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ABORTION PRACTICE IN INDIAA REVIEW OF LITERATURE

Heidi Bart Johnston

Abortion Assessment Project - India

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First Published in May 2002

ByCentre for Enquiry into Health and AlliedThemes (CEHAT)Research Centre of Anusandhan TrustSai Ashray, Aram Society Road, VakolaSantacruz (East), Mumbai - 400 055Telefax : 91-22-614 7727/613 2027Email: cehat@vsnl.com

©CEHAT/HEALTHWATCH

Printed at :Chintanakshar GraficsMumbai - 400 031The views and opinions expressed in this pub-lication are those of the author alone and donot necessarily reflect the views of the collabo-rating organizations.

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TECHNICAL ADVISORY COMMITTEE (TAC)

q Dr. R.N. Gupta, Social Scientist andResearcher, Indian Council of MedicalResearch, New Delhi

q Dr. Leela Visaria, Coordinator ofHealthwatch and Researcher, New Delhi

q Dr. Saramma Thomas Mathai, Consultantin Maternal & Child Health, New Delhi

q Dr. Thelma Narayan, Epidemiologist -Community Health Cell, Bangalore

q Dr. Padmini Swaminathan, SeniorEconomist and Researcher, MadrasInstitute of Development Studies, Chennai

q Ms. Manisha Gupte, Health and Women’sActivist, Mahila Sarvangeen UtkarshaMandal (MASUM), Pune

q Dr. Sudarshan Iyengar, Researcher andAcademician, Director of Gujarat Instituteof Development Research, Ahmedabad

q Ms. Sudha Tewari, Provider of AbortionServices, Parivar Seva Sanstha, New Delhi

q Dr. Kamini Rao, Professional, PresidentFederation of Obstetrician and Gynaeco-logical Societies of India (FOGSI),Bangalore

q Dr. Narika Namshum, Asst. Commissioner(Maternal Health), Dept. of Family Welfare,Government of India, New Delhi

q Ms. Ena Singh, Assistant Representativein UNFPA India Country Office, a memberin her personal capacity as an experiencedResearch Administrator, New Delhi

ETHICS CONSULTATIVE GROUP (ECG)

q Dr. Sudarshan Iyengar, Representing theTAC, Gujarat Institute of DevelopmentResearch, Ahmedabad

q Dr. S.V. Joga Rao, National Law School ofIndia University, Bangalore

q Dr. Sanjay Gupte, Chairperson, Ethics andMedico-Legal Committee, FOGSI, Pune

q Dr Vasantha Muthuswami, Expert on Bio-Medical Ethics DDG (SG), Indian Councilof Medical Research, New Delhi

q Dr. Ritu Priya, Researcher andAcademician Jawaharlal Nehru University,New Delhi

q Ms. Padma Prakash, Deputy Editor,Economic and Political Weekly, Mumbai

q Dr. V.R. Muraleedharan, Researcher andAcademician, Department of Humanitiesand Social Sciences Indian Institute ofTechnology, Chennai

q Dr. Amar Jesani, Programme Co-ordinator,Achutha Menon Centre for Health ScienceStudies, Sree Chitra Tirunal Institute forMedical Sciences and Technology,Thiruvananthapuram, Kerala

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ACKNOWLEDGEMENTS

This paper was developed in coordination with the AbortionAssessment Project - India (AAP-I).

The author would like to thank members of the Abortion AssessmentProject - India for their comments on an earlier draft of the paper, aswell as Ravi Duggal, Bela Ganatra, Saramma Mathai, Manisha Gupte,Malini Karkal, Dale Huntington, Priya Nanda and Robert Pelto for theirinsightful comments.

At Ipas, Jaine Benson, Barbara Crane, Ronnie Johnson and KarenOtsea provided constructive feedback.

The Ford Foundation provided financial support for the developmentof this paper. Inaccuracies in and shortcomings of the paper are thefault of the author alone.

Please address comments to the author at johnstonhb@ipas.org

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Abortions have been around forever. Butat different points of time in history it hasreceived attention for differing reasons,some in support of it, but often against it.Abortion is primarily a health concern ofwomen but it is increasingly being governedby patriarchal interests which more oftenthan not curb the freedom of women to seekabortion as a right.

In present times with the entire focus ofwomen’s health being on her reproduction,infact preventing or terminating it, abortionpractice becomes a critical issue. Given theofficial perspective of understanding abortionwithin the context of contraception, it isimportant to review abortion and abortionpractice in India.

The Abortion Assessment Project India(AAP-I) has evolved precisely with thisconcern and a wide range of studies are beingundertaken by a number of institutions andresearchers across the length and breadthof the country. The project has fivecomponents:

I. Overview paper on policy related issues,series of working papers based onexisting data / research and workshopsto pool existing knowledge andinformation in order to feed into thisproject.

II. Multicentric facility survey in six statesfocusing on the numerous dimensionsof provision of abortion services in thepublic and private sectors

III. Eight qualitative studies on specificissues to compliment the multicentricstudies. These would attempt tounderstand the abortion and relatedissues from the women’s perspective.

IV. Household studies to estimateincidence of abortion in two states inIndia.

V. Dissemination of information andliterature widely and development of anadvocacy strategy

This five pronged approach will,hopefully, capture the complex situation asit is obtained on the ground and also givepolicy makers, administrators and medicalprofessionals’ valuable insights into abortioncare and what are the areas for public policyinterventions and advocacy.

The present publication, the first in theAAP-I series evolved along with the develop-ment of this project. In that sense it was auseful input in that process. Ford Foundationsupported Ipas to undertake this review andthis publication was undertaken throughthat support. While efforts have been madeto cover as much ground as possible theremay still be gaps in covering somedimensions of the abortion issue, which wehope to cover in subsequent publicationsemerging from this project.

We look forward to comments and feed-back which may be sent to cehat@vsnl.comInformation on this project can be obtainedby writing to us or accessing it from thewebsite www.cehat.org

_ Ravi DuggalCoordinator, CEHAT

PREFACE

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TABLE OF CONTENTS

EXECUTIVE SUMMARY

I. INTRODUCTION ................................................................................................. 1

II. ABORTION RATES AND ASSOCIATED MORBIDITY AND MORTALITY

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

III. MEDICAL TERMINATION OF PREGNANCY (MTP) IN INDIA

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

IV. POSTABORTION CARE SERVICES

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

V. RECOMMENDATIONS

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

VI. CONCLUSIONS

REFERENCES ................................................................................................... 19

APPENDIX

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

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The Medical Termination of PregnancyAct of 1971 greatly liberalised the indicationsfor which abortion is legal in India. The Gov-ernment intended for this Act to reduce theincidence of illegal abortion and consequentmaternal morbidity and mortality. However,30 years after the groundbreaking legisla-tion, the majority of women seeking abor-tion still turn to uncertified providers for abor-tion services because of the barriers to legalabortion. While some uncertified providersoffer safe services, many provide unsafeabortions that result in complications ordeath. Women with access to fewer re-sources, for example low-income ruralwomen and adolescents, are among thosemost likely to turn to unsafe abortion andhave complications. Studies suggest that thechoice of specific provider is most often notmade by the woman inducing abortion butwith or by her husband or other family mem-bers.

While the incidence of abortion in Indiais unknown, the most widely cited figure sug-gests that around 6.7 million abortions takeplace annually. According to governmentdata, only about one million of these are per-formed legally. The remaining abortions areperformed by medical and non-medical prac-titioners. Levels of unsafe abortion are veryhigh in India, especially given that abortionis legal for a broad range of indications, andavailable in the public and private healthsector.

In the current situation abortion servicesare not adequately decentralized, and regu-latory reform will have to take place beforedecentralization of legal services will hap-pen in a meaningful way. To reduce morbid-ity and mortality from unsafe abortion in thiscontext, several broad activities requirestrengthening: decreasing unwanted preg-nancies; increasing access to safe abortionservices; and increasing the quality of abor-

tion care, including postabortion care.

Results of the studies reviewed suggestthat reducing recourse to unsafe abortionwill be a complex multi-step process thatincludes increasing women’s access throughimprove-ments in service delivery andaddresses the more complicated issues ofrights and gender power inequities.Strategies to make safe and legal abortionservices more attractive to women anddecision makers include: increasinggeographic accessibility; increasingaffordability; providing high quality abortioncare and prioritising confidentiality ofservices. Addressing the system of barrierslimiting women’s access to safe abortionservices may require review and revision ofthe MTP Act, 1971 and associated rules andregulations.

