India Must Improve Monitoring Of Pill-induced Abortions To Safeguard Women’s Health

Mumbai: Four out of five abortions in Gujarat, Bihar and Uttar Pradesh are induced using a drug or a combination of drugs, according to a new study.

While this medical method of abortion (MMA) has a success rate of 95%-98% if administered properly and before nine weeks of gestation, the study found that the lack of medical supervision has resulted in a significant number of botched abortions in India.

Incomplete abortions after the use of pills caused 65% of complications in women seeking post- abortion care in Assam, 59% in UP and 51% in Bihar, stated the report. The method was legalised in India by amending MTP act in 2002 to strengthen access to safe abortions up to seven weeks and it is still considered one of the safest and most effective measures.

The reportThe Incidence of Abortion and Unintended Pregnancies in Six Indian States’, published on November 13, 2018, provides data for Assam, Gujarat, Bihar, Madhya Pradesh Tamil Nadu and Uttar Pradesh, which together account for 45% of women of reproductive age in India. The study was conducted jointly by Indian Institute for Population Sciences, Mumbai, Population Council, New Delhi and New York-based Guttmacher Institute, a research organization that promotes reproductive health and rights globally.

The prime reason for the abortion complications, the study found, was that women did not undergo the stipulated 15-day procedure for termination of pregnancy which requires at least two visits to a health facility.

Of the 7.6 million abortions that took place in 2015 in the six study states, 77% or 5.8 million were carried out through non-facility MMA and Uttar Pradesh alone accounted for 2.6 million.

The guidelines in the Handbook for MMA, issued by the ministry of health and family welfare, require that Mifepristone and Misoprostol, the two-drug regimen used to induce abortion, can only be provided only by a registered medical practitioner or a government hospital. But, the UPAI study found that most women obtained it from informal vendors and chemists. This means that they are not counselled and lack adequate information about the usage and side-effects of these drugs.

More than half of all abortions in India continue to be unsafe, and incomplete abortions have increased from around 30% to over 50% in the last five years, which shows the increase in unsuccessful home medical abortion attempts, IndiaSpend had reported on November 5, 2016.

The new study underlines the importance of abortion as an indicator that reflects a region’s contraceptive behaviour, unintended pregnancies and the type of termination services offered.

‘Abortion numbers are underestimated in India’

While abortion has been legal in India for over five decades, maternal deaths remain an issue: As many as 56% abortions in India are unsafe; 8.5% of all maternal deaths in India are due to unsafe abortion; and 10 women die every day due to this reason, IndiaSpend had reported on November 22, 2017.

The new study is a follow-up of the report published by The Lancet Global Health in December 2017 titled The Incidence of Abortion and Unintended Pregnancy in India, 2015.

The previous report estimated 15.6 million abortions in the country in 2015, of which 73% or 11.5 million were obtained through MMA medication outside health facilities, 22% or 3.4 million occured in health facilities and 5% were done outside facilities using unsafe methods.

But the NFHS-4 survey estimated that a majority of abortions, as many as 52%, were provided in private health facilities, about 20% in public facilities and 26% were performed by women themselves.

“Statistics compiled by the Indian Government on the number of abortions provided in facilities are known to greatly underestimate abortion incidence because the coverage of facility-based services is incomplete and in addition, many abortions occur outside of a facility setting,” the report argues. Hence, the study used data from indirect sources, by conducting a large-scale sample survey of public and private facilities that provide abortion and data on sales of medication abortion drugs.  

Public health facilities plagued by shortage of trained doctors and stigma

Of all the facility-based abortions in the six states studied, about 13% were performed in private facilities; public facilities accounted for only 5% of abortions. Only Assam registered 15% of induced abortions in public facilities while Bihar, Gujarat and UP lagged behind at 2%, 3% and 4% respectively.

“The state government of Assam had over the last four- five years made a concerted attempt to improve comprehensive abortion care in the public health facilities,” said Vinoj Manning, chief executive officer of Ipas Development Foundation India, an advocacy group that works to prevent unsafe abortions. “They allocated adequate money in their annual health budget and ensured utilisation of the budgets for training and certifying new MBBS providers to provide abortion care at primary and community health centres (PHCs and CHCs).”

