The Abortion Assessment Project—India: Key Findings and Recommendations

Abstract

The Abortion Assessment Project—India, begun in August 2000, is one of the largest studies on abortion ever undertaken in India. This article synthesises the findings of the six facility surveys, two community-based surveys, eight qualitative studies, policy review and commissioned working papers that were produced as part of the project by researchers from across India. Public investment in abortion services nationally was found to be grossly inadequate. 75% of facilities were found in the private sector in the six states and were overwhelmingly perceived to give better services. Although some important changes were made in the 1971 Medical Termination of Pregnancy Act related to clinic certification and medical abortion, further changes during the second phase of the government’s Reproductive and Child Health Programme are recommended, based on this research and state and national-level consultations organised by the project. These include integrating abortion services into primary and community health centres, increased investment in public facilities, promoting use of vacuum aspiration and medical abortion, convincing providers to stop using curettage, broadening the base of abortion providers by training paramedics to do first trimester abortions, and reskilling traditional providers to play alternative roles that support women’s access to safe abortion services.

Résumé

Le projet d’évaluation lancé en ao 2000 est l’une des plus vastes études sur l’avortement jamais entreprises en Inde. Cet article synthétise les conclusions de six enquÁtes dans les centres, deux enquÁtes communautaires, huit études qualitatives, une étude des politiques et des documents de travail produits dans le cadre du projet par des chercheurs de tout le pays. Le financement public des services d’avortement au niveau national s’est révélé insuffisant et dans six Átats, 75% des installations appartenaient au secteur privé ; une écrasante majorité considérait qu’elles offraient de meilleurs services. Bien que la Loi de 1971 sur l’interruption de grossesse ait été modifiée en rapport avec l’agrément des centres et l’avortement médicamenteux, de nouveaux changements pendant la deuxième phase du Programme gouvernemental de santé génésique et infantile sont recommandés, sur la base de cette recherche et des consultations aux niveaux national et des Átats organisées par le projet. Il faudrait notamment intégrer les services d’avortement dans les centres de soins de santé primaires et communautaires, investir davantage dans les équipements publics, promouvoir l’avortement médicamenteux et par aspiration et convaincre les prestataires de cesser l’utiliser le curetage, élargir la base des praticiens en formant le personnel paramédicalàréaliser des avortements pendant le premier trimestre, et former les praticiens traditionnels afin qu’ils soutiennent l’accès des femmesàdes services d’avortement s»r.

Resumen

El Proyecto de Evaluación de Aborto iniciado en agosto de 2000, es uno de los estudios más extensos sobre aborto en la India. En este artáculo se sintetizan los resultados de las seis encuestas efectuadas en establecimientos de salud, dos encuestas comunitarias, ocho estudios cualitativos, revisión de poláticas y documentos de trabajo encargados producidos por investigadores de toda la India. Se encontró que la inversión pública en los servicios nacionales de aborto es insuficiente y que el 75% de los establecimientos de salud se encuentran en el sector privado, y la gran mayoráa percibe que éstos prestan mejores servicios. A pesar de los cambios en la Ley de Interrupción Médica del Embarazo de 1971 realizados con relación a la certificación clánica y al aborto con medicamentos. Se recomienda realizar más cambios durante la segunda fase del programa gubernamental de Salud Reproductiva e Infantil, conforme a esta investigación y a las consultas estatales y nacionales organizadas por el proyecto. Entre ellos figuran integrar los servicios de aborto a los centros de salud de primer nivel y de la comunidad, aumentar la inversión en los establecimientos públicos, promover el uso de la aspiración endouterina y el aborto con medicamentos. Convencer a los proveedores de abandonar el uso del curetaje, ampliar la base de proveedores capacitando a paramédicos en la práctica de aborto en el primer trimestre, y ampliar las funciones de los proveedores tradicionales para apoyar a las mujeres en su acceso a los servicios de aborto seguro.

