ABORTION COSTS AND FINANCING A REVIEW

Ramamani Sundar

Abortion Assessment Project - India First Published in September 2003

By Centre for Enquiry into Health and Allied Themes Survey No. 2804 & 2805 Aaram Society Road Vakola, Santacruz (East) Mumbai - 400 055 Tel. : 91-22-26147727 / 26132027 Fax : 22-26132039 E-mail : [email protected] Website : www.cehat.org

© CEHAT/HEALTHWATCH

The views and opinions expressed in this publication are those of the author alone and do not necessarily reflect the views of the collaborating organizations.

Printed at Chintanakshar Grafics Mumbai 400 031

TABLE OF CONTENTS ○○○○○○○○○○○○○○

PREFACE ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ v ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○

ABSTRACT ○○○○○○○○○○○ vii ○○○○

GLOSSARY OF TERMS AND ACRONYMS ○○○○○○○○○○○○○○○○○○○○○○○ viii ○○○○○○○○○○○○○○○○○○○○○○○○ I. INTRODUCTION ○○○○○○○○○○○○○○○ 1

II. HOUSEHOLE EXPENDITURE ON ABORTION : FINDINS FROM SURVEYS ○○○○ 2

III. COST OF ABORTION AT DIFFERENT TYPES OF MTP CLINICS IN DELHI ○○○○ 7 ○○○○○○○○○○○○○

A. FAMILY PLANNING ASSOCIATION OF INDIA ○○○○○○○○○○○○○ 7 ○○○○○○○○○○○

B. PARIVAR SEVA SANSTHA (MARIE STOPES CLINICS)8○○○○○○○○○○○

C. PRIVATE MTP PROVIDERS (GOVERNMENT APPROVAL)9○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○

D. PRIVATE ILLEGAL PROVIDERS OF ABORTION ○○○○○○○○ 11

IV. COST EFFECTIVENESS OF DIFFERENT METHODS OF ABORTION ○○○○○○○ 12

A. DILATION AND CURETTAGE (D & C) VS. MANUAL VACCUM ASPIRATION (MVA)○○○○○○○○ 12 ○○○○○○○○○ B. MEDICAL ABORTION VS SURGICAL ABORTION ○○○○○○○○○○○○○○○ 15

V ROLE OF THE STATE IN IMPROVING THE ACCESS TO MTP SERVICES ○○○○ 17 ○○○○○○○○○○○○

VI HEALTH INSURANCE SCHEMES AND ABORTION ○○○○○○ 21 ○○○○○○○○○○○○○○○○○

VII CONCLUDING REMARKS ○○○○○○○○○○○○○○○○ 25 ○○○○○○ REFERENCES ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ 26 PREFACE

Abortions have been around forever. But IV. Household studies to estimate incidence at different points of time in history it has of abortion in two states in India. received attention for differing reasons, some V. Dissemination of information and litera- in support of it, but often against it. Abortion ture widely and development of an advo- is primarily a health concern of women but cacy strategy it is increasingly being governed by patriar- chal interests which more often than not This five pronged approach will, hope- curb the freedom of women to seek abortion fully, capture the complex situation as it is as a right. obtained on the ground and also give policy In present times with the entire focus makers, administrators and medical profes- of women’s health being on her reproduction, sionals’ valuable insights into abortion care infact preventing or terminating it, abortion and what are the areas for public policy in- practice becomes a critical issue. Given the terventions and advocacy. official perspective of understanding abortion The present publication is the Forth in within the context of contraception, it is im- the AAP-I series of working papers. portant to review abortion and abortion prac- Ramamani Sundar has reviewed research tice in India. literature and emprical data on abortion costs The Abortion Assessment Project India and financing and presented significant in- (AAP-I) has evolved precisely with this con- formation on public and private service pro- cern and a wide range of studies are being viders. Author suggested state intervention undertaken by a number of institutions and is more effectively needed in the form of researchers across the length and breadth regulation, subsidies and social security. of the country. The project has five compo- nents: We thank Sunanda Bhattacharjea for as- sisting in the language editing of this publi- I. Overview paper on policy related issues, cation and Mr. Ravindra Thipse, Ms. Muriel series of working papers based on exist- Carvalho and Margaret Rodrigues for timely ing data / research and workshops to pool publication of this entire series. existing knowledge and information in order to feed into this project. This working paper series has been sup- II. Multicentric facility survey in six states ported from project grants from The focusing on the numerous dimensions Rockefeller Foundation, USA and The Ford of provision of abortion services in the Foundation, New Delhi . We acknowledge this public and private sectors support gratefully. III. Eight qualitative studies on specific is- We look forward to comments and feed- sues to compliment the multicentric back which may be sent to [email protected] studies. These would attempt to under- Information on this project can be obtained stand the abortion and related issues by writing to us or accessing it from the from the women’s perspective. website www.cehat.org Ravi Duggal 22nd September 2003 Coordinator, CEHAT ABSTRACT

The growing literature on abortions in A visit to different types of MTP providers the developing countries tend to focus on the in Delhi reveals that there are a wide range health consequences of unsafe abortions and of services available across the city. The type the limited access to abortion services, but of providers include government hospitals, does not look at the real and often crippling family welfare centres, clinics run by NGOs economic cost of abortion. A woman under- like the Family Planning Association of In- going an abortion has to incur expenditure dia and Marie Stopes, government approved in various forms, both direct and indirect. as well as not approved qualified private doc- tors and illegal providers like dais and quacks. So far no all India household survey on These providers cater to different segments abortion related expenditure has been con- of the city’s population and the quality of ser- ducted. However there are micro level sur- vices offered and the charges for abortion veys, which had been carried out in a spe- services also vary accordingly. cific state or a district, specially focussing on abortion. These surveys do throw some light The safety and the cost of abortion, to a on the expenditure incurred by women on large extent would depend upon the method abortion, although the sample size of abor- of abortion used. The dilation and curettage tion seekers covered by some of these stud- (D&C), is still the most commonly used ies is fairly small. method of abortion in India. The alternative method for early abortion, manual vacuum These studies show that women have to aspiration (MVA) is not widely available in the incur some expenditure to get MTP services country even in the government run MTP even from public clinics, which are expected clinics. As a result the average cost of abor- to provide free services. However, by and large tions becomes very high. the government providers seem somewhat cheaper and are probably safer than the oth- Finally as far as abortion services are ers, especially the illegal providers. concerned, the option of insurance schemes is almost non- existent in the country. In fact Unfortunately, none of these studies in India health insurance is yet to pick up in have tried to look into the sources of financ- a big way. Of the various schemes meant for ing the abortion expenses by the women. Also, the employees of the organized sector the the surveys included only women who had un- ESIS, CGHS and the Railway Health Scheme dergone an abortion from the approved MTP provide MTP services for the women covered centres ; none of the surveys made an at- under their schemes in the hospitals run by tempt to include the abortion seekers from them. Other insurance schemes as yet do not illegal providers. Another limitation of these cover abortions . survey data on abortion cost is that it does include the cost of follow up care and this cost A review of the available literature indi- can be very high in case there is a complica- cates that there is very limited data on the tion after the MTP. cost of abortion care in the country and hence

vii the first step is to increase the research in look into this. In the case of private certified this critical area of financing for abortion approved MTP centres, there do not seem to care. We need to know not only about the abor- be any control over the quality of services as tion charges at the various types of MTP cen- well as on the charges for the abortion ser- tres, but also the household dynamics like vices. We need much better regulation of the source of financing the abortion etc. It is private medical practitioners as well as dis- evident that even in the government facili- semination of information to them so that ties, the abortion seekers had incurred sub- women seeking an abortion are not exploited stantial expenditure. The state has to really financially.

viii GLOSSARY OF TERMS AND ACRONYMS

ANMs Auxiliary Nurse Midwife

CHCs Community Health Centres

Dai Untrained birth attendant

D&C Dilation and c urettage

FRUs First Referral Unit

GA General anaesthesia

IUD Intrauterine Device

MCH Mother & Child Health

MVA Manual Vacuum Aspiration

OPD Out Patient Department

OT Operation Theatre

PHCs, Primary Health Centres

PP Post partum

RH Rural Hospitals

ix ABORTION COSTS AND FINANCING A REVIEW

I. INTRODUCTION 1996, the system of staff requiring to meet quotas for sterilisation acceptance is There is a growing literature on the supposed to have been abolished, in practice health consequences of unsafe abortions in nothing much has changed. This is not only the developing world and the need to make true of public providers, but is also the case safe and easy abortion available to all women with some of the leading NGOs, who offer safe who need them. However, this growing abortion services at a fairly reasonable cost. literature tends to focus on the health and For instance, the data collected from the out psychological costs of poor or limited access patient department (OPD) registers of the to abortion. It does not look at the very real clinics of the Family Planning Association of and often crippling economic costs of India at Delhi showed that of the sample of obtaining abortion. The access to abortion 811 women who underwent MTP in their services not only includes the availability of clinics during the year 2001-02, 70 per cent good quality care in all geographical locations had undergone tubectomy and another 27 per (especially at the primary level of care) and cent had gone in for IUD. While contraceptive assured privacy and confidentiality, but also counselling is essential to prevent the means that the services should be available common phenomenon of repeat abortions, free or at an affordable cost. The cost of an what is of concern is that too often this abortion can be substantial for women who counselling is replaced by pressure to accept turn to the private sector and even when terminal methods of birth control. women seek an abortion from the MTP There is very little data on the economic centres run by the government, the services factors that may limit access to abortion. are not free and women do incur some Several groups of women may not be able to expenditure (CORT, 1996, CORT 1997a, afford the cost of an abortion. This includes IIHMR, 2000). not only poor women, but also women who In addition, the public health facilities have to obtain an abortion in secret and have a tendency to put pressure on women therefore cannot get family money for this to accept sterilisation or a long acting and young unmarried women who similarly contraceptive like intrauterine device (IUD) cannot turn to their families for help. Since after an abortion (Passano, 2002, Khan, M.E. there is lack of privacy and confidentiality et al 2001, Ganatra, B.R., et.al. 1996). The in public health facilities, these women turn linking of MTP services with compulsory to private providers who exploit the situation adoption of contraception reduces women’s and charge an exorbitant fee (Chakravarthy willingness to use the free services that are S, 1996, Passano, P .2002). A woman available (Ravindran, T.K.S. and R.Sen, undergoing an abortion has to incur 1994). Although after the official expenditure in various forms, both direct and announcement of a ‘ target free approach’ in indirect. While the direct cost includes

