hospital under pharmacists and practitioners. supervision, the rest felt that medical abortion was convenient and could be taken at home.25

13 METHODOLOGY

Chapter Two: Methodology

This chapter outlines the b. Are pharmacies and 2.3 Study design practitioners supportive methodology of this study of increased access to The study design was a cross- as well as the background medical abortion? Why? sectional survey implemented through a randomised sample characteristics of the 3) Experiences of medical of households and through men, women and abortion (Chapter Five) purposively selected healthcare providers and women who healthcare providers. a. How do women describe had had a medical abortion. their experiences of medical MSI only surveyed urban settings The aim of the study was to abortion and surgical abortion? because we understood that assess the attitudes towards medical abortion was not widely and experiences of medical b. What types of complications available in rural areas.17 Four abortion by the two main do women report after cities were chosen in each state, constituencies: women and medical abortion? based on which were the most their husbands (demand side) urbanised and geographically and providers (supply side). The c. What are the levels of dispersed. In Jharkhand, these study included three populations: satisfaction with medical cities were: Ranchi, Hazaribagh, abortion? Bokaro and Dhanbad. In Gujarat, 1) 811 women and 403 the cities were: Ahmedabad, husbands sampled in Vadodara, Rajkot and Surat. a household survey. 2.2 Study setting

2) 87 purposively sampled The study was undertaken 2.3.1 Household survey pharmacies and 86 in two very different states of design and sampling purposively sampled India: Gujarat and Jharkhand. practitioners. Although these states represent In each of the cities, five some of India’s diversity, the enumeration areas were 3) 33 purposively sampled results cannot be extrapolated identified based on dispersed women who had had to the country as a whole from geographical locations with a medical abortion. two states alone. Gujarat was approximately 200 households chosen due to reports of high per area. In each area, the first levels of medical abortion useii household was drawn randomly. 2.1 Research questions and Jharkhand was chosen for Each further household was then programmatic reasons as this selected by walking to the fifth The research questions fell into is the main area in which MSI’s house along from the last house three main lines of enquiry: Partner in India - Population sampled. Households were Health Services (PHS) - operates. considered eligible to participate 1) Attitudes towards abortion in the survey if they contained and medical abortion in As the map on Page 15 married women under the age of particular (Chapter Three): shows, Gujarat is located in 35. Only one eligible woman per the west and Jharkhand in the household was included. When a. To what extent are women eastern part of the country. The the selected household did not and their husbands supportive population of Gujarat is relatively have an eligible woman, the next of medical abortion? rich: only 7.2% live in the lowest household in the enumeration wealth quintile compared area was approached. In b. Who makes decisions with 49.6% in Jharkhand. every second interviewed regarding abortion? The Gujarat population is also household, the husband was more educated: Gujarat has a also interviewed. Repeat visits 2) Attitudes and experiences female literacy rate of 58.6% were undertaken to increase the of medical abortion compared with only 39.4% in likelihood that eligible husbands providers (Chapter Four) Jharkhand (Census 2001). and wives were interviewed. a. In what way do pharmacies and practitioners supply medical abortion to women?

14 METHODOLOGY

2.3.2 Purposively sampled survey was not well suited to 2.4 Data collection healthcare providers identifying sufficient numbers of instruments women who had used medical Within each enumeration area, abortion.iii A two-pronged Based on the overarching two pharmacists and two health approach was taken to identify research questions, a clinics were identified through medical abortion users. First, questionnaire was developed, snowballing techniques - both the abortion providers surveyed pre-tested and translated by asking providers about were asked to refer researchers into local languages. The other providers and by asking to women who had recently questionnaire for women women interviewed through used their services for medical included sections on the household survey about abortion. Second, a snowballing demographic and socio- abortion service providers. As technique was used in which economic characteristics, the sample was purposively women who had reported having attitudes towards medical selected, the results are not had a medical abortion in the abortion and experiences representative of all healthcare household survey were asked of medical abortion. The providers, and over-sample if they knew anybody else who questionnaires for husbands healthcare professionals who had had a medical abortion. included the same topics, provide abortion-related services. By following this approach, an but excluded experiences additional 33 women who had of abortion. A separate had a medical abortion were questionnaire was designed 2.3.3 Purposively sampled identified and interviewed. for the healthcare providers medical abortion users Respondents answered the with sections on background same questionnaire as those characteristics, attitudes In addition to the household who were sampled through towards medical abortion survey, women who had the household survey. and approaches to providing had a medical abortion were medical abortion. Copies purposively sampled due to of the questionnaires are concerns that a household available upon request.

Figure 1 Map of India and study area

China Pakistan

Nepal

Bangladesh

Gujarat Jharkhand

ii Personal communication between CORT and local research groups. iii Given the taboo surrounding abortion, many women are still likely to under-report an abortion. 15 METHODOLOGY

2.5 Fieldwork compared women from the two 2.6.1 Discrepancies between different states, and also husbands’ and wives’ The fieldwork was contracted compared those women who accounts of abortion out by MSI to the local research reported never having had an company CORT India (Centre abortion with those who had had In six cases (highlighted in Table for Operations Research & a surgical or medical abortion. 1 below), women reported that Training). CORT was responsible Analysis was also conducted they had not had an abortion for designing and implementing between couples within when their husbands said that the sample strategy, training households. Differences were first they had. Five of the women the fieldworkers, implementing tested using Chi squared tests said they had had a , the study and compiling the and then for selected outcomes, and one reported continuing results into an initial dataset. more in-depth analysis was with an unwanted pregnancy. In The fieldwork took place between undertaken using logistic all six cases, the husbands said April and September 2008. For regression. Husbands’ responses their wives had had surgery with both the household survey and were also analysed separately, anaesthesia, that the pregnancy the survey of the purposively examining differences between had terminated successfully, and sampled medical abortion users, states and between husbands that there were no complications. female researchers interviewed who reported their wives had had Given that the men provided the women and male researchers an abortion with those who did numerous details of the abortion interviewed the husbands. not report wives’ abortions. such as cost and provider, it seems likely that the wives had The data on providers were undergone an induced abortion 2.6 Data analysis analysed separately and are at some point. They may also presented in Chapter Four. have had a miscarriage on a Data were coded and entered separate occasion or simply by data analysts at CORT India. The chapter on experiences of prefer to describe their induced Both CORT and the Research medical abortion (Chapter Five) abortion as spontaneous. Given and Metrics Team at MSI included the women from the that it is unlikely the men would undertook data editing and household survey who had had a have invented so many details data cleaning. The data were medical abortion and the women about their wives’ abortions, then analysed using the data who were purposively selected. these women have been analysis software STATA by MSI’s Because the medical abortion added to the “had abortion” Research and Metrics Team. sample includes the purposively group for the purposes of this selected women, the women who report. Because they did not The analysis is presented in three have had a medical abortion are give details about their abortion separate chapters. For the not representative of the general experiences, however, they chapter on attitudes (Chapter population in the way that the are not included in the chapter Three), the data from the women other women are, and so firm on abortion experiences. and husbands recruited through comparisons between women the household survey were who have had and have not had a In 17 cases, women reported analysed. The women who were medical abortion cannot be made. having attempted to terminate an purposively selected medical unwanted pregnancy while their abortion users are not included in husbands said they had not had this section. The analysis an abortion. Two of these women report attempting but failing to have an abortion, which helps to Table 1 Do reports of abortion by women and their husbands match up? explain the apparent discrepancy Husband reports abortion in these cases; their husbands are added to the “had abortion” Woman reports Yes No Total Total attempting abortion Number Number Number % group for the attitudes chapter. Of the remaining 15 women, none No 6 304 310 82.9 said they had hidden the abortion from their husbands. Indeed, five Yes 47 17 64 17.1 said their husbands had decided Total 53 321 374 100 to terminate the pregnancy and an additional three said they did

16 METHODOLOGY

not know how much it had cost husbands and healthcare - 68% versus 60% of women because their husband had paid. providers included in this study. were in the age group 25-34 As with the men, the women Most of the women and all of and four percent vs. 13% in reporting abortion reported their husbands were recruited the age group 35-45 for the numerous details about their through the household survey. two states respectively. experience, and it seems likely Women who were purposively that they did indeed undergo sampled are reported upon Women in Gujarat had fewer the procedures they describe. separately in the tables. children - 15% had three or more, compared with 36% of Four women in Gujarat reported the women from Jharkhand. they had attempted to terminate 2.7.1 Women an unwanted pregnancy but had Proportionally more women not succeeded. They are included In Table 2, we show background in Gujarat than Jharkhand among the women categorised demographic characteristics of report having had an abortion. as having had an abortion. the women from the household The Gujarati city of Vadodara survey by state. The women accounts for 22% of the total came from eight cities, four in women who report having 2.7 Background Gujarat and four in Jharkhand. an abortion. The other characteristics Approximately 100 women were cities account for roughly sampled per city. The women 10% each (not shown). This section provides a brief in Gujarat were somewhat overview of the women, older than those in Jharkhand

Table 2 Demographic characteristics of women, by state, with purposively sampled women also shown for information