Keywords:

• abortion services
• unsafe abortion
• abortion law and policy
• advocacy and political process
• quality of care
• India

India was a pioneer in legalising induced abortion under the Medical Termination of Pregnancy (MTP) Act of 1971. Under the Act a woman can legally have an abortion up to 20 weeks of pregnancy if the pregnancy carries the risk of grave physical injury, endangers her mental health, if it results from contraceptive failure in a married woman, or from rape, or is likely to result in the birth of a child with physical or mental abnormalities. No spousal consent is required. According to the Ministry of Health and Family Welfare, in 1996—97 465,705 abortions were reported nationally.¹ Against that, however, an estimated 6.7 million unreported abortions are performed each year by providers working outside registered and government-recognised institutions, often by untrained persons working in unhygienic conditions.²

The risks faced by women who are forced to use unsafe alternatives is tremendous; 13% of maternal deaths worldwide are due to unsafe abortions.³ In India, the proportion of maternal deaths due to unsafe abortion was estimated to be 13% in 1995.⁴ Despite an intensive national campaign for safe motherhood and attention to unsafe abortion in the 1960s and early 70s, which led to legalisation of abortion, public discussion in India on abortion-related morbidity and mortality has been practically absent since. Limited research data have led some researchers to conclude that “morbidity and mortality from unsafe abortion remain a serious problem for Indian women 28 years after abortion was legalised in India”.⁵ Given this scenario, in the past decade women’s health advocates and other health groups in India have drawn the attention of policymakers and administrators to the following issues in order to improve the availability, safety and use of abortion services:

•	There are an inadequate number of safe abortion facilities within reach of the majority of poor women in both rural and urban areas.
•	There is a dearth of medically approved abortion providers and registered facilities.
•	Post-abortion family planning counselling and services are inadequate.
•	Unsafe abortion is often not perceived as a women’s health issue.
•	There is a growing trend in some parts of the country towards sex-selective abortion.
•	The Government has developed a “do nothing” attitude towards unsafe abortions because they help to keep the population growth rate down in place of use of contraception for spacing births.

In the post-Cairo period, with the introduction of the more comprehensive Reproductive and Child Health (RCH) Programme, in place of unlinked safe motherhood, child survival and family planning programmes, abortion-related mortality and morbidity have received greater attention. Donors supporting the Government’s efforts (UNFPA, WHO, World Bank, European Community, SIDA, DANIDA and DFID) have highlighted the importance of looking at abortion-related mortality and morbidity as a part of the RCH package, and gave women’s health advocates an opportunity to re-establish the importance of making abortion safe.

Although the climate seems to be favourable, the lack of reliable information and wide regional and rural—urban differences have made it difficult to develop strategic interventions. The Abortion Assessment Project — India (AAP India) sought to fill this information gap by gathering a range of evidence on all facets of induced abortion. The project was an all-India, multicentre research project, launched in August 2000 and managed jointly by the Centre for Enquiry into Health and Allied Themes (CEHAT), Mumbai, and HealthWatch, New Delhi. This article is an attempt to synthesise the findings of this project, whose overall objectives were to:

•	Review government policy on abortion care, and the policy and programme environment in the country.6
•	Assess and analyse abortion services in six states in both the public and private sectors, including organisation, management, facilities, technology, registration, training, certification and utilisation.7 *
•	Study users’ perspectives, particularly women’s perceptions of quality, availability, accessibility (including barriers to utilisation), confidentiality, informed consent, post-abortion contraception and attitude of service providers.8 9 10
•	Study the socio-economic factors that influence decision-making, including changes in social values, male responsibility, family dynamics and decision-making.8 9 10
•	Estimate the rate of abortions, extent of morbidity and mortality, causes of spontaneous abortions and reasons for induced abortions.9, 10
•	Document related cost and finance issues.9, 10
•	Disseminate the information widely and develop an advocacy strategy on issues of concern in the context of the reproductive rights of women.