1 expenditure incurred on travel to the clinic, role of the government in improving the hospital and room charges, doctors fee and accessibility of MTP services. cost of medicine, food and follow up care, in l Section VI deals with health insurance case the abortion results in complications, schemes and abortion, the financial the indirect cost would also include the loss burden of abortion cost on the households of wages. and the availability of insurance In India, where there is no system of schemes are discussed. health insurance and private expenditure on l Section VII the last section, concludes health is much greater than government with suggestions on some policy expenditure, there is therefore a need to recommendations and a future empirical know much more about the costs of abortion research agenda on abortion cost and and the economic barriers to abortion. The finance. present paper reviews existing empirical data and the research literature to II. HOUSEHOLD EXPENDITURE understand some of these costs. This ABORTION : FINDINGS FROM information is likely to point to areas SERVEYS where the state can intervene more In India, nationally representative effectively in the form of additional household surveys on health care utilisation regulation, targeting the provision of and expenditures have been undertaken by abortion clinics, provide subsidies and the National Sample Survey Organisations social security in the form of insurance. (NSSO), the International Institute of l In Section II of this paper, the findings Population Sciences (IIPS) and the National of some of the household surveys Council of Applied Economic Research conducted in various parts of India are (NCAER). The two rounds of National Family put together to get an idea of the Health Surveys conducted by the IIPS and the expenditure incurred by women for NSS 52nd round on Maternal and Child seeking abortion services from different Health Care collected detailed information types of providers across various states. on maternal and child health seeking behaviour, but it did not gather any data on l Section III looks at the charges for household expenditure. Although the all abortion services in different types of India morbidity surveys conducted by the MTP clinics in Delhi and the socio- NSSO and the NCAER collected data on economic background of women who visit expenditures incurred by the households on these facilities. morbidity, they do not have any data on l Section IV covers the cost effectiveness abortion related expenses. However, there of different methods of abortion. The are smaller surveys, which had been carried discussion ranges over the debate on out in a specific state or a district, specially D&C Vs MVA and Medical abortion Vs focussing on abortion services. This includes Surgical abortion. studies undertaken by the Centre for l Section V studies the role of the state in Operations Research and Training (CORT) improving access to MTP services. It and Parivar Seva Sanstha (PSS). In addition provides an appraisal of the trend in to these studies, organisations like the government funding for MTP services Centre For Enquiry into Health Allied and government subsidies to institutions Themes (CEHAT), Foundation for Research providing MTP facilities in the form of in Community Health (FRCH) and the Indian supply of equipment and free training of Institute of Health Management Research doctors, followed by an assessment of the (IIHMR) have conducted surveys either on

2 health status of women in general or on the the cost was much lower. The study also reproductive health of women. Though the reported that it was the household, which sample size of abortion seekers covered by belonged to the lowest, and the lower middle some of these studies is fairly small, the economic status, which had spent more than studies do throw some light on the a thousand rupees per abortion. expenditure incurred by women on abortion. The Centre for Operations Research and The two studies conducted by the FRCH Training (CORT) had carried out situation are probably the earliest attempts to analysis of MTP services in the states of understand household expenditure on health Gujarat, Maharashtra, Tamil Nadu and care in the country. The first FRCH study Madhya Pradesh. Besides examining the covered 1629 households over three rounds availability of facilities, methods used for (average of 543 households per round) in the MTP, the status of health personnel, Jalgaon taluk of Maharashtra (Duggal Ravi including their training needs etc., these and Suchetha Amin, 1989). In addition to studies also made an attempt to contact collecting information on morbidity, this some of the women who had availed of the survey also collected data relating to MTP services from the sample clinics. The utilisation and expenditure on maternity CORT study in the state of Gujarat was services, for a period of 18 months (Jan 1986 carried out during 1995-96 in 11 selected to June 1987). Only 7 cases of MTPs were districts out of 19 districts in the state with reported during the period and all the a focus on rural areas (CORT, 1995). The abortions were performed in private hospitals study covered 54 PHCs, 27 CHCs and 54 both in the case of rural as well as urban private doctors\clinics performing MTP. In population. The average cost of an abortion all 36 acceptors of MTP were interviewed and had worked out to be Rs 300.43. Considering on an average, an acceptor had to spend that the mean per capita income of the Rs229, of which two thirds was towards sample households was as low as Rs1865.80 doctor’s fees. The remaining one-third was per annum, the abortion expenses must have towards hospital room charges, medicine, upset their budget, since these women had transport and miscellaneous expenses. The to pay out such a large proportion of their average expenditure for private clinics was income. given as Rs394 and for public clinics it was The second FRCH study was conducted lower at Rs136. in 770 households covering a population of The study on the situation analysis of 5202 in the two districts of Sagar and Morena MTP services carried out by CORT in the 17 in Madhya Pradesh (George, Alex et. al, districts of Maharashtra in 1995-96 covered 1994). The survey collected data on 60 PHCs, 38 Rural Hospitals (RH) and a maternity events viz., pregnancy, abortion sample of private doctors\clinics (CORT, and delivery during the period 1 Jan 1990 to 1996). As a part of the study 32 clients were 31 January 1991, i.e. for 13 months. Only 8 contacted. The mean monthly family income abortion cases were recorded and the average of the acceptors was Rs1884 and on an cost per abortion was as high as Rs1258.13. average they had spent Rs376 for MTP The cost of abortion was higher in rural services. While this was as high as Rs 447 (Rs1497.83) than in urban (Rs539) areas, in private clinics, in government clinics it indicating the poor accessibility of free was lower at Rs 361. abortion services in the rural areas. Furthermore, the two events reported from In the CORT study of situation analysis the urban areas had availed of free services of MTP services in the state of Uttar Pradesh, (not reported under paid events) and hence the sample survey covered health facilities

3 registered for conducting MTP, spread over On an average they had incurred an 25 districts including private rural doctors expenditure of Rs 450 for undergoing and private clinics in the semi-urban areas abortion. (CORT, 1997a). The study team contacted 126 All the four CORT studies showed that acceptors of MTP services - 38 from block the costs of abortion varied considerably PHCs, 38 from CHCs, 24 from other across the states and by type of provider, government facilities and 26 from private i.e. whether the services were received doctors/clinics. The average monthly family from the public or private clinics. The income was Rs1431 for those who came to studies revealed that the women had to the public sector clinics, but it was higher at spend between Rs136 to Rs 534 for Rs 2360 for those who went to private clinics. receiving the services from the The women who underwent MTP in block government clinics. In case of private level PHCs spent on an average Rs 450, in clinics, the cost ranged between Rs 394 to CHCs it went up to Rs 484 and in other Rs 649. On further questioning the government hospitals it was as high as Rs providers revealed that the expenses for 751. The acceptors of MTP services paid on MTP were directly linked with the gestation an average Rs 649 in the private clinics. In period at the time of MTP. For instance, it other words, while those who sought abortion ranged from Rs 331 in case of pregnancy services from the public health facilities within 12 weeks, Rs 574 when pregnancy spent more than one third (37.3 per cent) of was 12-20 weeks and Rs 935 if the their monthly income, the acceptors who pregnancy was more than 20 weeks (CORT, went to private clinics spent marginally more 1998). than one fourth (27.5 per cent) of their monthly family income. The acceptors of The study conducted by CEHAT in MTP services mentioned that they had paid Mumbai on women’s health care focussed doctors fees in all categories of hospitals, mainly on the pattern of morbidity, utilisation although it was supposed to be free in public of health care services and the expenditure facilities. This roughly accounted for 40-45 incurred on treatment (CEHAT, 2001). In this per cent of total expenses in different category study, from a sample of 466 currently married of clinics except in other government clinics women information relating to maternity where it was 52 per cent. In both government events and use of contraceptives was and private clinics hospital room charges also recorded for the reference period of one year contributed substantially to the total (May 1995 to April 1996). Only 3 cases of expenditure. Expenditure on medicines was abortion were reported and all these MTPs more or less the same in all categories of were performed at the private clinics. The clinics. average expenditure on abortion worked out to be Rs 989. The study on the situation analysis of MTP services in the state of Tamil Nadu was The IIHMR carried out a study on the carried out in 8 districts during 1996-97 financing of RCH care in Rajasthan in 1999 (CORT, 1997b). In all 38 block PHCs and 19 covering both the government financing of sub-district hospitals were included in the RCH program in the state as well as the sample. Since the private hospitals were household expenditure on maternal and child touchy about the subject the study team could health care (IIHMR, 2000). A survey of 1100 include only 6 of them. Similarly, due to households (726 rural and 374 urban) was difficulties in tracing the acceptors of MTP conducted in the Udaipur district of services, only 14 women who underwent Rajasthan. In these sample households all abortion in public facilities were interviewed. married women of reproductive age, except