This review suggests a need for expandedcommunity-based education to addressspecific issues of women’s reproductivehealth and the broader issues of women’sright to high quality health care services.Household decision-makers, men andwomen, would benefit from awarenessraising about the dangers of unsafe abortionand the availability of safe abortion services.Women with reduced access to reproductivehealth resources, such as adolescents andrural poor, should be a priority focus in com-munity-based education.

This review of the current literature ofabortion in India suggests that abortion and

EXECUTIVE SUMMARY

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qualified practitioners to attend MTP trainingcourses; reviewing MTP Act and associatedrules and regulations to determine how thelaw can be revised to decentralize abortionservices and otherwise better meet theneeds of women; upgrading facilities thatcurrently offer MTP services; orienting MTPservices to meet the needs of women mostat risk of accessing unsafe abortion;increasing awareness among women andmen of reproductive age of the availability ofsafe abortion services and the dangers ofunsafe abortion; involving communities andproviders at all levels to improve reproductivehealth care; and improving adolescentreproductive health services in general.Innovative interventions need to bedeveloped, implemented, monitored andscaled up as appropriate.

Clearly a great deal is known aboutprovision of and access to safe and unsafeabortion services in India and the need toimprove safe abortion and contraceptivechoices to more adequately meet the needsof women experiencing unwanted pregnan-cies. Still, a great deal more needs to beknown before programs are implemented toensure low-resource Indian women canreadily access safe abortion services. Thecost in terms of women’s health and livesemphasizes the need to efficiently andeffectively pursue efforts to make abortionsafer and more accessible for Indian women.

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About the Author

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

Complications of unsafe abortion are amajor public health issue facing women indeveloping countries. In India, abortion islegal for a broad range of medical and socialreasons. Officially, women can access safeabortion services by trained medicalpersonnel in registered facilities, and minorsneed consent from their husband or father.In practice, limited access to authorizedabortion providers, the threat of forcedcontraceptive acceptance, the financial costsassociated with legal abortion, the stigmaassociated with induced abortion, and lowlevels of awareness regarding the legality ofthe procedure bar women from safe abortionservices (Khan et al. 1999; Sinha et al. 1998).As a result, women often resort to untrainedclandestine practitioners operating underunsafe conditions. The consequences ofabortions performed under suchcircumstances range from life threateningto chronic reproductive tract morbidity suchas infections, chronic disability andinfertility (Chhabra and Nuna 1994).

In India each year an estimated 453women die due to maternal causes for every100,000 live births (UNFPA 1997). Thisstatistic masks the vast variation amongstates. While national and state estimatesare imprecise, they are able to representcertain trends. Orissa and Madhya Pradeshhad approximately 738 and 711 maternaldeaths per 100,000 births in 1992. Amongthe large states, Kerala has a singularly lowratio of 87 maternal deaths reported per100,000 births. On an average, roughlyfifteen percent of maternal deaths in Indiaare thought to result from unsafe abortion(Chhabra and Nuna 1994). In whatconditions are these abortions provided?What impact do these unwanted pregnancies

have on women’s health and lives?Recognizing the high estimated incidenceof abortion-related mortality and morbidityin parts of India this paper reviews theliterature on safe and unsafe abortionservices, abortion facilities and providers,complications of unsafe abortion, andavailability of postabortion care in India. Thereview aims to synthesize what is knownabout abortion in India and identify stepsthat need to be taken to develop abortionrelated services that more closely meetIndian women’s needs.

II.ABORTION RATES AND ASSOCIATEDMORBIDITY AND MORTALITY

A. ABORTION INCIDENCE

Induced abortion incidence is extremelydifficult to measure in most countries andIndia is no exception. Data quality is animportant consideration in studying abortion.Abortion procedures, whether performedlegally by trained professionals using moderntechnology or illegaly using “traditional”methods are subject to substantialunderreporting (Huntington et al. 1993).Abortion data typically come from one of twosources: clinic or hospital records orindividual surveys of women. Clinic orhospital sources tend to be of poor qualitywhere abortion is illegal, highly stigmatizedor difficult to obtain (Baretto et al. 1992;Frejka 1985; Paxman et al. 1993; Remez1995). Individual surveys underestimate theincidence of induced abortion even whereabortion is legal (Anderson et al. 1994; Jonesand Forrest 1992).

No valid data exist on the incidence ofabortion in India (Mathai 1997). Clinic dataare published as government statistics butthese reflect only reported medical termi-

I. INTRODUCTION

ABORTION PRACTICE IN INDIAA REVIEW OF LITERATURE

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nation of pregnancy (MTP) cases conductedin clinics recognized by the government(Khan, et al n.d.). These abortion statisticsshow an increase in MTP since theliberalization of abortion laws in 1972 untilthe early 1980s (Khan et al. 1999 from FamilyWelfare of India Year Book, Government ofIndia, 1993). Since 1982-83 there has beenan increase in MTP centers, but no corres-ponding increase in the reported numbersof MTP performed. Underreporting of MTPcould be a reason for this (Mathai 1997).

Illegal and thus unreported abortions areestimated to outnumber legal abortions by afactor of between three and eight (Gupte n.d.;Karkal 1991, as cited in Chhabra and Nuna1994). Surveys like the National FamilyHealth Survey collect abortion data (Inter-national Institute for Population Sciences1995). These data report a very low incidenceof abortion among Indian women and are alsoconsidered gross underestimates (Arnold1999; International Institute for PopulationSciences 1995; Mishra et al. 1998). Ingeneral, large scale DHS-like surveys areinadequate tools for investigating sociallystigmatized topics such as induced abortion(Huntington et al. 1996).

The Indian Council of Medical Research(ICMR) conducted induced abortion research

in the five states of Haryana, Orissa,Rajasthan, Tamil Nadu and Uttar Pradeshin 1983-84. According to ICMR findings, forthe five states combined, 19 per 1000pregnancies were terminated. Six perthousand were terminated legally, and 13 per1000 pregnancies were terminated illegally.Applying these proportions to 1990 nationalabortion data implies that the approximately600,000 legal abortions reported in 1990indicate that in total 1.3 million illegalabortions were performed nationwide (IndianCouncil of Medical Research 1988; WorldBank 1996). The ICMR national abortionestimate is substantially lower thanChhabra and Nuna’s widely cited indirectestimate of 6.7 million induced abortionsannually (Chhabra and Nuna 1994).

Because available direct estimates ofabortion rates from clinic and survey dataare generally acknowledged to be under-estimates, various indirect estimationtechniques have been used to measureabortion incidence and relative rates(Chhabra and Nuna 1994; Johnston and Hill1996; Mishra et al. 1998; Shah 1966). Eachof the indirect estimation techniques usedemploy assumptions that affect the resultingestimates. Estimated rates of inducedabortion are presented by state in Table 1.See Appendix 1 for details on the calculationof these estimates.

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Table 1. Total Abortion Rate Estimates from Three Indirect Estimation Techniques

TAR TPIAR TARAbortion:Birth Potential Induced Residual Technique

Ratio Abortion Rate

India __ 0.97 2.65North IndiaDelhi 1.72 __ 2.08Haryana 1.72 0.94 1.37Himachal Pradesh 1.68 __ 0.59Jammu (J&K) __ __ 2.25Punjab 1.91 0.53 1.61Rajasthan 1.62 0.57 5.35Central IndiaMadhya Pradesh 1.60 0.73 5.29Uttar Pradesh 1.64 1.39 5.77East IndiaBihar 1.53 1.13 6.24Orissa 1.70 0.88 3.88West Bengal 1.74 1.22 2.39Northeast IndiaArunachal Pradesh 1.81 __ 4.89Assam 1.91 1.20 2.53Manipur 2.16 __ 2.00Meghalaya 1.93 __ 5.55Mizoram __ 0.70Nagaland 2.35 __ 6.23Tripura 1.87 __ 3.13West IndiaGoa 1.95 __ 2.02Gujarat 1.68 0.27 1.25Maharashtra 1.66 0.68 1.73South IndiaAndhra Pradesh 1.55 0.43 3.78Karnataka 1.72 1.08 2.24Kerala 1.91 0.42 0.88Tamil Nadu 1.66 0.79 3.13

Sources: Chhabra and Nuna 1994; Mishra et al. 1998; and original data generated for this report:Please see Appendix 1 for brief descriptions of the three estimation techniques.

Data for Sikkim and Union territories not available. Chattisgarh, Uttaranchal and Jharkhand areincluded in MP, UP and Bihar respectively.

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The data presented in Table 1 show thatdifferent methods of estimating abortiongenerate vastly different rates and relativerates. Rates vary substantially by state. Thepotential induced abortion and residualestimation techniques take into accountvariations in reproductive behavior by stateand are thought to more accurately reflectrelative rates. For the entire country thenumber of abortions a woman will have onan average throughout her reproductiveyears is estimated to be betweenapproximately 1.0 and 2.6.

