February 2004
Abortion Assessment Project –
India: Key Findings
For many decades
now maternal health has been recognised as a crucial area of concern. In this
context, access, safety and legality issues regarding abortion and abortion
services in India have assumed serious dimension in the context of women’s
reproductive health needs. The Abortion Assessment Project-India (AAP-I), an
all-India research study that commenced in August 2000, was initiated with the
objective of assessing ground realities through rigorous research. The overall
objectives of the project were:
·
Review
Government policy towards abortion care, and policy/programme environment in
the country
·
Assess
and analyse abortion services, including organisation, management, facilities,
technology, registration, training, certification and utilisation in the public
and private sector.
·
Study user perspective with special focus on
women’s perceptions of quality, availability, accessibility (including barriers
to utilisation of safe abortion facilities), confidentiality, consent,
post-abortion contraception and attitude of service providers.
·
Study
social, economic and cultural factors that influence decision-making: impact of
changing social values, male responsibility, family dynamics and
decision-making.
·
Estimate
rate of abortion, resultant morbidity and mortality; causes of spontaneous and
reasons for induced abortion.
·
Document cost and finance issues related to the
above.
·
Disseminate
information on abortion issues widely and develop an advocacy strategy on
issues of concern in the context of reproductive rights of women.
The policy
review, working papers and various studies undertaken in this project
highlights the inadequate attention given to abortion within the health and
population policy of the country and reiterates the often voiced concern that
even the recent Reproductive and Child Health programme, initiated by GOI in
1997, has failed to address issues related to abortion.
Key findings
1.
The
study of abortion facilities across six states (Kerala, Madhya Pradesh, Orissa,
Rajasthan, Haryana and Mizoram) tells us that there are 4 formal (medically
qualified though not necessarily certified for abortions) abortion facilities
per 100,000 population in India. This adds up to 40,000 facilities or 48,000
providers (each facility averages 1.2 providers). Of all the formal abortion
providers 55% are gynaecologists and 64% of the facilities have at least one
female provider. Each of these facilities average 120 abortions per year and
this adds up to 4.8 million (one third in public facilities) abortions being
handled in formal abortion facilities annually. In addition to this there are
more or less similar number of informal (traditional and medically
non-qualified) abortion providers but they undertake about one-third of the
cases handled by formal providers. This gives us a total of about 6.4 million
abortions annually in India.
2.
The
Medical Termination of Pregnancy Act (MTP Act), which legalised abortion, has
been around for 33 years. Though amended earlier this year to facilitate better
implementation the proportion of certified and legal abortion facilities
accounts for only 24% of all private abortion facilities in the country. The
380 facilities (285 private) across six states (Kerala, Madhya Pradesh, Orissa,
Rajasthan, Haryana and Mizoram) covered in the study provide evidence that
those who were certified had obtained certification on an average within a
month and of those who were not certified, 68% had never tried to obtain
certification. Thus the problem lies largely in the domain of the medical
professionals who are not keen to register and become accountable to the
authorities. Lack of ethics in medical practice and absence of self-regulation
amongst the profession is largely responsible for the present state of affairs.
On the positive side it is observed that two-thirds of the providers in the
non-certified facilities had the requisite training or qualification as per MTP
Act to conduct abortions; thus a majority of uncertified facilities were
perhaps providing safe abortions. The latter is confirmed with by fact that
with regard to technical aspects and infrastructure facilities the difference
between the certified and non-certified facilities was small.
3.
On the
method of abortion, our research found that 73% of abortions are conducted for
pregnancies with less than 12 weeks gestation. However, dilatation and
curettage (D&C) seems to be the preferred method for nearly 89% of induced
abortions; even amongst those who use vacuum aspiration the practice of check
curettage is very common. This obsession with curettage both adds to the cost
of the procedure as also contributes substantially to post-abortion
complications and infections.
4.
While
physical access seems to be reasonably good, social access remains restricted
since providers, especially in formal and certified facilities, do not provide
services to women if they come alone and/or if the spouse or some close
relative does not give consent. In the household and qualitative studies women
said that the decision for undergoing an abortion is rarely their own; more
often than not their spouse or some relative decides for them. This affects the
woman’s freedom to access such services and hence to protect her
confidentiality and privacy she may often resort to providers who may not be
very safe. As regards reasons for seeking induced abortions, only 15% of them
fall into what is permitted under the MTP Act (failure of contraceptives,
threat to the woman’s life, biological reasons), the rest were unwanted
pregnancy, economic reasons and even unwanted sex of the foetus. The
community-based household surveys, qualitative
studies and working papers all indicate the prevalence of the practice of
sex-determination and female-selective abortions.
5.
