The Role of Village Health Nurses in Mediating Abortions in Rural Tamil Nadu, India

Abstract

Abstract

This paper reports on qualitative research on abortion services in the Coimbatore district of Tamil Nadu in south India, and the role of government village health nurses (VHNs) in assisting women to obtain abortions. The aim of the research, carried out in 1997, was to document the process married women go through to obtain abortions in both the public and private sectors, particularly women in rural areas, and why they preferred private clinics. The research consisted of direct observation of “sterilization/medical termination of pregnancy camps” at rural primary health centres and in hospital settings, plus informal and in-depth, open-ended interviews with medical officers, gynaecologists, government medical administrators, VHNs and other health care personnel. It found that VHNs were not only helping their clients to obtain abortions in government facilities but also and more often with qualified private providers. Unmarried girls were excluded from this process by the need for secrecy, however, and were perceived to still be going to unqualified providers. Government records show that there were clear reductions in the availability of public abortion services in the rural areas throughout the 1990s. The widespread perception that private services were safer and treated women better, the increased availability of qualified private abortion providers and the help of VHNs to access private services all encouraged married women to use the private sector.

Résumé

Cette recherche qualitative porte sur les services d'avortement dans le district de Coimbatore dans le Tamilnadu au sud de l'Inde, et le rôle des infirmières de village des services gouvernementaux pour aider les femmes à avorter. L'étude, menée en 1997, portait sur les démarches accomplies par les femmes mariées, particulièrement dans les zones rurales, pour obtenir un avortement dans les secteurs publics et privés, et pourquoi elles préféraient les cliniques privées. Les chercheurs ont observé des “camps d'interruption de grossesse/stérilisation” dans les centres ruraux de soins de santé primaires et à l'hôpital, et ont interrogé des médecins, des gynécologues, des administrateurs médicaux de l'Etat, des infirmières de village et d'autres personnels de santé. Ils ont montré que les infirmières de village aidaient leurs patientes à obtenir des avortements dans les centres gouvernementaux, mais aussi de plus en plus auprès de prestataires privés qualifiés. Néanmoins, les célibataires étaient exclues de ce processus par nécessité de garder le secret et s'adressaient encore à des praticiens non qualifiés. Les dossiers administratifs révèlent que, dans les années 90, la disponibilité des services publics d'avortement a diminué dans les zones rurales. L'idée fréquente que les services privées étaient plus sûrs et traitaient mieux les femmes, la disponibilité accrue de praticiens privés et l'aide des infirmières de village pour accéder aux services privés étaient autant de facteurs encourageant les femmes mariées à utiliser le secteur privé.

Resumen

En 1997 se llevó a cabo una investigación cualitativa sobre los servicios de aborto existentes en el distrito de Coimbatore en Tamilnadu en el sur de la India, y sobre el papel de las enfermeras comunitarias en ayudar a las mujeres a obtener abortos. El objetivo de la investigación era documentar el proceso por el cual pasan las mujeres casadas para obtener abortos, tanto en los sectores públicos como privados, especialmente las mujeres en áreas rurales. Se indagó además acerca de su preferencia por las clı́nicas privadas. La investigación consistió en la observación directa de los “campos de esterilización/aborto médico” en los centros de salud primaria rurales y en hospitales, además de entrevistas informales y a profundidad con directores médicos, ginecólogos, administradores médicos estatales, enfermeras comunitarias, y otro personal de la salud. Los resultados revelaron que las enfermeras comunitarias no solamente ayudaban a sus clientes a obtener abortos en los servicios de salud estatales sino también, y con más frecuencia, con proveedores privados calificados. Las jóvenes solteras estaban excluı́das de este proceso debido a la necesidad de mantener el secreto; sin embargo existı́a la percepción de que ellas recurrı́an a proveedores no capacitados. Los datos gubernamentales muestran claras reducciones en la disponibilidad de servicios de aborto públicos en las áreas rurales durante la década de los 90. La percepción generalizada de que los servicios privados fueran más seguros y que trataran mejor a las mujeres, el aumento en la disponibilidad de proveedores privados capacitados para hacer abortos, y la ayuda de las enfermeras comunitarias impulsaban a las mujeres casadas a utilizar los servicios del sector privado.