Table 2 makes some sense of the indirectestimates by showing agreement betweenthe different estimation techniquesaccording to states ranked among thosehaving highest abortion rates in the country.States in one or more ranking systems aremarked in bold. The states that have highrates of induced abortion in more than oneranking system are Nagaland, Meghalaya,Uttar Pradesh, West Bengal, Assam, Bihar,Arunachal Pradesh, Orissa, Madhya Pradesh,and Tripura. This suggests that abortionrates are highest in Northeast and CentralIndia. Not all states were included in eachanalysis. However, the larger states were.

Table 2. Abortion Rates by Three Different Indirect Estimation Methods

Abortion:Birth Ratio Abortion Potential Residual Estimation

1 Nagaland 2.35 Uttar Pradesh 1.39 Bihar 6.242 Manipur 2.16 West Bengal 1.22 Nagaland 6.233 Meghalaya 1.93 Assam 1.20 Uttar Pradesh 5.774 Punjab 1.91 Bihar 1.13 Meghalaya 5.555 Assam 1.91 Karnataka 1.08 Rajasthan 5.356 Kerala 1.91 Haryana 0.94 Madhya Pradesh 5.297 Tripura 1.87 Orissa 0.88 Arunachal Pradesh 4.898 Arunachal Pradesh 1.81 Tamil Nadu 0.79 Orissa 3.889 West Bengal 1.74 Madhya Pradesh 0.73 Andhra Pradesh 3.7810 Delhi 1.72 Maharashtra 0.68 Tripura 3.13

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

Various alternative estimationtechniques also yield wide variations inestimates of the number of abortionsoccurring annually in India, as shown inTable 3. In 1966 the Shah Committeeestimated that 3.9 million induced abortionstook place annually in India (Chhabra andNuna 1994). In 1970 IPPF assumed that 200abortions occurred per 1000 births, andsuggested the national figure was close to6.5 million (Mishra et al. 1998). [Goyal et al.(1976) presented a range of four to six millionin 1976 (Khan et al. n.d.).] UNICEF reportsthat roughly five million induced abortionsoccur annually in India. Four and a halfmillion of these are said to be performedillegally, and only one-half million areperformed within the health servicesnetwork (Jejeebhoy 1996; UNICEF/India1991). Based on clinical records, which arerecognized to undercount the incidence ofabortion, the Government of India reportedthe total number of induced abortions inIndia in 1991-92 at 0.63 million. Chhabraand Nuna (1994) used the same techniqueas the Shah Committee to estimate that 6.7million induced abortions occur in Indiaannually. This comparison of the sametechnique suggests that the number ofabortions has increased over time.

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Table 3. Estimates of number of inducedabortions nationwide annually

Source Number of InducedAbortions

Nationwide (millions)

Shah, 1966 3.9

IPPF, 1970 6.5

Goyal et al., 1976 4.6

UNICEF, 1991 5.0

GOI, 1991-92 0.6

Chhabra and Nuna, 1994 6.7

The gap between reported legal abortionand total abortion estimates suggests thatless than 10 percent of the abortions thattake place in India are conducted legally(Khan et al. n.d.). In the 1983-84 ICMRabortion study, of the 55 percent of abortionsconducted in the first trimester, only about25 percent were conducted by certifieddoctors or other health staff (Indian Councilof Medical Research 1988; World Bank 1996).Abortions conducted in the second trimesterare more difficult to access, requiring theauthorization of two physicians (UnitedNations 1993). As such they are more likelyto be performed by uncertified providers.While abortion services from someuncertified providers can be completely safemany uncertified providers performdangerous abortion procedures that result inmorbidity and death.

B. Morbidity and Mortality from UnsafeAbortionLimited data exist on the number of ma-

ternal deaths from abortion in India. TheSurvey of Causes of Death reports that nearly18 percent of maternal deaths result fromabortion (Office of the Registrar General ofIndia n.d.). Data from other sources suggestthat the percent of maternal mortality re-sulting from unsafe abortion ranges from 4.5to 16.9 percent (See Table 4).

Table 4. Maternal Mortality Attributableto Abortion

MaternalMortality

Location Attributable Sourceto Abortion(percent)

India, 1982-1983 18.1 ICMRIndia, Rural, 1989 10.8 Office of the Registrar

General 1991*India, Rural, 1993 11.7 Office of the Registrar

General 1993*India, 1992-1994 11.1 Bhatt 1997@India, 1993-1994 12.6 ICMR task force

1998@India, 1994 12.6 GOI 1998@India, 1991-1995 18.0 Office of the Registrar

General of India n.d.#

Sources : * Mathai 1998# World Bank 1996;@ Ganatra 2001:

Each abortion related death representsmany more abortion related complications.In India, the most frequently recognized com-plications from unsafe abortion are: pelvicinfection, incomplete abortion, hemorrhage,uterine injury and cervical injury (Barge etal. 1997; Kerrigan et al. 1995). Mathai (1998)found Indian women are presenting to medi-cal facilities with grade III sepsis, includingsepsis associated with generalized perito-nitis, septicemia, septic shock, acute renalfailure and disseminated intravascular co-agulation (Sharma et al. 1992; Sood et al.1995 as cited in Mathai 1998). Gas gangrene,tetanus, severe adhesions and renal failureassociated with the use of Fetex Paste arealso reported (Mathai 1998). Women present-ing at clinics in Uttar Pradesh with abortioncomplications were reported to have at-tempted to abort using insertion of a foreignbody such as a stick or a root; orally ingesteddrugs; improper dilation and curettage andother less common means (Barge et al. 1997).

Second trimester abortions are a parti-cular health concern. Women who delayaccessing abortion or MTP until the secondtrimester place themselves at a greater riskof complications and death, particularly if theabortion provider is untrained (Jones 1991;

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Kerrigan et al. 1995). Studies show thatunmarried adolescents and womenundergoing sex selective abortion are thegroups most likely to attempt secondtrimester abortion (Ganatra et al. 2000; Raoand Rao 1990, Aras et al. 1987).

Adolescents are particularly prone toabortion related morbidity and mortality. In1995 almost 50 percent of deaths amongwomen age 15-19 were abortion related. Thisimplies that around twenty percent ofabortion-related deaths occur among adole-scents (Government of India n.d. as found inMathai 1998). Adolescents, particularlyunmarried adolescents, face fear, anxiety,and the social implications of having apregnancy. These make unmarriedadolescents as a group particularly at risk ofdelaying obtaining abortion services and ofobtaining services from untrained but moreconfidential providers. Thus adolescents aremore vulnerable to suffering complicationsof second trimester abortions. Of adolescentswho sought abortion in the second trimesteralmost one in four suffered complications,compared to only one percent of those whounderwent abortion in the first trimester(Aras 1987).

III. MEDICAL TERMINATION OFPREGNANCY (MTP) IN INDIA

A. Legal Status of AbortionThe Medical Termination of Pregnancy

Act, approved in India in 1971 and enactedin 1972, permits abortion (or MTP) for a broadrange of social and medical reasons,including: to save the life of the woman; topreserve physical health; to preserve mentalhealth; to terminate a pregnancy resultingfrom rape or incest and in cases of fetalimpairment. Contraceptive failure also issufficient ground for legal abortion (UnitedNations 1993).

Barring medical emergencies, legalabortions must be performed within the first20 weeks of pregnancy and must be

performed by a registered physician in ahospital established or maintained by thegovernment or in a facility approved for thepurpose by the government (Mathai 1998).For abortions taking place between twelveand twenty weeks of pregnancy, a secondopinion is required except in urgent cases.Women must grant consent prior to theperformance of the abortion. In the case ofminors (defined as under age 18) andmentally retarded women, written consentof guardian is necessary (United Nations1993).

Critics of the abortion law admit thatwhen it was introduced it was a greatachievement for women’s health. Nearly 30years later, the law and associated rules andregulations are considered overlymedicalised and bureaucratic, and as such,not oriented torward women’s right to accesssafe and legal abortion services. The lawoffers substantial protection for medicalproviders. Chhabra and Nuna (1947) notethat “doctors . . . receive blanket indemnityunder the MTP Act – instead of functioningas for other surgical procedures and takingthe consequences of any default or neglect”.Jesani and Iyer (1995) state “[C]learly theMTP Act does NOT encompass a fundamentalright to induced abortion but is limited to theliberalisation of the conditions under whichwomen may have access to abortion servicesprovided by approved medical practitioners”.The law constrains women’s access to legalabortion services by requiring providersreceive a level of training that is difficult toachieve given the shortage of trainingfacilities in the country and the absence ofincentives to receive formal training (Khanet al. 1999).

