ABORTION PRACTICE IN INDIA

A REVIEW OF LITERATURE

Heidi Bart Johnston

Abortion Assessment Project - India

1
First Published in May 2002

By
Centre for Enquiry into Health and Allied
Themes (CEHAT)
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rating organizations.

2
TECHNICAL ADVISORY COMMITTEE (TAC) ETHICS CONSULTATIVE GROUP (ECG)

q Dr. R.N. Gupta, Social Scientist and q Dr. Sudarshan Iyengar, Representing the
Researcher, Indian Council of Medical TAC, Gujarat Institute of Development
Research, New Delhi Research, Ahmedabad
q Dr. Leela Visaria, Coordinator of q Dr. S.V. Joga Rao, National Law School of
Healthwatch and Researcher, New Delhi India University, Bangalore
q Dr. Saramma Thomas Mathai, Consultant
q Dr. Sanjay Gupte, Chairperson, Ethics and
in Maternal & Child Health, New Delhi
Medico-Legal Committee, FOGSI, Pune
q Dr. Thelma Narayan, Epidemiologist -
Community Health Cell, Bangalore q Dr Vasantha Muthuswami, Expert on Bio-
Medical Ethics DDG (SG), Indian Council
q Dr. Padmini Swaminathan, Senior
of Medical Research, New Delhi
Economist and Researcher, Madras
Institute of Development Studies, Chennai q Dr. Ritu Priya, Researcher and
q Ms. Manisha Gupte, Health and Women’s Academician Jawaharlal Nehru University,
Activist, Mahila Sarvangeen Utkarsha New Delhi
Mandal (MASUM), Pune q Ms. Padma Prakash, Deputy Editor,
q Dr. Sudarshan Iyengar, Researcher and Economic and Political Weekly, Mumbai
Academician, Director of Gujarat Institute
q Dr. V.R. Muraleedharan, Researcher and
of Development Research, Ahmedabad
Academician, Department of Humanities
q Ms. Sudha Tewari, Provider of Abortion and Social Sciences Indian Institute of
Services, Parivar Seva Sanstha, New Delhi Technology, Chennai
q Dr. Kamini Rao, Professional, President
q Dr. Amar Jesani, Programme Co-ordinator,
Federation of Obstetrician and Gynaeco-
Achutha Menon Centre for Health Science
logical Societies of India (FOGSI),
Studies, Sree Chitra Tirunal Institute for
Bangalore
Medical Sciences and Technology,
q Dr. Narika Namshum, Asst. Commissioner Thiruvananthapuram, Kerala
(Maternal Health), Dept. of Family Welfare,
Government of India, New Delhi
q Ms. Ena Singh, Assistant Representative
in UNFPA India Country Office, a member
in her personal capacity as an experienced
Research Administrator, New Delhi

3
 ACKNOWLEDGEMENTS
This paper was developed in coordination with the Abortion
Assessment Project - India (AAP-I).
The author would like to thank members of the Abortion Assessment
Project - India for their comments on an earlier draft of the paper, as
well as Ravi Duggal, Bela Ganatra, Saramma Mathai, Manisha Gupte,
Malini Karkal, Dale Huntington, Priya Nanda and Robert Pelto for their
insightful comments.
At Ipas, Jaine Benson, Barbara Crane, Ronnie Johnson and Karen
Otsea provided constructive feedback.
The Ford Foundation provided financial support for the development
of this paper. Inaccuracies in and shortcomings of the paper are the
fault of the author alone.
Please address comments to the author at johnstonhb@ipas.org