Gujarat Jharkhand Total Recruited purposively % % No. No. %

State Gujarat 100 0 410 7 21 Jharkhand 0 100 401 26 79 Total 100 100 811 33 100 Women’s age 16-24 28 27.3 223 13 39.4 25-34 68.1 60 517 19 57.6 35-45 3.9 12.8 67 1 3 Total 100 100 807 33 100 Parity 0 11.5 8.2 80 3 9.1 1 31.4 22.7 219 9 27.3 2 41.5 32.7 300 14 42.4 3 10.8 19.2 121 1 3 4 3.9 9.5 54 1 3 5 0.5 5.2 23 3 9.1 6+ 0.2 2.5 11 2 6.1 Total 100 100 808 33 100 Had abortion? No abortion attempt 78.2 86.5 627 0 0 Non-medical abortion only 19.1 12.7 121 0 0 Medical abortion at least once 2.7 0.8 13 33 100 Total 100 100 761 33 100

17 METHODOLOGY

The women from each state in Jharkhand. Although most head of household. In Jharkhand also differed in terms of their women said they did not get the figure was lower - 85%. socioeconomic characteristics. paid in cash or in kind, the Correspondingly more women The women sampled in Gujarat proportion of those who did in Jharkhand reported having had somewhat higher levels of not get paid was highest in a Muslim head of household schooling, with only 11% having Jharkhand - 95% versus 87% in - 15% vs. 3% in Gujarat. no schooling, compared with Gujarat. In the Gujarat sample, 23% of the women sampled 97% of women reported a Hindu

Table 3 Socioeconomic characteristics of the women, by state, with purposively sampled women also shown for information Gujarat Jharkhand Total Recruited purposively % % No. No. % Years of schooling completed Zero 11.1 22.7 136 3 9.1 1-5 6.9 8 60 4 12.1 6-10 50.1 47.1 393 13 39.4 11+ 31.9 22.2 219 13 39.4 Total 100 100 808 33 100 Pay per month (rupees) 100-500 ($2-$10) 2.9 1.5 18 2 6.1 501-999 ($10-$20) 2.9 0.2 13 0 0 1000-1399 ($20-$28) 2.7 1.2 16 1 3 1400-2499 ($28-$50) 2.2 1 13 2 6.1 2500-32000 ($50-$640) 2.2 0.7 12 3 9.1 Does not get paid in cash or kind 87 95.3 736 25 75.8 Total 100 100 808 33 100 Type of work Service 2.7 2 19 6 18.2 Daily labour/Bidi maker 5.9 0.5 26 0 0 Skilled labour 1.7 1 11 1 3 Contract labour/peeling garlic 0 0.2 1 1 3 small business/tailoring work, 1 0.5 6 0 0 selling vegetables Self-employed 0.5 0.5 4 0 0 Cook 1.2 0 5 0 0 Does not get paid in cash or kind 87 95.3 736 25 75.8 Total 100 100 808 33 100 Religion of head of household Hindu 97.1 84.5 734 25 75.8 Muslim 2.7 14.7 70 8 24.2 Jain 0.2 0.5 3 0 0 Sikh 0 0.2 1 0 0 Total 100 100 808 33 100

18 METHODOLOGY

2.7.2 Women: background Table 4 Relationship between education level and women’s report of characteristics associated having had an abortion with self-reported abortions Gujarat Jharkhand

As can be seen in Table 4, Had Had abortion Total abortion Total women in Gujarat reported more % No. % No. terminations of pregnancy than those in Jharkhand. However, Years of within each state, there were schooling completed other characteristics that were also associated with higher Zero 11.4 44 7 86 reports of terminations. In 1-5 28 25 3.1 32 Gujarat, 34% of all the abortions reported came from Vadodara, 6-10 21.6 185 17.2 186 and 25% from Ahmedabad. Far 11+ 27 122 19.8 81 fewer came from Surat (15%) and Rajkot (18%). In Jharkhand, Total 22.6 376 14.3 385 the cities were not significantly Pearson chi2(3) = Pearson chi2(3) = different in terms of proportions 5.0734 Pr = 0.167 10.2784 Pr = 0.016 of women reporting abortion.

In Jharkhand, years of schooling completed was significantly related to whether or not women reported abortion. Women with little schooling reported the lowest number of abortions and women with the most schooling reported the most. In Gujarat the association was not significant, but women with no education reported proportionally fewer (approximately half as many) abortions than those with education.

Photograph: Stuart Freedman / Panos Pictures

19 METHODOLOGY

2.7.3 Husbands Table 5 Background characteristics of husbands, by state Gujarat Jharkhand Total Through the household survey, % % No. a subset of husbands was recruited in every second State house where a woman was Gujarat 100 0 202 interviewed. Husbands’ Jharkhand 0 100 201 background characteristics are Total 100 100 403 shown in Table 5. Approximately Husband’s age 50 husbands were recruited from each of the eight cities. 16-24 6.9 7 28 25-34 60.9 47.8 219 The husbands’ characteristics 35-60 32.2 45.3 156 varied by state, as in the case of Total 100 100 403 the women. The men sampled in Gujarat were younger than Husband: years of schooling completed in Jharkhand (61% vs. 49% aged 25-34 and 32% vs. 45% Zero 1 9 20 aged 35-60, respectively). 1-5 11.4 6 35 Proportionally fewer husbands 6-10 54.5 43.3 197 in Gujarat had no schooling 11+ 33.2 41.8 151 (1% vs. 9% in Jharkhand). Probably related to this is Total 100 100 403 the finding that more men in Husband’s pay per Gujarat were in the highest month (rupees) pay bracket. Approximately 501-999 0 1 2 the same proportion of men 1000-1399 1 2 6 in both states had wives 1400-2499 15.2 24.6 79 who had had abortions. 2500-32000 83.8 72.4 310 Total 100 100 397 Wife had abortion? Yes 15.4 11.4 53 No 84.6 88.6 343 Total 100 100 396

Table 6 Relationship between husband’s education level and whether or In Jharkhand, the husbands’ not wife had an abortion education levels were associated with whether or not their wives Gujarat Jharkhand had had an abortion. As with Wife had Wife had the women, higher education abortion Total abortion Total levels among husbands were % No. % No. also associated with higher levels Husband: years of of abortion. The association schooling completed was not significant in Gujarat. Zero 0 2 5.6 18

1-5 13 23 8.3 12

6-10 10.7 103 5.7 87

11+ 23.9 67 19 84

Total 15.4 195 11.4 201 Pearson chi2(3) = Pearson chi2(3) = 5.9271 Pr = 0.115 8.3094 Pr = 0.040

20 ATTITUDES

2.7.4 Background the pharmacists interviewed, 26% Gujarat, and the practitioners characteristics of did not have a degree in were generally older than the practitioners and pharmacy. Of the practitioners pharmacists. The pharmacists pharmacists interviewed, 18% reported neither reported dealing with more family MBBS (Bachelor of Surgery and planning clients per week - 46% The providers were first asked Medicine) nor a qualification in said they had over 30 clients per about their personal background Obstetrics/Gynaecology. The week, compared with six percent and qualifications. The results are providers in Jharkhand were of the practitioners. summarised in Table 7 below. Of typically older than those in

Table 7 Pharmacist and practitioner background characteristics, by state

Pharmacists Practitioners

Gujarat Jharkhand Total Gujarat Jharkhand Total % % % % % %

Age Age

20-29 31.8 16.3 24.1 20-29 4.4 0.0 2.3

30-39 36.4 30.2 33.3 30-39 40.0 12.2 26.7

40-49 25.0 32.6 28.7 40-49 31.1 31.7 31.4

50+ 6.8 20.9 13.8 50+ 24.4 56.1 39.5

Total 100 100 100 Total 100 100 100

Total (N) 44 43 87 Total (N) 45 41 86

Do you have What is your a degree in professional pharmacy? qualifi cation?

Yes 75.6 72.1 73.9 MBBS 6.7 31.0 18.4

No 24.4 27.9 26.1 DGO/Gynaec 75.6 50.0 63.2

Others 17.8 19 18.4

Total 100 100 100 Total 100 100 100

Total (N) 45 43 88 Total (N) 45 42 87

Family Family planning planning customers clients per per week week

None 0.0 4.7 2.3 None 0.0 0.0 0.0

1-4 0.0 7.0 3.4 1-4 29.5 7.1 18.6

5-10 13.6 18.6 16.1 5-10 40.9 35.7 38.4

11-30 36.4 30.2 33.3 11-30 27.3 47.6 37.2

31-99 40.9 30.2 35.6 31-99 2.3 7.1 4.7

100+ 9.1 9.3 9.2 100+ 0.0 2.4 1.2

Total 100 100 100 Total 100 100 100

Total (N) 44 43 87 Total (N) 44 42 86

21 ATTITUDES

Chapter Three: Attitudes to abortion

In this chapter, we examine women’s and men’s knowledge about and attitudes to abortion.