Key Words:

• induced abortion
• abortion providers and services
• health policy and programmes
• India

India legalised abortion with the Medical Termination of pregnancy (MTP) Act in 1972. Yet in 1994, Chhabra and Nuna estimated that the majority of the six to seven million induced abortions performed annually in India are carried out illegally in private facilities [1]. In the Indian context, a “legal” abortion is one that is performed by a medical doctor who has had training and certification for performing abortions, in a facility certified by health authorities as properly equipped, and within 20 weeks of pregnancy [2][3].

Research of only a decade ago showed that large numbers of rural Indian women were still going to unqualified, traditional abortionists, who often caused serious complications and deaths [1][4]. However, more recent research in Gujarat and Maharashtra has found that most women are now going to qualified but not necessarily certified medical practitioners for abortions [5][6].

In a 1995–96 study of government MTP facilities and services in eight districts of the south Indian state of Tamil Nadu, most of the health providers interviewed reported that the overall number of abortions was increasing. Yet official MTP statistics for Tamilnadu showed declines in the five years (1990–1994) previous to the study [7][8]. We decided to investigate this apparent disparity in one district, Coimbatore, a relatively affluent district of Tamilnadu.

Coimbatore is a major textile producing area, particularly in the two main cities. Other industrial activity is growing and large parts of the district are agricultural, with rice paddy, coconut plantations and sugar cane. Migrant labourers come from other districts and from neighbouring states of Andhra Pradesh, Kerala and Karnataka.

Like Kerala, Tamil Nadu has made substantial gains in health services despite relatively low per capita income. During the 1990s there was widespread acceptance of the “small family norm”, even among low-income rural villagers. By 1997, the state was rapidly reaching replacement-level birth rates [9]. Given the low levels of reversible contraceptive use for spacing and limiting births in rural India [10], a high demand for abortion services among the many women who are not sterilised is likely. Our study, carried out in 1997, sought to document the process women go through to obtain abortions in both the public and private sectors, particularly women in rural areas, and why they were going to private practitioners for abortions.

Primary health centres and village health nurses

Primary health centres (PHCs) in India are staffed by two medical doctors, two nurses, male multi-purpose workers, an extension educator, a statistician and a laboratory technician. In most areas, each PHC serves approximately 25,000 inhabitants. Each PHC has from five to ten sub-centres, each staffed by a community health worker who, in Tamilnadu, is called a village health nurse (VHN). ¹

Each VHN has a service area comprised of approximately 5000 population in up to seven or eight villages [9][11], and receives two years of health care training to become eligible for service. Starting salaries are about US$120 per month, plus uniform allowance and travel expenses, so VHNs are well-paid in comparison to most rural occupations.

Multi-state studies have generally found that Tamil Nadu's VHNs have better knowledge levels and more effective contacts with service communities than their counterparts in other states [9][12]. Most of the VHNs lived in their service villages, and emergency cases are brought to them night or day. Because of their close contacts with the community, and the extensive records they keep, VHNs were familiar with the needs and problems in their communities. Their services and the PHCs are widely seen as intended mainly for women and children. VHNs are responsible for house-to-house contacts and provide preventive health care especially to mothers and their small children. Their services have generally included immunisations, nutrition and other health education, antenatal care, childbirth services and referrals, and family planning.

Until the mid-1990s, the primary focus of VHNs' work was family planning, which required VHNs to meet given quotas of “family planning acceptors”. Sterilisation was the most important component of this target approach; reversible contraception was not widely promoted or used by rural populations. Thus, VHNs spent much of their time seeking out women who could be convinced to accept sterilisation, including women having abortions, who were seen as good candidates for sterilisation [10][11][13]. In 1997 there was a paradigm shift in India's population policy which eliminated the top-down assignment of targets. It was replaced by greater emphasis on reproductive health, including increased attention to antenatal care, childbirth, post-partum care and reproductive tract infections [10].

Methodology

We began our study with observations at “sterilisation/MTP camps”, which are one-day clinics aimed at making surgical services, particularly female sterilisation and in Tamilnadu also abortion, available at the more distant rural PHCs that do not have the personnel or facilities for full-time surgical services. These camps gave us the opportunity to do informal interviews with VHNs and medical officers at PHCs. In-depth interviews were also carried out with health personnel at every level in the district health care system and became a major source of data. We also collected statistical data from the district's health and welfare office records. Data from in-depth interviews with 42 VHNs from seven PHCs, who were purposively selected to represent the different geographic sectors of the district, plus data from their registers and records, were crucial for understanding the complexities of abortion service provision and use.

