Press Release

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!

 

  1. 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.

 

8.       There was an overwhelming perception that private facilities were better. The reason for preferring private providers was quite wide, suggesting that the women and their families do weigh the alternatives before deciding where to go. Reasons cited by women were:

a.        Abortion in private facility takes much less time – everything is done in one visit, meaning that they do not waste time waiting and going through formalities (as most government hospitals are not client friendly) and the everything could be wrapped up in one visit.

    1. 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.
    2. Private doctors treat women better and ensure confidentiality.

 

  1. 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