Second Trimester Abortions in India

Abstract

This article gives an overview of what is known about second trimester abortions in India, including the reasons why women seek abortions in the second trimester, the influence of abortion law and policy, surgical and medical methods used, both safe and unsafe, availability of services, requirements for second trimester service delivery, and barriers women experience in accessing second trimester services. Based on personal experiences and personal communications from other doctors since 1993, when I began working as an abortion provider, the practical realities of second trimester abortion and case histories of women seeking second trimester abortion are also described. Recommendations include expanding the cadre of service providers to non-allopathic clinicians and trained nurses, introducing second trimester medical abortion into the public health system, replacing ethacridine lactate with mifepristone-misoprostol, values clarification among providers to challenge stigma and poor treatment of women seeking second trimester abortion, and raising awareness that abortion is legal in the second trimester and is mostly not requested for reasons of sex selection.

Résumé

Cet article étudie l'avortement du deuxième trimestre en Inde, notamment les raisons pour lesquelles les femmes le demandent, l'influence de la législation et de la politique relatives à l'avortement, les méthodes chirurgicales et médicamenteuses utilisées, sûres ou non, la disponibilité des services, les besoins en prestation de services au deuxième trimestre et les obstacles que les femmes rencontrent pour accéder aux services. Sur la base de mon expérience et de communications personnelles avec d'autres médecins depuis 1993, quand j'ai commencé à pratiquer des avortements, je décris également les réalités pratiques de l'avortement du deuxième trimestre et les histoires des femmes qui souhaitent avorter à ce stade. Il est recommandé d'élargir le cadre de prestataires de services et d'y inclure des cliniciens non allopathiques et des infirmières qualifiées, d'introduire l'avortement du deuxième trimestre dans le système de santé publique, de remplacer le lactate d'éthacridine par la mifépristone et le misoprostol ; il faut aussi clarifier les valeurs chez les soignants pour lutter contre la stigmatisation et le traitement médiocre réservé aux femmes qui veulent avorter au deuxième trimestre, et faire savoir que l'avortement est légal à ce stade et n'est en général pas demandé pour des raisons de sélection du sexe du bébé.

Resumen

En este artículo se resume los conocimientos del aborto en el segundo trimestre en la India, incluidos los motivos por los cuales las mujeres buscan abortos en el segundo trimestre, la influencia de las leyes y políticas de aborto, los métodos quirúrgicos y médicos utilizados, tanto seguros como inseguros, la disponibilidad de los servicios, los requisitos para la prestación de los servicios y las barreras que encuentran las mujeres al tratar de acceder dichos servicios. A raíz de mis experiencias personales y comunicaciones personales con otros médicos desde 1993, cuando empecé a proporcionar servicios de aborto, las realidades prácticas del aborto en el segundo trimestre y las historias de casos de mujeres que buscan abortos en el segundo trimestre también se describen. Las recomendaciones son: ampliar el tipo de prestadores de servicios a médicos no alopáticos y enfermeras capacitadas, incorporar los servicios de aborto con medicamentos en el segundo trimestre en el sistema de salud pûblica, cambiar el lactato de etacridina por mifepristona-misoprostol, aclarar valores entre los prestadores de servicios para cuestionar el estigma y el mal trato de las mujeres que buscan abortos en el segundo trimestre y crear mayor conciencia de que el aborto es legal en el segundo trimestre y, por lo general, no se solicita por motivos de selección del sexo.

Key Words:

• second trimester abortion
• abortion law and policy
• unsafe abortion
• abortion methods
• sex determination and selection
• India

The literature on second trimester abortion in India is scanty, and accurate and disaggregated data are difficult to obtain. Although India is believed by some authors to have the highest number of second trimester abortions in the world, these claims are not backed up with any conclusive data.¹

Estimates of numbers of abortions in India have always varied. For instance, the Shantilal Shah Committee, which reviewed abortion law and practice in the 1960s before the law was revised in India, estimated in 1964 that for every 73 live births, there were 15 induced abortions. In the mid-1990s, it was estimated that there were 6.7 million induced abortions per year in India. Another estimate was of three illegal abortions for every legal abortion in rural areas and 4–5 illegal abortions for every legal abortion in urban areas.^1–3 None of these estimates distinguished between first and second trimester abortions.