4
 PREFACE
Abortions have been around forever. But V. Dissemination of information and
at different points of time in history it has literature widely and development of an
received attention for differing reasons, advocacy strategy
some in support of it, but often against it.
This five pronged approach will,
Abortion is primarily a health concern of
hopefully, capture the complex situation as
women but it is increasingly being governed
it is obtained on the ground and also give
by patriarchal interests which more often
policy makers, administrators and medical
than not curb the freedom of women to seek
professionals’ valuable insights into abortion
abortion as a right.
care and what are the areas for public policy
In present times with the entire focus of interventions and advocacy.
women’s health being on her reproduction, The present publication, the first in the
infact preventing or terminating it, abortion AAP-I series evolved along with the develop-
practice becomes a critical issue. Given the ment of this project. In that sense it was a
official perspective of understanding abortion useful input in that process. Ford Foundation
within the context of contraception, it is supported Ipas to undertake this review and
important to review abortion and abortion this publication was undertaken through
practice in India. that support. While efforts have been made
to cover as much ground as possible there
The Abortion Assessment Project India
may still be gaps in covering some
(AAP-I) has evolved precisely with this
dimensions of the abortion issue, which we
concern and a wide range of studies are being
hope to cover in subsequent publications
undertaken by a number of institutions and
emerging from this project.
researchers across the length and breadth
of the country. The project has five We look forward to comments and feed-
components: back which may be sent to cehat@vsnl.com
Information on this project can be obtained
I. Overview paper on policy related issues, by writing to us or accessing it from the
series of working papers based on website www.cehat.org
existing data / research and workshops
to pool existing knowledge and
information in order to feed into this _ Ravi Duggal
project. Coordinator, CEHAT
II. Multicentric facility survey in six states
focusing on the numerous dimensions
of provision of abortion services in the
public and private sectors
III. Eight qualitative studies on specific
issues to compliment the multicentric
studies. These would attempt to
understand the abortion and related
issues from the women’s perspective.
IV. Household studies to estimate
incidence of abortion in two states in
India.

5
 TABLE OF CONTENTS
EXECUTIVE SUMMARY

I. INTRODUCTION ................................................................................................. 1

II. ABORTION RATES AND ASSOCIATED MORBIDITY AND MORTALITY

A. ABORTION INCIDENCE .................................................................................. 1

B. MORBIDITY AND MORTALITY FROM UNSAFE ABORTION .......................................... 5

III. MEDICAL TERMINATION OF PREGNANCY (MTP) IN INDIA

A. LEGAL STATUS OF ABORTION ......................................................................... 6

B. INADEQUATE LEGAL ABORTION SERVICE PROVISION ............................................... 7
C. ILLEGAL ABORTION – PROVIDERS AND METHODS ................................................. 9
D. CHARACTERISTICS OF WOMEN WHO TERMINATE UNWANTED PREGNANCIES .................... 10
E. DECISION-MAKING ISSUES ............................................................................. 11

IV. POSTABORTION CARE SERVICES

A. MANAGEMENT OF ABORTION-RELATED COMPLICATIONS ......................................... 12

B. CONTRACEPTIVE COUNSELING AND SERVICES ....................................................... 14
C. LINKAGES WITH OTHER REPRODUCTIVE HEALTH SERVICES ....................................... 14

V. RECOMMENDATIONS

A. IMPROVING KNOWLEDGE OF ABORTION INCIDENCE ................................................... 15

B. IMPROVING PREGNANCY TERMINATION SERVICES ..................................................... 15
C. IMPROVING ABORTION CARE ............................................................................ 17

VI. CONCLUSIONS

REFERENCES ................................................................................................... 19
APPENDIX
TECHNIQUES USED TO ESTIMATE ABORTION RATES PRESENTED IN THIS REVIEW ................ 23

6
 EXECUTIVE SUMMARY

The Medical Termination of Pregnancy tion care, including postabortion care.

Act of 1971 greatly liberalised the indications
for which abortion is legal in India. The Gov- Results of the studies reviewed suggest
ernment intended for this Act to reduce the that reducing recourse to unsafe abortion
incidence of illegal abortion and consequent will be a complex multi-step process that
maternal morbidity and mortality. However, includes increasing women’s access through
30 years after the groundbreaking legisla- improve-ments in service delivery and
tion, the majority of women seeking abor- addresses the more complicated issues of
tion still turn to uncertified providers for abor- rights and gender power inequities.
tion services because of the barriers to legal Strategies to make safe and legal abortion
abortion. While some uncertified providers services more attractive to women and
offer safe services, many provide unsafe decision makers include: increasing
abortions that result in complications or geographic accessibility; increasing
death. Women with access to fewer re- affordability; providing high quality abortion
sources, for example low-income rural care and prioritising confidentiality of
women and adolescents, are among those services. Addressing the system of barriers
most likely to turn to unsafe abortion and limiting women’s access to safe abortion
have complications. Studies suggest that the services may require review and revision of
choice of specific provider is most often not the MTP Act, 1971 and associated rules and
made by the woman inducing abortion but regulations.
with or by her husband or other family mem-
This review suggests a need for expanded
bers.
community-based education to address
While the incidence of abortion in India specific issues of women’s reproductive
is unknown, the most widely cited figure sug- health and the broader issues of women’s
gests that around 6.7 million abortions take right to high quality health care services.
place annually. According to government Household decision-makers, men and
data, only about one million of these are per- women, would benefit from awareness
formed legally. The remaining abortions are raising about the dangers of unsafe abortion
performed by medical and non-medical prac- and the availability of safe abortion services.
titioners. Levels of unsafe abortion are very Women with reduced access to reproductive
high in India, especially given that abortion health resources, such as adolescents and
is legal for a broad range of indications, and rural poor, should be a priority focus in com-
available in the public and private health munity-based education.
sector.
This review of the current literature of
In the current situation abortion services abortion in India suggests that abortion and
are not adequately decentralized, and regu-
latory reform will have to take place before
decentralization of legal services will hap-
pen in a meaningful way. To reduce morbid-
ity and mortality from unsafe abortion in this
context, several broad activities require
strengthening: decreasing unwanted preg-
nancies; increasing access to safe abortion
services; and increasing the quality of abor-

