Physicians’ and non-physicians’ views about provision of medical abortion by nurses and AYUSH physicians in Maharashtra and Bihar, India

Abstract

There is only limited evidence on whether certified and uncertified health care providers in India support reforming the Medical Termination of Pregnancy (MTP) Act to expand the abortion provider base to allow trained nurses and AYUSH physicians (who are trained in Indian systems of medicine) to provide medical abortion. To explore their views, we conducted a survey of 1,200 physicians and other health care providers in Maharashtra and Bihar states and in-depth interviews with 34 of them who had used medical abortion in their practices. Findings indicate that obstetrician-gynaecologists and other allopathic physicians were less supportive than non-physicians of nurses and AYUSH physicians providing early medical abortion. The physicians did not think that these providers would be able to assess women’s eligibility for medical abortion correctly. In contrast, the majority of non-physicians found task shifting of medical abortion provision to trained nurses and AYUSH physicians acceptable, and they were confident that these providers would be able to provide medical abortion as safely and effectively as trained physicians. Assuming the reforms are passed, efforts will need to be made by government and medical professional bodies to train these new providers to undertake this role, prepare the health infrastructure to include them, and create an environment, including among physicians, that is conducive to enabling non-physicians to provide medical abortion.

Résumé

Il est difficile de dire si les prestataires de santé agréés ou non en Inde soutiennent la réforme de la loi sur l’interruption médicale de grossesse qui devrait élargir la base des prestataires de services d’avortement pour permettre aux infirmières qualifiées et aux médecins AYUSH (qui sont formés au système indien de médecine) de pratiquer les avortements médicamenteux. Pour étudier leurs idées, nous avons réalisé une enquête auprès de 1200 médecins et autres prestataires de soins de santé dans les États du Maharashtra et Bihar et des entretiens approfondis avec 34 d’entre eux qui avaient eu recours à l’avortement médicamenteux dans leur pratique. Les conclusions indiquent que les gynécologues-obstétriciens et autres médecins allopathiques étaient moins favorables que les non-médecins à la possibilité pour les infirmières et les médecins AYUSH de réaliser des avortements médicamenteux précoces. Les médecins ne pensaient pas que ces personnels pouvaient évaluer correctement les conditions à remplir pour bénéficier d’un avortement médicamenteux. Au contraire, la majorité des non-médecins trouvaient acceptable le transfert de l’avortement médicamenteux aux infirmières qualifiées et aux médecins AYUSH, et ils pensaient que ces prestataires pourraient pratiquer l’avortement médicamenteux aussi sûrement et efficacement que les médecins qualifiés. Si les réformes sont adoptées, les pouvoirs publics devront s’efforcer de former les nouveaux prestataires à ce rôle, préparer l’infrastructure de santé pour les y inclure et créer, notamment parmi les médecins, un environnement qui soit propice à la réalisation d’avortements médicamenteux par des non-médecins.

Resumen

Existe limitada evidencia en cuanto a si profesionales de la salud certificados y no certificados en India apoyan la reforma de la ley de Interrupción Médica del Embarazo para ampliar la base de prestadores de servicios de aborto con el fin de permitir que enfermeras capacitadas y médicos de AYUSH (capacitados en sistemas indios de medicina) proporcionen servicios de aborto con medicamentos. Para explorar sus puntos de vista, encuestamos a 1200 médicos y otros profesionales de la salud en los estados de Maharashtra y Bihar y realizamos entrevistas a profundidad con 34 de ellos que habían utilizado el método de aborto con medicamentos en sus consultorios. Los hallazgos indican que los gineco-obstetras y otros médicos alópatas se mostraron más renuentes que profesionales no médicos para apoyar la prestación de servicios de aborto con medicamentos en las etapas iniciales del embarazo por parte de enfermeras y médicos de AYUSH. Los médicos no creían que estos profesionales de la salud podrían evaluar correctamente la elegibilidad de las mujeres para tener un aborto con medicamentos. En cambio, la mayoría de los profesionales no médicos consideraron aceptable asignar a enfermeras y médicos de AYUSH capacitados la tarea de proporcionar servicios de aborto con medicamentos, y confiaban en que estos profesionales de la salud podrían proporcionar dichos servicios tan segura y eficazmente como los médicos capacitados. Suponiendo que las reformas sean aprobadas, el gobierno y las asociaciones de profesionales médicos deberán realizar esfuerzos para capacitar a estos nuevos prestadores de servicios para que asuman este rol, preparar la infraestructura de salud para incluirlos y crear un ambiente, incluso entre médicos, que se preste para permitir que profesionales no médicos proporcionen servicios de aborto con medicamentos.

Keywords:

• abortion law and policy
• medical abortion
• task shifting
• mid-level providers
• AYUSH physicians
• nurses
• India

Acknowledgements

The authors acknowledge the technical and financial support from HRP (UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction). The authors would like to thank Shireen Jejeebhoy, Sushanta Kumar Banerjee and Kurus Coyaji for insightful comments on earlier versions of this paper.

Notes

* Abortion is legal in India when performed by a certified medical practitioner in a hospital or institution approved by the Government. Obstetrician-gynaecologists (Ob/Gyns) are certified by way of their training. Other doctors with a degree equivalent to MBBS or higher can provide abortions up to 12 weeks of pregnancy LMP if they have received theoretical and practical training involving observing, assisting and performing a total of 25 abortions in a registered facility. Only Ob/Gyns can provide abortions of pregnancies between 13–20 weeks. Certified medical practitioners can also prescribe medical abortion pills up to nine weeks of pregnancy in an unapproved clinic, provided they have referral access to a facility approved for abortions.

* AYUSH encompasses physicians trained in Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy. A separate Department of AYUSH has been set up in the Ministry of Health and Family Welfare, Government of India, for the provision of services relating to these officially recognized Indian Systems of Medicine.

* Rural medical practitioners usually learn their skills in the course of assisting trained medical doctors.

a Multiple responses were allowed, %s may add up to more than 100%.