4 those who had been sterilised, were asked centres to be more expensive than the illegal whether they had used any abortion services service providers, the actual cost of abortion in the past two years Out of 864 women, only from the latter (mean cost of abortion is Rs 40 women had reported that they had had an 802) turned out to be higher than in legal abortion. Among those who responded centres (where the mean cost is Rs725), affirmatively, 50 per cent chose government particularly in Lucknow and Calcutta. In providers and another 50 per cent had opted Delhi, women who had sought abortion for a private facility. The study found that 90 services from legal providers had on an per cent of all women who had an abortion average spent Rs 1195, whereas those who incurred expenditure of some kind. The went to ‘illegal but good’ (qualified doctors but average expenditure for all users (including without the government approval as a MTP those who did not pay anything) worked out clinic) had paid only Rs 930. However, women to be Rs 925 and the average expenditure for who sought the services of ‘illegal and bad’ the users of private and public facilities were providers (quacks, dais etc) had paid on an Rs 977 and 873 respectively. Medicines average Rs 1000. absorbed the major proportion of expenditure This only goes to prove that seeking (51 per cent), especially among women using abortion services from quacks and dais government services, implying that users of need not work out to be cheaper than the public services also had to purchase service provided by qualified doctors medicines from outside. Users of private However, another recent study by the services had comparatively paid more for Parivar Seva Sanstha showed that on an travel and lodging. Interestingly even in the average the acceptors of MTP services at case of users of government services the government facilities incurred more consultation charges accounted for 23 per expenditure as compared to women who cent of the expenses. sought abortion services from private doctors, The Parivar Seva Sanstha had conducted dais and ANMs (who conducted abortions a survey of abortion seekers in Calcutta, privately) (PSS, 2002). Although the rapid Lucknow and Delhi in 1999 with the help of appraisal of abortion clients undertaken in Grasp consultants and with financial and the districts of Orissa had a sample of only technical support from the Population 23 abortion seekers, the study was Council (PSS, 1999-2000). Three hundred qualitative in nature and case studies were women who had undergone an abortion conducted to understand the dynamics of during the past six months from the date of unintended pregnancies. The abortion the survey (November 1999) were seekers who went to government facilities interviewed. The sample was split equally had incurred an average expenditure of Rs across three cities and both rural and urban 553 as compared to Rs 400 for private, Rs 300 areas were covered equally. The urban for dais and Rs 400 for ANMs. In addition to sample included population living in slums this, the abortion seekers had spent Rs 455 and resettlement colonies as well as all other towards the cost of drugs. It is interesting to population. The rural population included note that the average cost of treating post women who usually visit untrained birth abortion complication has worked out to be attendant (dais) who may not have received marginally lower for those who went to any training in conducting abortions. Thus, government facilities (mean cost Rs 217) as the sample of abortion seekers was selected compared to those who went to private (mean from different localities, accessing different cost Rs 250). types of facilities. The survey showed that It is evident from all the studies that though abortion seekers considered legal women have to incur some expenditure to

5 Table 1. Cost of Abortion: Findings from Household Surveys Sl. Study Study Area Reference Period Sample Size Av. Household No. of Abortion Expenditure Per Seekers Abortion (Rs) 1 FRCH,1989 Jalgaon Taluk, Jan 1986- June 1987 Private - 7 Private - 300.43 Maharashtra 2 FRCH,1994 Sagar & Morena Jan 1990 -91 - 8 Rural - 1497.83 Districts, MP Urban - 539 Total - 1259.13 3 CORT,1995 Gujarat 1995-96 -36 Private - 393.50 (Mainly Rural) Govt. - 135.80 Total - 228.90 4 CORT, 1996 Maharashtra 1995-96 Private - 4 Private - 446.80 (Mainly Rural) Govt. - 28 Govt. - 361.30 Total - 32 Total - 375.50 5 CORT, 1997a Uttar Pradesh 1996-97 Private - 26 Private -649.20 (Rural) Govt. - 100 Govt. - 533.90 Total - 126 6 CORT,1997b Tamil Nadu 1996-97 -14 Govt. - 450 (Rural) 7 CEHAT, 2001 Mumbai 1995-96 Private - 3 Private - 989 8 IIHMR,2000 Udaipur 1999 Private - 20 Private - 977 Dist. Rajasthan Govt. - 20 Govt. - 873 Total - 40 Total - 925 9 PSS, 1999-2000 Delhi 1999 - 300 Legal Providers - 725 Calcutta Illegal but good - 846.67 Lucknow Illegal and bad - 802 10 PSS, 2002 Orissa 2002 - 23 Private -400 3 Districts Dais - 300 ANMs - 400 Govt. - 553 get MTP services even from public clinics, of abortion seekers seem to know that which are expected to provide free services. abortion is legal and a large proportion of them These studies show that in the public health are not aware that a service provider needs facilities the abortion seekers not only a special license authorising him/her to purchase the medicines from outside, but conduct an abortion (PSS, 2000-01). also seem to pay ‘fees’ in some form or the These household surveys also point out other. However, based on the findings of most the fact that the expenditure incurred by the of the studies one could conclude that by and abortion seekers varies a lot since there are large the government providers seem a wide range of service providers. Even in somewhat cheaper (although the differences the case of government approved MTP clinics in expenses were marginal in some cases) there are wide variations and there is no and probably safer than the others, especially government control either on the quality of the illegal providers. Only a small proportion services or on the charges to be levied. This

6 is confirmed by the visit to a number of MTP family welfare centres, clinics run by NGOs providers in Delhi, as the next section will like the Family Planning Association of India indicate. and Marie Stopes, government approved as well as non-approved qualified private doctors As pointed out earlier, in all the studies and illegal providers like dais and quacks. mentioned above, the sample size of the These providers cater to different segments abortion seekers is very small and hence one of the city’s population and the quality of cannot draw much inference based on such services offered and the charges for abortion a small sample. It may be difficult to get hold services also vary accordingly. of a large number of abortion seekers and interview them in a survey of this sort. The A. FAMILY PLANNING ASSOCIATION OF CORT studies also faced a lot of field problems INDIA in getting MTP acceptors on the day the team The Delhi branch of the Family Planning visited the sample clinics. To overcome Association of India (FPAI) was inaugurated these problems the names of acceptors who in 1963 and the FPAI currently has clinics had availed the services within three weeks at two places in Delhi, one at RK Puram and preceding the visit, were taken from the another at Pitampura and is providing area registers. However, some of the acceptors specific health and family welfare services. refused to be interviewed. These two clinics, which are called Since the various surveys are Reproductive Health & Family Planning comparable neither in terms of sample size, Clinic (RHFPC), provide services like nor in terms of their geographical coverage, immunisation of children, antenatal check- one cannot draw any conclusion about the ups and family planning services including trend over the years in the household MTP. Though these clinics cater to poor and expenditure on abortion. low-income households of Delhi, currently (as of 2002) women who seek abortion services Unfortunately, none of these studies have to pay Rs 405. This includes Rs10 for have tried to look into the women’s sources the OPD card, Rs 45 for the Syringe and of financing abortion expenses. This is Laboratory charges and Rs 350 as fee for MTP especially important for poor women, women services. In these clinics MTP is performed who seek the abortion services without the only up to 10 weeks of pregnancy or in the consent of their husbands, women who are first trimester, since they do not want to take not economically independent and for any risks and the Manual Vacuum Aspiration unmarried girls who get the MTP done in (MVA) method is used in these clinics. While utmost secrecy. Another limitation of the the charges are uniform for all the patients, survey data on abortion cost is that it does if a really poor patient makes a request, a 50 include the cost of follow up care and this per cent concession is offered on the charges. cost is often very high where complications Most of the women who undergo abortion are follow an MTP. given painkillers and other medicines like III.COST OF ABORTION AT antibiotics free of cost, since they get free supplies of these medicines from the Delhi IFFERENT YPES F D T O MTP Government. The acceptors of abortion have CLINICS IN DELHI to spend only 3 or 4 hours at the clinic. A visit to different types of MTP providers Though there is no coercion to subject in Delhi revealed that there is a wide range the women to either undergo sterilisation or of services available across the city. The type go in for an IUD insertion along with the of providers include government hospitals, abortion, they are counselled to accept a

7 method of family planning. Even though there Though originally started only as a provider is growing pressure on the government to of abortion services, today the services dispense with the scheme of incentives and available at the Marie Stopes/Parivar disincentives, cash incentives are offered in Sanstha Clinics include family planning these clinics for accepting sterilisation, in counselling, supply of contraceptives, keeping with the policy of the Delhi medical termination of pregnancies, government. If a woman agrees to adopt the gynaecological consultations, insertion of terminal method along with the abortion, not IUDs, male and female sterilisation, only is the abortion service free, but she is treatment for RTI/STI, diagnosis and also given a cash incentive of Rs 250 for treatment of infertility, mother and child undergoing a tubectomy or Rs 160 to her immunisation (PSS 2000-2001). husband for accepting vasectomy. The charges for MTP services vary from To understand the socio-economic clinic to clinic, depending on the location of background of the women who seek abortion the clinic. Each clinic has a different price services in the FPAI clinics, a random sample structure depending on the image of the of 197 women was drawn from the OPD clinic i.e. whether it caters to low or middle registers out of the 811 women who income households. Though there are no underwent MTP in 2001-02. The average age differences in the basic health care facilities of the women and their husbands was 28 and offered by different Marie Stopes clinics, 32 respectively. Nearly half of the women and there might be ‘Cosmetic’ differences, e.g. 25 per cent of their spouses were illiterate. better furniture etc. According to the PSS, While only 8.6 per cent of women were the rates are fixed keeping in mind the graduates, among the husbands the paying capacity of women who seek the percentage of graduates was higher at 17.8. services and the rental value of the building The average monthly household income in which the clinic is located etc. We are told worked out to be Rs 3614 and as many as 39 that, as a policy they ensure that fee for an per cent of them had a household income of abortion does not exceed one week’s wages. less than Rs2000 per month. Another 25 per It is not very clear as to how this is ensured, cent belonged to the Rs 2001 to 3000 monthly since the rates are already fixed and within income categories (Table 2). Thus, most of the clinic the charges do not vary from the abortion seekers at this FPAI Clinic individual to individual. However, if a woman belonged to poor or low- income households. is really poor a clinic may subsidise her The cost of an abortion for these women works expenses, but each clinic has a limited out to be 11 per cent of their monthly number of cases (quota), which they can household income and this excludes other subsidise in a year. The charges for an direct expenses like transport charges and abortion in Marie Stopes clinics vary from indirect costs like loss of wages. Rs 250 to 600 if the abortion is performed during the first trimester and the method B. PARIVAR SEVA SANSTHA (MARIESTOPES used is Menstrual Regulation Syringe or CLINICS) MVA. If the MTP is performed within 12 to 16 The first Marie Stopes Clinics was weeks of pregnancy, the charges vary from opened in Delhi in 1979 with the objective of Rs 450 to 1500. Beyond 16 weeks, starting providing access to safe abortion, subsequent with Rs1200, the charges may go up to to legalisation of abortions in India in 1972. Rs3000. If the abortion is done in the second Today there are 34 clinics spread over a trimester, women may be asked to number of states and by the end of 2002-03, either stay for one more day or asked to come the number of clinics is likely to go up to 40. twice.