Several studies in India have looked at the gestational period at which abortion is carried out.⁴⁵ These indicate that the vast majority of abortions take place during the first trimester.⁶ It was observed that women who wanted to space or limit births decided fairly early, by eight weeks, although there may have been delays in actually availing of the services.

However, there have also been a significant number of second trimester abortions identified in some studies. In a 1996 study in rural Maharashtra, 26% of 1,717 abortions took place in the second trimester and about 3% beyond 20 weeks.⁷ Estimates from Government of India data for 2003 were that 11% of all abortions had taken place in the second trimester.⁸ While some second trimester abortions may have been preceded by sex determination, a 2006 study suggests that unintended pregnancy rather than the sex of the child underlies the demand for most of these abortions in India.⁹

Unmarried women have greater barriers to accessing abortion due to the stigma of out-of-wedlock pregnancy and public sector providers' reluctance to provide abortions for unmarried women, leading to delays. In one hospital in rural Maharashtra, 72.2% of induced abortions in unmarried women took place in the second trimester, as compared to 42.6% among married women. A similar observation was made in a case–control study in Chandigarh, in which 60% of unmarried women were second trimester abortion seekers, as compared to only 7% of married women.¹⁰

Delay may also be caused by the woman’s failure to recognise the pregnancy. This may occur when pregnancy follows sterilisation failure¹¹ or during lactational amenorrhoea, when many women believe they cannot get pregnant. Women for whom poor nutrition and irregular periods may be the norm may also have difficulty identifying a delayed period as a symptom of pregnancy until other symptoms such as morning sickness begin to appear.

Second trimester abortion methods used in India

A range of methods used in India for carrying out second trimester abortions have been described. Surgical methods include dilatation and evacuation (D&E) and hysterotomy. The latter is rarely indicated, since it has a high morbidity rate. A modified D&E method has also been used in combination with prostaglandins.¹² However, surgical methods require a higher degree of training and skills, and require equipment, and are not the preferred methods in India.

Medical methods used include intra-amniotic instillation of various chemicals (now obsolete) and extra-amniotic instillation of ethacridine lactate (alone or in combination with a prostaglandin). The latter is still the method most commonly preferred by gynaecologists in India, but it is not recommended by WHO. The induction-to-abortion interval can be reduced to an average of 24 hours when the combination is used.¹³¹⁴ The use of povidone–iodine in saline has also been described in Indian studies as a cost effective method,¹⁵ but is also not recommended. The combination of mifepristone and misoprostol is now an established medical method and highly effective for termination of pregnancy, including in the second trimester. It was approved in 2002 only for use up to 49 days by the Drug Controller of India,¹⁶¹⁷ However, off-label second trimester use is seen increasingly in the private sector in India.

Women in India usually try every possible remedy before seeing a qualified doctor, however. This includes consuming a wide range of foods, as well as activities such as sleeping on the stomach or riding a bicycle.¹⁸ They also obtain (often ineffective) medication over the counter from pharmacists.¹⁹ These can result in delays of some weeks. Many women, even urban women, are unaware of the legal status of abortion²⁰ and will often go to one or more unqualified providers first, and look for a doctor or hospital only when that fails or complications ensue.

Although second trimester abortions only account for a small percentage of induced abortions, they may be associated with a disproportionately higher rate of morbidity, especially if unsafe or less safe methods are used. In India, disaggregated data on deaths due to second trimester abortion complications.

Laws and policies affecting abortion in India

The Indian Penal Code of 1860,²¹ a relic of the colonial past, draws heavily from the British Offences against the Person Act of 1861, which criminalised causing a miscarriage unless it was done to save the woman’s life.