Because the interviewees were Gujarat, more of the women who baby. In all of these cases, more sampled from two different themselves had had an abortion women in Gujarat than Jharkhand states, and because their said that it was legal (36% vs. said they agreed with abortion responses were very different 22% of women who had not under these circumstances. according to the state they had an abortion). In Jharkhand, More women in Jharkhand than came from, we have presented there was no difference between Gujarat, however, agreed that most findings according to women who had had abortions abortion should be allowed whether the respondents were and those who had not. In both in the case of contraceptive from Jharkhand or Gujarat. In states, over half of the women failure (93% vs. 88%) and if the addition, because ideas about who had had an abortion said foetus is female (13% vs. 10%) abortion are likely to change if that abortion was illegal. or male (12% vs. 1%), or over the woman herself has had an 20 weeks old (23% vs. 7%). abortion, we decided to examine For the men, there was no women who had had an abortion difference according to whether Among the women in Gujarat, and those who had not had or not their wives had an there was also a significant an abortion as two separate abortion. Very few thought difference in attitude between groups. For some analyses, we abortion was legal - women who had had an also found that men differed, approximately 15% in both abortion and those who had depending on whether they states. not in terms of their attitude reported their wives had had to abortion in the case of abortions or not, and so again contraceptive failure: 96% we present the results separately. 3.1.1 Attitudes: when is of women who had had an abortion acceptable? abortion themselves were in favour compared with a 3.1 Women’s knowledge Attitudes to abortion and when somewhat lower figure of 87% about and attitudes to it is acceptable were significantly of women who had not had an abortion, by whether different in Gujarat and Jharkhand abortion (not shown). For the or not they have for all of the scenarios presented other scenarios, and for the had an abortion to the women. Generally, the women in Jharkhand, there majority of women were in were no significant differences There was no difference between favour of abortion in the various between those who had the two states in terms of scenarios: if the health of the experienced abortion and those women’s knowledge of the legal woman is in danger; if the who had not. For the men, status of abortion. Approximately woman does not want another there was no difference by two-thirds of women said child; is unmarried; is pregnant abortion status of their wives. abortion was illegal, and one- as a result of ; or there is a quarter said it was legal. In strong chance of a defect in the

Table 8 Knowledge of the legal status of abortion, by state and for the women, by whether or not they had experienced an abortion Gujarat women Jharkhand women Gujarat Jharkhand

No abortion Had Total No abortion Had Total Husbands Husbands attempt abortion attempt abortion (all) (all) As far as you know is abortion legal or illegal* % % Legal 22.0 36.5 25.3 24.5 29.1 25.2 14.4 16.4 Illegal 69.1 52.9 65.4 64.2 56.4 63.1 80.0 81.6 Do not 8.9 10.6 9.3 11.2 14.5 11.7 5.6 2.0 know Total 100 100 100 100 100 100 100 100 Total (N) 291 85 376 330 55 385 195 201 *Signifi cant difference in Gujarat by abortion status (p<0.05)

22 ATTITUDES

Figure 2: Percentage of women and husbands agreeing that abortion should be allowed under different circumstances, by state Gujarat Jharkhand The woman is more than 20 weeks pregnant

The foetus is male

The foetus is female

There is a strong chance of serious defect in the baby

The woman’s health is endangered by the pregnancy

The pregnancy is a result of rape

The pregnancy is a result of contraceptive failure

The woman is unmarried

The woman does not want another child

100 90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 80 90 100 Husbands Percent of women and husbands Women Percent of women and husbands

Over 90%, and in most cases of a pregnancy over 20 weeks, 90% - of both men and women over 95% of the men supported where only about 10% of men supported the idea that women the idea that a woman should be said that women should still be should be allowed to have allowed to have an abortion in allowed to have an abortion. abortions in a range of different almost all of the scenarios. circumstances. More women The only exceptions were for sex Overall, the men were somewhat supported the idea of women selection, which over 95% of the more liberal than the women, being allowed abortion for men opposed, and in the case but the vast majority - around sex selection.

Photograph: Robert Wallis / Panos Pictures

23 ATTITUDES

Figure 3 Women and men’s responses about how important costs are when selecting a provider for abortion Not Important Somewhat Important Important Very Important 100

90

80

70

60

50 40

30 20

10 Proportion of response 0 No abortion Had abortion Husbands No abortion Had abortion Husbands attempt attempt Gujarat Jharkhand

3.1.2 Important responses spread from “not Where opinions differed characteristics of important” to “very important”. according to whether abortion providers respondents had experienced In most cases, there are no abortion or not, we wished to Women were asked what factors measureable differences in know more. Because privacy they thought were important in attitude between women who was cited as unimportant by the selection of a provider for had had an abortion and those only four women in Jharkhand, abortion. In Jharkhand, women who had not. There are only two the numbers are too small to generally thought almost all the exceptions to this: in Jharkhand, investigate any further. In the factors mentioned were important women who had had an abortion case of the women in Gujarat, and very few (under three placed less importance on privacy however, there were enough percent) said any of the following (one percent vs. seven percent responses for further analysis. were “not important”: having said privacy was not important We wished to examine whether a female provider, cost of the (N=385, p < 0.05). In Gujarat, the difference in attitude to abortion, provider skill, equipped women who had had an abortion cost between women with and facility, legal provider. The only placed less importance on cost without abortion experience place where some said a factor (67% vs. 52% said cost was not remained the same if we took was not important was “distance important (N = 376, p<0.01)). into account their education from home”, which was cited as level, age and religion, which not important by approximately Men in both states considered we considered to be likely one-third of the women. most of the options presented confounding factors. We found to be important. There were that even once these variables In Gujarat, most women very few factors they considered had been accounted for in a agreed that provider skill, a not important. The only factors logistic regression analysis, legal provider, and an equipped that at least 10% of the men women who had had an facility were important. Very thought not important were abortion were about half (0.53) few women cited these as “not female provider (10%) and as likely to report that the cost important”. There was a range of distance from home (14%). of an abortion is important responses to the other factors, compared with women who including cost of the abortion, Figure 3 shows the summary had not had an abortion. importance of a female provider, responses per states for both privacy, distance from home, women and men combined. and husband’s consent not being required, with women’s

24 ATTITUDES

3.1.3 Perception of abortion (45% vs. 24% of women are dangerous, although dangers of abortion who had not had an abortion). more disagree in Gujarat. In Jharkhand, 24% of men Women were asked about Men also responded differently strongly agreed abortions are their view of how dangerous according to state. Half of dangerous, while in Gujarat abortion is. Women in Jharkhand the men in Gujarat strongly only 13% strongly agreed were more likely to agree that disagreed that abortion leads with this. Men did not differ abortion leads to major negative to major negative side effects, according to whether their wives side effects if they had had while only 15% disagreed in had had an abortion or not. an abortion themselves (42% Jharkhand. About half of the strongly agreed, compared with men in Jharkhand strongly Overall, then, the view of 25% of women who had not had agreed with the statement, abortion among the men and an abortion). By contrast, women while only nine percent strongly women in Jharkhand was in Gujarat were more likely to agreed in Gujarat. On the other more negative than among the strongly disagree that abortions hand, about half of all the men and women in Gujarat. are dangerous if they had had an men disagreed that abortions

Table 9 Views of women and men on side effects and dangers of abortion, by state, and by whether or not they themselves have had an abortion Women Husbands Gujarat Jharkhand

No No abortion Had abortion Had attempt abortion Total attempt abortion Total Gujarat Jharkhand Total % % % % % % % % % Undergoing abortion leads to major negative side effects Strongly 28.2 32.9 29.3 16.1 5.5 14.5 49.5 14.9 32.3 disagree Disagree 16.8 14.1 16.2 9.7 10.9 9.9 10.4 9.0 9.7 somewhat Neither agree 14.4 21.2 16.0 30.3 16.4 28.3 5.4 16.4 10.9 nor disagree Agree 17.5 11.8 16.2 19.1 25.5 20.0 25.2 15.4 20.3 somewhat Strongly 23.0 20.0 22.3 24.8 41.8 27.3 8.9 44.3 26.6 agree Total 100 100 100 100 100 100 100 100 100 Total (N) 291 85 376 330 55 385 202 201 403 Abortions are dangerous Strongly 24.1 44.7 28.7 53.6 38.2 51.4 55.0 48.3 51.6 disagree Disagree 6.5 8.2 6.9 5.2 9.1 5.7 7.9 5.0 6.5 somewhat Neither agree 14.8 10.6 13.8 8.5 9.1 8.6 2.5 10.4 6.5 nor disagree Agree 29.9 17.6 27.1 20.9 27.3 21.8 19.8 12.4 16.1 somewhat Strongly 24.4 18.8 23.1 11.8 16.4 12.5 13.4 23.9 18.6 agree Total 100 100 100 100 100 100 100 100 100 Total (N) 291 85 376 330 55 385 202 201 403