Our study was wholly focused on MTP in the married population of women and almost exclusively on the rural sector. From July to November 1997 we observed 10 sterilisation/MTP camps in different PHC locations. These were selected to be representative of the different geographical localities of the district. In each camp we observed the entire sequence of procedures: initial registration and pre-operative examination, the actual MTP operations, post-operative care and recovery and other activities that took place until each woman went back to her home village. To understand why women were refused abortions in the camps and referred elsewhere, we had informal discussions with all of the operating surgeons and other health personnel at the camps, as well as VHNs and some of the women who came for abortions. We also visited four taluka (sub-district) hospitals, in which we interviewed the medical officers, operating surgeons, other medical doctors, government officials, VHNs and women having abortions in the camps.

Quality of abortion services in PHC camps

Sterilisation/MTP camps in Coimbatore are staffed by mobile teams of experienced female gynaecologists, anaesthetists and other medical personnel and take place at PHCs around the district [8]. Abortions are provided as a “same day” service unless the woman is referred elsewhere by the camp doctor. Whenever a woman seeks MTP and/or sterilisation in the government sector, her VHN generally accompanies her, and also accompanies her to any referrals. Women are dependent on VHNs for information on the dates and locations of camps. They have to travel as much as 20–25 km to other PHC camps if they require these services at times other than their own semi-annual PHC camp days. Typical camps received five or six abortion cases; a few had 10–12 cases.

The operating surgeons and medical doctors deputed to the camps appeared to be quite concerned about maintaining adequate levels of quality of care, particularly in the actual surgical procedures. Nonetheless, MTP operations were carried out.

In many cases the PHC medical officer's consulting room had been converted into a temporary “operating theatre”. As operating theatres, these were in many ways substandard as there was a lack of blood transfusion facilities, they were generally poorly lighted and many lacked running water. Although cleanliness was difficult to maintain, PHC personnel appeared to expend considerable effort to clean and disinfect the operating tables, and to fumigate the operating rooms. However, the sites usually lacked beds for post-operative recovery, and patients had to lie on mats on the floor. Toilet facilities were generally extremely poor. In one case we observed a major power cut that stopped surgical operations for several hours as the back-up generator was not working. Lack of personnel in relation to the number of cases also added to the stress.

“We find it very difficult to maintain the recommended quality of care here at the periphery. We have to compromise with minimum infrastructure facilities. Therefore we are extra cautious as far as MTP clients are concerned.” (Operating surgeon)

“It is very strenuous to conduct MTP in a sub-standard room which is certainly not an operating theatre. Under such circumstances, D&C or any other procedure cannot be done with proper care. If there are complications we are blamed.” (Gynaecologist)

“During the camps there is usually only one gynaecologist to conduct all the MTP cases. How is it possible for a single doctor to handle so many cases? … In a camp situation, despite all our efforts and caution one or two cases do end up with perforation, bleeding or other complications. There are no facilities available to manage such complications. That is why we do not want to take any risks. We are very cautious and reject even some of the borderline cases.” (Operating surgeon)

There was a distinct lack of privacy in the camp settings. Registration activities, waiting areas and movement between the sterilisation and MTP areas were in publicly visible, open-air locations. It was therefore unlikely that unmarried girls, or any married women seeking MTP secretly, would utilise these services. Furthermore, women who wanted an abortion had to accept a sterilisation as a precondition, with rare exceptions. Married women who did not want to be sterilised would therefore not resort to the government health facilities, though recent changes in government policies have altered this practice.

Why women were refused abortions at the camps and referred

About one third of the women who had come to the camps we observed for MTP services were refused abortions in the camps and referred to the taluka hospitals or the Central Medical Hospital in Coimbatore city. The operating surgeons gave strictly medical reasons for disqualifying cases. Anaemia and pregnancies that were over 10 weeks were the primary reasons, they said. (PHCs are supposed to provide MTP only up to 10 weeks of pregnancy and refer the rest.) Doctors engaged in pre-operative screening gave additional medical reasons, including symptoms of fever at the time of registration, minor ailments, condition of the woman's heart and lungs and obstetric history.

However, additional, non-medical factors were also operative. Some of the doctors who were not involved with gynaecological procedures told us that the gynaecologists often preferred to turn away MTP cases because they were eager to get back to their private practices. This was said to happen not only at the camps but also at taluka hospitals and even sometimes at the District Central hospital.