To achieve these objectives, a range of studies were undertaken, covering a wide geographic area, with five main components:

•	A policy review6 and a number of commissioned working papers5 11 12 13 14 15 16 17 18 that focused on the dynamics of the MTP Act in practice and involved consultation with a wide range of stakeholders to identify lacunae and concerns about abortion policy.
•	Multicentre facility surveys in six states, Kerala, Rajasthan, Haryana, Madhya Pradesh, Orissa and Mizoram.19 20 21 23 24
•	Eight qualitative studies on decision-making pathways, reasons for seeking abortion, inter-generational differences in abortion-seeking behaviour, access and provider selection, quality of care, perspectives of providers, sex-selective abortions and cultural dimensions, to complement the six multicentre facility surveys.8 These were carried out by researchers, grassroots groups and medical establishments in six states, Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra, Gujarat and Haryana. A multicentre, qualitative study of informal providers was also undertaken, in Rajasthan, Maharashtra, Madhya Pradesh, Karnataka, Uttar Pradesh, Haryana and Delhi.
•	Community-based studies to estimate the abortion rate and out-of-pocket expenditures in Maharashtra and Tamil Nadu.9, 10
•	An information dissemination and advocacy programme through workshops, consultations and meetings with various stakeholders and publication of findings through academic outlets, NGOs and the popular media.

In the last six years donors have been working with the Government of India and various State Governments to develop district-specific plans for implementing the Reproductive and Child Health Programme. The first phase is now coming to an end and plans for the next phase are being finalised. While the first phase of the Programme may have had limited achievements, the participation of a larger number of stakeholders in the review of the Programme and in planning the next phase shows willingness on the policy front to move ahead. These efforts have been noteworthy, as administrators try to grapple with hitherto unexplored public policy issues. With regard to abortion, despite the US Global Gag Rule via USAID, during the first phase of the RCH Programme some important changes in the MTP Act and Rules related to decentralisation of the certification process, shifting the onus of proof of illegality of abortion on the provider and inclusion of a separate clause on medical abortion have been made in 2003.²⁵ Also the struggle by activists seeking ways of preventing sex selection has moved this issue higher on the state agenda and implementation within the states of the Pre-Natal Diagnostics Techniques (Regulation and Prevention of Misuse) (PNDT) Act 1994²⁶ has improved substantially. In addition, the Government of India has recently passed a completely amended PNDT Act, which now covers pre-conception techniques that facilitate sex determination.²⁷

The findings of the policy review, working papers and various studies undertaken as part of this project highlight the inadequate attention given to abortion within the health and population policy of India and confirm the often-voiced concern that even with the Reproductive and Child Health Programme, initiated by the Government in 1997, issues related to abortion have not been addressed.

Summary of key findings

The multicentre facility study of 380 abortion facilities, of which 285 were private, across six states showed that on average there were four formal abortion facilities (medically qualified though not necessarily certified to carry out abortions) per 100,000 population in India and an average of 1.2 providers per facility. At the country level, this would mean there were 40,000 facilities and 48,000 providers. Of the formal abortion providers, 55% were gynaecologists and 64% of the facilities had at least one female provider. Each of these facilities averaged 120 abortions per year, which adds up to 4.8 million abortions in formal abortion facilities annually (of which one third were in public facilities). In addition, there are a similar number of informal (traditional and/or medically unqualified) abortion providers who undertake on average about one-third of the cases handled by formal providers. This gives an estimate of 6.4 million abortions annually in India.⁷ This figure is arrived at by extrapolating the three-month data collected from each of the 380 formal facilities and the 1,270 informal providers studied across the country.