Though the medical termination of pregnancy (MTP) Act, 1971 was passed 50 years ago, safe abortion is still not a reality for women in India. Manning puts this down to multiple reasons. “Lack of access to safe abortion for women owing to the paucity of services where it is needed the most – close to their homes/communities – and shortage of legal providers, is one of the core reasons,” he said. “Additionally, many women continue to be unaware about abortion being legal in India, and the knowledge about where, when and how they can access safe services.”

PHCs need to step up abortion services

Barriers to abortions were commonly observed in PHCs, which are essentially the first point of contact to a qualified medical practitioner for those living in rural areas. “PHCs typically have limited capacity to offer the service, and across the six study states, only a small proportion do so (3–14%)”, the report said. Hence the burden of performing abortions shifted to the large public facilities like the public hospital or the community health centres.

“MTP trained doctors are mostly located in the urban area,  while majority of our population live in the rural areas,” Sushanta Banerjee, head of research and evaluation team at Ipas Development Foundation, told IndiaSpend. “We still have high unmet need for safe abortion at PHCs. Even when a PHC doctor is trained on providing abortion services, the community remains unaware of this service.”

Although there is a provision for one gynaecologist in every CHC, there is a 76.3% shortfall of obstetricians and gynaecologists compared to their requirement at CHCs, IndiaSpend had reported on November 22, 2017.

Why women end up looking for informal, dangerous abortion services

Public and private health facilities denied women abortion beyond the prescribed 20-week  gestational period, as per the study. As many as 29% of public hospitals in Bihar and 63% in Assam provided second trimester abortions, the study showed. But in Gujarat and Tamil Nadu, CHCs and PHCs did not provide second trimester abortions which made women look to informal methods of termination.

The report also states that 54-87% of facilities in the six study states had turned away at least one woman seeking termination of pregnancy. The reasons cited by facilities included shortage of staff, lack of supplies or for not having consent from their husbands or a family member which are not legal grounds for denying abortions.

To ensure that women do not buy MMA pills from informal vendors, Banerjee recommended improved abortion services at all levels of public health facilities. “There is also an urgent need to move from medical doctors to mid-level providers, including nurse and midwives,” he said. “Over reliance on medical doctors will restrict the access and will influence to women to go to informal providers.”

Update: The story's headline has been updated on March 1, 2019.

(Nihalani is an intern with IndiaSpend.)

Mumbai: Four out of five abortions in Gujarat, Bihar and Uttar Pradesh are induced using a drug or a combination of drugs, according to a new study.

While this medical method of abortion (MMA) has a success rate of 95%-98% if administered properly and before nine weeks of gestation, the study found that the lack of medical supervision has resulted in a significant number of botched abortions in India.

Incomplete abortions after the use of pills caused 65% of complications in women seeking post- abortion care in Assam, 59% in UP and 51% in Bihar, stated the report. The method was legalised in India by amending MTP act in 2002 to strengthen access to safe abortions up to seven weeks and it is still considered one of the safest and most effective measures.

The reportThe Incidence of Abortion and Unintended Pregnancies in Six Indian States’, published on November 13, 2018, provides data for Assam, Gujarat, Bihar, Madhya Pradesh Tamil Nadu and Uttar Pradesh, which together account for 45% of women of reproductive age in India. The study was conducted jointly by Indian Institute for Population Sciences, Mumbai, Population Council, New Delhi and New York-based Guttmacher Institute, a research organization that promotes reproductive health and rights globally.

The prime reason for the abortion complications, the study found, was that women did not undergo the stipulated 15-day procedure for termination of pregnancy which requires at least two visits to a health facility.

Of the 7.6 million abortions that took place in 2015 in the six study states, 77% or 5.8 million were carried out through non-facility MMA and Uttar Pradesh alone accounted for 2.6 million.

The guidelines in the Handbook for MMA, issued by the ministry of health and family welfare, require that Mifepristone and Misoprostol, the two-drug regimen used to induce abortion, can only be provided only by a registered medical practitioner or a government hospital. But, the UPAI study found that most women obtained it from informal vendors and chemists. This means that they are not counselled and lack adequate information about the usage and side-effects of these drugs.

More than half of all abortions in India continue to be unsafe, and incomplete abortions have increased from around 30% to over 50% in the last five years, which shows the increase in unsuccessful home medical abortion attempts, IndiaSpend had reported on November 5, 2016.

The new study underlines the importance of abortion as an indicator that reflects a region’s contraceptive behaviour, unintended pregnancies and the type of termination services offered.