“The theatre surgeon is a gynaecologist. The surgical team had come from a taluka hospital. She was the one who rejected many cases. She was above everybody inside the theatre. So how can I take up the cases when she has rejected them?” (PHC Lady Medical Officer)

The district administrative officer, herself a gynaecologist, appeared sympathetic to the needs of the women and the VHNs, and several times expressed her criticism of the operating surgeons at the camps. She was quite frank in pointing out the weaknesses of the assessment of women's haemoglobin levels:

“To tell you the truth, these doctors [the operating surgeon and the anaesthetist] go strictly by the clinical tests. These tests are not always reliable. The results could be erroneous. Rejecting cases based strictly on PHC laboratory results is not justified.”

There was no consensus among the doctors as to whether referrals were appropriate or inappropriate. The VHNs and other paramedical and non-medical people were aware of the contradictions, and easily found reasons to criticise the management of MTP cases.

Regardless of the reasons given for a refusal and referral, it was considered a serious problem by the VHNs and the women. We observed several cases of women pleading with VHNs, insisting that they must have their pregnancy terminated. In some cases VHNs pleaded with the gynaecologist to consider the plight of the women. Several times the women insisted that they were less than ten weeks pregnant when the doctor said they were “too many weeks pregnant”. The VHNs were clearly caught in the middle, no matter whether a refusal was justified or not. Any refusal on the part of the doctors was damaging to their reputation in the local community. In many cases the VHNs had brought their clients from far-off villages, assuring women they would get MTP services:

“I brought one MTP client who was examined by the Lady Medical Officer. My PHC doctor estimated her pregnancy to be eight weeks only. I took her to another PHC during the camp. She was rejected because those doctors said she was 12 weeks. Imagine my plight. She is poor and a wage labourer. She is not willing to come to the private clinic to get the services. She is continuing her pregnancy.”

A group of four media officers from the District Health and Family Welfare Bureau were also unhappy about the number of referrals:

“The government has displayed boards indicating that free MTP services are available at the PHC. We are media people and our job is to inform the community that women can go to the PHC and get MTP free. But when women come to the facility with their VHNs they are rejected. These medical doctors are contradicting our messages and also creating confusion for the people. It is due to this rejection at every camp site that women have started going to private facilities.”

Problems with referrals for abortion in taluka hospitals

Whenever women were referred, they generally expected the VHNs to find alternative services for them, and referral to the taluka or District Central Hospital would be the appropriate next step in the Tamilnadu health care system. Those who were near Coimbatore city took their cases to the District Central Hospital, particularly if the women were from low-income households and could not afford to pay the fees in the private sector. For others, there were supposed to be the taluka hospitals, but several VHNs and doctors told us that these hospitals were no longer providing MTP services. Indeed, four of the six taluka hospitals we visited had recently discontinued abortion services. Many spoke of the poor quality of care in taluka hospitals and we ourselves observed the abuse of women seeking abortions.

“The government doctors do not want to take any risk doing MTP in taluka hospitals. There is no facility for blood transfusion, hence management of complications becomes difficult … [Women rejected at the camp] go to private doctors or to other providers. We feel more mentally comfortable in our own private nursing homes. We are in a position to give better services. Private clinics and nursing homes are equipped with good theatre facilities and other support systems.” (Taluka hospital surgeon deputed to a PHC camp)

“I went to the outpatient department and found Dr A receiving patients. She invited me to sit down beside her … There were quite a number of pregnant women in the queue. The interaction between the doctor and the women was quite unpleasant. She was abusing them, and not giving them any counselling or information. She wasn't spending even a minute with each woman. From 10:00 to 12:30 I counted 13 MTP cases [among others]. None had come with a VHN. They had come on their own, along with their mothers or other women. The doctor said to several of them: `When we ask you to accept a method … you don't accept … Where is your VHN? Has she not motivated you? As if I am meant to do only this … so that you come for termination. I am not here for doing all this nonsense … Please go away from here. She then turned to me and said: `See these stupid people … How many times do we have to tell them … to use some method …' She was telling me this in Tamil, within their hearing. I was bending my head. I didn't look at her as she was saying all this.” (Field notes, taluka hospital visit)

VHN: I refer and take women to private [practitioners] for MTP.

L: What about the taluka government hospital?

VHN: No, I do not take them, because they are not providing any MTP services. When we take clients to get MTP services those doctors say, `Let her continue this pregnancy, be delivered and come back; then we will operate.' Who are they to suggest such nonsense? If the women wanted to continue the pregnancy why would they approach for termination?