7
qualified practitioners to attend MTP training Clearly a great deal is known about
courses; reviewing MTP Act and associated provision of and access to safe and unsafe
rules and regulations to determine how the abortion services in India and the need to
law can be revised to decentralize abortion improve safe abortion and contraceptive
services and otherwise better meet the choices to more adequately meet the needs
needs of women; upgrading facilities that of women experiencing unwanted pregnan-
currently offer MTP services; orienting MTP cies. Still, a great deal more needs to be
services to meet the needs of women most known before programs are implemented to
at risk of accessing unsafe abortion; ensure low-resource Indian women can
increasing awareness among women and readily access safe abortion services. The
men of reproductive age of the availability of cost in terms of women’s health and lives
safe abortion services and the dangers of emphasizes the need to efficiently and
unsafe abortion; involving communities and
effectively pursue efforts to make abortion
providers at all levels to improve reproductive
safer and more accessible for Indian women.
health care; and improving adolescent
reproductive health services in general.
Innovative interventions need to be
developed, implemented, monitored and
scaled up as appropriate.

8
 About the Author

Heidi Bart Johnston, Ph.D.

Dr. Johnston is a specialist in demography and reproductive health. Her research
includes testing methods of quantifying induced abortion rates and identifying
perceptions and practices of abortion clients and providers in rural communities.
Her current work focuses on exploring means of increasing the demand for
high-quality reproductive health care among rural women and decision-makers.
She contributes research expertise to Ipas’s Asia program.