In contrast to the trend in the western world, where legislative reform of abortion laws took place in the 1960s and 70s, the feminist movement did not play a central role in law reform in India. In fact, it was demographers who justified legalising abortion to help curb population growth, while the medical profession advocated liberalising the law in order to reduce the high morbidity and mortality from unsafe abortions. The Shantilal Shah Committee, appointed in 1964, reviewed published studies of complications of unsafe abortion and prevailing abortion legislation in a number of other countries, including Britain. The Committee’s 1966 recommendations were very progressive and included the statement that: “When the woman, (with or without the concurrence of her partner) feels that a particular pregnancy is intolerable and does not desire to bear the child…. [she] should be the master of her own body and decide the question of motherhood for herself.” ²²

The Medical Termination of Pregnancy (MTP) Act was tabled and approved in the Parliament in 1971 and came into force from April 1972²³ except in Jammu and Kashmir, where it was extended in 1980. (The Union Territory of Lakshadweep still has a restrictive abortion law.²⁴) The Act permits the termination of pregnancy up to 20 weeks, on the following grounds:.

	where the continuance of the pregnancy would involve a risk to the life of the pregnant woman or of grave injury to her physical or mental health; or
	where substantial risk exists of the child being born with serious physical or mental abnormality.

In the explanation of the Act, the note also indicates that a pregnancy due to rape or failure of contraceptive methods could also be aborted as “the anguish caused by such unwanted pregnancy may be presumed to contribute a grave injury to the mental health of the pregnant woman”. It further clarifies that in determining whether the continuance of a pregnancy would involve a risk of injury to the woman’s health, account may be taken of the pregnant woman’s “actual or reasonably foreseeable environment”.

The termination of pregnancy can be carried out only by registered medical practitioners as defined in the Act. For the termination of a second trimester pregnancy, the opinion of two such qualified registered medical practitioners is needed to confirm that there is a valid reason for the termination. The grounds for first and second trimester terminations are not differentiated in the Act.

The emphasis of public health policy continues to be on limiting family size. Even though the unmet need for contraception among women of reproductive age in India is 13.2% (10% urban and 14.6% rural),²⁵ the total fertility rate of the country declined from 5.2 in 1971 to 2.68 in 2005-06.²⁶²⁸ In 2006, the Indian Parliament passed a law promoting the two-child family norm.²⁷ The combination of fertility decline with strong son preference in some parts of the country has led in a growing number of cases to abandonment of girls, and during pregnancy to sex determination via ultrasound followed by second trimester termination.²⁸ However, discrimination against girls is in itself a complex issue with long-standing cultural sanction, long before ultrasound technology came in to facilitate it.

Currently in India, although abortion has been legal for over 30 years, the persistent reduction in the sex ratio²⁹ is prompting policymakers to consider a ban on second trimester abortions as a possible strategy. There was even a suggestion by the Minister for Women and Child Development, Renuka Chowdhury, to record all pregnancies as they occur so that their continuation can be tracked.³⁰ While this is not a practical suggestion, it does indicate the urgent need for the sensitisation of policymakers to issues of women’s rights, reproductive and sexual rights, and autonomy.

Meanwhile, safe abortions, even in the first trimester, continue to be difficult to access for a variety of reasons, and unsafe abortions (8.9%) continue to contribute to the high rate of maternal mortality (407 per 100,000 live births in 1998).³¹

Facilities providing second trimester abortion

Across India, the number of facilities that are registered and fully equipped to do abortions is extremely low in proportion to the population, and their distribution is highly skewed. The majority are located in urban areas. Further, the less developed but more populous states have fewer abortion facilities than the smaller, more developed states. Maharashtra, with 9.4% of the total population has 21.2% of the total registered abortion facilities in India, while Bihar, with 10.3% of the total population, has only 1.2% of the approved centres.³² A little more than 70% of all facilities across the country provide only first trimester services.³³³⁴ This is another obstacle and cause of delays.

The public sector, particularly for the poor and for women seeking abortions, is associated with humiliation and poor quality services. Not only are these services not free in themselves, but they also entail expenses such as travel, medicine costs, and token payments to cleaners and ward staff.³⁵ Public sector centres may not always have adequate, qualified staff or functioning equipment either.

Not only are there often a lack of qualified providers, especially in rural areas, but the number of providers who are able and willing to provide abortion as pregnancy progresses falls. Unlike with first trimester abortions, second trimester abortions require a more comprehensive set-up, including an operation theatre with facilities for emergency surgery, blood transfusion, referral and transport if necessary. Given the average induction-to-abortion interval of 24–72 hours with the older methods, round-the-clock staffing is also required. Hence, these procedures are most likely to be confined to doctors and within nursing homes. However, with the greater utilisation of mifepristone–misoprostol and misoprostol alone in the private sector, often in an outpatient setting in the initial phase, this scenario is likely to change rapidly.³⁶

The cost of an abortion increases with gestational age, ambiguous marital status and local market forces. The Abortion Assessment Project-India found that in 2004, early abortion was available in India for an average of 500–1000 INR and later abortion for 2000–3000 INR.³³ Although low from the providers’ perspective, these costs are still high enough to create serious barriers for many women seeking services, who still turn to providers without skills or training.

