Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1163 Simplifying Reproductive Health in Low-Resource Settings Access to medical abortion and contraceptive choice, the importance of gendered structures in Rajasthan MANDIRA PAUL ACTA UNIVERSITATIS UPSALIENSIS ISSN 1651-6206 ISBN 978-91-554-9414-8 UPPSALA urn:nbn:se:uu:diva-267167 2015 Dissertation presented at Uppsala University to be publicly examined in Gustavianum, Akademigatan 3, Uppsala, Monday, 11 January 2016 at 13:00 for the degree of Doctor of Philosophy (Faculty of Medicine). The examination will be conducted in English. Faculty examiner: Professor Johanne Sundby (University of Oslo). Abstract Paul, M. 2015. Simplifying Reproductive Health in Low-Resource Settings. Access to medical abortion and contraceptive choice, the importance of gendered structures in Rajasthan. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1163. 144 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-554-9414-8. India introduced family planning in the ‘50s, legalized abortion in the ‘70s, and accomplished a remarkable drop in maternal mortality and fertility since 1990. Nevertheless, abortions account for a large proportion of maternal deaths, and sterilization is the most frequently used contraception. This thesis aims to identify the means to simplify and increase access to reproductive health in low-resource settings, focusing on abortion and contraception in Rajasthan. A randomized controlled trial compared simplified follow-up, where women assess their abortion outcome at home after early medical abortion, with in-clinic follow-up. Additionally, contraceptive use was compared between study groups post-abortion. In order to explore young women’s opportunities to access reproductive health services in the area, we conducted in-depth interviews with recently-married women. Women in the home-assessment group preferred home-assessment in the future to a greater extent than the women in the clinic follow-up group, who preferred in-clinic follow-up. Complete abortions were reported in 95% of women in the ‘home-assessment group’ and 93% in the ‘in-clinic group’, suggesting that efficacy of simplified follow-up is non-inferior to in- clinic follow-up. A majority (81%) of women carried out the pregnancy test and found it easy to use. Women (96%) were satisfied with their abortion. There were no differences in contraceptive use between study groups at three months; however, women in the ‘in-clinic group’ were most likely to initiate contraception at two weeks. A majority of women preferred the three- month injection, while only 4% preferred sterilization. The recently-married women considered reversible contraception to be unfeasible due to misconceptions and taboos, yet women wanted effective contraception because their current use of traditional methods resulted in unintended pregnancies. Abortions were common, and were procured from private or informal providers. Allowing women to take an active role in reproductive health services can enable simplification of, and access to, reproductive services in low-resource settings as well as in other settings. Simplifying medical abortion, providing contraception ‘intra-abortion’, and offering a context-appropriate and effective means of contraception, creates a great potential to increase access to reproductive health services and can result in a more equal society where women, and men, can attain their sexual and reproductive rights. Keywords: Medical abortion, Contraception, Access, Simplified, Gender, Sexual and reproductive health and rights, India Mandira Paul, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University, SE-75185 Uppsala, Sweden. © Mandira Paul 2015 ISSN 1651-6206 ISBN 978-91-554-9414-8 urn:nbn:se:uu:diva-267167 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-267167) For ‘Thama’ Women in our country are brought up to think that she is well only with her husband or on the funeral pyre. I would far rather see India’s women trained to wield arms than that they should feel helpless. Suppression of woman is a denial of Ahimsa [do no harm]. - M.K. Gandhi List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Paul, M., Iyengar, K., Essén B., Gemzell-Danielsson K., Iyengar S., Bring, J., Soni, S., Klingberg-Allvin, M. (2015) Acceptability of Home- Assessment Post Medical Abortion and Medical Abortion in a Low- resource setting in Rajasthan, India. Secondary Outcome Analysis of a Non-inferiority Randomized Controlled Trial. Plos One, 2015; 10(9): e0133354. II Iyengar, K., Paul, M., Iyengar S., Klingberg-Allvin, M., Essén B., Bring, J., Soni, S., Gemzell-Danielsson K. (2015) Self-assessment of the out- come of early medical abortion versus clinic follow-up in India: a ran- domised, controlled, non-inferiority trial. Lancet Global Health, 2015; 3: 9:e537-545. III Paul, M., Iyengar S., Essén B., Gemzell-Danielsson K., Iyengar, K., Bring, J., Klingberg-Allvin, M. (2015) Does mode of follow-up influ- ence contraceptive use after medical abortion in a low-resource setting? Secondary Outcome Analysis of a Non-inferiority Randomized Con- trolled Trial. Re-submitted. IV Paul, M., Essén B., Sariola, S., Soni, S., Iyengar S., Klingberg-Allvin, M. (2015) Negotiating collective and individual agency – a qualitative study of young women’s reproductive health in rural India. Qualitative Health Research, 2015; Nov 3:pii: 1049732315613038 [Epub ahead of print] Reprints are made with permission from the respective publishers. List of Related Papers The papers listed below are not empirical research papers and do not make direct contribution to the thesis per se, however, they are published within the same project and are related and relevant to the thesis. V Paul, M., Iyengar, K., Iyengar S., Gemzell-Danielsson K., Essén B., Klingberg-Allvin, M. Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a pictorial instruction sheet in Rajasthan, India – Study protocol and intervention adaptation of a randomised control trial. BMC Women’s Health, 2014; 14: 98. VI Paul, M., Gemzell-Danielsson K., Essén B., Klingberg-Allvin, M. The importance of considering the evidence in the MTP 2014 Amendment debate in India. Unsubstantiated arguments should not impede improved access to safe abortion. Global Health Action, 2015; 8: 27512. Contents Glossary of Terms and Concepts ...................................................................... 13 Collaborating Partners and Funding ................................................................. 14 Preface ............................................................................................................... 15 Introduction ....................................................................................................... 17 Sexual and Reproductive Health and Rights ............................................... 18 Gender in Health .......................................................................................... 19 Maternal Mortality and Morbidity ............................................................... 22 Adolescents and Young People ................................................................... 23 Unsafe Abortion – The Preventable Pandemic ............................................ 25 Comprehensive Abortion Care .................................................................... 26 Simplified Medical Abortion ....................................................................... 28 Contraception and Family Planning ............................................................ 30 Reproductive Health and Abortion in India ................................................. 33 India’s Health System Response to Maternal Mortality .............................. 33 The Legal Framework of Abortion in India ................................................ 35 Access to Safe Abortion in India ................................................................. 36 Family Planning in India .............................................................................. 37 Conceptual Framework ..................................................................................... 39 Access – Expanding the 5 A’s Framework .................................................. 39 Rationale for the Thesis .................................................................................... 43 Aim .................................................................................................................... 44 Material and Methods ....................................................................................... 45 Study Setting ................................................................................................ 46 Rajasthan – “the Land of Kings” ............................................................ 46 Udaipur City and Surroundings .............................................................. 48 Understanding the Context (Reflexivity) ..................................................... 48 Randomised Controlled Trial (Study I) ....................................................... 54 Study Rationale and Design .................................................................... 54 The Intervention ...................................................................................... 54 Intervention Adaptation and Pilot