Bureaucracy associated with registeringMTP facilities with the government and withreporting and recording MTP procedures,further contributes to the end result thatmany physicians provide abortion illegally(Chhabra and Nuna 1994). When a physicianperforms abortion without registering the

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procedure, the physician can avoid theextensive paperwork associated with re-porting MTP (Barge et al. 1994; Chhabra andNuna 1994; Kerrigan et al. 1995).

B. Inadequate Legal Abortion Service Pro-visionDespite the broad range of indications for

legal abortion, illegal and unsafe abortionsare common in India for many reasons.Women access care from uncertifiedproviders because certified providers aregeographically inconvenient; staff atcertified facilities tend to not respectwomen’s confidentiality; because women areunaware of certified facilities; becauseregistered facilities often do not have atrained provider and/or the necessaryequipment to provide safe abortion services;and many women are unaware that abortionis legal and publicly available. Cost, coercion,moral dilemma, late knowledge of pregnancyand unmarried status are addi-tional reasonswomen seek abortion from illegal providers.Some providers do not approve of electiveabortion and scold the client as they providetreatment; the pressure to acceptsterilization or other long-termcontraception after an abortion discourageswomen from using registered facilities.When the reason a woman elects to abort apregnancy is not legally sanctioned, forexample for a sex-selective procedure; orwhen the procedure is highly socially stig-matized, for example to terminate anextramarital pregnancy, women must accessthe more confidential services of uncertifiedabortion providers (Barge et al. 1997; Barge,et al. 1994; Chhabra and Nuna 1994; Gupte1997; Kerrigan et al. 1995; Khan et al. 1999;Khan et al. 1998; Ravindran and Sen 1994;World Bank 1996).

Government facilities are acknowledgedto be inadequate providers of abortionservices. MTP facilities are most often locatedin urban areas while the vast majority ofIndian women live in rural areas. Only aboutten percent of the clinics that are registeredto provide MTP actually have a trained

provider and the necessary equipment toprovide safe abortion services. Many doctorswho are authorized to provide MTP feelinadequately trained to provide the servicesafely. In addition, many women do not knowMTP is legally available at governmentfacilities. Unfortunately, many governmentfacilities that are supposed to provide MTPservices free of charge actually chargeclients for MTP services, placing anotherbarrier to women’s access of safe abortionfrom the formal health care system (Khan etal. 1999; Khan et al. 1998). Furthermore,evidence suggests that contraceptiveacceptance can be a precondition to theabortion (Ganatra et al., 2000; Lakshmi andPelto, 1999; Gupte et al. 1997, as cited inGanatra 2001).

Table 5 shows that on an average, MTP fa-cilities do not perform high numbers of MTPsannually. Still, there is significant variationamong the states in terms of average num-ber of MTPs performed per MTP facility.Assam has the highest number of MTP per-formed per institution, followed by West Ben-gal, Orissa, Madhya Pradesh, and Haryana.Gujarat and Karnataka have the fewest num-ber of MTP performed per facility. It is notclear whether states with higher levels ofMTP per facilities better meet women’s needsand thus attract more clientele or have in-sufficient number of clinics and thus aheavier client load. Likewise states withfewer MTP per facility may have more ad-equate number of facilities or may run in-adequate facilities that prevent clients frompresenting.

More telling statistics are the number ofMTPs per 1000 people and the number of MTPfacilities per population by state in Table 5.Uttar Pradesh and Bihar have the lowest ra-tios of MTP per 1000 person yet are rankedto have among the highest levels of totalabortion (see Table 1). This combination in-dicates that more abortions are performedoutside certified facilities in Uttar Pradeshand Bihar than in any other Indian statesand suggests that the level of unsafe abor-

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tion may be higher in Uttar Pradesh andBihar than elsewhere in India.

The population per MTP facility ratios inTable 5 show that Bihar has one MTP centerfor every 445,000 people. In Uttar Pradesh,Madhya Pradesh, Assam and Orissa MTP fa-cilities are more prevalent but still each fa-cility serves an average of over 200,000people. The six states that have the highestnumber of abortions (Assam, Bihar, MadhyaPradesh, Orissa, Uttar Pradesh and WestBengal according to results of three indirectestimation techniques presented in Table 1)mirror the states with fewest facilities perpopulation. This suggests the populationmost needing access to MTP facilities arealso the population least likely to have ac-cess to MTP facilities.

The data presented in Table 5 togetherwith the incidence data presented in Table1 suggest that though MTP facilities are in-adequate to meet the needs of the popula-tion, the available facilities are underused.

Table 5: Ratios of MTPs, Government Approved MTP Facilities and Population by StateState No. of No. of State MTP: MTP: 1000 Population

MTPs Facilities Population Facility Population Facility ratio(1993-94) (1993-94) (1996) ratio ratio

Andhra Pradesh 13719 373 72,155,000 37 0.19 193,445Assam 21372 100 24,726,000 214 0.86 247,260Bihar 11060 209 93,005,000 53 0.12 445,000Gujarat 10263 700 45,548,000 15 0.23 65,069Haryana 22438 228 18,553,000 98 1.21 81,373Karnataka 9077 471 49,344,000 19 0.18 104,764Kerala 34433 559 30,965,000 62 1.11 55,394Madhya Pradesh 33086 295 74,185,000 112 0.45 251,475Maharashtra 97079 1775 86,587,000 55 1.12 48,781Orissa 19510 169 34,440,000 115 0.57 203,787Punjab 19436 242 22,367,000 80 0.87 92,426Rajasthan 29023 316 49,724,000 92 0.58 157,354Tamil Nadu 42364 623 59,452,000 68 0.71 95,429Uttar Pradesh 12103 425 156,692,000 29 0.08 368,687West Bengal 64273 452 74,601,000 142 0.86 165,047

India 609915 9271 934,218,000 63 0.65 100,768Sources: Number of MTP: Government of India. Ministry of Health and Family Welfare. Family WelfareProgram in India: Year Book (1993-94). Number of MTP Facilities: Nirman Bhavan, New Delhi: Ministry ofHealth and Family Welfare, [n.d.]; State Populations: (UNFPA 1997).

This further suggests that MTP facilitiescould explore means of improving servicesto the population the facilities are meant toserve. This would include exploring meansof making MTP more accessible to thewomen meant to be served by the facilities.

Figure 1. Percent of PHCs and CHCsoffering MTP services by state

Primary Health CentreCommunity Health

Centre100

90

80

70

60

50

40

30

20

Gujarat Maharashtra Tamil Nadu Uttar Pradesh

18

Source: Khan et al. 1999

In the Seventh Five-Year Plan (1985-1990) the Government of India stated theintention to equip all primary health cen-tres1 with staff and supplies to conduct abor-tion services. Khan et al. (1999) relay that“according to the national norm, all commu-nity health centres2 , postpartum centres,and similar higher level facilities are ex-pected to provide abortion services”. Figure1 shows this goal remains unrealised.Around one-quarter of primary health cen-ters in Uttar Pradesh and Maharashtra pro-vide abortion services. One-third and almosttwo-thirds provide these services in Gujaratand Tamil Nadu, respectively. Among com-munity health centres only 59 percent inUttar Pradesh and 78 percent in Gujarat pro-vide abortion services. Eighty-nine percentof community health centres provide MTP inMaharashtra. In Tamil Nadu, 95 percent ofcommunity health centers and sub-districthospitals provide MTP. However, in TamilNadu abortions are offered primarily on ster-ilization days and according to several stud-ies abortion providers pressure abortion cli-ents to accept sterilization (Khan et al. 1999).

Information presented in this section sug-gests that abortion services from PHCs areinadequate, yet underutilised. This corrobo-rates data from other sources suggestingthat women often turn to certified anduncertified providers at private facilities forabortion services. For example, inMaharashtra, over two-thirds of the approvedMTP centers are in the private sector (Bargeand Rajagopal 1996).

C. Illegal Abortion – Providers and

MethodsBecause of the barriers preventing

women from accessing MTP, women accessabortion from unregistered, uncertifiedproviders. Abortion services fromunregistered providers range fromcompletely safe – provided by trained medicaldoctors in appropriate facilities – to life-threatening – provided by a range of providersin various settings (Mathai 1998; Kerriganet al. 1995; Johnston et al. 2001). Uncertifiedabortion providers can include trainedmedical doctors and nurses in hospitals,Auxiliary Nurse Midwives (ANM), ayurvedics,homeopaths, dais or traditional birthattendants, family health workers, villagehealth practitioners, pharmacy shop-keepersand village women (Bandewar n.d.; Mathai1998; Johnston et al. 2001).