25 ATTITUDES

We examined further whether 3.1.4 Perceived social would not support use of the differences in opinion about support for abortion abortion, or both agreed he the danger of abortion varied would. However, in nearly half of according to whether women Women and men were asked cases in Gujarat, the wife said had had abortion experiences various questions to try to she agreed her husband would themselves by analysing whether understand their perceptions support her use of medical the differences remained after of social support for abortion abortion when in fact her controlling for age, religion among their social networks. husband said he disagreed or and education level in a Women differed by state in their was neutral about it. In logistic regression analysis. perceptions of social support Jharkhand the figure was lower, around abortion. In Gujarat, but still accounted for 20% of the The association between 32% of women agreed that only women. In Jharkhand, some attitudes and abortion experience the man can decide whether women took an over-negative remained significant. Women or not his wife should have an view of their husband’s attitude, in Jharkhand who had had an abortion, compared to 40% in thinking he would not support abortion were nearly three (2.72) Jharkhand; 61% of the husbands their use of medical abortion. In times as likely as other women in Jharkhand also agreed with 18% of cases, the women said to report they thought abortion this. However, only 14% of he would not when in fact he had major negative side effects. men in Gujarat agreed and a agreed that he would support it. Once the other variables were large majority (78%) disagreed. The equivalent disparity in taken into account, women Most women said that their Gujarat was smaller - 2.5%. from Gujarat were about half spouse would support them if (0.46) as likely to say that they they used abortion pills (94% in Overall, women tended to have thought abortion was dangerous Gujarat, and 70% in Jharkhand). an over-positive view of their if they had had an abortion However, the men did not agree: husband’s support for their themselves. In other words, half the men in Gujarat and 26% possible use of medical abortion, women who had not had an of those in Jharkhand disagreed. thinking he would support abortion were more likely to think them when in fact he said that that abortions are dangerous. Because these results were for he would not. This was true in the all the women versus all the both states, but was particularly It seems that experience of men, we examined their evident in Gujarat. In Jharkhand abortion may have had a responses in husband-wife pairs about the same proportion of negative impact on women to see whether there was also women who had an over-positive from Jharkhand. It is possible disagreement within couples view (22%) had an over-negative that this is because services about a wife’s idea of her view of their husbands’ likely are poorer, or because husband’s support of her use of reaction to their use of medical abortion is generally seen more medical abortion. In 55% of abortion (18%), i.e. assuming negatively in Jharkhand. cases, the responses of the he would not support her when husband and wife tallied - either in fact he said he would. they both thought the husband

Table 10 Women’s and men’s responses to whether or not the husband would support the wife if she decided to use medical abortion tablets Spouse would support medical abortion Gujarat Jharkhand Total Total use – husband and wife responses % % No. %

Husband and wife agree in their responses 50.5 60.2 221 55.4

Wife agrees but husband disagrees/neutral 47.0 21.9 137 34.3

Husband agrees but wife disagrees/neutral 2.5 17.9 41 10.3

Total 100 100 399 100

26 ATTITUDES

While 69% of women in Gujarat 38% and 44% among men. appearing to perceive a social and 50% in Jharkhand said There appears to be a bigger environment broadly supportive they thought their friends and disparity in perceptions between to abortion, and men perceiving family would support them if women and men in Gujarat the opposite. In Jharkhand, they used abortion services, compared with Jharkhand, men’s and women’s views were the equivalent figures were with the women in Gujarat more similar to one another.

Table 11 Perceptions of the social support around abortion, women and husbands, by state

Women Men Gujarat Jharkhand total Gujarat Jharkhand total % % % % % %

In my community, only the man can decide whether or not his wife should undergo abortion

Strongly disagree 25.8 37.4 31.6 77.7 22.4 50.1

Disagree somewhat 15.0 12.5 13.7 4.5 12.4 8.4

Neither agree nor 27.5 9.7 18.7 4.0 4.5 4.2 disagree

Agree somewhat 15.7 24.2 19.9 6.4 17.4 11.9

Strongly agree 16.0 16.2 16.1 7.4 43.3 25.3

Total 100 100 100 100 100 100

Total (N) 407 401 808 202 201 403

If I/my wife decide to use abortion tablets my spouse would support me/I would support her

Strongly disagree 2.0 7.5 4.7 50.5 26.4 38.5

Disagree somewhat 2.5 11.2 6.8 1.0 5.0 3.0

Neither agree nor 2.2 11.2 6.7 0.5 7.0 3.7 disagree

Agree somewhat 33.4 42.1 37.7 12.9 23.4 18.1

Strongly agree 60.0 27.9 44.1 34.7 38.3 36.5

Total 100 100 100 100 100 100

Total (N) 407 401 808 202 201 403

I think my friends and family will support my/my wife’s using abortion services

Strongly disagree 9.8 25.7 17.7 47.0 32.8 40.0

Disagree somewhat 9.8 10.5 10.1 3.5 8.0 5.7

Neither agree nor 11.1 13.7 12.4 11.4 14.9 13.2 disagree

Agree somewhat 32.7 30.9 31.8 13.4 22.4 17.9

Strongly agree 36.6 19.2 28.0 24.8 21.9 23.3

Total 100 100 100 100 100 100

Total (N) 407 401 808 202 201 403

27 ATTITUDES

3.1.5 Perceptions of Table 12 Perceived availability of abortion services by women and service availability husbands Women Husbands Women and men all report that abortion services are generally Gujarat Jharkhand Total Gujarat Jharkhand Total % % % % % % available nearby. There were differences by state, but within There is a healthcare provider with states, the women who had information on abortion tablets less than a 30 minute walk from my house had abortions did not differ from Strongly those who had not, and men 3.4 6 4.7 0.5 3 1.7 whose wives had abortions did disagree not differ from those whose Disagree 6.4 14.5 10.4 2.5 6 4.2 wives had not. Around 85% or somewhat more women and men said that Neither abortion services were available agree nor 4.9 2.2 3.6 4.5 5.5 5 nearby. However, more women disagree in Gujarat (71% vs. 48% in Agree 31.4 19.2 25.4 29.2 15.9 22.6 Jharkhand) strongly agree that somewhat they could talk confidentially to Strongly 53.8 58.1 55.9 63.4 69.7 66.5 their doctor about terminating an agree unwanted pregnancy. More of the men in Gujarat also strongly Total 100 100 100 100 100 100 agree that they could talk to Total (N) 407 401 808 202 201 403 their doctor confidentially about this (86% vs. 54% in Jharkhand) I can confi dentially talk to my doctor about terminating unwanted pregnancy and 22% of the men and 16% Strongly of the women in Jharkhand 0.7 6.2 3.5 0.5 17.4 8.9 say they either disagree or disagree strongly disagree with this. Disagree 0.7 9.7 5.2 0 4.5 2.2 somewhat

Neither 3.2 Medical abortion: agree nor 0.7 6.7 3.7 0 5.5 2.7 knowledge and attitudes disagree Agree 26.3 29.4 27.8 13.4 18.9 16.1 Women and men were asked somewhat specifically about medical Strongly 71.5 47.9 59.8 86.1 53.7 70 abortion. Most women had agree not heard of medical abortion, although it is possible that Total 100 100 100 100 100 100 they might have known it by Total (N) 407 401 808 202 201 403 a different name, as three of the women who later reported having medical abortion also said they had not heard of quarters of those men knew were in favour than men (65% it. Women who had not had that medical abortion tablets are vs. 57% of men in favour of abortion had heard of it via the available from pharmacists. promotion of medical abortion). media, whereas women who had had an abortion found out Women and men were asked Men whose wives had had an through healthcare providers whether medical abortion should abortion (57%) were different or personal contacts. Most be promoted as a method. to the men who reported no women thought it was effective More said that medical abortion abortion. More of them said they and over half knew it could be should be promoted than said had heard of medical abortion obtained from pharmacists. it should not. Around two- (vs. 40% of men whose wives thirds of all respondents were in had not had an abortion), and Nearly half of the men (42%) had favour of promotion of medical a much higher proportion of heard of medical abortion. Three- abortion, but even more women the men whose wives had

28 ATTITUDES

experienced abortion (81%) Table 13 Attitudes to medical abortion, women and husbands, by said that medical abortion whether or not they or their wives have previously had an abortion should be promoted compared Women Husbands with a lower proportion No (53%) of the other men. abortion Had No attempt abortion Total Abortion abortion Total Women were asked in the % % % % % % survey to come up with reasons Heard of medical abortion for their view that medical abortion should or should Yes 27.3 34.3 28.5 56.6 40.2 42.4 not be promoted. The most popular reasons women gave No 72.7 65.7 71.5 43.4 59.8 57.6 for saying that medical abortion should be promoted were that Total 100 100 100 100 100 100 pills are better than surgical abortion (half of respondents Total (N) 627 134 761 53 343 396 in favour of promotion of medical abortion - a total of How effective is medical abortion? 35% of all the women) ,there Very is no need for hospitalisation 52.6 52.2 52.5 56.7 44.9 47 and that pills are cheap. effective

Somewhat The most popular reasons for 18.7 17.4 18.4 23.3 27.5 26.8 effective saying that medical abortion should not be promoted were Not 4.1 10.9 5.5 0 10.1 8.3 that “it is illegal”, belief that the effective tablets are harmful, and there is a chance of misusing the tablets. Can’t say 24.6 19.6 23.5 20 17.4 17.9 Given that the major reason cited against the promotion of medical Total 100 100 100 100 100 100 abortion is the incorrect belief that it is illegal, the number of Total (N) 171 46 217 30 138 168 people in favour of its promotion might rise if they were better informed about its legal status.