8 Table 2. Socio-Economic Profile of varies from state to state depending on the Abortion Seekers at FPAI* & state government’s policy. For instance in Marie Stopes Clinics in 2001-02 the states like West Bengal, UP and Delhi there is incentive money, where as in FPAI Marie Stopes Rajasthan it is not there. It is worth noting No. of MTPs 811 74307 that of the 74,307 abortions conducted at the Income ** various Marie Stopes clinics in the country <1001 0.51 6.30 % during the year 2001-02, only 18% had undergone sterilisation. Another 10% had got 1001-1500 5.58 0.40 % the IUD inserted after the abortion and as 1501-2000 32.49 24.30 % many as 29% of the women did not opt for 2001-3000 25.38 22.04 % any method of family planning. 3001-above 36.04 46.96 % The profile of the abortion seekers at the Marie Stopes Clinic revealed that nearly 19% No. of Living of them already had 3 or more living children Children ** when they came for the abortion and another 0 3.05 17.77 % 28% had two living children (Table 2). Though 1 12.18 23.97 % most of the MTP clients of Marie Stopes 2 45.18 27.89 % clinics also belonged to poor or low income households, they seemed to be better of than 3 24.37 18.77% the clients of FPAI clinics at Delhi. As many 4+ 15.23 11.59% as 47 % of the abortion seekers at the Marie Post Abortion Stopes clinics had a monthly household Contraception income of more than Rs3000. Another 22 per cent belonged to the Rs 2001 to 3000 monthly Condom - 25 % income categories. However, more than 30% Oral Pills 0.50 % 15 % had a monthly income of Rs.2000 or less. Of DMPA - 3 % the total number of MTP clients 87.5 per cent were Hindus and another 10 per cent were IUCD 26.80 % 10 % Muslims. Sterilisation 70 % 18 % C. PRIVATE MTP PROVIDERS None 2.70 % 29 % (GOVERNMENT APPROVAL) All 100 100 According to the data available with the Department of Family Welfare, Ministry of Note (*) : Data refers only to the Clinics in Delhi. Health and Family Welfare, in 2001 the city (** ) : In the case of FPAI the percentage of Delhi had nearly 400 government approved distribution is based on the sample of 197 MTP MTP centres. The private nursing homes/ Seekers clinics have to get the certificate from the The abortion seekers at the Marie Stopes government to run an approved MTP Centre clinics are also counselled into accepting an and once in three years it has to be renewed. appropriate method of family planning. There is a wide range of service providers However, unlike the FPAI clinics in Delhi, and the charges vary according to the quality in the Marie Stopes clinics, even if a woman of services, location of the centre and the accepts a post abortion sterilisation, she is patients to whom they cater. charged for the MTP, may be at a subsidised Under this category of Government rate. The incentive for accepting sterilisation approved MTP providers, gynaecologists from

9 four nursing homes were contacted- two from are around Rs1200. This nursing home too East Delhi, one from South and one from West does not seem to attract unmarried girls Delhi. A visit to a full-fledged nursing home wanting to abort unwanted pregnancies. in East Delhi which caters to the middle and While opting for an abortion the educated upper middle class population, revealed that upper middle class women of Delhi seem very MTP services are offered to women only up fastidious about the nursing home. A to a maximum of 10 to 12 weeks of pregnancy. gynaecologist in a small nursing home (run The gynaecologist mentioned that she would by her husband and herself) in South Delhi not like to take the risk of performing an mentioned that even though the nursing abortion beyond the first trimester. The home is located in an upper middle class nursing home charges Rs 3000 for an locality, only women from the lower middle abortion and this includes charges for the class background attend the clinic, since her operation theatre (OT) and fee for an nursing home is not posh enough. Though anaesthetist (since in this nursing home the nursing home not being posh enough was MTP is done under general anaesthesia). The mentioned by the gynaecologist, as a reason nursing home does not seem to be getting for the upper middle class women not visiting unmarried girls as clients for MTP services. her nursing home, there could well be other On the road opposite this nursing home, reasons. The women in the neighbourhood there is another government approved MTP may not prefer to be patients of this nursing centre run by a lady doctor. This centre seems home, as they may be keen to undergo to be handling mainly abortion cases (17 to abortion in secrecy. The charges for MTP 18 cases a month), though she claims to services in this nursing home vary from Rs provide other services as well. The doctor 600 -1000 with local anaesthesia and Rs1600 who is running the centre has a MBBS degree to 2000 with General anaesthesia. The and training to conduct MTP. She seems to charges do not increase in the case of be terminating only pregnancies up to 10 to unmarried girls. On an average the 12 weeks, and her charges vary from Rs 400 gynaecologist does 15 abortions in a month to 600. Interestingly, she had no hesitation and again she would not entertain pregnant in revealing the fact that her charges are women coming for an abortion after the first much higher for unmarried girls and the trimester. Interestingly, she also offers charges may go up as high as Rs1500. It has medical abortion (see the next section for a been found in other studies also that detailed discussion on medical abortion) to generally the costs were higher for women who come for the termination of unmarried girls when the procedure had to pregnancy at an early stage (within 6 weeks). be conducted in utmost secrecy (Passono, P. Though the medicine cost has come down 2002). Unfortunately it was not possible to drastically, she continues to charge a high get a profile of these girls, since the doctor fee (Rs 2000). In her opinion other doctors in was quite secretive and was not willing to South Delhi are charging much higher rates- reveal any details. Rs 3000 - 5000 for a medical abortion. A gynaecologist in a nursing home in Two interesting observations emerge Northwest Delhi, which is registered under from the visits to the government approved the Nursing Home Act of the Delhi private clinics in Delhi. Government catering to middle class l Firstly, gynaecologists generally do not households of the locality, was contacted. want to take the risk of providing MTP Here again the gynaecologist seems to be services to pregnant women beyond the providing MTP services only up to 10 to 12 first trimester. One probable reason for weeks of pregnancy. The charges for a MTP this could be that these nursing homes

10 might not have the necessary back up (herbal etc) are not particularly inexpensive. services, in case there is some They may charge anything between Rs 800 - complication during the MTP procedure. 1000. In the case of terminating the unwanted pregnancy of an unmarried girl, l Secondly, as far as unmarried girls are the charges could be even higher. In spite of concerned, even if they do approach an this, women prefer to approach the dais or approved clinic, they seem to avoid full- the unqualified doctors because of ignorance fledged nursing homes (since these of the availability of approved clinics, as has nursing homes are generally crowded) been pointed out by the PSS study (PSS, 2000- and choose the secluded ones. The doctor 01). If a woman has to go to any of the clinics in the East Delhi clinic is attracting a run by the NGOs or the government facilities, lot of unmarried girls, since her clinic a whole day would be needed; distance and is on the first floor with the advantage of time constraints are a major problem. This a lot of privacy. Hence, she seems to be is especially difficult for women who seek the taking advantage of her location and abortion services without the knowledge of charging a high price. This is similar to their husbands or their in-laws and for the findings of other studies. For women having small children. They are more instance, the CEHAT study of Rural familiar with the dai next door and also Maharashtra also found that for probably have more confidence in her, since abortions outside marriage, most women the dais also take care of them through child gave secrecy the greatest priority and birth. It has been found by a recent study that opted for a discreet and distance location nearly two-thirds of women living in the involving a short waiting period (Gupte, slums and resettlement colonies of Delhi Manisha et al 1997). deliver at home with the help of untrained D. P RIVATE ILLEGAL PROVIDERS OF dais (Sundar, R. et al 2002). This familiarity ABORTION with the local dais and quacks gives the acceptors of abortion an additional The predominance of unauthorised advantage. It offers informal arrangements providers like the dais, female paramedics for paying the abortion charges like paying and doctors practising in other systems of in instalments, loan against some surety, medicine seem very common in many parts deferred payment etc. of the country (Chhabra, R.and S.C. Nuna, n.d., and Maitra, N, 1997). However what is IV. COST EFFECTIVENESS OF surprising is that even in a city like Delhi DIFFERENT METHODS OF where nearly 400 government approved clinics are available, and a number of NGOs ABORTION have outreach MCH activities specially in the A. DILATION AND CURETTAGE (D & C) VS. slums and resettlement colonies, women MANUAL VACCUM ASPIRATION (MVA) still opt for the illegal providers. What are the reasons for this? How important is the cost The safety and the cost of abortion would factor? A visit to the Tigri camp and the depend to a large extent on the method of resettlement colonies (near Khampur, abortion used. Dilation and curettage (D&C) Sangam Vihar) and discussions with the is still the most commonly used method of female field workers of an NGO working with abortion in India. D&Cs are usually done adolescent girls and women in the under general anaesthesia as an in-patient reproductive age spans, provided some procedure. The alternative method for early answers to these questions. The traditional abortion, manual vacuum aspiration (MVA) dais who try various methods of abortion is not widely available in the country even

11 Table 3 : Cost of Abortion at Different Types of Providers in Delhi Sl. Type of Provider Type of Clients Services Offered Charges No. 1 FPAI Clinics Poor & Low Income Only up to 10 • Rs 405 Households Weeks Pregnancy (Rs10 for an OPD card, Rs 45 for Syringe & Lab Charges & Rs 350 as Fees). 2. PSS (Marie Poor, Low and Up to 20 weeks Up to 12 weeks- Stopes Clinics) Middle Income Pregnancy • Rs 250 to Rs 600. Households 12 to 16 weeks- • Rs 450 to Rs 1500. Over 16 weeks- • Rs1200 to Rs 3000. 3 Full fledged Middle and upper Maximum up to • Rs 3000 under general Private Nursing middle income 12 weeks anaesthesia (GA). Home in East households Pregnancy Delhi 4 Approved MTP Lower middle & Up to 10 to Married women- Clinic, East Delhi middle income 12 weeks • Rs 400 to Rs 600. households Unmarried girls- • Rs 1200. Medical Abortion • Rs 2500. 5 Private Nursing Middle income 10 to 12 weeks • Rs 1200. Home in North Households Pregnancy West Delhi 6 Private Nursing Lower Middle Up to 12 weeks Under local anaesthesia- Home in South Income Households Pregnancy • Rs 600 to Rs 1000. Under Delhi GA- • Rs1600 to Rs 2000 Medical Abortion- • Rs 2000 7 Untrained Dais at Poor and Low Up to 12 weeks • Rs 800 to Rs 1000. Tigri Camp & Income Households Pregnancy Resettlement Colony in the government run MTP clinics. The trimester abortions, the use of manual operational strategies spelt out in the vacuum aspiration is low and the use of D&C National Population Policy, 2000 includes was much higher at 72 per cent in CHCs, expansion of access to safe abortion services and 65 per cent in PHCs. (CORT, 1995). through the introduction of simple and safe abortion techniques such as the Manual The MVA has been pilot tested in three Aspiration Technique. Till recently in major government hospitals in Delhi and in government hospitals D&C and Electrical view of its efficiency, the Medical Officers are Suction methods were being used. For being trained in this method, especially for instance the CORT study found that for first use in rural areas for MTP. The Government