Common methods of inducing abortioninclude vaginal and oral methods. Dais usemethods such as inserting sticks, herbs,roots, and foreign bodies into the uterus toinduce abortion. Other vaginal methodsinclude pins, laminaria tents, and FetexPaste3 . Rural Medical Providers (RMPs or“quacks”) sell medicines for oral use toinduce abortion. ANMs (Auxiliary Nurse/Midwives) and ISMPs (Indian System ofMedical Practitioners) use intramnioticinjections such as intramniotic saline andintramniotic glycerine with iodine to induceabortion. Orally ingested abortificantsinclude indigenous and homeopathicmedicines, chloroquine tablets,prostoglandins, high dose progesterones andestrogens, papaya seeds with high doseprogesterones and estrogens, liquor beforedistillation, seeds of custard apple andcarrots, etc. (Mathai 1998; Johnston et al.

1 Primary health centres (PHCs) cover a population of about 30,000, staffed by a medical officer, associated facility staff and fieldsupervisors (World Bank 1996)

2 Community health centres (CHCs) serve as “first referral units” and cover a population of approximately 100,000 staffed byspecialists in pediatrics, surgery and obstetrics and gynecology (World Bank 1996).

3 Fetex Paste (brand name) contains benzoin, iodine, thymol, potassium iodide and saponified vegetable oil paste. It is introducedvaginally as an abortificant (Marathi 1998).

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2001). Chloroquine is appliedintramuscularly as an abortificant. Abdo-minal massage, witchcraft, dilation andcurettage, vacuum aspiration and heat appli-cations are also used to induce abortion(Indian Council of Medical Research 1989;Kamalajayaram and Parameswari 1988;Maitra 1998; Meenakshi, et al 1995; Rani etal. 1996; Sood 1995, as found in Mathai 1998).

D. Characteristics of women who termi-nate unwanted pregnanciesThe reasons Indian women terminate

unwanted pregnancies are many and varied.Conditions that can lead to a pregnancybeing unwanted include: financial reasons;already having too many children or havingtoo many female children; becomingpregnant after too short a birth interval;experiencing health problems duringpregnancy; becoming pregnant at an olderage; becoming pregnant soon after marriage;suspecting husband’s infidelity; having anextra-marital pregnancy and becomingpregnant as a result of rape are all conditionsthat can lead to a pregnancy being unwanted(Barge et al. 1997; Jejeebhoy 1998; Sinha etal. 1998).

For most of these conditions, a moreproximate determinant of unwantedpregnancy is lack of access to appropriatecontraception. For some women, contracep-tion is not an option because of familypressure. Other women can not access acontraceptive method appropriate for them.For unmarried adolescents, contraception isgenerally not available. In such cases,abortion may be the predominant means ofbirth control (Gupte et al. 1997).

Contraceptive failure and user failurecan lead to unwanted pregnancies that canbe aborted legitimately in the Indian medicalsystem. Reasons for contraceptive failureshould be explored and addressed andcontraceptive options should be made moreadequate. Though awareness of

contraception is generally high, lack ofavailability of spacing methods,misinformation and apprehension about thedifferent contraceptive options preventswidespread contraceptive use and abortionis used as an alternative to contraception(Parivar Seva Sanstha 1998).

Indian women access abortion through-out their reproductive years. A 1990-91 studyshows that more than 80 percent of womenwho obtain MTP are in the 20-34 age group(Chhabra and Nuna 1994). Adolescents, bothmarried and unmarried, also obtain abortionservices in significant numbers. Accordingto Chhabra, 27 percent of the 2755 abortionsconducted in a clinic in rural Maharashtrain the period 1976-87 were for adolescents(Chhabra 1988) and as many as 30 percentof 1684 abortions conducted in an urbanhospital setting were for adolescents(Solapurkar and Sangam 1985). A substantialnumber of unwanted pregnancies amongadolescents result from forced sexualintercourse. A Bombay study published inthe late 1970s showed that around 20 percentof pregnancies of adolescents obtainingabortion were reported to have resulted fromrape (Divekar et al. 1979, as cited inJejeebhoy 1996).

As adolescents have less access toreproductive health information andservices compared to older marriedcounterparts, they are more likely to delayrecognising pregnancy, to delay obtainingcare, and to access care from unsafeproviders (Jejeebhoy 1996; Mathai 1998).Seventy two percent of the unmarriedwomen who sought abortion at a rural clinicalfacility, most of whom were under age 20,sought MTP in the second trimester(Chhabra 1988). In a clinic-based studyconducted in the mid 1980s, a majority (59percent) of unmarried adolescents presentedfor second trimester abortions, while aminority (26 percent) of married adolescentscame in during their second trimester of

20

pregnancy (Aras 1987; Jejeebhoy 1996). Datafrom the 1970s suggest that eighty percentof adolescents receiving abortion soughtabortion in the second trimester (Bhatt 1978;Purandare and Krishna 1994). This comparesto 34 percent of older women who soughtabortion in their second trimester.

India’s second trimester abortion rate isthought to be among the highest in the worldand increasing (Chhabra and Nuna 1994).Of women accessing legal abortion servicesat specific teaching hospitals in 1981, arange of between ten and forty percent werein their second trimester (Indian Council ofMedical Research 1981). Second trimesterabortions increase risks to women in twoways. First, women are more likely to go toan uncertified provider because theprocedure is more difficult to obtain legallythan first trimester abortion (Kerrigan, et al.1995; Ravindran and Sen 1994). Second, inthe second trimester the risk ofcomplications is higher for physiologicalreasons (Jones 1991).

Sex selective abortions and delay ofaccessing abortion services for an unwantedpregnancy are the two most common reasonsfor second trimester abortions (Mathai 1997).A strong son preference and the availabilityof prenatal diagnostic techniques haveresulted in an increased use of prenatal sextests, even among rural poor. Some privateclinics provide prenatal sex tests and offerabortion services (United Nations 1993).While this practice was outlawed in 1994,it apparently remains widespread andimpossible to accurately quantify. In 1989,eleven percent of abortions were thought tobe to abort a female fetus (Indian Councilof Medical Research 1989). Indian non-governmental organizations suggest thatover 2 million sex selective abortions arereported every year, representing only thetip of the iceberg, according to a recentnewspaper article-Reuters 1999. The

National Family Health Survey (1992-93)reports the sex ratio at birth to have beenalmost constant at 106.3-106.6 for five-yearperiods since 19724 , offering no support toarguments that sex selective abortion isskewing sex ratios at birth at the nationallevel. As a comparison, in China and SouthKorea, where sex selective abortion isreportedly common, sex ratios at birth were119 and 114 respectively in 1992(International Institute for PopulationSciences 1995).

While women from all socio-economicgroups access abortion, there is a classdifferential in where women from differentsocio-economic groups obtain abortions.Women who obtain abortions at safe facilitiestend to be the women who can afford to paythe transport costs and additional associatedfees (Barge et al. 1997). Because legalabortion is not an option for most Indianwomen from lower socio-economic classes,these women tend to obtain abortion servicesfrom less trained, but more accessibleproviders (Jejeebhoy 1998).

E. Decision-making issuesMaking the decision to abort a pregnancy

can be difficult and cause delays in abortionseeking. Factors that cause delays in acces-sing abortion services include not initiallyrecognizing the pregnancy, postponingcommunicating the news of an unwantedpregnancy to a decision maker, lack ofawareness of available abortion services,lack of resources (financial, transport etc.)to access available services and fear of socialstigmatization. For adolescents andunmarried women, the confidentiality of theabortion service is particularly crucial anddelays in accessing abortion are more likely(Ganatra 1997; Indian Council of MedicalResearch 1989 as found in Mathai 1998).

A woman may make the decision to aborta pregnancy but often the decision-making

4 The typical sex ratio at birth is 104-107 males to 100 females (Shryock and Siegel 1976)

21

role is taken by husbands, mothers-in-lawor other household members or community-level health care providers. Decision makersmay support a woman’s choice, pressure herinto having an abortion or object to herhaving an abortion. Sinha et al. (1998) reportwomen turn to a range of confidants to helpmake the abortion decision. In a study of 132women conducted in Uttar Pradesh, themajority of women (32 out of 49) who wantedto abort their unplanned pregnancy firstdiscussed the prospect with their husband.Many husbands were supportive of thedecision to abort and actually facilitated theabortion process. Mothers-in-law, sisters-in-law, health workers, neighbours and otherrelatives were also consulted (Sinha et al.1998). On the other hand, fear of disapproval,opposition or violence can result in womenhiding the abortion from her family (Ganatra2001; Gupte et al. 1996).