Figure 4 Pros and cons of promoting medical abortion: women’s spontaneous reasons for saying the method should or should not be promoted*

40% Advantages 40% Disadvantages 35% 35% 35% 30% 30%

25% 25%

19% 20% 20% 16% Percentage 15% 15% 13% 10% 11% 11% 10% 10%

5% 5%

0% 0% Tablets are It’s a Operation is No need for Tablets are not Chance of misusing It is illegal better than non-surgical costly/tablets hospitalisation good for the a D&C method are cheap body Reasons

*footnote as per other fi gures about women able to give multiple responses and we only present those given by at least 10% of them

29 SERVICE PROVISION

Chapter Four: Abortion service provision: practitioners and pharmacists

As well as asking women used up to between 30 and 59 Very few practitioners or days of gestation (69%), but the pharmacists gave a reason and their husbands about remaining 31% either quoted for saying why they would their views and shorter or longer periods, or said not provide medical abortion, they did not know. although three practitioners and experiences of abortion, four pharmacists incorrectly MSI also wanted to fi nd Over half of the pharmacists said that it was because (57%) said they would the method was illegal. out about service like to know more about provision from the point of medical abortion. Among the Most providers thought it practitioners interviewed, 83% would be useful to make view of practitioners and said they would like to know medical abortion available pharmacists. more in Jharkhand, compared in the community (see Table with 38% in Gujarat. 14 over the page). Only 21% In order to assess the types of of pharmacists and 10% of services available from Two-thirds and three-quarters practitioners said they thought it pharmacists and medical of pharmacists in Gujarat and would not be useful. Pharmacists practitioners in the areas where Jharkhand respectively said and practitioners perceived the women and husband they stocked medical abortion various advantages and interviewees lived, 88 tablets. Approximately 10% in disadvantages to making medical pharmacists and 87 practitioners both states said they did not abortion available. The most were interviewed, approximately stock them, but would be willing popular reasons for believing it half coming from each state. to do so. The remaining 22% in would be useful were connected Gujarat and 14% in Jharkhand with the idea that medical said they would not be willing to abortion is better than other 4.1 Healthcare providers’ stock medical abortion tablets. methods and does not require knowledge and opinions surgery. Side effects were the about medical abortion For the practitioners, 44% and most common concern of those 19% in Gujarat and Jharkhand who felt it would not be useful. Pharmacists and practitioners respectively reported providing were asked what they knew medical abortion services. about medical abortion and Around 20% in both states said what their opinions were on the they were not currently providing method (see Figure 5 over the medical abortion, but would page). Seventy-eight percent be willing to do so. However, of pharmacists and 85% of a relatively large proportion of practitioners considered the practitioners interviewed - 33% method to be somewhat or in Gujarat and 60% in Jharkhand very effective. However, -10% - said they would not be willing said it was not effective, with to provide such services. the proportion rising to 16% among practitioners in Gujarat. Those who were not opposed to providing medical abortion Pharmacists had very different were asked how much they views on the length of gestation would charge for the method. for which medical abortion could Pharmacists all quoted amounts be used, ranging from 10 days to under 600 rupees (US$12). 90 days. It seems likely that they Practitioners quoted a large were also passing these varying range of prices, from 200 to estimates on to their clients. 3000 rupees. They estimated Practitioners more consistently clients would pay a maximum of stated that the method can be approximately the same amount.

30 SERVICE PROVISION

Figure 5 Pharmacist and practitioner knowledge and opinion about medical abortion Effectiveness of medical abortion used? Up to what day of gestation can medical abortion be used?

100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Pharmacists Practitioners Pharmacists Practitioners Very effective Somewhat effective Not effective Can’t say 10-29 30-59 60-90 Don’t know or missing

Would you like to know more about medical abortion? Would you stock/provide medical abortion tablets? 100 100 90 90 80 No. 43.2% No, 40.2% 80 70 70 60 60 50 50 40 40

30 Yes, 56.8% Yes, 59.8% 30 20 20 10 10 0 0 Pharmacists Practitioners Pharmacists Practitioners

Already stocked/providing Yes No Depends

Table 14 Would it be benefi cial to make medical abortion available to the community? Pharmacists’ and practitioners’ responses and reasons, by state

Pharmacists Practitioners Gujarat Jharkhand Total Gujarat Jharkhand Total % % % % % % How benefi cial would it be to make medical abortion available to the community?

Very useful 42.2 37.2 39.8 46.7 45.2 46.0

Somewhat useful 35.6 44.2 39.8 33.3 54.8 43.7

Not at all useful 22.2 18.6 20.5 20.0 0.0 10.3

Total 100 100 100 100 100 100

Total (N) 45 43 88 45 42 87

31 SERVICE PROVISION

4.2 Service provision men and women sometimes of misoprostol in most cases practices reported by come for the services together. ranged from 200-800 µg. healthcare providers Only 34 practitioners reported When asked why they chose The number of medical abortion providing abortion tablets, but medical abortion tablets over clients ranged from one every even among this small group other methods of abortion, couple of months to around the quantities they reported practitioners said the method 50 per month for pharmacists, that the clients should take was easier (18%), there were and up to 20 per month for varied. Most practitioners (88%) fewer side effects (20%), practitioners. Pharmacists report who offered medical abortion and that they would use it that more men than women services said clients took 200mg if the pregnancy was less request the method, and that of mifepristone but the amount than seven weeks (18%).

Table 15 Summary of medical abortion service provision by pharmacists and practitioners, by state Pharmacists Practitioners

Gujarat Jharkhand Total Gujarat Jharkhand Total % % % % % %

Medical abortion customers per month Medical abortion customers per month

<3 per month 37.8 17.6 28.2 <3 per month 13.0 0.0 9.1

3-9 32.4 26.5 29.6 3-9 60.9 20.0 48.5

10-20 24.3 35.3 29.6 10-20 26.1 50.0 33.3

21-50 5.4 20.6 12.7 21-50 0.0 30.0 9.1

Total 100 100 100 Total 100 100 100

Total (N) 37 34 71 Total (N) 23 10 33

Who usually comes for medical abortion tablets? Do you normally stock or prescribe the tablets?

Husband 83.3 90.6 87.1 Stock 78.3 60.0 72.7

Wife 76.7 59.4 67.7 Prescribe 21.7 40.0 27.3

Both 23.3 3.1 12.9 Total 100 100 100

Total (N) 30 32 62 Total (N) 23 10 33

4.2.1 Assessing suitability to a doctor’s prescription. Less However, despite the well-known for medical abortion than half of those interviewed side effects of the method, such and providing information said they provided information on as prolonged bleeding and to clients dosage, and only 16% said they abdominal pain, only five (15%) gave information on advantages said that they discussed side The providers were asked what and side effects. Twenty-three effects and their management. questions they used to assess percent of pharmacists said that It seems possible that medical clients for suitability before they gave no information when abortion clients would not know providing medical abortion and selling medical abortion pills. that many perceived side effects what information they gave are a normal consequence clients about the method. Practitioners reported asking of this method because questions to assess eligibility for so few of the practitioners Few of the pharmacists medical abortion. About three- and pharmacists reported interviewed reported asking quarters said they asked about discussing what would happen questions before dispensing the obstetric history. Over 90% of after taking this medication. method, although most said they them said they gave information provided the method according about how to take the tablets.

32 SERVICE PROVISION

Table 16 Questions asked and information given before providing medical abortion: pharmacists and practitioners, by state

Pharmacists Practitioners Gujarat Jharkhand Total Gujarat Jharkhand Total % % % % % % Questions before providing medical abortion Asks if client Previous has a doctor’s 83.3 62.5 72.6 obstetric 66.7 100 76.5 prescription. history Asks about date of last Timing of last 10 12.5 11.3 20.8 10 17.6 menstrual menstrual cycle period. Nature of Only after client request seeing 3.3 9.4 6.5 25 0 17.6 and body sonography language. report Asks about last menstrual 16.7 40 23.5 period Confi rmation of 12.5 20 14.7 pregnancy Any illness 12.5 0 8.8 Health of client 4.2 0 2.9 Information provided Regimen of the None 30 15.6 22.6 83.3 100 88.2 tablet Consume as per doctor's 30 31.3 30.6 How to take it 87.5 100 91.2 advice Advantages of Dosage 53.3 40.6 46.8 91.7 100 94.1 the method Advantages Side effects and side 0 31.3 16.1 and their 20.8 0 14.7 effects management Timings 13.3 15.6 14.5

Total (N) 30 32 62 Total (N) 24 10 34

Practitioners who did not offer medical abortion were asked why not. The reasons are summarised below. Side effects and risk of method failure were the most common reasons given.