Public
investment in abortion services is grossly inadequate. Only 25% of abortion
facilities in the formal sector are public facilities, 87% of the abortion
market is controlled by the private sector; the average (median) cost of
seeking abortion in the private sector is Rs.1294, 7.5 times more than the cost
in public facilities. This constitutes a major handicap for women who come from
poorer classes or other disadvantaged groups like dalits and adivasis. The
household studies under this project reveal that women from poorer classes and
from dalit and adivasis communities have significantly lower rates of induced
abortion because they often do not have the purchasing power to access abortion
services from the private sector or travel long distances to access public
services. This makes a strong case for both strengthening as well as expanding
public abortion facilities across the country. The RCH-2 phase currently under
preparation needs to factor this in if reproductive health and healthcare of
women have to improve.
6.
The
eight qualitative studies revealed that the
overwhelming reason for seeking abortion among married women was to limit the
family size. When women were asked to indicate the situations in which they
would seek abortion or had actually sought abortion, the majority of the women
in studies conducted in Maharasthra, Gujarat, Andhra Pradesh and Tamil Nadu
reported limiting the family size as the main reason for abortion. Equally
disturbing was the finding that non-use of contraception rather than
contraceptive failure was reported to be the chief reason why the unwanted
pregnancy situations described above tended to occur. Actual contraceptive
failure was reported in very few cases. Though all respondents across studies
reported knowledge of sterilisation as a method of limiting family size and a
majority of the women knew about the reversible methods of contraception such
as condoms, oral pills and IUD for spacing births – yet this knowledge did not
translate into practice for a range of reasons – fear about its effect on
health, pain and discomfort, irregular supply and problems with obtaining
permission from husband. Use of condoms for contraception was rare!
Paradoxically, there was a perception that abortion was safe and did not have
any long-term adverse health consequences. For some respondents it was seen as
a ‘safer’ option than the use of IUDs and other spacing methods!
- Also,
almost all women were aware that sex selective abortion was illegal, and
admitted that women approach different facilities for ascertaining the sex
of the foetus and for abortion. Awareness of the new PNDT Act was far
greater among women and service providers in comparison to the details of
the MTP Act. Group discussions invariably turned spirited when sex
selection was discussed. While most respondents admitted that sex
selective abortion is indeed illegal, they expressed helplessness as their
status in the family and sometimes the very survival of their marriage
depended on their ability to produce sons. Women openly and without any
hesitation talked about it in almost all the areas. The studies also revealed that when
couples have more than two female children, then female selective abortion
was approved by the family and condoned by the community. There was no
social stigma associated with sex selective abortion – especially for
mothers with many daughters. Women from Gujarat and Haryana also reported
that while they were not comfortable with abortion per se, when it was
done for the sake of the family, then they accepted it.
- Private doctors have
better facilities and equipment and that they are not in a hurry to
discharge women soon after the procedure if they need rest for an hour or
so before going home. In public hospitals, on the other hand, given a
shortage of beds women are asked to leave as soon as possible.
- Private doctors treat
women better and ensure confidentiality.
- It was accepted that while the
services of private providers cost money, visits to the government
hospitals were also not cost-free because women had to pay for medicines
separately. They were sometimes required to make repeat visits before the
abortion was performed. The long waiting period implied that the time of
the service seeker and of the accompanying person (generally women do not
go alone to impersonal large facilities) was wasted, leading particularly
in poor families foregoing wages for that time. The cost varied according to the type of
provider and the gestation period. For example the
cost in private facilities in urban Gujarat varied between Rs. 400-600,
similar to what women in urban Andhra Pradesh had to pay.
Emerging
Advocacy issues
o
Changing
mindset of providers through their professional associations to accept
certification on a universal basis
o
Integrating
abortion services under Primary Health Centres and Community Health Centres
through a strengthened RCH programme – which would automatically enhance
women’s access to abortion care services.
o
Promoting
safer technologies by changing the mindset of providers away from unnecessary use
of curettage
o
Strengthening
regulation of abortion facilities to evolve minimum standards for quality care
and accreditation
o
Promoting
safe spacing methods of contraception to reduce the need to resort to abortion
as a spacing method
o
Broadening
the base of providers by training paramedics for early trimester abortions as
is done in many countries like South Africa, Bangladesh etc.
o
The
need to widely display certification status of abortion facilities so that
women can recognise a safe abortion facility
o
The
need to educate providers on ethics of sex-determination tests and respecting
the provisions of the PNDT Act
o
The
need for medical associations to get active in training abortion providers,
especially those in the private sector
o
Promoting
apprenticeship as a method of training
o
Reskilling
of traditional providers to play alternative roles in supporting abortion
services
These studies
were carried out by various research institutions in the different states and
coordinated by Ravi Duggal from CEHAT, Mumbai and Vimala Ramachandran from
Healthwatch, Delhi. The AAP-I was supported by the Ford Foundation, Delhi,
MacArthur Foundation, Chicago and Rockefeller Foundation, New York. Copies of
papers and reports are available at the address below.
CEHAT and
HealthWatch
Sai Ashray,
Aram Society Road
Vakola,
Santacruz East
Mumbai 400055