Choosing an abortion provider can beinfluenced by multiple factors. Study resultsshow that people who obtain abortion fromlegal and unregistered facilities generallyhave different characteristics and priorities.Low-income women and women who live inrural areas are severely limited in choicesfor abortion services, causing such womento be more likely to access abortion fromproviders of unsafe abortion. In rural areas,uncertified providers thrive because they canoffer abortion services at an affordable price,and are often located closer to women’sresidences than legal providers (Parivar SevaSanstha 1998). As a result of limited accessto safe providers in rural areas, rates ofunsafe abortion are thought to besignificantly higher in rural than in urbanareas (Kerrigan et al. 1995).

Women who have the choice betweenpublic and private providers report feelingmore satisfied with the services of privateproviders. Care in government facilities isreportedly inadequate; such facilities

reportedly do not maintain client confi-dentiality; can be expensive5 ; and tend to befar from where women live and thus difficultto access (Barge et al. 1997; Indian Councilof Medical Research 1989).

In Uttar Pradesh, a study of women whosought abortion from either legal public orprivate sector clinics found that the mostimportant priority of women accessingabortion services from private clinics wasthe clinic’s reputation for providing highquality care. In contrast, the most importantpriority for women who sought care frompublic clinics was the convenience of thelocation of the clinic. Other reasons forchoosing clinics that were much lessimportant to the respondents includedknowing the doctor, family members’suggestions, cooperative behavior of staff anddoctor and confi-dentiality of services (Bargeet al. 1997).

IV. POSTABORTION CARE SERVICES

A. Management of Abortion-relatedComplicationsIssue of comlications related to abortion

will exit while, safe abortion services areeccessible to all whomen. Clearly activitiesshould address decreasing unwantedpregnancies and increasing women’s accessto safe abortion services. However, the needto address ongoing complications fromunsafe abortion services cannot be ignored.

The majority of morbidity and deathsfrom unsafe abortion are preventable.Recognizing abortion complications andaccessing appropriate medical care promptlycan reduce the risks of chronic morbidity andmortality from complications of unsafeabortion (Greenslade et al. 1994; Johnson etal. 1992; Salter et al. 1997; World HealthOrganization 1994). The successfultreatment of abortion-related complications

5 While abortion services are supposed to be free in public sector clinics, clients report having to pay for doctor’s fee, hospitalroom fee, medicine, transport and food (Barge et al. 1997).

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is highly dependent on the availability ofsome degree of treatment at all levels of thehealth care system. The elements ofpostabortion care (PAC) services that can beintegrated into a comprehensive abortioncare program include: emergency treatmentof incomplete abortion and potentially life-threatening complications; abortioncontraceptive counseling and services andlinks to other emergency services andreproductive health care services(Greenslade et al. 1994). The studies andinformation gathered on abortion in Indiasuggest that both the availability and qualityof such aspects of abortion care are in-adequate.

Emergency treatment of a complicationis an essential aspect of abortion care. Thefirst step for a woman seeking care is re-cognising that she needs care. Thenfrontline health providers at the communitylevel must be able to recognise what isneeded and treat or refer the woman.

The care a woman receives when a com-plication is first recognised is crucial.Typically, the woman is first cared for in herown home by the female head of household(Potts et al. 1998). Women with complicationstend to play a peripheral role in making thedecision of whether or not they should obtaincare (Ganatra, et al. 1998). If obtaining careis determined necessary, the woman maygo to a traditional birth attendant, trainedmidwife, a range of community levelproviders or a qualified allopathic doctor.There is a general lack of information in ruralcommunity about the type of treatment andthe providers accused by women for abortioncare. If the women who require emergencycare following an abortion complication arenot obtaining it in the health care system,this serivce-delivery gap needs to be betterunderstood and addressed (Potts et al. 1998;Johnston et al. 2001).

Accessing appropriate facilities is a com-plex issue. Research suggests that providers

are not giving women appropriate care afterabortions are provided. For exampleabdominal pain and prolonged bleedingfollowing abortion are often ignored byproviders after providing abortions (IndianCouncil of Medical Research 1989).

Even when women access facilities thathave the basic skills and technology toprovide emergency care, women may getinappropriate care. In Uttar Pradesh Potts etal. (1998) noted a tendency of registeredproviders to scold patients when they presentwith complications of abortion from an unsafeprovider. Some clinicians feel the scoldingattitude discourages women from havingrepeat unsafe abortions. There areindications that emergency treatment canbe painful, even when pain control is applied(Potts et al. 1998).

Delays in receiving appropriatetreatment may occur for a number ofreasons, including: delay in identifying thesymptoms of a com-plication; inability on thepart of the community-level health careprovider to diagnose, manage or stabilisepatients; lack of awareness or concern ofpotential compli-cations; lack of awarenessof an appropriate higher level facility thataccepts referrals for complications ofabortion; and lack of transport to higher levelfacilities and inability to pay for care andassociated costs at higher-level facilities(Ganatra, et al. 1998; Maitra 1998; Potts etal. 1998). Furthermore, women with severecomplications have reportedly been sent awayfrom private clinics because the clinic doesnot want the reputation that women die attheir clinic (Kerrigan, et al. 1995).

Ensuring the appropriate referral ofpatients for clinical care is crucial for im-proving emergency care for complications ofabortion. Components of appropriate referralinclude: accurate clinical assessment of thewoman; appropriate stabilization; accuratediagnosis; complete written record of herpresenting and referral condition; communi-

23

cation between the initiating center and thereferral center; and assistance withtransport to the referral center (Potts et al.1998; Salter et al. 1997).

Women with abortion complications needcare immediately. Too few resources areavailable to women who experience abortioncomplications. The missing resourcesinclude knowledge, authority, transport,close appro-priate medical care and others.

At the level of District Hospitals andMedical College Hospitals, service-deliverychallenges include improving providerattitudes toward abortion patients; ensuringthat facility-based policies and managementactivities support immediate and high-quality emergency postabortion care;ensuring availability of blood products andmedicines essential for clinical treatment;working to minimize problems of diagnosisand referral; improving providers’ attitudestoward women experiencing abortioncomplications; main-taining equipment andexpertise for suction machines for thetreatment of incomplete abortion; promptlytreating women with complications andensuring that patients are not lost to follow-up; recognizing and treating women’sreproductive health and other health needs;and identifying women who have been inabusive situations and referring thesewomen to appropriate resources (Potts et al.1998).

B. Contraceptive counseling andservicesAnother critical element of abortion care

is contraceptive counseling and services.Several studies report that the majority ofabortion clients accept contraception afteran MTP procedure (Barge et al. 1997;Chhabra et al. 1988). However, acceptorsreport that accepting the method can be aprecondition for getting an MTP (Barge et al.1997). Chhabra et al. (1988) report that manywomen obtaining MTP have to be motivatedto accept contraception by clinic staff. They

also noted that women obtaining secondtrimester abortion at a rural Maharashtraclinic often would agree initially to acceptIUD contra-ception, only to refuse the IUDafter the procedure and leave the clinicwithout any method of contraception. A studyconducted in rural Uttar Pradesh shows thatunregistered abortion providers rarely offercontraceptive services (Johnston et al. 2001).

Where postabortion contraceptivecounseling exists, it is reportedly inadequateand not based on the principle of informedchoice. In Uttar Pradesh only one-third ofacceptors were counseled about how themethod works, the possible side-effects, andsteps to take if side-effects are experienced(Barge et al. 1997). Issues such as increasingcontraceptive method mix and maintaininga stable supply of contraceptives arelongstanding in India. Major logistical issuesneed to be addressed before thecontraceptive needs of Indian couples will bemet.

Negative attitudes toward MTP clients byproviders and insufficient contraceptiveknowledge and counseling skills among MTPproviders are thought to be major reasonspostabortion contraception is not widelyaccepted (Kerrigan et al. 1995). Other issuesthat may limit the extent to which contra-ception is accepted after an abortion include:fear of contraceptive side-effects; husbandor other family members may be againstcontraceptive use; ignorance of the womanand the provider of the immediate return tofertility after an abortion; a lack of knowledgeabout appropriate contraceptive methods touse; and an inadequate supply of equipmentand contraceptive commodities. Additio-nally, weak referral networks may limit therange of contraceptive method available(Barge et al. 1997; Potts et al. 1998).

