Characteristics of abortion service providers in two northern Indian states

Abstract

Background

Despite liberal laws, abortions are a major cause of maternal morbidity and mortality in India.

Study Design

This study uses health provider data (N=2039) collected in Bihar and Jharkhand states, India, in 2004. Logistic regression models are fitted to identify correlates of providers' practice of abortion services and intention to offer medical abortions.

Results

While a majority of respondents (63.2%) provide abortion services, only 2.9% currently provide medical abortions and 23.8% intend to provide medical abortions. Private rather than public clinic providers and female rather than male providers are more likely to offer abortion services and intend to provide medical abortions. Aspects related to medical abortion's market demand, its safety, efficacy and perceived ease of delivery weigh more than patients' rights and personal interests on providers' decision to provide medical abortions.

Conclusion

This study enlarges the knowledge base on abortion service providers and offers recommendations for improving access to safe abortion services in India.

Introduction

The Medical Termination of Pregnancy (MTP) Act of 1971 significantly liberalized abortion laws in India. An abortion is permitted in order to save the life of a woman, to preserve her physical and mental health, in cases of rape or incest, in case of fetal impairment and for economic or social reasons; additionally, contraceptive failure on the part of the wife or husband constitutes valid grounds for legal pregnancy termination. However, abortion is not available on request. Legal abortions must be performed during the first 20 weeks of gestation by a registered physician in a hospital established or maintained by the Indian Government or in a facility approved by specific legislation [1].

A variety of methods used for MTP include dilatation and curettage, electronic and manual vacuum aspiration in the first trimester, extraamniotic and intraamniotic instillations, and dilatation and evacuation in the second trimester of pregnancy. Aiming to expand safe abortion services, in April 2002, the Government of India approved mifepristone coupled with misoprostol for induced abortion in gestations of up to 49 days [2]. Hence, surgical and medical abortions are both available in India. Although abortions in the public sector are free of charge if the woman accepts some form of contraception, government facilities are not the leading providers of abortions; rather, private sector services are predominantly accessed [3]. The Abortion Assessment Project that began in mid-2000 is one of the largest studies on abortion ever undertaken in India; it showed that three quarters of abortion-certified facilities are found in the private sector and are overwhelmingly perceived to offer better services than public facilities [4].

Nonetheless, induced abortions represent a major cause of maternal mortality and morbidity in India. According to government data, only about 1 million abortions are performed annually under the MTP Act, while the number of abortions performed outside approved facilities varies between 2 and 6 million per year; it is estimated that unsafe abortions account for 12–20% of maternal deaths in India [1], [2], [5]. The level of awareness on the legality of abortion is fairly low; implementation of the 1971 Act has been slow and geographically uneven. There is a mismatch between availability of government-equipped facilities, MTP-certified providers and facilities where services are available [1], [6]. Access to legal abortion services is particularly inadequate in Bihar and Jharkhand states in India, especially so for 75% of the population living in rural areas. About 10% of the country's population lives in these states, where only 1.2% of all certified abortion facilities are located [7].

It appears that medical abortion offers great potential for improving access to abortion services in India. Several studies investigated the safety, efficacy and acceptability of mifepristone and misoprostol in this country. They showed that medical abortion is quite acceptable and increasingly requested by Indian women [6], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Moreover, a large comparative trial of mifepristone and misoprostol versus surgical abortion conducted in China, Cuba and India found that a higher number of medical than surgical abortion patients indicated they would opt again for the same procedure [15]. Additionally, a recent study by Mundle et al. [16] showed that provision of medical abortions is feasible and acceptable in Indian rural facilities that do not offer surgical abortion services, suggesting that introduction of medical abortion at lower levels of the health care system could increase access to safe abortion in rural India.

Little is known about how providers practice and perceive medical abortions. Ramachandar and Pelto [12] reported on attitudes toward and practice of medical abortion by qualified abortion providers in a rural area of Tamil Nadu, India, in 2005. About one third of the private doctors interviewed provided medical abortion to 70–80% of their patients, another third of the private doctors provided medical abortion to a selected minority, while the rest either rejected or did not know the method [12]. A survey of 209 chemists conducted in Bihar and Jharkhand states by Ganatra et al. [17] found that only 34% of the interviewees stocked mifepristone and misoprostol, that sales volumes were low and that there was greater demand for cheaper ineffective abortion preparations; moreover, while chemists knew that mifepristone and misoprostol were prescription drugs, they were often not clear on dosage and side effects.

This study has two objectives: (a) to identify sociodemographic and work-related characteristics of Indian providers offering or assisting with medical and/or surgical abortions, providing postabortion care as main abortion service offered, and intending to offer medical abortions in Bihar and Jharkhand states in India, and (b) to examine the providers' reasons for offering medical abortions.