Figure 6 Reasons practitioners gave for not providing medical abortion, by state

Due to religious belief aborting a foetus is a crime 14 3

After taking medical abortion tablets pregnancy does not terminate completely 25

Method causes inconvenient bleeding 10 13

Abortion does not terminate successfully and clients need surgery 14 9

Using this method involves risk 5 22

So far clients have not used this service 10 3

Do not have experience 5 3

Do not want to provide abortion service 10 13

Can not provide it legally 14 13

Proportion of response Proportion It is a gynaecologist’s job 14 3

Do not have certificate to provide abortion services 10 3 Gujarat Pregnancy does not terminate completely 5 13 Jharkhand

0 5 10 15 20 25 30

33 ABORTION Chapter Five: Experiences of abortion

This chapter focuses on to, what type of abortion they the number of children they had had and other details such had was the reason given by the experiences of women as cost. These are described 30% of women in Gujarat and who reported that they below. The women who had only 14% in Jharkhand. The had a medical abortion were husband not wanting the child had had an abortion. asked additional questions was given as a reason by 24% about that method in particular. of women in Jharkhand and In total the sample included 118 Their answers are described seven percent in Gujarat. women who had had a surgical in the final section of this abortion and 45 women who chapter. In many of the tables In Gujarat, four percent of had had at least one medical in this section, we divide the women who had had a non- abortion. As mentioned in women according to the type medical abortion and 12% who Chapter Three, this sample of of abortion they have had. had had a medical abortion at women includes those identified least once said they had hidden through the household survey as Most women report having their abortion from someone. well as those identified through their most recent termination in The figures for Jharkhand were purposive sampling so the the first trimester of pregnancy approximately double: eight figures for experiences of medical and the most popular reason percent and 21% respectively. It abortion are not generalisable. given for termination was is notable that the women who birth spacing (35% and 44% have had a medical abortion Women were asked to describe of women in Gujarat and report hiding their abortion in the provider they had gone Jharkhand respectively). Limiting higher proportions than the other

Table 17 Details of most recent abortion, by state and by type of abortion Gujarat Jharkhand Non- Medical Non- Medical medical abortion medical abortion abortion at least abortion at least only once Total only once Total % % % % % % In which month of your pregnancy did you undergo your last abortion? First trimester 86.1 100 88.8 84.8 84.6 84.7 Second trimester 12.5 0 10.1 13.0 15.4 13.9 Third trimester 1.4 0 1.1 2.2 0 1.4 Total 100 100 100 100 100 100 Total (N) 72 17 89 46 26 72 Why did you have this abortion?* Spacing 34.7 35.3 34.8 46.9 37.9 43.6 Limiting 29.2 35.3 30.3 0 37.9 14.1 Husband did not want 4.2 17.6 6.7 26.5 20.7 24.4 the child Health problems 2.8 11.8 4.5 16.3 0 10.3 Foetus had congenital 8.3 0 6.7 4.1 0 2.6 defects Bleeding started so 8.3 0 6.7 2.0 0 1.3 opted for abortion Total (N) 72 17 89 49 29 78 Did you hide your abortion from anyone? Yes 4.2 11.8 5.6 8.2 20.7 12.8 No 95.8 88.2 94.4 91.8 79.3 87.2 Total 100 100 100 100 100 100 Total (N) 72 17 89 49 29 78 *Women were asked to come up with reasons. Only those given by at least fi ve percent of each subgroup are presented here. Multiple responses were allowed.

34 ABORTION

women. However, because have surgical abortions; largely they themselves had decided the medical abortion figures because medical abortion is to terminate their pregnancy. In are not representative of the cheaper and does not usually Gujarat and Jharkhand, 54% general population, further study require hospitalisation. and 74% respectively said their would be needed to ascertain husband decided, and 35% whether this is generally the Of the 89 women in Gujarat and and 17% that another family case or not. It seems plausible the 78 women in Jharkhand member decided. Note that that women who have medical who had had an abortion, 44% women could give more than abortions would be more able of the women in Gujarat and one response, so these options to hide them than women who 73% in Jharkhand said that are not mutually exclusive.

Figure 7 Who decided the pregnancy should be terminated, by abortion type and state* Gujrarat Jharkhand

100% 100%

90% 90% 80% 80%

70% 70%

60% 60% 50% 50%

40% 40%

30% 30%

20% 20%

10% 10% 0% 0% Self Husband Other family Private doctor Self Husband Other family Private doctor member member

Non-medical abortion only Medical abortion at least once *Women could give multiple answers and were not restricted in what they could answer. Only those responses applying to at least 10% of any one subgroup are shown here.

35 ABORTION

5.1 Provider percent and 17% in Gujarat having their abortions out of characteristics and Jharkhand respectively town left town on purpose to reported that their most recent terminate their pregnancies. Women were asked to describe provider was in another town or It is possible, however, that the provider for their most city. None of the women who some travelled in order to recent abortion. Most women had had a medical abortion conceal their terminations. (75% in Gujarat and 65% in reported the provider being If this is true, however, such Jharkhand) who had had a located in another town or women are in the minority. surgical abortion used providers city. We do not know whether from their area, although six the women who reported

Figure 8 Women’s reports of location of most recent and second most recent abortion provider, by state, and by whether or not they report ever having medical abortion

Medical abortion at least once 72 28

Jharkhand Non-medical abortion only* 65 19 17

Same area in the city Another area in the same city Another town/city

Medical abortion at least once 71 29 Gujarat Non-medical abortion only 75 19 6

0 10 20 30 40 50 60 70 80 90 100 Percentage of respondents * fi gures add up to more than 100 as rounded up

36 ABORTION

Women were asked who the larger in Gujarat (83% of women Population Health Services (PHS) provider was, and what type vs. 63% in Jharkhand). The next clinic. In Gujarat and Jharkhand, of abortion they had had. Most most commonly-used provider 13% and 30% respectively of women went to a private doctor was a government doctor (15% the women who had had a for their most recent abortion, in Gujarat, 12% in Jharkhand). medical abortion had gone to the although the proportion was In Jharkhand, 11% went to a pharmacist to obtain the method.

Table 18 Type of abortion women report having with most recent provider

Gujarat Jharkhand

Most recent pregnancy: Medical Medical what type of provider Surgery abortion Other* Total Surgery abortion Other* Total did you go to? % % % % % % % %

Government doctor 18.8 6.3 0.0 14.8 16.2 0.0 18.8 11.8

Private doctor 81.3 81.3 100.0 83.0 70.3 47.8 68.8 63.2

Chemist 0.0 12.5 0.0 2.3 2.7 30.4 0.0 10.5

Herbalist/traditional birth attendant/other 0.0 0.0 0.0 0.0 2.7 0.0 0.0 1.3 traditional practitioner

PHS clinic 0.0 0.0 0.0 0.0 5.4 21.7 6.3 10.5

Other (central 0.0 0.0 0.0 0.0 2.7 0.0 0.0 1.3 government)

Total 100 100 100 100 100 100 100 100

Total (N) 64 16 8 88 37 23 16 76 *Illegal, injections, indigenous, roots, herbs, foreign bodies, massage.

One of the advantages of women who had had a medical under 1000 rupees (US$20) medical abortion is its low cost. abortion reported paying less for for medical abortion. In some Women were asked about the their treatment than those who cases, women did not know the cost charged by the most recent had had surgery. The majority cost charged by the provider abortion provider they had used. (63% in Gujarat and 78% in because their husband had paid. As would be expected, the Jharkhand) reported a cost of

Figure 9 How much women report paying for their most recent abortions, by state and by type of abortion <1000 1000-3000 3000+ Don’t know 100%

80%

60%

40%

Proportion of response Proportion 20%

0% Surgery Medical abortion Other* Surgery Medical abortion Other*

Gujarat Jharkhand Type of abortion reported by state

37 ABORTION

5.2 Complications reported complications (64%). although women’s perceptions For the medical abortion users, of them are important. All women were asked whether however, the most common Approximately the same they had had any health problems complications were moderate proportions of women who had after their most recent abortion. to heavy bleeding for 2-4 weeks surgical and medical abortions Overall, nearly half of the women (46% of women who had a went to a healthcare provider for reported some complications medical abortion) and abdominal help with the complications, and after having an abortion. For pains or cramps (49% of women double the proportion of women those who had had surgery, 42% who had a medical abortion). with complications after surgery reported complications. Among These are known side effects of were hospitalised as the result those who had had medical the method and are therefore of them (10% vs. four percent abortion, nearly two-thirds not considered complications, of the medical abortion cases).

Figure 10 Complications reported by women after their most recent abortion, by type of abortion

Surgery Sought care from health care provider 21 28 for complications Medical abortion Complications affected ability to do housework 17 28

In bed for 1+ days because of complications 21 32

Continuing pregnancy 2 3

Fatigue and weakness 3 18

Abdominal pain/cramps 34 49

Backache 10 10

Had persistent bleeding (moderate to heavy) 5 for >4 weeks post abortion

Had persistent bleeding (moderate to heavy) 4 46 for 2-4 weeks post abortion Had complications after abortion 42 58

0 10 20 30 40 50 60 70 80 90 100

Proportion of response

5.3 Post-abortion Table 19 Whether or not women used contraception after their abortion, family planning and if not, why not, by abortion type Surgical Medical Women were asked whether or abortion abortion Other* Total not they had started using any % % % % Did you start using form of contraception after their abortion. Half of the respondents contraception after abortion? (51%) said they did start using Yes 56.4 41 45.5 51.0 contraception after their most No 43.6 59 54.5 49.0 recent abortion. Of the half who Total 100 100 100 100 did not, most said they or their Total (N) 94 39 22 155 husband did not want to use a Reasons for not adopting method. Women who had had post-abortion contraception a medical abortion rather than Didn’t want to use 88.0 57.1 70.0 73.2 a surgical abortion were less likely to take up contraception Both didn’t want to use and didn’t 4.0 23.8 0.0 10.7 following their abortion and have info were more likely to cite lack of Didn’t have info 8.0 19.0 30.0 16.1 information as the reason why. Total 100 100 100 100 Total (N) 25 21 10 56 * Illegal, injections, indigenous, roots, herbs, foreign bodies, massage.