C. Linkages with other reproductive

24

health servicesThe third critical aspect of abortion care,

linking women to other reproductive healthservices suffers from a lack of informationand appropriate facilities in most countriesincluding India. Several studies conductedin Uttar Pradesh have documented a lack ofawareness among medical providers of therisk of sexually transmitted diseases (STDs)or reproductive tract infections (RTIs) contri-buting to the spread of HIV or morbidity suchas secondary infertility and thus a lack ofconcern for postabortion reproductive healthcare such as screening for and treating STDsand RTIs (Barge et al. 1997; Potts et al. 1998).In addition, women who experience repeatspontaneous abortion deserve appropriatecounseling and the option of fertilitytreatment.

Women who obtain abortions and post-abortion care may have experienced rape ordomestic violence. Jejeebhoy (1998) reportsthat an alarming proportion of adolescentabortion seekers became pregnant as aresult of rape. In a study conducted in ruralMaha-rashtra, Ganatra et al. (1988) foundthat domestic violence was the second mostcommon cause of deaths during pregnancy,representing additional morbidity associatedwith pregnancy. The concept of identifyingwomen with additional reproductive healthand other needs and effectively linking withappropriate reproductive health services isclearly an area where additional researchand training is necessary.

V. RECOMMENDATIONS

Results of the research studies reviewedin this paper suggest that abortion andassociated morbidity and mortality fromunsafe abortion are common and should bea top priority safe motherhood issue in Indiaand point to areas that need to be explored toimprove abortion care. Operations researchcould be conducted to test the effectivenessof innovative interventions. In addition a

thorough review of MTP policy and service-delivery guidelines may be beneficial.

A. Improving knowledge of abortion in-cidence

There is an identified absence of verifi-able abortion incidence data in India. Sug-gested rates of abortion and unsafe abortionvary widely. Methods of collecting acceptableabortion incidence data are intensive, usemultiple methods of data collection and in-struments must be designed based on localcultural norms (Anderson et al. 1994; Hun-tington et al. 1996). These fundamental re-quirements necessitate medium-scale stud-ies (several districts or statewide). Intensivestudies of the incidence of abortion and abor-tion complications would be informative andwould yield valuable information particularlyas baseline measures and guides for inter-vention studies.B. Improving pregnancy termination ser-

vices

Results of the literature reviewed pointto areas that need to be addressed to improveabortion care in India. Operations researchcould be conducted to test the effectivenessof innovative interventions. A thoroughreview of MTP policy and service-deliveryguidelines may be required. In addition areview of MTP policy and service-deliveryguidelines could suggest means of increasingwomen’s access to safe abortion services.

Training: Motivate qualified practitionersto attend MTP training courses. The pro-cedures for training and licensing providersand licensing abortion facilities need to beadapted to current situations. MTP trainingshould include training in the various formsof providing MTP (manual vacuumaspiration, electric vacuum aspiration, anddilation and curettage), emergencypostabortion care, postabortion contraceptiveservices and counseling and linking womento additional reproductive health services

25

(Khan et al. 1999).

Review the MTP Act to determine meansin which the Act can be revised to betterimprove abortion services for women. Eachrecom-mendation presented here representsmultiple steps of reviewing and improvingservices to better meet the needs of womenand men at the community level. Somerecommendations to improve health care gobeyond current MTP Act, indicating that thecurrent MTP policy needs to better meet thereproductive health needs of women. Expertshave recommended reviewing the criteriafor certifying providers and consideringincluding additional care of providers for MRand MTP service delivery; reviewing providertraining required; reviewing procedures forlicensing facilities and reconsidering MTPrules and regulations in light of medicalmethods for terminating pregnancies(Chhabra and Nuna 1994; Mathai 1998; Khanet al. 1999).

Upgrade facilities that currently offerabortion services. Monitoring of safe abortionservice providers may be necessary toensure that providers are at their sitesduring clinic hours, that charges do notexceed a set standard, that high quality careis provided from the patient’s entry into theclinic throughout service provision andcontra-ceptive counseling. Public and privatemedical officers could provide monitoringservices (Mathai 1998; Khan et al. 1999;Bandewar 2000).

Orient abortion services to meet theneeds of women by:

Prioritizing confidentiality of abortionservices at public facilities. Confiden-tiality of abortion services is a priorityfor many women obtaining abortionservices. When safe services are notconfidential many women will turnto unsafe but more confidentialservices (Mathai 1998).

Providing high quality care for

women accessing abortion services.Women report scolding attitudesamong pro-viders when presentingfor abortion services. Counselingtraining for providers is essential interms of providing high quality carein service provision, by interactingwith women in a positive manner,providing them with the informationthey need and helping them to makeinformed choices (Mathai 1998).

Increasing geographical accessibilityof safe abortion services for womenof reproductive age in general, andfor adolescents in particular. One keyreason women turn to untrained pro-viders is that untrained providers aremore accessible at the communitylevel compared to trained providers,which tend to require additionaltravel time and associated costs. Toincrease accessibility of safe abortionservices, additional providers could bebased in rural areas. Certainly moremedical providers, particularlywomen pro-viders, could be trained inabortion provision to staff ruralclinics. As many medical providersare unwilling to be based in ruralareas, the strategy of trainingBachelor of Science Nurses, LadyHealth Visitors (LHV) and AuxiliaryNurse Midwives (ANM), to providesafe abortion services with manualvacuum aspiration equip-ment mightbe considered (Khan et al. 1999).

Increasing affordability of safeabortion services. Costs associatedwith publicly and privately providedsafe abortion services prompt womento access abortion services from lessexpensive and untrained providers.Addi-tionally, costs associated withtravel and overnight stays preventwomen from obtaining care fromtrained providers who are often

26

located at substantial distances fromwomen’s residences and increasethe likelihood women will obtainabortion services from an untrainedbut more accessible local provider(Johnston et al. 2001).

Increase awareness among women andmen of reproductive age of the availability ofsafe abortion services and the dangers ofunsafe abortion. Household decision-makersare often husbands and mothers-in-law aswell as pregnant women. All could be thefocus of campaigns that educate about theavailability of safe abortion facilities andmethods and the dangers of unsafe abortionservices. Safe abortion services need tobecome a priority for women accessingabortion and those who decide from whomwomen will access abortion care. The stageof gestation at which a woman can safelyabort a fetus is an important component ofany campaign to increase awareness (Khanet al. 1999; Mathai 1998).

Involve communities and providers at alllevels to improve reproductive health care.In implementing activities to make healthand medical facilities more responsive to thepopulations served, important roles can beplayed by community-level women’s, men’sand adolescents’ organizations. Private,public and NGO medical providers, includingparamedics and unregistered practitionersat the community level, the government fromthe national level to the village level and thepress and other media groups can all beincluded in campaigns to help women accessimproved reproductive health services, in-cluding safe abortion and a wide array ofvoluntary contraceptive services (Khan et al.1999). This multi-sector involvement isparticularly relevant as states are activelydecentralizing health systems and localpanchayats become increasingly involved inhealth care delivery.

Involve men in reproductive health edu-

cation. Many women turn to their husbandsfor decision-making about reproductivehealth issues. In addition to being informedabout the importance of safe abortionservices and signs of abortion complications,men should be addressed in reproductivehealth campaigns that promote smallfamilies and educate about temporary orpermanent contraceptive use (Khan et al.1999; Mathai 1998; Johnston et al. 2001).

Improve adolescent reproductive healthservices in general. Adolescents are particu-larly at risk of serious morbidity and mortal-ity from unsafe abortion. Family Life Educa-tion programs that target unmarried andmarried male and female adolescents needto address issues such as preventing un-wanted pregnancy and recognising and safelymanaging unwanted pregnancy. Statisticsshowing increasing rates of unwanted preg-nancies and unsafe abortion among unmar-ried adolescents demonstrate a need for ado-lescents to be included in reproductive healtheducation and to be able to access reproduc-tive health services, including abortion andcontraception, without the consent of a par-ent or guardian (Jejeebhoy 1998; Mathai1998).

C. Improving abortion careSparse literature on the care surround-

ing abortion service delivery demonstratesthat this is a target area for additional re-search. From the available evidence, the fol-lowing recommendations have been made.

Develop demand for quality emergencyabortion care. Women and key decision-mak-ers need to be advised of the need to accesshigh-quality abortion care services imme-diately if having complications of induced orspontaneous abortion. Women and decision-makers should know that care for abortioncomplications includes stabilization and re-ferral to appropriate service facilities; emer-gency treatment as necessary; high qualitycare, including contraceptive counseling andservices and referral to other health facili-

27

ties as necessary (Maitra 1998; Johnston etal. 2001).