Although the MTP Act was passed 33 years ago and amended in 2003 to facilitate service delivery, only 24% of all private abortion facilities in the country are certified and thereby legal. The facilities that were certified had obtained certification on average within a month and of those that were not certified, 68% had never tried to obtain certification as they were not keen to register or become accountable to the authorities; of the rest 19% had tried and failed to secure certification and 13% did not give reasons for not registering. This betrays a lack of ethics in medical practice and an absence of self-regulation amongst the profession. On the positive side, two-thirds of the providers in the non-certified facilities had the requisite abortion training or qualifications required under the MTP Act to conduct abortions. Thus, a majority of uncertified facilities may be providing safe abortions. This assumption is strengthened by the fact that the difference between the certified and non-certified facilities was insignificant with regard to technical aspects and infrastructure, such as availability of equipment and instruments, skills and training of personnel and physical conditions of the facilities.⁷

The survey found that in 73% of cases, abortions were conducted for pregnancies of less than 12 weeks. However, dilatation and curettage (D&C) was the method used for nearly 89% of the abortions, and even amongst those who used vacuum aspiration, the practice of using curettage to “check” it was complete was very common. The continuing insistence on curettage both adds to the cost of the procedure and contributes substantially to post-abortion complications and infections. Physical infrastructure was better overall in private facilities, as was availability of equipment and instruments as compared to public facilities, but information provision to women and counselling were better in the public facilities.⁷

As regards referrals for abortion cases which the facilities cannot handle, such as second trimester cases, incomplete abortions and cases with higher medical risks, about two-thirds of the facilities said that they referred cases to higher facilities and as many as 20% were referring more than 50% of their cases. 78% of the providers mentioned that it was the second trimester cases that were most commonly referred for abortion at higher level facilities. Provider perception of medical risk and incomplete abortion following procedures obtained elsewhere constituted 58% and 25% of the referrals, respectively. The data suggest that providers, especially those in uncertified private facilities, do not take any chances by handling cases they are not comfortable with. The referrals were mainly to government hospitals, including district hospitals (44%), medical colleges (25%), post-partum centres (15%), sub-district hospitals (11%) and community health centres (7%).⁷

While geographic access seems to be reasonably good, access remains restricted because providers, especially in formal and certified facilities, often do not provide services to women if they come alone or if the spouse or a close relative does not give consent.⁷ In the household and qualitative studies, women said that the decision to have an abortion is rarely their own; more often than not their spouse or a relative decides for them. Hence, from all sides, women’s freedom to access services is controlled, limiting confidentiality and privacy, which means they may resort to unsafe providers with fewer scruples.⁸

The incidence of abortion recorded in both Maharashtra⁹ and Tamil Nadu¹⁰ in the household studies was higher than hitherto reported. In Maharashtra induced abortion in 1996 to 2000 was 4.5% of all pregnancy outcomes and 7% in Tamil Nadu. The difference in the abortion rate across rural and urban areas as well as across classes and social groups in both states was significant — in urban areas abortion rates were nearly twice those in rural areas (more so in Maharashtra) and those who were economically and socially better off had much higher rates than those who were disadvantaged. Two main reasons why women said they could not access abortion services were the fact that government facilities were geographically less accessible and their lack of ability to pay for private sector services. This implies that access, both physical and financial, is a critical factor in determining abortion rates and use of abortion services.

Public investment in abortion services is grossly inadequate. Only 25% of abortion facilities in the formal sector were public facilities, and 87% of abortions were being done in the private sector. Access to public services was far better in urban than in rural areas in both states. Poorer women were much more frequent users of public facilities for abortion wherever and whenever they were available.

The median cost of an abortion in the private sector in the facilities studied was Rs.801, seven times more than in the public facilities.⁷ On the one hand, this constitutes a major handicap for women from poorer classes and other disadvantaged groups such as dalits (scheduled castes) and adivasis (tribals). The household studies in this project reveal that women from these communities have significantly lower rates of induced abortion because they often do not have the cash to access abortion services in the private sector or travel the sometimes longer distances to access public services.⁹ This makes a strong case for strengthening as well as expanding public abortion facilities across the country. The second phase of the RCH Programme needs to factor this in if reproductive health and health care for women are to improve.

