Original research articleCharacteristics of abortion service providers in two northern Indian states☆
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.
Section snippets
Materials and methods
This study uses health provider data collected between January and June 2004 in Bihar and Jharkhand states in India. A multistage cluster sampling was applied to the entire two states, except for some of the southwest districts that were politically unsafe for fieldwork. Districts within the states' regions were listed, and two were selected with probability proportional to size for each region. The district was then divided into urban and rural strata, and further divided into blocks within
Results
Table 1 shows the health provider sample's characteristics. A majority (63%) of providers in our sample directly provide or supply some type of abortion services, with 4.7% performing either surgical or medical abortions, 2.9% being current providers of medical abortion, 3.1% assisting with provision of abortions and 13.4% offering mainly postabortion care. The most interesting difference found between rural and urban providers is that rural providers are almost twice as likely to offer medical
Discussion
The first objective of this study was to examine the characteristics of Indian abortion service providers in Bihar and Jharkhand states 2 years after the implementation of the last abortion policy amendments. More than three fifths of the providers interviewed in this 2004 study are offering some type of abortion care (i.e., perform abortions, assist with provision of abortions, offer postabortion care or counseling). However, given the legal restrictions whereby only physicians working in
Acknowledgments
The authors acknowledge the collaboration and support of the Janani program of DKT International and the field staff of Taylor-Nelson-Sofres-Mode, India, for data collection. The authors also appreciate the helpful comments of an anonymous reviewer.
References (17)
Abortion law, policy and services in India: a critical review
Reprod Health Matters
(2004)The political economy of abortion in India: cost and expenditure patterns
Reprod Health Matters
(2004)- et al.
The Abortion Assessment Project India: key findings and recommendations
Reprod Health Matters
(2004) - et al.
Attitudes about medical abortion among Indian women
Int J Gynaecol Obstet
(2005) - et al.
Medical abortion in rural Tamil Nadu, South India: a quiet transformation
Reprod Health Matters
(2005) - et al.
Mifepristone–misoprostol abortion: a trial in rural and urban Maharashtra, India
Contraception
(2002) - et al.
Mifepristone abortion outside the urban research hospital setting in India
Lancet
(2001) - et al.
Safety, efficacy, and acceptability of medical abortion in China, Cuba, and India: a comparative trial of mifepristone–misoprostol versus surgical abortion
Am J Obstet Gynecol
(1997)
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Home administration of misoprostol for early medical abortion in India
2010, International Journal of Gynecology and ObstetricsCitation Excerpt :The uptake of the method and regimens used varies widely by region, location (i.e. urban vs rural), and type of provider [6–8]. Private sector providers are more likely to offer abortion services, as well as medical abortion, while the public sector has been slow to incorporate the new technology [6,8]. A regimen that allows the choice of home administration can potentially make medical abortion more acceptable to women and providers by eliminating the need for additional clinic visits that may be costly and inconvenient.
Support for provision of early medical abortion by mid-level providers in Bihar and Jharkhand, India
2009, Reproductive Health MattersWhy do women abort their pregnancies? Evidence from the National Family Health Survey (2019-21) of India
2023, Journal of Biosocial SciencePatterns and correlates of post-abortion complications in India
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2019, Global Public Health
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The authors acknowledge study funding support from the David and Lucile Packard Foundation.