“We had a woman admitted with an incomplete abortion. She kept on deteriorating despite uterine evacuation and antibiotics. Finally we did an exploratory laparotomy and found multiple punctures in the bowel. The hospital operating theatre attendant had been taking the instruments home after work. He used to offer ‘abortion services’ in the slum where he lived. This was one of his ‘clients’. However, we had no concrete proof and were not able to take any action.” (Senior colleague, large public hospital, Mumbai, personal communication, 2006)

The private sector is perceived as being of “better quality”, in terms of confidentiality, cleanliness, waiting times and follow-up services.³⁷ However, these come with a hefty price tag and may require payments prior to any procedure. At the same time, if any medico-legal issues or serious complications are involved or anticipated, private practitioners would promptly direct a woman to the public sector.

Non-governmental facilities wishing to provide abortions must be registered and approved by the appropriate government authority. This is an often cumbersome and long drawn-out procedure, with waiting times of up to 2–3 years for inspection and registration, and discourages doctors from applying. Hence, there are a large number of qualified gynaecologists who are providing safe but “illegal” abortions, as their nursing homes are unregistered. This makes data collection even more difficult, since their data are not recorded with the appropriate local authority.

India’s National Population Policy of 2000 recommended enhancing abortion service provision at primary health centres.³⁸ In an attempt to facilitate registration of private abortion clinics, the Indian Parliament passed an amendment to the MTP Act in 2003 that decentralises the clinic registration process to the district level.³⁹

Furthermore, the new Reproductive and Child Health programme (RCH-2) has emphasised addressing the unmet need for safe abortion services and thus has increased training in manual vacuum aspiration to increase availability at primary health centres.⁴⁰ In 2003, the MTP Act was amended to recognise the distinction between the infrastructure and provider training required for first and second trimester abortions.⁴¹ This has made it easier for facilities and providers to be registered only for first trimester abortion provision without having to fulfil the criteria for the second trimester, such as an having an operating table and instruments for performing abdominal or gynaecological surgery, and anaesthetic equipment. However, this does nothing to aid registration for second trimester services.

Women’s stories as described by providers

Recent anti-sex selection propaganda has confused women who do not know that abortion is legal in India even more, by making it appear as though all abortions are illegal rather than the sex determination tests that may lead to sex-selective abortion. Moreover, government-endorsed informational material condemning sex selection is reaching communities who have never been given any other information about the status of abortion in India.⁴² The campaigns and campaigners seem unable (or possibly unwilling) to promote awareness that sex selection stems from gender discrimination and not from the availability of safe abortion.

Women seek abortions in the second trimester for the same reasons as they do in the first trimester. For a woman, the divide between trimesters is artificial. She has a pregnancy that she does not wish to continue to term. What needs to be analysed are the reasons for later abortion. The literature pertaining to this in the Indian context is quite scanty, but there are some studies from the Asia region. According to a study from Viet Nam, where legal and safe induced abortion services are available on request, three factors were causing delays in obtaining abortions: most women failed to recognise their pregnancy in the first trimester; there were structural barriers to accessing services earlier; they needed a long time to make a decision or only decided to abort after other events had transpired.⁴³

Women who are mentally handicapped, institutionalised in remand homes or in prisons are in a vulnerable situation and may be victims of sexual abuse. A pregnancy may become obvious to them only in the second trimester. Migrant workers and housebound domestic servants may also find themselves in this situation.