12 has developed the ‘Guidelines for Medical Federation of Obstetrics and Gynaecological Officers for Medical Termination of Societies of India (FOGSI) has issued a Pregnancies up to eight weeks using Manual statement in support of the MVA method. Vacuum Aspiration Technique’ to help the MVA is considered to be quicker, safer and Medical Officers to provide safe abortion can be performed as an out patient procedure services using simple and safe techniques and often there is no need for general (Government of India, 2001-02). The anaesthesia, hence there is less risk for

Table 4. Cost of MVA Vs D&C Title of Study Study Details / Country Key Findings Reference Interventions considered The cost of Manual vacuum Kenya MVA reduced equipment Bradley J. treating aspiration Vs sharp costs by 3 per cent , Unpublished incomplete curettage, in two reduced total stay in (Popline abortion in hospitals, Eldoret hospital by 41-76 per search Kenya : a cost and Machakos cent and reduced finding), comparison of patient costs by 50 and 1990 two treatment 66 per cent in the two regimes hospitals

Linkages with Analysing data from Kenya 35 per cent of Solo J, treatment for six hospitals, the gynaecology ward Billings D. incomplete study aimed to admissions resulted Taken from abortions compare the cost, from incomplete Population improve effectiveness and abortion. The Council family quality of introduction of MVA website. n.d. planning alternative required no anaesthetic, services in approaches to & smaller operation Kenya integrating theatres. This reduced emergency waiting times, and in treatment of Mombasa the average abortion length of stay fell from complications with 60 to 21 hours family planning

Hospitals To cost post-abortion Africa Cost per patient for D&C King TDN, reduce costs care in six Latin = $ 78.81, cost per Benson by improving countries in Africa America patient for MVA = $ 8.50. J, Stein K. post-abortion and Latin America. 89 per cent lower 1998 care Cost data for both median costs for MVA MVA and D&C were patients. Average length collected of stay was reduced from 36 to 15 hours The bulk of costs for both interventions are salaries, and costs

13 Title of Study Study Details / Country Key Findings Reference Interventions considered

associated with inpatient overnight stay.

Use of MVA in Comparison of MVA Brazil Patients treated for Fonseca W, reducing cost and and sharp curettage incomplete abortion Misago C, duration of interventions for with MVA spent 77 per Fernandes L, hospital-isation post- abor tion care. cent less time in the Correia L, due to incomplete hospital and Silveira D. abortion in an consumed 41 per cent Revista De urban area of fewer resources than Saude Publica north-eastern similarly diagnosed 1997;31(5);472- Brazil patients treated with 478 SC.

Treatment of Comparison of MVA Peru The total time Guzman A, incomplete and sharp curettage (preoperative, Ferrando; D, abortion ; manual interventions for operative, post Tuesta L. vacuum aspiration post- abortion care operative) was 271 Unpublished - versus curettage in min. for MVA, 290 Taken from the Maternal min. for outpatient Popline Perinatal Institute curettage with database in Lima, Peru hospitalisation. The 1995. total mean cost per patient (manpower, supplies, and administration) was US $16.30 for MVA, $16.70 for outpatient curettage and $ 84.11 for curettage with hospitalisation. Given an average of 20 incomplete abortion cases per day, the Institute would save about $50,000 a year by treating uncomplicated abortion cases on an outpatient basis.

Source : Jowett, M, ‘Safe Motherhood; Interventions in Low-Income Countries: An Economic Justification and Evidence of Cost Effectiveness’ Health Policy 53 (2000) pp.201-228

14 women (Passano, 2002). Since using the MVA administration was much lower for MVA as method does not require sophisticated back compared to D&C with hospitalisation. up equipment, it has been recommended In India too the cost of abortion would that in early abortions MVA should be be much less if the MVA method were used preferred over D&C to increase accessibility since the apparatus is cheaper and it could and for ensuring safety. While in the public be chemically sterilised. Moreover, since health facilities MVM is being used only till electricity is not required, it can be used eight weeks of pregnancy, in the private even in the rural PHCs where the supply of sector this method is used up to the first electricity is very erratic. trimester. Currently all the gynaecologists at the medical college hospitals are being B. MEDICAL ABORTION VS SURGICAL trained in MVA and they would in turn train ABORTION the doctors at the lower level. In recent years a considerable debate is A number of studies have shown that going on about the feasibility of introducing using MVA with local anaesthesia reduces medical abortion, using the drugs patients’ health risks, lowers hospital costs Mifepristone and Misoprostol (RU486), as an and ensures speedy recovery. The use of alternative to surgical abortion for the manual vacuum aspiration rather than D&C termination of early pregnancy. Since can reduce the costs to both the providers medical abortion requires less extensive and the patients and the evidence regarding infrastructure than surgical abortion, it is the cost effectiveness of MVA is available argued that medical abortion can improve especially for the treatment of complications access to abortion and safety. There has also arising from abortion. The studies conducted been a debate on the side effects of Medical in countries like Kenya, Africa, Brazil and abortion versus surgical abortion. Peru show that cost per patient works out to An international study of Mifepristone- be lower for MVA as compared to D&C for Misoprostol medical abortion and surgical abortion procedure and for treating abortion was held in China, Cuba and India complications arising from abortion, in from October 1991 to August 1993 in which particular incomplete abortion (Jowett, M. six urban clinics participated. In this study 2000). The findings of these studies show women with a pregnancy duration of 56 days that as compared to D&C, in the case of MVA, could enrol for either surgical or medical the cost per patient gets reduced due to abortion. The data collected from this various reasons like a fall in the average comparative study showed that medical length of stay in the hospital, requiring only abortion clients experienced more side effects small operation theatres, not requiring than surgical abortion (Elul, Batya et al 1999). anaesthesia etc. The studies conducted in The disparity between the two groups was Africa and Latin America showed that the particularly pronounced for bleeding (except bulk of hospital costs for both D&C and MVA for India where there were no significant are salaries, and costs associated with in- differences by method) and pain. However, patient’s overnight stay. Since the average the study concluded that despite more reports length of stay gets reduced in the case of of side effects among women who had opted MVA, the cost also gets reduced. (For details for medical abortion, assessments of well- being see Table 4). The study conducted in a and reports of satisfaction at the exit interview Maternal Perinatal Institute in Lima, Peru were similar in both treatment groups. also showed that as a result of reduced total time, the total mean cost per patient which Based on three studies conducted in included cost of manpower, supplies and India (including the already mentioned

15 international multicenter projects with sites considerably, the private doctors who are in China, Cuba and India) in the 1990s, it administering medical abortions continue to has been concluded that medical abortions charge a high fee. A visit to some of the are effective, acceptable to women, feasible clinics in Delhi revealed that since not many and safe (Coyaji, K. 2000). According to the women are aware of the cost of the tablets, author, since it is not possible in the near the gynaecologists and doctors exploit those future to create adequate infrastructure for who opt for medical abortion. Some of the surgical abortions in India, medical abortion gynaecologists seem to offer abortion could provide the alternative options packages to women and the charges vary from especially in village settings. The author Rs 2000 to 3000, depending on the location views were that though the cost of of the clinic and the clientele. This package Mifepristone was high, cost could be safely includes an ultra sound test to make sure and effectively reduced, by reducing the dose the abortion is complete. from 600mg to 200mg. Besides which, as Currently, Parivar Seva Sanstha is compared to medical abortion, under surgical carrying out a project, sponsored by the abortion one has to take into account other Ministry of Health and Family Welfare, expenses like staff training and wages, Government of India to study the clinical and operating room time etc. Moreover, the social behaviour of women accepting author was of the opinion that the cost of termination of early pregnancy up to 56 days Mifepristone would drop considerably, once with oral Mifepristone followed by India started manufacturing the drug locally Misoprostol. This aim of the project is to find and included the drug in government out the efficacy of the drugs with the reduced programmes. Free distribution or dosage of Mifepristone (instead of 600 mg of distribution at subsidised rates through Mifepristone, only 200 mg is given) and to existing family planning clinics would be understand the behaviour and attitude of more cost effective. women. The Indian Council of Medical In April 2002, the Drug Controller of India Research (ICMR) has already conducted a approved the manufacture of Mifepristone in study in medical college hospitals to find out India and three pharmaceutical companies the efficacy of a reduced dosage of are already in the market. Prior to this, the Mifepristone. The results were positive, in tablet was being smuggled into the country the sense that the abortions were complete. mainly from China and the gynaecologists This 18-month project commenced in April were illegally getting the supply from the 2002 and is being carried out at the Marie agents. Obviously the tablet was very Stopes clinics in Delhi, Agra and Jaipur. expensive (costing nearly a thousand rupees) Though the final results of this project are and hence women who opted for the medical not available, according to the PSS the abortions were also charged heavily. success rate so far is fairly high. Since the Currently, three pharmaceutical companies government sponsors the project, women who are importing Mifepristone and packaging opt for medical abortion under this project do and marketing it in India and the price of not have to pay for the medicine. They have the tablet has come down drastically - it now to pay a consultation fee of Rs 50 and incur ranges around Rs 300 for 200mg. Including expenses on other tests (e.g. pregnancy test) the cost of Misoprostol, which is available at which may cost another 50 rupees. If the 20 to 30 rupees, the total cost of the tablets findings of this project are positive, instead comes well within 350 rupees and due to of 600 mg of Mifepristone, 200 mg. may be competition it is likely to fall further. Even sufficient and this may reduce the cost even though the cost of the tablets has reduced further.