9
 ABORTION PRACTICE IN INDIA
A REVIEW OF LITERATURE
I. INTRODUCTION have on women’s health and lives?
Complications of unsafe abortion are a Recognizing the high estimated incidence
major public health issue facing women in of abortion-related mortality and morbidity
developing countries. In India, abortion is in parts of India this paper reviews the
legal for a broad range of medical and social literature on safe and unsafe abortion
reasons. Officially, women can access safe services, abortion facilities and providers,
abortion services by trained medical complications of unsafe abortion, and
personnel in registered facilities, and minors availability of postabortion care in India. The
need consent from their husband or father. review aims to synthesize what is known
In practice, limited access to authorized about abortion in India and identify steps
abortion providers, the threat of forced that need to be taken to develop abortion
contraceptive acceptance, the financial costs related services that more closely meet
associated with legal abortion, the stigma Indian women’s needs.
associated with induced abortion, and low
levels of awareness regarding the legality of II. A BORTION R ATES AND A SSOCIATED
the procedure bar women from safe abortion MORBIDITY AND MORTALITY
services (Khan et al. 1999; Sinha et al. 1998).
As a result, women often resort to untrained A. ABORTION INCIDENCE
clandestine practitioners operating under Induced abortion incidence is extremely
unsafe conditions. The consequences of difficult to measure in most countries and
abortions performed under such India is no exception. Data quality is an
circumstances range from life threatening important consideration in studying abortion.
to chronic reproductive tract morbidity such Abortion procedures, whether performed
as infections, chronic disability and legally by trained professionals using modern
infertility (Chhabra and Nuna 1994). technology or illegaly using “traditional”
In India each year an estimated 453 methods are subject to substantial
women die due to maternal causes for every underreporting (Huntington et al. 1993).
100,000 live births (UNFPA 1997). This Abortion data typically come from one of two
statistic masks the vast variation among sources: clinic or hospital records or
states. While national and state estimates individual surveys of women. Clinic or
are imprecise, they are able to represent hospital sources tend to be of poor quality
certain trends. Orissa and Madhya Pradesh where abortion is illegal, highly stigmatized
had approximately 738 and 711 maternal or difficult to obtain (Baretto et al. 1992;
deaths per 100,000 births in 1992. Among Frejka 1985; Paxman et al. 1993; Remez
the large states, Kerala has a singularly low 1995). Individual surveys underestimate the
ratio of 87 maternal deaths reported per incidence of induced abortion even where
100,000 births. On an average, roughly abortion is legal (Anderson et al. 1994; Jones
fifteen percent of maternal deaths in India and Forrest 1992).
are thought to result from unsafe abortion No valid data exist on the incidence of
(Chhabra and Nuna 1994). In what abortion in India (Mathai 1997). Clinic data
conditions are these abortions provided? are published as government statistics but
What impact do these unwanted pregnancies these reflect only reported medical termi-
nation of pregnancy (MTP) cases conducted in the five states of Haryana, Orissa,
in clinics recognized by the government Rajasthan, Tamil Nadu and Uttar Pradesh
(Khan, et al n.d.). These abortion statistics in 1983-84. According to ICMR findings, for
show an increase in MTP since the the five states combined, 19 per 1000
liberalization of abortion laws in 1972 until pregnancies were terminated. Six per
the early 1980s (Khan et al. 1999 from Family thousand were terminated legally, and 13 per
Welfare of India Year Book, Government of 1000 pregnancies were terminated illegally.
India, 1993). Since 1982-83 there has been Applying these proportions to 1990 national
an increase in MTP centers, but no corres- abortion data implies that the approximately
ponding increase in the reported numbers 600,000 legal abortions reported in 1990
of MTP performed. Underreporting of MTP indicate that in total 1.3 million illegal
could be a reason for this (Mathai 1997). abortions were performed nationwide (Indian
Council of Medical Research 1988; World
Illegal and thus unreported abortions are Bank 1996). The ICMR national abortion
estimated to outnumber legal abortions by a estimate is substantially lower than
factor of between three and eight (Gupte n.d.; Chhabra and Nuna’s widely cited indirect
Karkal 1991, as cited in Chhabra and Nuna estimate of 6.7 million induced abortions
1994). Surveys like the National Family annually (Chhabra and Nuna 1994).
Health Survey collect abortion data (Inter-
national Institute for Population Sciences Because available direct estimates of
1995). These data report a very low incidence abortion rates from clinic and survey data
of abortion among Indian women and are also are generally acknowledged to be under-
considered gross underestimates (Arnold estimates, various indirect estimation
1999; International Institute for Population techniques have been used to measure
Sciences 1995; Mishra et al. 1998). In abortion incidence and relative rates
general, large scale DHS-like surveys are (Chhabra and Nuna 1994; Johnston and Hill
inadequate tools for investigating socially 1996; Mishra et al. 1998; Shah 1966). Each
stigmatized topics such as induced abortion of the indirect estimation techniques used
(Huntington et al. 1996). employ assumptions that affect the resulting
estimates. Estimated rates of induced
The Indian Council of Medical Research abortion are presented by state in Table 1.
(ICMR) conducted induced abortion research See Appendix 1 for details on the calculation
of these estimates.