“L, a 12-year-old girl, had been abandoned at birth and was living in a state-run orphanage. She was being sexually abused regularly by the watchman. When she was brought to us because she had been feeling ill; she was found to be 16 weeks pregnant. (Personal communication, gynaecology resident, large public hospital, 1996)

Often, women or girls in these situations attempt to conceal the pregnancy until it becomes evident. This is most common in adolescents who are likely to be in denial or concerned about confidentiality issues, and unwilling to face the unsupportive attitudes and behaviour of providers until the pregnancy can no longer be hidden. This is also seen in women who are unmarried, widowed and separated, i.e. not in a socially accepted relationship. Large public hospitals continue to admit some of these women to the antenatal ward for delivery under the rubric of “social admission for unmarried primi” when they are too late for a legal abortion.

“ZH, a young girl working as a housemaid, was engaged to be married, but was in a relationship with the cook working in the same household. She did not realise that she was pregnant until three months had gone by. She could not confide in anyone and could not access the hospital without the mistress finding out. So, the cook took her to a local quack who worked out of the marketplace. Four days later she was admitted to hospital in a delirious state and died of septic shock.” (Personal communication, senior gynaecologist from a public hospital 2006)

Another important cause for a late decision is a change in circumstances.⁴⁴ This may happen when the pregnancy may be wanted or not entirely unwanted, but where the ability to have the child depends on external factors such as continuing employment, financial stability and/or partner support.

“M, a 32-year-old woman, had a 9-year-old son from her previous marriage. She was now married again and at eight weeks of pregnancy had come for antenatal care. She returned after two months asking for an abortion. I was surprised. I asked for the reason. She said her husband was behaving extremely badly and kept saying this was not his child and that he would do a DNA test after birth to check. She said if he was not going to accept and love the child she would have to leave the marriage and she was not in a position to bring up a child alone.” (Patient seen by the author, private hospital, 2007)

Adolescents are unlikely to have access to enough money if costs are high. The public sector may not offer them the confidentiality, even secrecy, that they desire so highly, and which they may value even more than safety. In India, many adult women do not have money at their disposal to be used at their own discretion either.

Incest and rape victims are likely to want to shut out the episode, and it may only be the growing pregnancy that brings to light the events. Menopause too may lead to lack of recognition of signs of pregnancy.

“I am 40. I had an operation done five years ago, to stop more children. Then my period stopped some months ago. I thought it was over. My sister’s was over too. When the baby started moving I realised I was pregnant. My daughter has two children. I am a grandmother. It is shameful for me to have a baby now.” (Ward attendant seen by medical officer, NGO clinic, personal communication, 2002)

Most fetal anomalies cannot be diagnosed or confirmed in early pregnancy. Therapeutic abortions carried out on these grounds are usually in the late second trimester in India, and even in the third trimester. Certain maternal health conditions, physical and mental, may also be identified in later pregnancy.

In countries like India where son preference is deeply rooted in the culture and traditions, there have always been many ways to get rid of an unwanted girl – by infanticide, abandonment, starvation and neglect. Tests such as chorion villus biopsy (10–12 weeks), amniocentesis (14+weeks)⁴⁵ and diagnostic ultrasonography (14+weeks) which were developed to detect fetal anomalies and complications of pregnancy are now also being used to identify the sex of the fetus in pregnancy. Since these tests can confirm the sex of the fetus only in the late first trimester or early second trimester, they contribute to the cohort of late abortions.

Where universal HIV testing is carried out in antenatal clinics, often without pre-test counselling, many women who test positive receive the results in the early second trimester. These women are often abandoned by their husband and in-laws, as well as ostracised by the community. Under these circumstances they often choose to terminate the pregnancy.

“A 20-year-old girl came to me. She had been married one year ago, in a mass marriage ceremony to a man who was 35 years old. She got pregnant four months ago. Since antenatal HIV testing was being done at the local clinic she got her test done and was told she was positive. Her husband’s family threw her out. She wanted an abortion. But in these abortions, there is too much bleeding and my staff will object if I take in HIV positive cases. Also, she had no money.” (Private practitioner, personal communication, 2005)

Providers’ perspectives

The providers find themselves occupying multiple identity spheres. They are a part of the society from which certain ideologies emerge (such as sex selection, religious and moral objection). They are figures of authority and gatekeepers. But they also need to function within the purview of the laws and policies governing them.