16 Although the abortion pill holds much data collected in the two rounds of the promise, it has its problems. In particular, National Family Health Survey on the even though it can be sold only by pregnancy outcomes of married women in the prescription, in a country like India it is very age group of 15-49, the percentage of difficult to implement this and take pregnancies resulting in induced abortion stringent action against the lawbreakers. A has increased marginally from 1.3 in 1992- leading newspaper had recently reported the 93 to 1.7 in 1998-99 (IIPS, 1995 & IIPS, 2000). rampant illegal over the counter sale of (Since the cases of induced abortions are Mifepristone. This sounded alarm bells in the generally suppressed by women, or may be state of Uttar Pradesh (Times of India, 6 reported as spontaneous abortions, the August 2002). Even though the tablets may spontaneous abortions are grossly cost around Rs 350, women may find this underestimated in the surveys and hence easier and a less expensive option than should be interpreted with caution). going in for surgical abortion. In addition they It is fairly well known that that these can get this done in secrecy. The free legal abortions form only a small proportion availability and the unsupervised con- of the total abortions taking place in the sumption of abortion pills can lead to severe country. It is estimated that the number of haemorrhages and incomplete abortion illegal abortions is 2 to 6 times more common resulting in life threatening emergency. than legal abortions. What are the reasons Constant supervision and adequate backup for this? The lack of awareness about the facilities of trained doctors is required. availability of safe abortion services and the Furthermore women have to be very alert and lack of privacy and the impersonal aware, which is hardly the case in India. In atmosphere in government run clinics are fact if taking abortion pills without the some of the factors responsible for this supervision of a gynaecologist leads to phenomenon. Besides this, the availability complication, medical abortion could prove of the government approved MTP clinics is to be more expensive. inadequate. Firstly, the availability of V. ROLE OF THE STATE IN abortion services varies widely across states. Almost half of the facilities for safe abortions IMPROVING THE ACCESS TO MTP are concentrated in four states SERVICES (Maharashtra-21 per cent, Gujarat-12 per The number of government approved cent, Tamil Nadu-10 per cent and West institutions in the country has increased Bengal-7 per cent), which accounts for only from 3294 in 1980-81 to 9759 in 2000-01, and 28 per cent of the country’s population. There the number of terminations done per year is also a concentration of these centres in in these centres has gone up from 388,405 the cities, though more than 70 per cent of to 721,428 during the same period. The Indians live in the rural areas. increase in the number of legal abortions The non-availability of authorised clinics could be partly due to the passing of the MTP in the rural areas and lack of financial Act, which has resulted in the increase in resources to reach the clinics in urban areas the number of approved MTP centres. During is one of the reasons for women living in the the last two decades, the number of women villages opting for illegal abortion. For rural in the reproductive age group has also gone women the Primary Health Centre is up. Unfortunately, no data\information is probably the nearest place where they can available which could tell us whether the avail safe abortion services at a reasonable number of abortions per woman has cost (even though in government facilities increased over the years. According to the the services are free there could still be some

17 expenditure). However, most of the PHCs do medical officer trained in MTP, 22 per cent not have the facility for conducting MTPs. of the PHCs are providing MTP services. This According to Phase 1 of the Facility Survey is possible because in many states if the conducted in 1999 in 221 districts, hardly 3 PHC does not have a doctor trained in MTP it per cent of the PHCs in the country are is a common practice to arrange for doctors providing MTP services (IIPS, 2001). The from the CHCs to visit the PHCs on a Facility survey shows that there are wide particular day (may be once every variations across the states in the week\fortnight) and carry out abortions. availability of medical officers and the PHCs According to the studies conducted by offering MTP services (Table 5). It is CORT in the four states of Gujarat, interesting to note that states like Tamil Maharashtra, Tamil Nadu and Uttar Pradesh, Nadu and Goa respectively have 35 per cent the main reason for not providing abortion and 59 per cent of PHCs with at least one services in the PHCs and the CHCs turned medical officer trained in MTP, but only 2 per out to be a lack of trained doctors to conduct cent and 8 per cent of the PHCs respectively the procedure and non availability of required are providing abortion services. This clearly equipment (Khan, M.E. et al 2001). Other reflects the mismatch between both the studies have also focussed on the inadequacy availability of skilled manpower and the of trained manpower and equipment to carry infrastructure facilities. It is quite possible out abortion services in the rural areas that in these PHCs although the Medical through the public health care system and Officers are trained, they are not able to the lack of funding for the maintenance and provide the services because the PHCs may expansion of abortion services (Ravindran not have proper buildings and other facilities. T.K.S and R.Sen, 1994 and Jesani, A., and On the other hand, in the state of Punjab, A.Iyer 1993). The CORT studies concluded although only 10 per cent of the PHCs have a that the vast gap between demand and supply Table 5. Availability of MTP Services at PHCs Sl. States/Union % of PHCs having at % of PHCs having % of PHCs No. Territories (UTs) least one medical suction aspirator giving services officer trained in MTP in MTP 1 Andhra Pradesh 14 15 2 2 Assam 14 7 8 3 Bihar 6 7 1 4 Delhi 0 20 20 5 Goa 59 35 18 6 Gujarat 14 40 1 7 Haryana 4 21 1 8 Himachal Pradesh 14 18 14 9 Karnataka 10 13 8 10 Kerala 18 8 4 11 Madhya Pradesh 3 3 2 12 Maharashtra 17 28 1 13 Orissa 9 21 1 Continued.... 18 Sl. States/Union % of PHCs having at % of PHCs having % of PHCs No. Territories (UTs) least one medical suction aspirator giving services officer trained in MTP in MTP

14 Punjab 10 49 22 15 Rajasthan 2 18 4 16 Tamil Nadu 35 17 2 17 Uttar Pradesh 4 19 1 18 West Bengal 3 3 1 All India (Incl. other States & UTs) 13 16 3 Source : Facility Survey, Phase-I, 1999, International Institute for Population Sciences, Mumbai is largely due to lack of proper planning and for the abortion programme. Though in 1995- allocation of resources. In the opinion of the 96 Rs 980 lakhs was requested for increasing authors all the ‘A’ type Post Partum (PP) the abortion centres and strengthening the Centres that have adequate case loads could services, but because of the resource crunch be converted into training centres. To again only Rs 150 lakh was allocated for the designate an A type PP centre as an abortion abortion programme (Khan,M.E. et al 2001). training centre a maximum of Rs 2000 per After the initiation of the Reproductive & year would be required (Khan, M.E. et al Child Health (RCH) programme in 1997-98, 2001). Though these studies were done in Medical Termination of Pregnancy became the mid- 1990s, nothing much has changed one of the important components of the RCH since then. The first phase of the Facility programme. Since then, in the budget Survey conducted in 1999 also revealed that documents the allocation of funds for the MTP only 13 per cent of the PHCs in the country programme has not been shown separately had at least one medical officer trained in and been included as a part of the RCH MTP. In Tamil Nadu the situation seemed programme. Now under the 10th Five Year slightly better with 35 per cent of the PHCs Plan, an amount of Rs 1.20 crores has been having medical officers trained in performing allocated as transfer to states in the year MTP (Table 5). 2002-03 (Budget Estimate 2002-03) exclusively ear marked for MTP services Similarly, only 16 per cent of the (Ministry of Health and Family Welfare PHCs covered by the Facility Survey had 2002-03). MTP equipment like suction aspirators, though the situation was somewhat In an effort to expand and strengthen better in states like Gujarat (40 per safe abortion services, under the RCH cent) and Punjab (49 per cent). This programme the government has taken some reveals the apathetic attitude of the initiatives. For instance, to meet the government towards expansion of shortage of trained manpower in PHCs/CHCs abortion services and attempts at and sub-district hospitals, the scheme of Safe improving the accessibility of safe Motherhood Consultants are being abortion services. introduced. Under this scheme, the central government releases funds to states and Since 1991-92, the central government Union Territories for engaging private has been allocating only Rs150 lakhs per year doctors trained in MTP techniques, to visit

19 Table 6. State/UT wise Allocation of Funds for SM Consultants and Supply of MTP Equipment under RCH Program Sl. MTP Set # SM Consultant - Funds States No No. of Kits Estimated Value (Rs) released - in lakhs