38 ABORTION

For the women who did adopt Table 20 Post-abortion contraception adopted, by type of abortion some form of post-abortion Medical contraception, most adopted Post-abortion Surgery abortion Other* Total a modern method. Among contraception % % % % those who had had surgery, Sterilisation/intrauterine 52.8 25.0 30.0 44.3 53% adopted long-acting or device (IUD) permanent methods and 19% Oral contraceptive pill 18.9 37.5 30.0 24.1 used oral contraceptive pills (OCP)/injectables or injectables. were 28.3 37.5 30.0 30.4 used by 28%. Among the Traditional method 0.0 0.0 10.0 1.3 women who had had a medical Total 100 100 100 100 abortion, 25% adopted long- acting or permanent methods, Total (N) 53 16 10 79 38% used pills or injectables, *Illegal, injections, indigenous, roots, herbs, foreign bodies, massage. and 38% used condoms.

Approximately two-thirds of who used condoms said they up methods as a precondition women who took up long- were still using them 12 months of their abortion. Of these, acting methods said they were after the abortion. The numbers two say they used pills and still using them over 12 months are very small, so it is difficult two intrauterine devices (IUD), after the abortion. Only one-third to draw any firm conclusions. and even more seriously, four who used pills and injectables say that they sterilised. said they used them for this Alarmingly, eight women report long, although 46% of those having been obliged to take

Table 21 Details of post-abortion contraception Sterilisation/ OCP/ Traditional IUD injectables Condom method Total % % % % %

For how long did you use those methods after abortion?

<1 month 8.6 21.1 16.7 0.0 13.9 2-6 months 11.4 21.1 25.0 0.0 17.7 7-12 months 14.3 21.1 12.5 0.0 15.2 >12 months 65.7 36.8 45.8 100.0 53.2 Total 100 100 100 100 100 Total (N) 35 19 24 1 79

Did you want to accept method or was it precondition for abortion?

Willing 77.8 75 94.1 100 82 Precondition for abortion 22.2 12.5 0.0 0.0 13.1 services Don’t know/missing 0.0 12.5 5.9 0.0 4.9 Total 100 100 100 100 100 Total (N) 27 16 17 1 61

*Illegal, injections, indigenous, roots, herbs, foreign bodies, massage

39 ABORTION

5.4 Medical abortion: abortion and so these findings terminate their pregnancy in specific details are not generalisable to the the first six weeks. Eighty- wider population of women three per cent reported their The women who had had a having medical abortions. spouse was supportive and medical abortion were asked However, they provide an only one woman reported to give details about their indication of some features of that her spouse was unhappy experiences. Most of these how the method is used. about her use of the method. women were specifically sampled for interview because A majority of the women they had had a medical (78%) reported deciding to

Figure 11 Week of pregnancy and spouse support for termination using medical abortion

7-15 weeks, 22% Neutral, 15% Unhappy, 2%

1-6 weeks, 78% Supportive, 83%

Week of pregnancy one decided to terminate pregnancy Husband’s reaction to your use of medical abortion

Figure 12 Women’s spontaneously stated reasons for choosing medical abortion* [*disclaimer as per other fi gures]

Does not require hospitalisation 9

Cheaper than other methods 2

Effective method 26

Was suggested by relatives/friends/other users 15

Other techniques not available 2

Did not want surgery 17

Easily available 61

Recommended by provider 24

0 10 20 30 40 50 60 70 Percentage of response

Table 22 Women’s reports of the questions they were asked before they Over half the women said were given medical abortion they chose medical abortion No. % because it was easily available.

How many months of pregnancy? 19 41.3 Women were asked what Why do you not want child? 21 45.7 questions had been posed by the provider before they Any intake of pills or not 4 8.7 were given medical abortion. Total 46 Under half (41%) said they had been asked how many months pregnant they were.iv

40 ABORTION

About two-thirds (67%) of Table 23 Process of taking the medical abortion tablets women obtained the method No. % from doctors, and one-third Source of medicine (32%) from pharmacists. Just under half of the women Doctor 31 67.4 interviewed could remember Pharmacist 15 32.6 the name of the tablets. Where Total 46 100 they could remember the Name of tablets name, it was either medical MTP pills 8 17.4 termination of pregnancy (MTP) Mifepristone 10 21.7 pills or mifepristone. Most were given instructions on use by Kushi-Misho 1 2.2 the provider and 61% reported Unknown 27 58.7 also having read the instructions Total 46 100 given with the tablets. Less than Did you receive instructions from provider about how to take tablets? half of the women went for follow Yes 44 95.7 up after taking the tablets. Of those women who did go, about No 2 4.3 half went in the first week. Total 46 100 Did you read instructions given with tablet? In 65% of cases, women said Yes, read instruction 28 60.9 they were very satisfied with Saw instruction, did not read 4 8.7 the method and 56% would Did not read instruction 14 30.4 recommend it to others. In four cases, women said they had Total 46 100 to take more tablets before the How many days after last tablet did you go for follow up? pregnancy was terminated. It Within fi rst week 16 34.8 is not clear, however, that they Between one week and one month 5 10.9 had taken the correct tablets Did not go for follow up 25 54.3 or dosage in the first place as we do not have details of this. Total 46 100 Two of these women report they were very satisfied and would recommend the method Figure 13 Results of medical abortion use and reported satisfaction with to others, suggesting that this the method: women who had had medical abortion was not a major problem. The most unsatisfied women were those where the pregnancy No, 44% Yes, 57% did not terminate with medical abortion and surgery was required. This happened in 10 cases. Just under half of women interviewed said they would not recommend the method to others. The main reason for this, Would you recomend medical abortion to others? which 28% of women cited, was the risk of incomplete abortion. Despite this, among the whole Not satisfied, 20% sample of women who had Somewhat satisfied Very satisfied, 65% had a medical abortion, 80% 15% said they were satisfied or very satisfied with the method.

How satisfied are you with your experience of medical abortion? iv Note: women were not restricted in how many questions they could cite. Only those cited by at least 5% of women per subgroup are included here. 41 CONCLUSIONS

Chapter Six: Conclusions and recommendations

Medical abortion distributed through low-level providers (such as pharmacists) has gained acceptability and uptake among providers and consumers alike with no major causes for concern. Medical abortion in the two states of Gujarat and Jharkhand is easily accessible, popular and associated with fewer serious complications than surgical abortion – even in the context of low levels of knowledge and training.

In conclusion, India’s model of is that knowledge about the Perceived side effects liberalised access to medical legal status of abortion is low abortion has, on the whole, with a majority of women and Interestingly, women from gained high levels of acceptability men thinking that abortion is Jharkhand who had had an from both women and men illegal. This lack of knowledge abortion were 2.72 times more (demand side) and healthcare demonstrates possible taboos likely to report that abortions providers (supply side). Although around open and accurate had major negative side effects the law does not allow for discussion on issues related than women who had not pharmacists to provide the to abortion as well as a failure had an abortion. In Gujarat, drugs without prescription, it of government to educate the inverse relationship was is clear that over-the-counter communities about the MTP Act. found, whereby women who sales are fairly widespread. had had an abortion were 0.46 In terms of what women and times less likely to say that The study has implications men view as important in an there were major side effects. beyond India as well. While abortion provider, women and India is perhaps unique in its men in both states view a range It is difficult to interpret this extensive network of literate of quality indicators as important. finding but it does suggest that pharmacists who often self- Interestingly, women who have abortion services in Jharkhand educate by reading package had an abortion are less likely might be of a lower quality and inserts and reference to see cost as an important that women who have abortions manuals, other countries should issue, regardless of their socio- in that state may be more likely also consider the possibility of economic characteristics. to have major side effects. This extending access to medical possible difference in service abortion via low-level providers. About two-thirds of all quality between the two states The findings suggest that lower respondents thought medical is also supported by the finding level healthcare providers such abortion should be more widely that far fewer men and women as pharmacists and informal promoted to communities, in Jharkhand compared with doctors (“quacks”) can provide with support being even higher Gujarat reported that they could medical abortion safely and amongst women, especially talk confidentially to their doctor effectively. Ideally, they would those who had had an abortion. about abortion. An alternative be trained to ensure correct hypothesis is that there is regimen administration, There was a fairly widespread less abortion counselling in quality counselling on view that women could get Jharkhand and therefore women complications and effects, medical abortion pills from a are misunderstanding minor and effective post-abortion pharmacy and few stated that and expected side effects and contraception counselling. they would go to a doctor to are perceiving them as major obtain the pills. This suggests side effects. This possibility is that these pills are generally supported by the findings in Attitudes toward abortion seen as being available over Chapter Five, which suggest the counter and without that many women who undergo Overall, both women and men a prescription despite the a medical abortion interpret in the two states are generally law stating otherwise. the expected side effects as accepting of abortion under complications. Whatever the a wide range of conditions. reason, there are generally more What is somewhat worrying negative attitudes to abortion