Training in theoretical aspects of safe abortion is in the mainstream of medical education in India, but practical hands-on training is mostly restricted to obstetrician–gynaecologists. This training is imparted during residency programmmes and for second trimester abortion is usually limited to the use of ethacridine lactate (Rivanol, or Emredil/Abortil in India) in combination with various regimes of prostaglandins or oxytocin.

For those in the private sector, there are numerous practical considerations to deal with in providing second trimester abortions. These relate to registration requirements, documentation and record-keeping, confidentiality, availability of overnight stay and emergency care facilities, disposal of the fetus, and skilled, motivated staff. The possibility of medico-legal complications is always a de-motivating factor.

“I could not believe the girl was 12 but her ‘aunt’ said she was. She was so malnourished and frail, she looked eight. Her parents had died and she lived with her older sister in the village. The sister’s husband had been sexually abusing her for over a year. She never got her first period but got pregnant. When the sister discovered this, she sent her away to their maushi (maternal aunt) in the city for an abortion. The girl was 16 weeks pregnant when I saw her. I did not know whether to believe that the old woman was her aunt at all. They had very little money and I could not take such risks in my private nursing home. I sent them to the nearest public hospital.” (Gynaecologist, private practice, personal communication, 2006)

Thus, there are many doctors who choose not to provide second trimester abortions at all. Those who do have to contend with harassment from government officials and sting operations aimed at enforcement of the Pre-Conception Pre-Natal Diagnostics (Prohibition of Sex Selection) Act or PCPNDT Act.⁴⁶

“I don’t mind helping a genuine case. But last week a woman came to me. She had two daughters already and wanted an abortion at 16 weeks. How do I know if she had an ultrasound done elsewhere? I may get caught. If my name gets into the [news]paper, my reputation will be gone. After 15 years of good practice, why take such a risk just for some money?” (Gynaecologist, private practice, personal communication, 2006)

Products of conception below 500 g are disposed with other biomedical waste, but some doctors hand these over to the woman and her relatives for disposal, to avoid attracting the attention of law enforcement officials by having disposal on record. This is not only unspeakably traumatic for the woman but also violates biomedical waste disposal practices. Some families do bury or cremate the tissues but they often also attempt disposal in rubbish bins, tips, ponds, lakes and such like.

Lastly, the financial returns for doctors willing to do second trimester abortions are not always adequate, given the difficulties involved. Despite this, there are many doctors who provide second trimester abortions (and obviously many who do so after sex selection).

Discussion and recommendations

There is much we do not know about second trimester abortions in India. What is clear is that awareness in the community needs to be increased about the legal status of abortion in India, particularly given the recent blitz of anti-sex selection campaigns, which have given people the message that all abortions are now illegal, when abortion has not been made illegal at all. Research, documentation and high profile advocacy efforts are needed at national level to ensure that second trimester abortion is not equated only with sex selection practices. Sensitisation of policymakers, health managers, media, lawyers and doctors is vital to ensure the understanding that the practice of sex selection emerges from patriarchal systems, son preference and discrimination against girls and women.

Medical abortion with mifepristone–misoprostol needs to be introduced in the public health system to replace ethacridine lactate. The use of medical abortion in rural and semi-rural India would greatly enhance access for women.⁴⁷

Expansion of the cadre of service providers to carry out early manual vacuum aspiration and manage both first and second trimester medical abortions would also greatly expand access. Inclusion of non-allopathic doctors and qualified nurses who have the requisite clinical skills, obtained through training and experience, and who can be monitored and supervised and given ongoing capacity-building and guidance, could also be considered. However, the literature shows that improving access to first trimester abortions would reduce the need for second trimester abortion only to an extent.⁴⁸

Values clarification among providers is necessary to challenge the barriers experienced by the most vulnerable women in accessing services. The teaching faculties of medical and nursing colleges should be an important focus since they can influence many generations of providers. Unsafe, illegal providers need to be identified and brought within the ambit of safe service delivery wherever possible, or prevented from performing unsafe abortions. With an increasingly greater role for mifepristone–misoprostol, pharmacists and chemists should also be involved in capacity-building and sensitisation programmes.

India is in a position to reduce mortality and morbidity from second trimester abortion and improve services. Greater information is needed on these abortions in order to motivate and inform change. Lastly, there is a urgent need for national policy which addresses safe abortion within the context of women’s sexual and reproductive rights.