1 Andhra Pradesh 10 65000 7.44 2 Arunachal Pradesh 3 19500 1.20 3 Assam 10 65000 2 4 Bihar 7 45500 0 5 Jharkhand 3 19500 0 6 Goa 1 6500 0 7 Gujarat 10 65000 10.08 8 Haryana 10 65000 15 9 Himachal Pradesh 3 19500 0.50 10 J & K 3 19500 1.80 11 Karnataka 10 65000 8 12 Kerala 10 65000 0 13* Madhya Pradesh * 10 65000 2 14 Maharashtra 10 65000 5 15 Manipur 3 19500 2 16 Meghalaya 3 19500 0.60 17 Mizoram 1 6500 20.74 18 Nagaland 3 19500 0 19 Orissa 10 65000 7.56 20 Punjab 10 65000 0 21 Rajasthan 10 65000 0 22 Sikkim 1 6500 3.60 23 Tamil Nadu 10 65000 0 24 Tripura 1 6500 0 25 Uttar Pradesh 10 65000 184.65 26 West Bengal 10 65000 41.88 27 And. & Nic. Island 1 6500 0 28 Chandigarh 1 6500 0 29 Dadra & Nagar Haveli 1 6500 1.80 30 Daman & Diu 1 6500 0 31 Lakshadweep 1 6500 0 32 Pondicherry 1 6500 0.20 33 Delhi 1 6500 0 34 Reserves 1 6500 - Total 180 1,170,000 316.05 Note (*) : Includes Chattisgarh (#): MTP Set worth Rs 6500 includes S. S. Bowl (18-20 inch diameter), Sponge Holding Forceps, IS: 7735,Sim’s Speculum, IS: 6112, Anterior Vaginal Wall Retractor, IS: 5849, Uterine Sound, IS: 5829, Vulsellum, IS 6114, Curette (Double ended), Sharp / Blunt, IS: 6505, Ovum Forceps, IS: 6578, Dissecting Forceps, IS: 3643, Dilators (Hegar’s pattern), I mm to 12 mm, IS: 6584, Suction Machine (Facility for negative suction upto 760 mm, with safety device), IS: 7080, Karman’s Cannula (No. 6,7,8), IS: 8313 (4 Sets each) (Source : From the records of the Ministry of Health and Family Welfare, Government of India.) 20 these institutions once a week or at least Manipur and Nagaland have so far received twice a fortnight on a fixed day for performing only 3 sets. All the other smaller states and MTPs. These doctors were initially paid at Union Territories have got just one set each. the rate of Rs 500 per day. Now the amount Considering the current status of availability, has been increased to Rs 800 per day. Since this is hardly going to improve the situation. 1997-98 (till Nov 2002) the government has In addition to the problem of non- released Rs 316.05 lakhs to the states and availability of trained manpower and the Union Territories (Table 6). availability of equipment, there is also a However, the states and Union mismatch between the availability of trained territories have so far utilised only one third doctors/specialists like anaesthetists and of the allotted amount and in fact very few the availability of infrastructure like OT in states have reported expenditure under this a number of CHCs (NCAER, 2002) account. This indicates either the non- EALTH NSURANCE CHEMES availability of trained manpower that is VI. H I S willing to work in rural areas at this rate or AND ABORTION lack of other infrastructure to implement this It has been well documented that scheme in the PHCs. It is indeed heartening households face enormous financial burdens to note that the government has taken a in the form of out of pocket expenses to pay decision to train all the medical officers of for health care and health spending in India the PHCs in MTP. The Facility Survey results goes mostly to private facilities (NSSO, 1998, (Table 5) indicate that this would solve only Sundar, 1995, Sevaraju, 2000). This has part of the problem. In addition to training significant adverse implications for the the doctors, other facilities and adequate economic well being of the affected infrastructure at the level of PHCs and CHCs households, especially the poor households. should also be improved. If the facilities at The failure of the Indian public health care the PHCs and CHCs were improved, perhaps system to provide quality care to the people more women would access these facilities is to be blamed for this excessive financial rather than spend a lot of money at private burden on poor households. Public health facilities. By switching over to methods like care in the country suffers from under MVA, the cost to the government would also funding and accessibility problems and as a be reduced since the apparatus required for result people are forced to depend on the MVA is cheaper, there is no need of private health care sector, which is relatively electricity and it can be sterilised chemically. more expensive. Keeping the financial In order to improve the availability of burden on the households within a abortion services, MTP equipment is being reasonable limit is a matter of policy concern. procured centrally and provided to District The solution for this could be found either by hospitals, first referral units (FRUs), CHCs improving the quality and accessibility of and PHCs through their respective medical public health services, or through the store depots. Since the inception of the RCH provision of health insurance schemes. programme i.e. since 1997-98, the In India, given the resource crunch it is government has supplied 180 MTP sets worth not possible to expect any drastic Rs11.70 lakhs (Table 6). The estimated value improvement in the public health services of each set is Rs 6500. The item description in the near future. In fact severe resource of the MTP set is presented along with the constraints have led the policy makers to table. While most of the major states have consider alternative sources of financing the received 10 sets, states like Himachal public health care system and the Health Pradesh, Jammu & Kashmir, Meghalaya, Policy 2002 ‘recognises the practical need

21 for levying reasonable user charges for nity related health care including MTP. The certain secondary and tertiary public health ESIS, launched in 1948 is essentially a com- services, for those who could afford to pay.’ pulsory social security benefit to workers in As far as abortion services are con- the industrial sector. The ESIS covers nearly cerned, the other option of insurance 80 lakh persons (employees and their fami- schemes is also almost non-existent in the lies) and this includes 14 lakh women (ESIS, country. In fact in India health insurance is 2001- 02). yet to pick up in a big way. The Maternity In the ESIS hospitals 14,878 MTPs have Benefit Act, which was enacted as early as been performed during the year 2001-02. 1961, provides leave benefits for women Since MTP services are offered only as a fam- workers during the six weeks immediately ily planning method (ESIS, 2001-02) the following the day of delivery, miscarriage or number of MTPs performed is shown as a part abortion. This maternity benefit is to be pro- of the ‘achievements under their Family vided to all women on completion of 80 work- Welfare Programme’. In fact, discussions ing days during the preceding twelve months. with a gynaecologist in one of the ESIS hos- Currently, the major health insurance pitals in Delhi revealed that they offer free schemes are either state run schemes for abortion services even to those women who the employees in the organised sector Em- are not covered under their scheme provided ployees State Insurance Scheme (ESIS) or they are willing to undergo sterilisation. The the schemes for government employees like same is true of the CGHS Maternity and the Central Government Health Scheme Gynaecology Hospital in south Delhi. While (CGHS) and the Railway Health Insurance the MTP services are available to all those Scheme for railway employees. Besides covered under the scheme, for outsiders, these, there are public sector insurance abortion services are available only as a fam- schemes like the Mediclaim Health Insur- ily planning measure i.e. with the accep- ance Plan of the General Insurance Corpo- tance of sterilisation, as this would enable ration, the Senior Citizen Plan of the Unit them to full fill their ‘quota’ of sterilisation. Trust of India and schemes like Asha Deep of the Life Insurance Corporation of India. Even though a target free approach has There are also community based health in- been officially announced, in practice there surance schemes primarily for workers out- are indirect pressures to meet the target. side the formal sector (e.g. SEWA of The Mediclaim plan, which is run by the Ahmedabad, Sevagram of Warda, CINI of General Insurance Corporation (GIC) of In- Daulatpur in West Bengal etc.). Although dia, which is meant for the general public, most of these community based health in- covers only hospital care. This scheme by and surance schemes provide preventive, promo- large caters to the upper middle and high- tive and curative health services, including income group and as on March 2002 more Mother & Child Health (MCH) activities, they than 70 lakh persons are receiving cover do not seem to cover MTP services. under the scheme (Annual Reports of the four Of the various schemes meant for the subsidiary companies of GIC-2001-02). There employees of the organised sector the ESIS, has also been a tremendous increase in en- CGHS and the Railway Health Scheme pro- rolment for the Medical Claim policy. How- vide MTP services for women covered under ever, under this policy only hospitalisation their schemes in the hospitals run by them. expenses are covered, while routine out pa- In the case of women employees who are tient care is excluded. The policy, however, insured under the ESIS scheme, both cash not only excludes reimbursement of expenses and medical benefits are provided for mater- against certain diseases, but also any ex-

22 penses related to pregnancy. Pregnancy and bers. It is rather surprising that even the childbirth are covered only under the group health insurance scheme of SEWA which is insurance scheme as a benefit policy. The specially designed for women, covers deliv- GIC in its effort to expand coverage intro- eries but does not include abortion care duced another policy in 1996 called the Jan (Gumber Anil and Veena Kulkarni, 2000). Arogya Bima Policy, to cater to the health needs of people belonging to lower income Given the current scenario of the groups. Since the annual premium is nomi- availability of health facilities and the nal, it has attracted a lot of people (around acceptors of abortion services, is it pos- 3.5 lakh people as on 31st March 2002). This sible or even feasible to introduce scheme also excludes pregnancy, childbirth schemes to include insurance cover for and voluntary termination of pregnancy. abortion care? In a country where ille- gal abortions are rampant, introduction Several NGOs and governments world- of insurance schemes may encourage wide have started micro- credit schemes for more women to opt for an approved MTP vulnerable groups as an effective tool for pov- clinic even if it proves to be more ex- erty reduction. To plug the erosion of income pensive. and reduce indebtedness for health care needs, some NGOs like SEWA (Self-Employed Some studies point out that a number of Women’s Association), have introduced women seek abortion services without the health insurance schemes for their mem- knowledge of their husbands and other fam-

Table 7. Salient Features of Important Health Insurance Schemes Sl. Type of Health Coverage, Age & Details about the No. Insurance Scheme and Sum Insured inclusions and Exclusions year of commencement

1 Mediclaim,1986 General Individual aged 5-75 & Only hospitalisation Insurance Corporation Family 3 months to 75 coverage with exclusion (individual\family\ years. Rs15,000 to of pre-existing conditions group) 5,00,000 Pregnancy & Abortion not included

2 Jan Arogya,1996, GIC Age group up to 70 Same as above (Individual\family) years Sum assured Rs 5000

3 Asha Deep, 1995 Life Individual aged 18-50 Endowment policy with coverage Insurance Corporation years Rs 50,000 to of four ailments- cancer, 3,00,000 paralytic strokes, renal failure and coronary heart diseases

4 Central Government Central government All types of services, including Health Scheme employees (current & MTP. retired) and families

Continued.... 23 Sl. Type of Health Coverage, Age & Details about the No. Insurance Scheme and Sum Insured inclusions and Exclusions year of commencement

5 Railways Health Railway employees Delivery of all types of services Insurance Scheme, and families (current including delivery and MTP, 1948 and retired) through hospitals and dispensaries located in Grade A stations

6 Employees State Any employee and Medical and cash benefits Insurance Scheme, his/her family in an through the dispensaries and 1948 organised sector with hospitals. Covers maternity monthly wages under benefits including MTP. MTP is Rs 6500 done free of cost in the ESIS hospitals. This extends to non insured persons also with acceptance of sterilisation

7. SEWA, Ahmedabad, Union of self SEWA’s health insurance Gujarat. Union started employed women scheme functions in co- in 1972,Health Helps to organise ordination with LIC and New Programme in 1984 cooperatives of India Assurance Company. various traders, Offers comprehensive health provides credit insurance package to address facilities and health women’s basic needs. Covers care deliveries but not abortion.