Medical officers told us that there are court cases pending against gynaecologists in relation to MTP cases in two of the taluka hospitals. In the one, a woman had died after an MTP operation; in the other, a woman had had very serious post-operative complications and was suing the hospital in the consumer court. The Medical Officer in charge at one of the hospitals told us that all of the gynaecologists were currently avoiding MTP operations, preferring women to go to the central hospital or the private sector. These unfortunate cases are part of the complex of reasons for the closure of MTP services in most of the intermediate hospitals.

VHN referrals to qualified private sector clinics

Several VHNs told us they would seek services in the private sector for women rejected at government facilities. The majority of VHNs had complex connections with both government and private medical doctors. In fact, the majority of rural women did not even consider government facilities for their abortions, particularly if they could afford the fees of private providers. In most cases the VHNs knew which women would want services from private doctors and made arrangements for them accordingly. The links with private providers were not new but developed during the target era, as illustrated by one VHN:

“I never take any of my MTP clients to the government sterilisation camps because the quality is poor. I inform my clients that they can get MTP at concessional rates in private clinics. But I insist they come with me to the District Central Hospital for sterilisation after MTP.”

The VHNs we interviewed had varied levels and styles of networking with the private sector. Not all of them were equally motivated, and some may have been more skillful than others in developing and maintaining such contacts. Approximately half of the 42 VHNs we talked with were well-connected with private providers as well as the government health care system. They often accompanied their clients to the private clinics, to make sure they received prompt service. In most cases they were able to bargain for lower fees. They also received a small commission, around 100 rupees per case. Their main concern, however, appeared to be to lessen the risk of post-abortion complications, which they believed were higher in the government services.

One VHN took all her MTP clients to one private lady doctor in the city, with whom she had worked in a PHC for more than a decade:

“This doctor is very understanding and not money-minded. Whenever she does MTP, there has not been a single case of complications … If anybody wants MTP they approach me, or when I go on follow-up visits I find out for myself. Then immediately I contact my doctor friend and inform her that I will be bringing a case for MTP.”

Five or six seemed to have less contact with private practitioners. One referred but did not accompany women to the private clinics, though she did occasionally accompany them to the District Central Hospital:

“If we take a case to a private doctor, and the doctor demands her fees, sometimes the woman openly abuses us. They think we are paid a high commission and therefore they are being charged so much. So, unnecessarily they start fighting with us. Hence I do not take the cases to the private doctors. I refer and never get involved in the financial transaction.”

Private providers – qualified and unqualified

We asked the VHNs to map the location of abortion providers in their areas. All of them indicated several private doctors and nursing homes in their vicinity, but said they only referred to those they regarded as “safe” and “qualified”. Most of the providers mentioned by the VHNs were not on the approved list of certified MTP facilities recognised by the government. Some of the nursing homes had sufficient bed space to handle a considerable number of MTPs, deliveries, sterilisations and others. Others had much smaller facilities.

One doctor confirmed what is widely rumoured – that women are rejected at the government facilities by the same government doctors, gynaecologists and others who take abortion cases after their official government working hours in their private clinics on the grounds of “safer and better quality of care”.

Unqualified abortion providers were also well-known to VHNs, women and government health personnel. They had not received medical training but had acquired their skills from apprenticeship and participation in medical settings, and in some cases from training in homeopathic and siddha (traditional) medicine. Most of them were practising medicine, including doing abortions, quite openly.

“There is one stupid woman who is an unqualified practitioner and she seems to be doing dangerous abortions … Her signboard `Consultant for Women's Problems' [in Tamil] is boldly displayed … Her clinic is very small; it looks like a shop … on the main highway to Kerala.”

“Some also go to Kerala to get MTP … And on the highway, near the border there are a lot of sheds, small shops. Some have no signs; some have put up boards, saying 'OPD' (Outpatient Department). They are all doing dangerous abortions. They are unqualified Keralite men. They are using a paste made from the neem tree. They take the raw leaves of the neem and grind it with a stone … and put in tamarind seeds and turmeric. They think these are antiseptic, so they believe it won't cause infection. The Keralites are famous for these indigenous remedies. They are all using the paste. For sedation they give injections.” (District Health Office statistician)

We interviewed one unqualified abortionist who said she had studied both siddha and homeopathic medicine, and passed an oral examination in Coimbatore for practising indigenous medicine. She boasted that she never caused post-abortion complications, unlike medically trained doctors, by using prostaglandin gel, usually followed by D&C.