On the other hand, the cost of private services varied according to the type of provider and the length of pregnancy. Women accepted that while the services of private providers cost more, government hospitals were also not cost-free as they had to pay for medicines separately. They were sometimes required to make repeat visits before the abortion was performed. There were often long waiting periods, often meaning that the person accompanying the woman^* had to forego wages for that time.⁸

The out-of-pocket cost (median Rs.1220 in Maharashtra and Rs.950 in Tamil Nadu) of an abortion, according to the household studies, is similar to that recorded in the facility surveys.⁹, ¹⁰ Extrapolating the cost per abortion to the estimated total number of abortions of 6.4 million, the abortion economy was worth some Rs.6,950 million (US$154 million) in 2001. This is a mere 0.58% of the total estimated out-of-pocket expenditure for health care. (Public expenditure on abortion services is not known as it is not a separate budget line in the public health budget.)

As regards women’s reasons for seeking abortions, only 31% fell strictly within the grounds permitted under the MTP Act; the rest were simply that the pregnancy was unwanted (71%), economic reasons (7%) and unwanted sex of the fetus (13%).^{9 †} The community-based household surveys,⁹, ¹⁰ qualitative studies⁸ and working papers¹¹ all indicated the prevalence of the practice of sex determination and abortion of female fetuses.

The eight qualitative studies revealed that the overwhelming reason for seeking abortion among married women was to limit family size. When women were asked to indicate the situations in which they would seek abortion or had actually sought abortion, the majority of the women in Maharasthra, Gujarat, Haryana, Andhra Pradesh and Tamil Nadu reported that limiting family size was the main reason for abortion. Furthermore, non-use of contraception was reported to be the chief reason why unwanted pregnancy occurred. Actual contraceptive failure was reported in very few cases though all respondents across studies reported knowledge of sterilisation for limiting family size and a majority of women knew about reversible methods of contraception, such as condoms, oral pills and IUDs for spacing births. This knowledge did not translate into practice due to fears about the effect on health, pain and discomfort, irregular supply and problems with obtaining permission from husbands. On the other hand, there was a perception that abortion was safe and did not have any long-term adverse health consequences. For some respondents it was seen as a “safer” option than IUDs and other spacing methods.⁸

Also, almost all women were aware that sex determination tests were illegal and admitted that women approach different facilities for ascertaining fetal sex and for abortion. Awareness of the new PNDT Act was far greater among women and service providers than the details of the MTP Act. Group discussions invariably turned spirited when sex selection was discussed, and women talked about it openly and without hesitation. Women expressed helplessness and said that their status in the family and sometimes the very survival of their marriage depended on their ability to produce sons. They said that when couples have more than two girls, sex-selective abortion was approved by families and condoned by the community. There was no social stigma associated with sex-selective abortion — especially for mothers with many daughters. Women from Gujarat and Haryana also reported that while they were not comfortable with abortion per se, when it was done for the sake of the family, then they accepted it.⁸

Private facilities were perceived to be far better than public ones because:

•	Abortion in private facilities takes much less time. Everything is done in one visit, no time is wasted waiting or going through “formalities”.
•	Private doctors have better facilities and equipment and are not in such a hurry to discharge women after the procedure if they need to rest for an hour or so before going home. In the public hospitals, given the shortage of beds, women are asked to leave as soon as possible.
•	Private doctors treat women better and ensure confidentiality.8

In the multicentre study of informal providers across seven states, it came out clearly that such providers are largely used by women to handle late periods and very early abortion. A majority of informal providers were using herbs, concoctions and other oral methods. However, in Rajasthan and Uttar Pradesh, where access to formal providers is very limited, informal providers continue to use invasive methods. In Maharashtra, Karnataka, Haryana and Delhi, where access to formal providers is reasonably good, they more often used oral methods. Informal providers were also catering in a very large way for unmarried women. In many areas, informal providers have begun serving as a link between formal providers and women seeking abortion, especially in rural areas, a trend that is expected to increase in future.²⁸

Outcomes of the project

The Abortion Assessment Project — India is one of the largest studies on abortion ever undertaken in India. The very process of bringing together a diverse group of researchers involved networking with institutions, service providers, the government and women’s health advocates. As the project reached the final stages, we convened an advocacy and dissemination meeting in November 2003. Participants included national and some state government officials, the Indian Council for Medical Research, leading researchers, Federation of Obstetric and Gynaecological Societies of India (FOGSI) members, and multilateral and bilateral donors involved in reproductive health programmes in India. All the studies and papers were presented.