Decentralise abortion care services atpublic and private facilities. Emergency carecapabilities should be expanded to lower lev-els of the formal health care system. Com-munity members and providers should be ableto recognize symptoms of emergency com-plications that require treatment or referraland be able to get women with these compli-cations to appropriate referral facilities.Higher level facilities should be prepared toeffectively and efficiently manage cases ofemergency complications and provide appro-priate postabortion contraceptive counselingand services (Kerrigan et al. 1995; Maitra1998).

The concept of integrating midlevel pro-viders into emergency treatment raisessome policy questions. To what degree canANMs and other midlevel providers and TBAsor dais be included in the abortion care sys-tem? Can ANMs receive training to provideelements of abortion care, including diagnos-ing, stabilizing and referral when necessary,aspirating the uterus, providing postabortioncontraceptive counseling and linking womento other reproductive health services? Whatincentives can be introduced to encourageproviders to refer patients when appropriateinstead of providing treatment for a profit?

Offer informed contraceptive choice.While postabortion contraceptive counselingand services are not being offered at manyabortion service sites, postabortion contra-ception is sometimes imposed coercively(Rajagopal et al. 1996). Identifying determi-nants of voluntary postabortion contraceptiveacceptance will be key to introducing suc-cessful postabortion contraception programs.Postabortion contraceptive counselingshould include information about the correctuse of the various available methods, poten-tial side effects associated with available con-traceptive methods, and means of maintain-ing a steady supply of the selected method.Post-abortion contraceptive services should

be reliably available at the community levelto ensure easy access (Maitra 1998;Johnston et al. 2001).

Provide comprehensive abortion care.Health care providers in general, and par-ticularly those at the referral level, need tobe aware that the interface between thewoman with the complication and the for-mal medical system typically represents arare opportunity to assess other aspects ofthe patient’s reproductive health and providetreatment or refer her to appropriate care.Providers need to be trained in this largelyunrecognized aspect of abortion-related care(Johnston et al. 2001; Potts et al. 1998).

Involve communities and providers at alllevels to improve abortion care. In imple-menting abortion care activities to makehealth and medical facilities moreresponsive to the population they serve,important roles can be played by communitylevel women’s, men’s and adolescentsorganizations, LHVs and ANMs, and publicand private and NGO medical communities.Community level providers, including ANMs,PHC nurses, Anganwadi workers and localdoctors, need to be included as much aspossible in pro-viding a wide array ofvoluntary contra-ceptive services (Johnstonet al. 2001; Kerrigan et al. 1995).

VI. CONCLUSIONSThis review of literature shows that

morbidity and mortality from unsafe abortionremains a serious problem for Indianwomen; 30 years after the indications forlegal abortion were greatly liberalized inIndia. Research results show that unsafeabortions are common; adolescents andunmarried women are most at risk ofmorbidity and mortality from unsafe abortion.Furthermore, studies show that for a numberof reasons current legal abortion services arenot meeting the needs of Indian women,particularly rural women. In four states, alarge sample of registered facilities andcertified providers have been intensivelystudied and from those four state studies,

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means of improving services have beenidentified. In addition, facility-based studiesof abortion provision have identified meansof improving clinical services. A number ofqualitative studies have described the needsof women at the community level.

Policy review recommendations based onthe literature review are made. Anymovement toward revising policy needs tobe made collectively involving Members ofthe Ministry of Health and Family Welfare,public and private abortion providers and keynon-governmental organizations.

This review of literature shows that agreat deal is known about provision of andaccess to safe and unsafe abortion servicesin India and the need to improve safeabortion and contraceptive choices to moreadequately meet the needs of womenexperiencing unwanted pregnancies. Still,a great deal more needs to be known beforeprograms are implemented to ensure low-resource Indian women can readily accesssafe abortion services. The cost in terms ofwomen’s health and lives emphasizes theneed to efficiently and effectively pursueefforts to make abo-rtion safer and moreaccessible for Indian women.

Anderson, Barbara, Kalev Katus, AllanPuur and Brian Silver. 1994. The Validity ofSurvey Responses on Abortion: Evidence fromEstonia. Demography 31 (1):115-132.

Aras, R. Y., N. P. Pai and S. G. Jain. 1987.Termination of Pregnancy in Adolescents.Journal of Postgraduate Medicine 33 (3):120-124.

Arnold, Fred. 1999. Personal Communi-cation.

Bandewar, Sunita. (2000) Unsafe Abor-tion. Seminar May.

Baretto, T., O. M. R. Campbell, J. L.Davies, V. Fauveau, V. G. A. Filippi, W. J. Gra-ham, M. Mamdani, C. I. F. Rooney and N. F.Toubia. 1992. Investigating induced abortionin developing countries: methods and prob-lems. Studies in Family Planning 23:159-170.

Barge, S. and S. Rajagopal. 1996.Situation an alysis of MTP facilities inMaharashtra. Social Change. 26: 226-244.

Barge, Sandhya, Nayan Kumar, GeorgePhilips, Ranjana Sinha, Seema Lakhanpal,Jawahar Vishwakarma, Seema Kumber,Wajahat Ullah Khan, Girish Kumar andVasant Uttekar. 1997. Situation Analysis ofMedical Termination of Pregnancy Services inUttar Pradesh. Baroda: Center for Opera-tionsResearch and Training.

Barge, S., K. Manjunath and S. Nair.1994. Situation analysis of MTP facilities inGujarat. Baroda, India: Centre for OperationsResearch and Training (CORT).

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Bongaarts, John and Robert G. Potter.1983. Fertility, Biology, and Behavior: Ananalysis of the proximate determinants:Academic Press.

Chhabra, Rami and Sheel C. Nuna. 1994.Abortion in India: An Overview. New Delhi:

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Chhabra and Nuna revised an estimatefrom a study conducted in 1966 by theCommittee to Study the Question ofLegalisation of Abortion or the ShahCommittee. The Shah Committee’sestimates were based on India’s 1966population of 500 million and crude birth rateof 39 and the assumption of a constant ratioof 15 induced abortions per 73 live births.The committee derived this ratio fromcommunity studies in Tamil Nadu andhospital studies in Delhi. Chhabra andNuna’s estimates were based on 1991 birthrates and population figures, using the sameShah Committee ratio of abortions to livebirths and suggested 6.7 million legal andillegal induced abortions take place annuallyin India (Chhabra and Nuna 1994). This isthe most widely cited estimate of numbersof induced abortion in India. The estimationtechnique is based on the questionableassumption that 15 abortions occur per 73live births. By assu-ming a constant ratio ofabortions per live births, the variations inabortion rates by state are masked.

Mishra et al. (1988) developed an“induced abortion potential” based oninformation recorded on ill-timed andunwanted pregnan-cies by the NationalFamily Health Survey 1992-93. Age-specificpregnancy rates (ASPR) are derived frompregnancies resulting in live births by ageand age specific fertility rates and representthe number of women in 1000 in a given agecategory who will conceive in a specifiedyear. Out of the number of women at risk ofpregnancy, the number of pregnanciesreported as ill-timed or un-wanted are thoseconsidered to be potentially aborted. Thenumber of potential abortions in the givenage categories is the ASPR multiplied by the

proportion of women reporting ill-timed orunwanted pregnancy. The method ofcalculating total induced-abortion potentialis similar to the method of calculating TotalFertility Rates with age-specific potentialinduced abortion rates used in place of age-specific fertility rates. The authoracknowledges that these rates could easilybe underestimates as once a child is born, awoman is much less likely to think of theassociated pregnancy as unwanted or ill-timed.

The indirect estimation technique is aresidual method based on Bongaarts’proximate determinants of fertility model(Bongaarts and Potter 1983), using dataavailable in the NFHS 1992-93. A standardmaximum potential fertility rate is reducedby delayed marriage, contraceptive use,postpartum infecundability and actualobserved fertility. The residual representsfertility reduced by the remaining proximatedeterminant of fertility and induced abortion.This residual can be translated into a totalabortion rate, which represents the averagetotal number of abortions a woman will havethroughout her reproductive years. A keyquestionable assumption behind this tech-nique is that the minor proximate deter-minants, fecundability (frequency of sexualintercourse), intrauterine mortality andsterility, which are included as constants inthe proximate determinants of fertility model,do not have a varying influence on residualfertility (Johnston and Hill 1996). Theaverage maximum total potential fertilityrate per woman is thought to be 15.3 birthsper woman. If Indian women experiencelower maximum total potential fertility rates,as has been proposed, the rates presentedhere will reflect overestimates. However, therelative rate of abortion will still be representative.

APPENDIX

TECHNIQUES USED TO ESTIMATE ABORTION RATESPRESENTED IN THIS REVIEW