None of the VHNs referred to the “legality” of specific private facilities. Either they were unaware of which services were officially recognised, or else they ignored this “technicality”. The preference, where possible, was for lady doctors, but this was not an overriding issue. Several VHNs were heard to lecture women about the dangers of going to unqualified providers. Narratives about abortion deaths, and cases of hospitalisation were known to village people and repeated to them by the VHNs. However, this message is complicated by the number of post-abortion complications occurring in the government facilities, which the VHNs are supposed to represent and promote.

Post-abortion complications

The doctors, VHNs and other health personnel in Coimbatore were practically unanimous that “old-fashioned abortions” and “stick abortions” have greatly diminished in the district. Yet according to government and private practitioners, including unqualified providers, D&C is still the main surgical method of abortion being used in both public and private practice in Tamilnadu, even though the risks are higher than with vacuum aspiration [7][8][15]. Others, both qualified and unqualified, were using prostaglandin gel to initiate the abortion, usually followed by D&C.

Post-abortion complications of varying degrees of severity are still common, and are found in both the government and private services. Many of these cases are managed by VHNs, often through referral to private clinics. Timely interventions appear to have reduced the risks from abortion complications.

“It has reduced a lot. We don't have any sepsis or complications due to crude methods. Ten years ago it was quite high. These days clients are smart, they have money, they have awareness. If they don't want to come to the government hospital they will go to the private and get an abortion. They know [what's available] …” (City-based gynaecologist)

“Post-abortion complications have reduced considerably. Crude methods of aborting pregnancies no longer exist. In the last one and one half years there were no cases of post-abortion complications being treated at either this Block PHC or referred to the taluka hospitals.” (Medical officer, PHC)

A doctor at one of the sterilisation camps told us that he attributed the reduction in post-abortion complications to the VHNs, because they are educating and creating awareness among women and dais (traditional birth attendants). In every dai's training sessions abortion is highlighted.

“Post-abortion complications have gone down. “Stick” abortion methods no longer exist. In the past, post-abortion complications were high and there were also instances of deaths. Villagers do not forget deaths. Hence, we generally refer to the deaths which have occurred years ago while we are educating the mothers.” (VHN)

Several of the VHNs narrated recent cases of post-abortion complications arising in government sterilisation/MTP camps and hospitals. In one camp we observed, five or six cases were reported to us by VHNs that involved severe bleeding due to incomplete D&C. Fortunately the VHNs have developed effective action in cases of complications, but these often involve costly treatment at private clinics.

Many of the VHNs spoke of the emotional and social stress they experienced when women in their villages had post-abortion complications:

“[The woman] was given tablets for two days [to stop the bleeding]. Bleeding continued even after she took the tablets. Two days later she had severe abdominal pain. Then the mother sent word for me. I visited her house and I was in a state of helplessness. The woman, her husband, her mother – all of them were very angry with me. They started shouting at me. I said that in the interests of her health something had to be done. There was no use in arguing and abusing me, the VHN. Speedy action had to be taken. I recommended a private nursing home. Accordingly, she was taken there and got a D&C done. It was an incomplete abortion.”

Cases of serious post-abortion complications were reported with private providers too, particularly those who were not medically qualified. One woman who had to be hospitalised described the abortionist as a male practitioner from a neighbouring state who had been practising in her village for the past 20 years. She had suffered severe haemorrhaging, due to incomplete removal of the products of conception, before she was brought to the hospital.

Expressed preference for qualified private providers

The number of well-equipped private clinics and nursing homes is growing in rural areas in recent years, partly because institutionalised childbirth is becoming the norm (52% in rural Tamilnadu in 1995) [9]. Every VHN we interviewed listed several such facilities within easy reach of their service communities.

Health authorities, VHNs and individual women who had had abortions said that the preference for private sector abortion services has to do with:

•	the preference for confidentiality and privacy;
•	the avoidance of sterilisation as a condition for MTP;
•	the perception that private practitioners gave safer, better quality of care; and
•	the fact that private practitioners were also more willing to provide services for women whose pregnancies were beyond the 20-week limit.

VHNs have contributed to the trend towards utilising private practitioners. Referring and accompanying women to private practitioners was much less complicated and time-consuming than waiting for and attending the camps, or the long waits and complex procedures at government hospitals. Private providers were also much less likely to abuse women and VHNs verbally. Although some referrals to private practitioners resulted in commissions for the VHNs, we found no evidence that this was their main motive. Most frequently VHNs said that the quality of care was better in private facilities and presented less likelihood of post-abortion complications. Many VHNs and other health personnel said that rural people themselves were becoming more informed about health care services and who the different private practitioners were, and could make systematic comparisons of costs and other factors between private and government facilities.