One positive outcome of the meeting was an invitation from the RCH Phase Two design team to make concrete recommendations for integrating a gender equity framework into the RCH Programme. To this end, a background document was commissioned,²⁹ and a gender-mainstreaming framework now forms a part of the Programme plans, related particularly to abortion access, safety and confidentiality.

Another is CEHAT’s engagement with the further possible amendment of the MTP Act, based on recommendations submitted to the Government following a wide-ranging consultative process. The amendment process will take time, especially now with the change in government in May 2004. However, a tacit understanding has been reached within the amendment working group and with Ministry officials that second trimester abortions, which it had been proposed to restrict to try to prevent sex-selective abortions, will not be tampered with.^*

To try to sort out the contradictions between the MTP Act and the PNDT Act, CEHAT, HealthWatch and Ipas India organised a national consultation to come up with recommendations.

Finally, to wrap up the project, between July and September 2004 state-level dissemination meetings were held in 24 states. These involved government officials, abortion providers, women and health groups, NGOs and academics working on health issues, who were informed of the findings of the project and asked to develop locally relevant advocacy strategies on abortion and related reproductive health issues. These are in the process of being consolidated into a national advocacy strategy for the next phase of the AAP India project.

Emerging advocacy issues and recommendations

A number of key issues and concerns vis-a-vis abortion and abortion services have emerged during the course of this project. In a national consultation held in New Delhi in November 2003 these were brought together in the presence of a wide array of stakeholders who are active on abortion and women’s health issues. The following advocacy issues were short-listed, to be taken forward during the dissemination phase of the project, together with what has emerged from the state-level meetings, with policymakers, medical professionals, NGOs and the donor community for future action:

•	Integrate abortion services into primary and community health centres through a strengthened RCH Programme to increase women’s access to abortion care services.
•	Increase investments in public facilities substantially to strengthen public abortion services.
•	Promote safer abortion methods, namely vacuum aspiration techniques and medical abortion, and convince physician providers to stop using curettage in almost all cases.
•	Broaden the base of abortion providers by training paramedics to do first trimester abortions, as is being done in many other countries, e.g. South Africa and Bangladesh.30
•	Encourage medical associations to become active in training abortion providers, especially those in the private sector.
•	Promote apprenticeship as a source of training.
•	Re-skill traditional providers to play alternative roles in supporting women’s access to safe abortion services.
•	Strengthen regulations to require abortion facilities to adhere to minimum standards of quality of care and accreditation.
•	Change the mindset of clinic directors through their professional associations to accept universal clinic certification.
•	Require all abortion facilities to display their certification status for women to see.
•	Promote safe contraception for spacing births in order to reduce unwanted pregnancies.
•	Educate providers on the ethics of sex determination and respect for the provisions of the PNDT Act.

Acknowledgements

A special issue of Seminar (No.532, December 2003) published 13 articles that were largely based on the studies carried out under the AAP India project. The AAP India project was supported by the Ford Foundation (New Delhi), John D and Catherine T MacArthur Foundation and Rockefeller Foundation. Copies of papers and reports may be requested from CEHAT at e-mail: [email protected] or HealthWatch, e-mail: [email protected].

Notes

* There were both separate studies of facilities in the six states, published by the six organisations involved, and an independent national synthesis report that was based on merged data from the six studies.

* Generally women do not go alone to large facilities like public hospitals.

† The total does not add up to 100% as it was a multiple response question.

* An important argument in this regard was that sex determination can increasingly be carried out during the first trimester of pregnancy.