11
 Table 1. Total Abortion Rate Estimates from Three Indirect Estimation Techniques
TAR TPIAR TAR
Abortion:Birth Potential Induced Residual Technique
Ratio Abortion Rate
__
India 0.97 2.65
North India
Delhi 1.72
__ 2.08
Haryana 1.72 0.94 1.37
__
Himachal Pradesh 1.68 0.59
__ __
Jammu (J&K) 2.25
Punjab 1.91 0.53 1.61
Rajasthan 1.62 0.57 5.35
Central India
Madhya Pradesh 1.60 0.73 5.29
Uttar Pradesh 1.64 1.39 5.77
East India
Bihar 1.53 1.13 6.24
Orissa 1.70 0.88 3.88
West Bengal 1.74 1.22 2.39
Northeast India
__
Arunachal Pradesh 1.81 4.89
Assam 1.91 1.20 2.53
Manipur 2.16
__ 2.00
__
Meghalaya 1.93 5.55
__
Mizoram 0.70
__
Nagaland 2.35 6.23
__
Tripura 1.87 3.13
West India
__
Goa 1.95 2.02
Gujarat 1.68 0.27 1.25
Maharashtra 1.66 0.68 1.73
South India
Andhra Pradesh 1.55 0.43 3.78
Karnataka 1.72 1.08 2.24
Kerala 1.91 0.42 0.88
Tamil Nadu 1.66 0.79 3.13
Sources: Chhabra and Nuna 1994; Mishra et al. 1998; and original data generated for this report:
Please see Appendix 1 for brief descriptions of the three estimation techniques.
Data for Sikkim and Union territories not available. Chattisgarh, Uttaranchal and Jharkhand are
included in MP, UP and Bihar respectively.

12
 The data presented in Table 1 show that Various alternative estimation
different methods of estimating abortion techniques also yield wide variations in
generate vastly different rates and relative estimates of the number of abortions
rates. Rates vary substantially by state. The occurring annually in India, as shown in
potential induced abortion and residual Table 3. In 1966 the Shah Committee
estimation techniques take into account estimated that 3.9 million induced abortions
variations in reproductive behavior by state took place annually in India (Chhabra and
and are thought to more accurately reflect Nuna 1994). In 1970 IPPF assumed that 200
relative rates. For the entire country the abortions occurred per 1000 births, and
number of abortions a woman will have on suggested the national figure was close to
an average throughout her reproductive 6.5 million (Mishra et al. 1998). [Goyal et al.
years is estimated to be between (1976) presented a range of four to six million
approximately 1.0 and 2.6. in 1976 (Khan et al. n.d.).] UNICEF reports
that roughly five million induced abortions
Table 2 makes some sense of the indirect occur annually in India. Four and a half
estimates by showing agreement between million of these are said to be performed
the different estimation techniques illegally, and only one-half million are
according to states ranked among those performed within the health services
having highest abortion rates in the country. network (Jejeebhoy 1996; UNICEF/India
States in one or more ranking systems are 1991). Based on clinical records, which are
marked in bold. The states that have high recognized to undercount the incidence of
rates of induced abortion in more than one abortion, the Government of India reported
ranking system are Nagaland, Meghalaya, the total number of induced abortions in
Uttar Pradesh, West Bengal, Assam, Bihar, India in 1991-92 at 0.63 million. Chhabra
Arunachal Pradesh, Orissa, Madhya Pradesh, and Nuna (1994) used the same technique
and Tripura. This suggests that abortion as the Shah Committee to estimate that 6.7
rates are highest in Northeast and Central million induced abortions occur in India
India. Not all states were included in each annually. This comparison of the same
analysis. However, the larger states were. technique suggests that the number of
abortions has increased over time.
Table 2. Abortion Rates by Three Different Indirect Estimation Methods

Abortion:Birth Ratio Abortion Potential Residual Estimation

1 Nagaland 2.35 Uttar Pradesh 1.39 Bihar 6.24

2 Manipur 2.16 West Bengal 1.22 Nagaland 6.23
3 Meghalaya 1.93 Assam 1.20 Uttar Pradesh 5.77
4 Punjab 1.91 Bihar 1.13 Meghalaya 5.55
5 Assam 1.91 Karnataka 1.08 Rajasthan 5.35
6 Kerala 1.91 Haryana 0.94 Madhya Pradesh 5.29
7 Tripura 1.87 Orissa 0.88 Arunachal Pradesh 4.89
8 Arunachal Pradesh 1.81 Tamil Nadu 0.79 Orissa 3.88
9 West Bengal 1.74 Madhya Pradesh 0.73 Andhra Pradesh 3.78
10 Delhi 1.72 Maharashtra 0.68 Tripura 3.13

Sources: Chhabra and Nuna, 1994; Mishra et al. 1998; and original data generated for this report.