Source : Health Insurance For Informal Sector: Problems and Prospects by Anil Gumber. Paper prepared for Indian Council for Research on International Economic Relations, New Delhi, November 2002 ily members (Gupte Manisha et al 1997 and have already started operating in the coun- Sinha, A.K et al 1998). The socio-cultural try. Any insurance scheme is based on the factors like the stigma attached to abortion uncertainty of an event taking place. Given compels women to trade off quality of care in this principle of insurance, it may not be fea- order to preserve confidentiality (Bandewar, sible for a health insurance plan like the Sunita 1997). Under such circumstances Mediclaim to include abortion expenses, women would be able to take advantage of without attaching some conditions (e.g. re- an insurance scheme, only if they have suf- striction on the number of abortions per in- ficient economic independence to join an sured woman). In a country like India, insurance policy, which also takes care of where there are illegal abortions, in par- abortion expenses. ticular since sex selective abortions are The other important question is whether not uncommon; the insurance companies it is feasible for insurance companies to ex- have to be careful about the legal aspects tend the coverage to include abortion care. while handling claims against abortion This question is relevant today, since the expenses. It may be possible to include insurance sector has been privatised and a abortion expenses along with other mater- number of private insurance companies nity benefits in a community based insur-

24 ance scheme like the SEWA plan, which ing money on transport or medicine is un- basically caters to women in the informal derstandable, but many of them seemed to sector. have had to even pay fees in some form or the Based on the admittedly limited informa- other while utilising public health facilities. tion available, we may conclude by saying it In the case of government approved MTP is of foremost importance to provide afford- centres, there does not seem to be any con- able, safe and accessible MTP services to trol either over the quality of services or on women. In addition, if at least some of the the charges for the abortion services. Since community based insurance schemes can the approved centres are required to renew also cover MTP it would reduce the financial their license periodically, the respective burden for women seeking abortion services. state government could streamline the ac- tivities of these centres. VII. CONCLUDING REMARKS We need much better regulation of pri- A review of the available literature indi- vate medical practitioners as well as dis- cates that there is very limited data on the semination of information to them so that cost of abortion care in the country. The first those women seeking abortions are not ex- step should be to intensify research in this ploited financially. There is too much anec- critical area of financing for abortion care. dotal data, which suggests that doctors do not We need to know not only what abortion hesitate to unethically overcharge for ex- charges are at the various types of MTP cen- ample unmarried pregnant women, or tres, but also the household dynamics like women who are otherwise concerned about the source of financing the abortion etc. In confidentiality. Similarly, decline in the the case of most of the surveys, the sample prices of drugs (e.g. for medical abortion) of- size of the abortion seekers was too small to ten do not get translated into decline in the draw any conclusion. A well designed quan- costs of the service for women because doc- titative survey, supplemented or rather tors continue to charge the old rates. It has complemented with qualitative research been found that even in the government ap- techniques like Focus Group Discussions, proved MTP centres, unmarried girls seek- with the exclusive objective of capturing the ing abortion are exploited and charged an various aspects of abortion including cost exorbitant rate. As a result those who can- and finance would serve a useful purpose for not afford the expense end up with the policy makers quacks. The main reason for unmarried girls From what little information is available, not approaching the public facilities is the it is clear that even in the government fa- lack of privacy and confidentiality. If privacy cilities, the abortion seekers had incurred and confidentiality can be ensured, some of substantial expenditure. The state has to the cases might consider attending public clin- really look into this. Abortion seekers spend- ics.

25

REFERENCES

Bandewar, Sunita, (1997) A Note on Abor- depth Study’ Paper Presented at the Inter- tion: Cause for Concern in India, Even 25 Years national Workshop on Abortion Facility and After its Legalisation. Centre for Enquiry into Post Abortion Care in the Context of RCH Pro- Health and Allied Themes (CEHAT), Sixth gram, March, 23-24. National Conference of Women’s Movement Coyaji Kurus, MD, (2000) ‘Early Medical at Ranchi, Bihar, December 28-30. Abortion in India: Three Studies and Their CEHAT, (2001) Women and Health Care in Implication for Abortion Services’, Journal of Mumbai: A Study of Morbidity, Utilisation and American Medical Women Association; Vol. 55, Expenditure on Health care by the Households No.3: 191-194. of the Metropolis. Duggal Ravi and Suchetha Amin, (1989) Chakravarty Sayantan, (1996) ‘Abortion: ‘Cost of Health Care - A Household Survey in The Double Death Syndrome’, India Today, an Indian District’, FRCH, Mumbai. August 11. Elul Batya et.al. (1999) ‘Side Effects of Chhabra Rami and Sheel C.Nuna n.d., Mifeprostone - Misoprostol Abortion Versus ‘Abortion in India: An Overview’, Veerendra Surgical Abortion, Data from a trial in China, Printers, New Delhi. Cuba and India’, Contraception; 59: 107-114. ESIS (2002) (Employees State Insurance Corporation) 2001-02, Annual Report. CORT, (1995) (Centre for Operations Re- search And Training), Situation Analysis of Ganatra, B. R. et al (1996), Induced Abor- Medical Termination of Pregnancy (MTP) Ser- tion in a Rural Community in Western Maha- vices in Gujarat, Baroda. rashtra: Prevalence and Patterns. Study con- ducted by the King Edward Memorial Hospi- CORT (1996) (Centre for Operations Re- tal and Research Centre, Pune. search And Training), Situation Analysis of Medical Termination of Pregnancy (MTP) Ser- George, Alex, Ila Shah and Sunil vices in Maharashtra, Baroda. Nandraj, (1994) A Study of Household Health Expenditure in Madhya Pradesh, FRCH, Mum- CORT (1997a) (Centre for Operations bai. Research and Training), Situation Analysis of Medical Termination of Pregnancy (MTP) Ser- Government of India, Ministry for Health vices in Uttar Pradesh, Baroda. & Family Welfare, Annual Report 2001-02. CORT (1997b) (Centre for Operations Government of India, Ministry of Health & Research and Training), Situation Analysis of Family Welfare, Performance Budget 2002-03. Medical Termination of Pregnancy (MTP) Ser- Gumber Anil and Veena Kulkarni, (2000) vices in Tamil Nadu, Baroda. Health Insurance for Workers in the Informal CORT (1998) (Centre for Operations Re- Sector: Detailed Results from a Pilot Study- Con- search And Training), ‘Availability and Qual- tribution of the Informal Sector to the Economy. ity of MTP Services in Gujarat, Maharash- Report No. 5, NCAER. tra, Tamil Nadu and Uttar Pradesh - An In- Gupte, M, Sunita Bandewar and

26 Hemalata Pisal (1997) ‘Abortion Needs of of Ailments, Report No. 441, National Sample Women in India: A Case Study of Rural Ma- Survey Organisation, Government of India, harashtra’, Reproductive Health Matters, N0 NSSO, Department of Statistics, New Delhi. 5(9): 77-86. Passano Paige (2002), ‘ Legal but not IIHMR (2000) Financing Reproductive & Available: The Paradox of Abortion in India’, Child Health Care in Rajasthan, Indian Insti- Mannish, Issue No: 126. tute for Health Management Research, PSS (1999-2000), ‘Perception & Experi- Jaipur. ence of Abortion seekers Study Conducted IIPS (1995) National Family Health Sur- in Delhi, Calcutta and Lucknow’ Parivar Seva vey (NFHS-1) 1992-93, International Institute Sanstha, New Delhi. for Population Science, Mumbai. PSS (2001) Parivar Seva Sanstha IIPS (2000) National Family Health Sur- (2000-01) Annual Report. vey, (NFHS-2) 1998-99, International Insti- PSS (2002), ‘Rapid Assessment of Abor- tute for Population Science, Mumbai. tion Clients - a qualitative Case Study in IIPS (2001) Facility Survey (Under Repro- Selected Districts of Orissa’, Unpublished ductive and Child Health Project) Phase - 1, Report, Parivar Seva Sanstha, New Delhi. International Institute for Population Sci- Ravindran, T. K. S. and R. Sen (1994), ence, Mumbai. ‘Service Delivery System in Induced Abor- tion: A Report’, Report of a workshop organ- Jesani, A. and A. Iyer, (1993) ‘Women ised by the Parivar Seva Sanstha in Febru- and Abortion’, Economic and Political Weekly, ary 1994 at New Delhi, with support provided Vol.— Nov. 27, pp. 2591-2594. by the Ford Foundation. Jowett, M, (2000) ‘Safe Motherhood: In- Sevaraju, V. (2000) ‘Health care Expen- terventions in Low-Income Countries: An diture in Rural India: A Micro Perspective’, Economic Justification and Evidence of Cost Paper Presented at International seminar on Effectiveness’ Health Policy Vol.53 No.3 Human Development, New Delhi, 27-29 No- pp. 201-228. vember. Khan, M.E., Sandhya Barge and Nayan Sinha, R., et al ‘Decision Making and Kumar (2001), ‘ Availability and Access to Acceptance and Seeking abortion of Un- Abortion Services in India: Myth and Reali- wanted Pregnancy’ Paper presented at the ties’, Paper Presented at the IUSSP Confer- International Workshop on Abortion facilities ence in Brazil. and Post Abortion Care in the context of RCH Maitra, N. (1998) ‘Unsafe Abortion: Prac- Program, March 23-24, New Delhi, Organised tices and Solutions’, Paper presented at the by the Centre for Operation Research and International Workshop on Abortion facilities Training. and post Abortion Care in the context of RCH Sundar Ramamani (1995), ‘Household Program, March 23-24, New Delhi, Organised Survey of Health Care Utilisation and Expen- by the Centre for Operation Research and diture’, Working Paper No: 53, NCAER, New Training. Delhi. NCAER (2002), Workforce Management Sundar Ramamani; Ajay Mahal and Options and Infrastructure Rationalisation Abhilasha Sharma (2002), ‘The Burden of Ill of Primary Health Care, Unpublished Report, Health among the Urban Poor: The Case of National Council of Applied Economic Re- Slums and Resettlement Colonies in Chen- search, New Delhi. nai and Delhi’, NCAER, New Delhi. NSSO (1998), Morbidity and Treatment Times of India (2002),’Abortion Pill Sounds Alarm bells in UP’, August 6, New Delhi. 27 ABOUT THE AUTHOR

Ramamani Sundar Ramamani Sundar holds a Masters Degree in Econo- mics from the Delhi School of Economics. She is currently working as a Senior Economist with the National Council of Applied Economic Research, New Delhi. For the past 15 to 20 years she has been working as a researcher in the field of Health Economics, Reproductive Health and Demo- graphy. Ramamani Sundar has several publications to her credit including the NCAER Working Paper on Household Survey of Health Care Utilization and Expenditure and The Burden of Ill Health Among the Urban Poor : A Case of Slums and Resettlement Colonies in Delhi and Chennai ”.

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