A similar situation has been reported in Maharashtra, where in one study only 16.7% of women went for MTP in government facilities and only 2% reported having resorted to traditional or unqualified practitioners [5]. Other studies, including in Maharashtra and Gujarat, found similar patterns of women going to private practitioners, with an emphasis on qualified doctors [6][16].

“Women and their families were aware of the potential complications from abortions, and were consciously choosing providers known to have low complication rates and better facilities”. [6]

Fees charged by private providers

The various private providers charged a wide range of fees for abortions. One woman reported paying only Rs. 375, but in general the low end of fees with an unqualified provider was Rs. 600–700 (approx. US$15 to $18). Unmarried girls were charged more, at least 1000 rupees (approx. US$23.50), and later pregnancies cost more as well.

Several VHNs told us that the qualified private doctors to whom they took their cases charged only Rs. 300–500 (about US$8 to $12.50) if the pregnancy was up to 10–12 weeks, and if the woman was referred by the VHN.

“If I take them cases below 12 weeks they charge Rs. 400 including antibiotics. Most of the doctors are government doctors whom I know, and they give me a concession. If others take them, they charge Rs. 600 and the prescriptions have to be bought from a chemist shop.” (VHN)

One informant said the charges went up by 500 rupees for each month of pregnancy. One unqualified provider demanded 2000 rupees from a recent client, apparently because the pregnancy was beyond three months.

Services at the PHC camps were free. At government hospitals, the doctors and others usually charged for services, but we did not get data concerning amounts.

The shift to private providers in statistics

The decline in attendance at and availability of government facilities in rural areas during the 1990s has been matched by a growth in private MTP facilities.

We asked the 42 VHNs to tabulate from their records how many MTP cases had gone to government services and how many to the private sector during the past year. The VHNs were able to provide these data, village by village, including for women they had not personally referred to MTP services. According to their records, a large majority of women went to the private sector.

There are approximately 650 VHNs in the Coimbatore district, so the 42 VHNs represent approximately 1/15th of the VHNs in the district. Extrapolating from their data, we estimate a total of 3720 private sector abortions in the district in 1996–1997 and 1440 government sector abortions (Table 1

Table 1 MTP cases as reported by 42 VHNs, Coimbatore, 1996–97

Number of PHCs	Number of VHNs	Private sector MTPs	Govt. sector MTPs
7	42	248 (72%)	96 (28%)
Whole district (estimate)	650	3720	1440

). If this simple calculation is correct, almost three-quarters of abortions took place in the private sector, an estimate that corresponds well to those from other parts of India [1][5][14].

This estimate is in sharp contrast to official health records for Coimbatore District (Table 2

Table 2 Trends in MTP Services in Coimbatore, 1991–1997

Year	MTPs in PHCs	MTPs in taluka hospitals	MTPs in central hospitals	MTPs in private sector	Total MTPs in the district
1991–1992	453	850	1419	254	2976
1992–1993	436	485	1376	254	2551
1993–1994	257	242	1363	257	2119
1994–1995	172	181	1470	170	1993
1995–1996	125	155	1257	218	1755
1996–1997	135	162	1430	263	1970

). For the year covered by our study the official figures show 1707 cases in the government sector (86%), and 263 in the private sector (14%). The differences are striking. They indicate that there were large numbers of unreported abortion cases in the private sector, as well as many cases of MTPs in government-approved facilities.

The decline in MTP services in government facilities is due to several factors. At the time of the study there was diminished emphasis on “population control” in general, hence a reduction in the frequency of “sterilisation camps”, which reduced availability of MTP services as well. Secondly, doctors at both PHC camps and taluka hospitals were concerned about quality of care, which was difficult to maintain even at the taluka hospitals. Fear of litigation in cases of complications and deaths added to these concerns. Thus, one taluka hospital that provided 267 MTPs in 1991–1992 reported only 17 cases in 1996–1997.

Lastly, and perhaps most importantly, the gynaecologists in government service were referring cases into the private sector, to their own private practices or those of others, and these increasingly well-equipped clinics and small hospitals were seen as providing better quality of care and safer abortions.

Source: Coimbatore District Health and Family Welfare Bureau.

Discussion and recommendations

This study did not deal with abortions among unmarried girls or include observations and interviews in the two central hospitals, as its primary focus was on rural facilities. Observation in private facilities and interviews with private providers, qualified and unqualified, was also beyond the scope of this research but should be a high priority for future research.