42 CONCLUSIONS

in Jharkhand than Gujarat, Act and the 1994 International The vast majority of both with husbands from Jharkhand Conference on Population pharmacists and practitioners more likely to think there are and Development (ICPD). viewed medical abortion as negative side effects of abortion effective and thought that (regardless of whether or not Given that data were collected it should be promoted to their wife had had an abortion). on couples within households, communities. Despite this it was possible to compare the high level of support for the views within a wife and husband procedure, levels of knowledge Support from husband pair. Overall, 55% of wives and and skills appear to differ their husbands agreed with somewhat between pharmacists In terms of decision-making, each other on whether or not and practitioners, with the women and their husbands the husband would support latter group less homogenous from Jharkhand were much the woman if she wanted an in the advice given regarding more likely to say that it was up abortion. However, in Gujarat, days of gestation and regimen to the husband to decide if the the remaining women were as well as the amount of wife should have an abortion overly positive that their husband information that they provide compared with couples from would support them when to clients. This suggests a Gujarat. There were striking in fact the husband reported possible knowledge and skills differences between men’s that he was not supportive. In gap amongst pharmacists that attitudes towards this between Jharkhand, where there was should be addressed through the states, with 61% of men disagreement it was either increased training about in Jharkhand saying that the because the wife thought her regimens and side effects. The decision was up to the man husband was less or more responses from the pharmacists only compared with only 14% in supportive than he actually correspond with the responses Gujarat. Again, this exemplifies was or more supportive than from women themselves, the more conservative and he really was. Twinned with the who were quite often unclear negative attitudes towards finding that women in Gujarat about side effects or about abortion in Jharkhand. The appear to perceive a social post-abortion contraception. power of the man in making the environment broadly supportive decision was not just confined of abortion while men perceive Although practitioners seemed to to perceptions of decision- the opposite, it seems that there have higher levels of knowledge, making but was also evident in are genuine differences within many still wanted to learn more the analysis in Chapter Five on couples about perceived support with especially in Jharkhand. experiences of women who had for abortion. Given the taboo Overall, procuring medical had an abortion: 74% of women surrounding sex and abortion abortion pills from pharmacies who had had an abortion in in India, more efforts need to is cheaper than going through Jharkhand said that it was their be made to encourage open practitioners, with pharmacists husband’s decision and more communication around these estimating costs below 600 than half agreed in Gujarat. issues that have an impact on rupees (US$12) in comparison both women and their husbands. with up to 3000 ($60) rupees It is worrying that more than amongst the practitioners. one-third of women believed that choosing to have an abortion Healthcare provider Interestingly, the majority of or not was up to the husband. perspectives healthcare providers report This suggests an imbalance that it is men who buy the of power when it comes to The study included the views medical abortion pills – yet again making decisions that directly of 87 pharmacists and 88 emphasising the important role affect a woman’s physical and healthcare practitioners to that men play in both states mental well-being. Education, assess their levels of knowledge in deciding about abortion campaigns and counselling can with regard to medical abortion and procuring the drugs. help to improve understanding as well as how they provide of women’s rights as well as their medical abortion services. sexual and reproductive health rights as laid out in the MTP

43 CONCLUSIONS

Experiences of abortion pills from a pharmacy. It is not they may have gone because clear whether or not these pills they had complications (so one Examining the experiences of had been prescribed earlier by would expect a higher rate of women who had had an abortion a doctor. The vast majority of complications here than in the was revealing. Compared with women were given instructions general population); the sample women who had had a surgical on how to take the pills, which size in any case is too small abortion, women who had had is a positive sign. However, it to find a generalisable rate; a medical abortion were: seems that, in many cases, only and finally, we do not know superficial information was given exactly what regimen of drugs  more likely to have hidden (as evidenced by confusion over the women followed. Overall their abortion from someone effects and lack of information though, satisfaction with medical about the family planning options abortion was high, with even  more likely to have had available following the abortion). half of the women for whom their abortion locally. the medical abortion did not About 54% of women did not work still saying they would Although there are various return for a follow up. It is not recommend the procedure. possible explanations for clear, however, whether or not these differences between they had been asked to go the behaviours of medical back and so these findings are Complications and surgical abortion users, difficult to interpret. On the one it does seem that, overall, hand, women are probably less A large proportion of women having a medical abortion likely to return if the termination reported complications following might be easier to hide. This of a pregnancy is successful their abortion: 40% of surgical increases the possibility for and there are no complications. abortion users and nearly two- women to keep the matter However, on the other hand, thirds of the medical abortion private, as well as to undergo without follow up it is impossible users. If these figures were the abortion closer to home. to know to what degree the to be interpreted as the real method was successful, complication rates then these In terms of experiences with or led to complications. results would be alarming to say providers, the vast majority the least. However, on closer of women went to a private Questions were included inspection it appears that the provider with very few going about what drug regimen each women were not actually suffering to a government clinic (this is woman followed. However, from complications but rather especially the case for medical less than half of the women from some of the known and abortion users). The cost of could remember the names of expected physical symptoms medical abortion is clearly much the drugs so it was difficult to following an abortion. For less than a surgical abortion: untangle what drugs had been example, the most commonly 78% of women paid less than taken, in what quantities and cited complications for medical 1000 rupees (US$20) for a with what intervals. The findings abortion users were abdominal medical abortion whereas the and analysis of this issue were cramps and heavy bleeding – median amount paid for a surgical therefore removed from the study. evidence that the process of abortion was between 1000 and medical abortion is working 3000 rupees (US$20 and US$60). Overall, 80% of women were rather than necessarily being satisfied with their medical evidence of complications. abortions and 56% would Instead, these findings point Specific medical abortion recommend the procedure to to a lack of awareness on the experiences others. Of those who were not part of women about what to satisfied, most were women for expect when they undergo an More in-depth questions were whom the medical abortion did abortion, which in turn suggests asked of the 45 women who had not work and they had to have a lack of adequate counselling had a medical abortion. Most a surgical abortion (ten women). from the abortion provider. women chose to have a medical We cannot calculate a success abortion because it was seen as rate for the method from these Women who had had a surgical easily available. Most women got data for three main reasons: abortion were more than twice the pills from a doctor although the women were purposively as likely as those who had one-third said they obtained their recruited from clinics where had a medical abortion to

44 CONCLUSIONS

have been hospitalised as a result, suggesting that major complications associated Recommendations about their options. At a with medical abortion were minimum, women need to be comparatively uncommon. Ideally, pharmacists who provide given information about what medical abortion pills should side effects to expect with a be able to assess the woman’s surgical or a medical abortion, Post-abortion family planning suitability, prescribe the pills, how to identify a complication, explain the side effects, give and what to do in the case Women who had had an counselling about abortion of a complication, or in the abortion were asked about and post-abortion care and case of failure of the method what contraception they used suggest follow up and referral to terminate the pregnancy following the termination of their mechanisms. In addition: pregnancy. The findings point  regulators need to ensure that to several worrying trends: first,  more training on counselling medical abortion products medical abortion users are less is needed for providers to meet the highest standards likely than surgical abortion users ensure that women are of quality and efficacy to report using any contraception given information about any following their abortion and more expected side effects in  more efforts are needed likely to cite a lack of information advance. This is particularly to support the uptake of as the reason why. Second, important in the case of contraception following medical abortion users were less medical abortion, where medical abortion and to likely to report taking up long- some of the side effects ensure that providers are acting or permanent methods may be misinterpreted as life trained on how to counsel of contraception compared with threatening and as a result women about family planning surgical abortion users (25% cause unnecessary distress vs. 53% of surgical abortion  women who wish to space users). Given the findings  medical abortion providers or limit their pregnancies above regarding complication should have a referral system following an abortion should rates, it seems that medical in place in case of incomplete be encouraged to consider abortion users are not receiving abortion. In these cases, long-acting, or permanent adequate information or women need to be referred methods of contraception counselling from their abortion to a safe and high quality as these are more reliable providers. Again, however, it surgical abortion provider in the long term is important to remember that the medical abortion users are  education programmes  law enforcement needs to be not necessarily representative should focus on improving strengthened to ensure that of all medical abortion users. communication within couples nobody is forced to undergo on reproductive health sterilisation against their will, Of extreme concern is that four issues and should target or in return for other services women claimed that they were men as well as women sterilised as a pre-condition for  more research is needed to having their abortion. It is difficult  power imbalances between determine the success and to know exactly what happened in men and women within complication rates associated these individual cases but clearly if couples need to be with over-the-counter any healthcare provider is forcing addressed, especially when prescriptions of medical women to be sterilised (or indeed the result is that women abortion drugs forcing women to use any form of are not in control of making contraception) then that is a decisions that affect their own  lessons from India (and serious infringement of the law physical or mental well-being Gujarat in particular) should and should be punished be applied to other countries accordingly.  quality standards need to be that wish to scale up access in place to ensure that women to medical abortion services. are adequately counselled

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