‘Abortion numbers are underestimated in India’

While abortion has been legal in India for over five decades, maternal deaths remain an issue: As many as 56% abortions in India are unsafe; 8.5% of all maternal deaths in India are due to unsafe abortion; and 10 women die every day due to this reason, IndiaSpend had reported on November 22, 2017.

The new study is a follow-up of the report published by The Lancet Global Health in December 2017 titled The Incidence of Abortion and Unintended Pregnancy in India, 2015.

The previous report estimated 15.6 million abortions in the country in 2015, of which 73% or 11.5 million were obtained through MMA medication outside health facilities, 22% or 3.4 million occured in health facilities and 5% were done outside facilities using unsafe methods.

But the NFHS-4 survey estimated that a majority of abortions, as many as 52%, were provided in private health facilities, about 20% in public facilities and 26% were performed by women themselves.

“Statistics compiled by the Indian Government on the number of abortions provided in facilities are known to greatly underestimate abortion incidence because the coverage of facility-based services is incomplete and in addition, many abortions occur outside of a facility setting,” the report argues. Hence, the study used data from indirect sources, by conducting a large-scale sample survey of public and private facilities that provide abortion and data on sales of medication abortion drugs.  

Public health facilities plagued by shortage of trained doctors and stigma

Of all the facility-based abortions in the six states studied, about 13% were performed in private facilities; public facilities accounted for only 5% of abortions. Only Assam registered 15% of induced abortions in public facilities while Bihar, Gujarat and UP lagged behind at 2%, 3% and 4% respectively.

“The state government of Assam had over the last four- five years made a concerted attempt to improve comprehensive abortion care in the public health facilities,” said Vinoj Manning, chief executive officer of Ipas Development Foundation India, an advocacy group that works to prevent unsafe abortions. “They allocated adequate money in their annual health budget and ensured utilisation of the budgets for training and certifying new MBBS providers to provide abortion care at primary and community health centres (PHCs and CHCs).”

Though the medical termination of pregnancy (MTP) Act, 1971 was passed 50 years ago, safe abortion is still not a reality for women in India. Manning puts this down to multiple reasons. “Lack of access to safe abortion for women owing to the paucity of services where it is needed the most – close to their homes/communities – and shortage of legal providers, is one of the core reasons,” he said. “Additionally, many women continue to be unaware about abortion being legal in India, and the knowledge about where, when and how they can access safe services.”

PHCs need to step up abortion services

Barriers to abortions were commonly observed in PHCs, which are essentially the first point of contact to a qualified medical practitioner for those living in rural areas. “PHCs typically have limited capacity to offer the service, and across the six study states, only a small proportion do so (3–14%)”, the report said. Hence the burden of performing abortions shifted to the large public facilities like the public hospital or the community health centres.

“MTP trained doctors are mostly located in the urban area,  while majority of our population live in the rural areas,” Sushanta Banerjee, head of research and evaluation team at Ipas Development Foundation, told IndiaSpend. “We still have high unmet need for safe abortion at PHCs. Even when a PHC doctor is trained on providing abortion services, the community remains unaware of this service.”

Although there is a provision for one gynaecologist in every CHC, there is a 76.3% shortfall of obstetricians and gynaecologists compared to their requirement at CHCs, IndiaSpend had reported on November 22, 2017.

Why women end up looking for informal, dangerous abortion services

Public and private health facilities denied women abortion beyond the prescribed 20-week  gestational period, as per the study. As many as 29% of public hospitals in Bihar and 63% in Assam provided second trimester abortions, the study showed. But in Gujarat and Tamil Nadu, CHCs and PHCs did not provide second trimester abortions which made women look to informal methods of termination.

The report also states that 54-87% of facilities in the six study states had turned away at least one woman seeking termination of pregnancy. The reasons cited by facilities included shortage of staff, lack of supplies or for not having consent from their husbands or a family member which are not legal grounds for denying abortions.

To ensure that women do not buy MMA pills from informal vendors, Banerjee recommended improved abortion services at all levels of public health facilities. “There is also an urgent need to move from medical doctors to mid-level providers, including nurse and midwives,” he said. “Over reliance on medical doctors will restrict the access and will influence to women to go to informal providers.”

Update: The story's headline has been updated on March 1, 2019.

(Nihalani is an intern with IndiaSpend.)