Most studies concerning quality of care and availability of services have focused on the need for more investment by state governments in the public sectors. In 1996 many of the PHC facilities in Tamilnadu designated for MTP services were seriously deficient in basic equipment and facilities [7][8]. As a result, only 58% of PHCs in Tamilnadu were currently providing MTP services in officially approved facilities; figures were even lower in Maharashtra (27%), Uttar Pradesh (24%) and Gujarat (32%) [7].

The government services, particularly at the PHC and taluka levels, were clearly lacking in equipment, properly maintained operating theatres, medical supplies and other essentials for insuring quality of care in MTP. In some cases the buildings themselves were seriously inadequate for maintaining high quality services.

Tamilnadu, unlike some other states in India, does not have a serious shortage of women doctors, and women in general are not as opposed to male doctors as is the case in some northern states. However, there are still problems in allocating trained medical personnel to the right places at the right times. While shortages in equipment and basic physical infrastructure are important, the larger reasons for diminished government services for MTP, we believe, are to found in lack of effective management, inefficient use of existing resources and a complex administrative public health structure at the district level. Enhancing MTP services at taluka hospitals, and to some extent at PHCs, is likely to be a slow and complex process, but it needs to be done in order to serve the poor and marginalised segments of the rural population, particularly those who cannot afford private services.

Although it would be desirable to have more MTP facilities at PHCs, taluka hospitals are sufficiently accessible to most communities, and maximum effort should be expended in enhancing their services. VHNs and women were not averse to travelling considerable distances to obtain good services. Doctors are regularly available at these hospitals, and laboratory facilities could be revitalised.

The problem will not be solved simply by making MTP services more available, however. The quality of services must also be improved, including the quality of provider–patient interactions. Other aspects such as confidentiality, privacy and lessened waiting times could also be substantially improved without large expenditure. Tighter regulation of government doctors, for whom the investment in their private practices is in conflict with their public duties, is probably also needed.

Greater political consciousness and pressure at state and local level is needed and will require much more community participation, including from local panchayats (community-based government structures) and NGOs.

The continued heavy reliance on D&C as the most commonly used abortion method is puzzling, due to the risk of post-abortion complications from incomplete evacuation and perforation of the uterus. The World Health Organization and other international experts recommend the use of vacuum aspiration up to 14 weeks of pregnancy [15] and medical methods are now also recommended and widely used in developed countries. Bringing MTP technology in line with these recommendations will require new equipment and training. The training of nurses and other paramedical staff should be explored as a way to expand the availability of services.

The active role of VHNs in supporting women seeking abortions in Coimbatore district has not been reported elsewhere in the literature, though it may be happening elsewhere. From the point of view of effective health care – not only for abortion services but also other reproductive health care – VHNs can serve the women in their communities well by maintaining connectedness to both the governmental and private medical services. In the current situation their practice of referring clients to government services where available and desirable, and also helping women to access private facilities according to the women's preferences and needs is an effective and positive response to a pluralistic health care system. If the VHNs were to neglect or ignore those women who prefer private MTP services, they would not be able to prevent them going to unqualified, dangerous providers. At the same time, they would run the risk of losing the good rapport they seem to have in their service communities. Given that women have a right to choose which providers they go to, VHNs appear to be supporting their choices.

The main exception to this are unmarried girls, who are generally poorly served in the health care system. VHNs are not usually contacted by unmarried girls for MTPs, especially because of the need for complete secrecy. VHNs in our study reported that unmarried girls were more likely to go to dangerously unqualified providers; Ganatra et al have reported the same trends elsewhere [5]. The newly expanded reproductive health programme needs to make a special effort to make it possible for adolescent girls to access reproductive and sexual health services, including for unwanted pregnancies.

The VHNs we encountered in Coimbatore were dedicated and capable community health workers. Their records on married women of reproductive age, antenatal care and other registers were well-maintained, partly due to weekly reviews at the PHCs. Their central role in mediating MTP services was evident. Improvement of the government MTP services would benefit from the knowledge and skills of the VHNs, which should be more fully utilised in the planning and management of services.

Acknowledgements

We gratefully acknowledge the support and cooperation of the Tamilnadu State Ministry of Health and Family Welfare, the many doctors and other personnel in the Coimbatore district health care system and especially the VHNs and women, who gave unselfishly of their time and valuable information. Thanks also to Lenore Mandelson for encouragement and very helpful editing.

Notes

1 Auxiliary Nurse-Midwife (ANM) is the usual designation in other parts of India.