13
Table 3. Estimates of number of induced Table 4. Maternal Mortality Attributable
abortions nationwide annually to Abortion
Maternal
Source Number of Induced
Mortality
Abortions Location Attributable Source
Nationwide (millions) to Abortion
(percent)
Shah, 1966 3.9
India, 1982-1983 18.1 ICMR
IPPF, 1970 6.5 India, Rural, 1989 10.8 Office of the Registrar
General 1991*
Goyal et al., 1976 4.6 India, Rural, 1993 11.7 Office of the Registrar
General 1993*
UNICEF, 1991 5.0 India, 1992-1994 11.1 Bhatt 1997@
India, 1993-1994 12.6 ICMR task force
GOI, 1991-92 0.6 1998@
India, 1994 12.6 GOI 1998@
Chhabra and Nuna, 1994 6.7 India, 1991-1995 18.0 Office of the Registrar
General of India n.d.#
The gap between reported legal abortion
Sources : * Mathai 1998
and total abortion estimates suggests that # World Bank 1996;
@ Ganatra 2001:
less than 10 percent of the abortions that
take place in India are conducted legally Each abortion related death represents
(Khan et al. n.d.). In the 1983-84 ICMR many more abortion related complications.
abortion study, of the 55 percent of abortions In India, the most frequently recognized com-
conducted in the first trimester, only about plications from unsafe abortion are: pelvic
25 percent were conducted by certified infection, incomplete abortion, hemorrhage,
doctors or other health staff (Indian Council uterine injury and cervical injury (Barge et
of Medical Research 1988; World Bank 1996). al. 1997; Kerrigan et al. 1995). Mathai (1998)
Abortions conducted in the second trimester found Indian women are presenting to medi-
are more difficult to access, requiring the cal facilities with grade III sepsis, including
authorization of two physicians (United sepsis associated with generalized perito-
Nations 1993). As such they are more likely nitis, septicemia, septic shock, acute renal
to be performed by uncertified providers. failure and disseminated intravascular co-
While abortion services from some agulation (Sharma et al. 1992; Sood et al.
uncertified providers can be completely safe 1995 as cited in Mathai 1998). Gas gangrene,
many uncertified providers perform tetanus, severe adhesions and renal failure
dangerous abortion procedures that result in associated with the use of Fetex Paste are
morbidity and death. also reported (Mathai 1998). Women present-
ing at clinics in Uttar Pradesh with abortion
B. Morbidity and Mortality from Unsafe complications were reported to have at-
Abortion tempted to abort using insertion of a foreign
Limited data exist on the number of ma- body such as a stick or a root; orally ingested
ternal deaths from abortion in India. The drugs; improper dilation and curettage and
Survey of Causes of Death reports that nearly other less common means (Barge et al. 1997).
18 percent of maternal deaths result from
Second trimester abortions are a parti-
abortion (Office of the Registrar General of
cular health concern. Women who delay
India n.d.). Data from other sources suggest
accessing abortion or MTP until the second
that the percent of maternal mortality re-
trimester place themselves at a greater risk
sulting from unsafe abortion ranges from 4.5
of complications and death, particularly if the
to 16.9 percent (See Table 4).
abortion provider is untrained (Jones 1991;
14
Kerrigan et al. 1995). Studies show that performed by a registered physician in a
unmarried adolescents and women hospital established or maintained by the
undergoing sex selective abortion are the government or in a facility approved for the
groups most likely to attempt second purpose by the government (Mathai 1998).
trimester abortion (Ganatra et al. 2000; Rao For abortions taking place between twelve
and Rao 1990, Aras et al. 1987). and twenty weeks of pregnancy, a second
opinion is required except in urgent cases.
Adolescents are particularly prone to
Women must grant consent prior to the
abortion related morbidity and mortality. In
performance of the abortion. In the case of
1995 almost 50 percent of deaths among
minors (defined as under age 18) and
women age 15-19 were abortion related. This
mentally retarded women, written consent
implies that around twenty percent of
of guardian is necessary (United Nations
abortion-related deaths occur among adole-
1993).
scents (Government of India n.d. as found in
Mathai 1998). Adolescents, particularly Critics of the abortion law admit that
unmarried adolescents, face fear, anxiety, when it was introduced it was a great
and the social implications of having a achievement for women’s health. Nearly 30
pregnancy. These make unmarried years later, the law and associated rules and
adolescents as a group particularly at risk of regulations are considered overly
delaying obtaining abortion services and of medicalised and bureaucratic, and as such,
obtaining services from untrained but more not oriented torward women’s right to access
confidential providers. Thus adolescents are safe and legal abortion services. The law
more vulnerable to suffering complications offers substantial protection for medical
of second trimester abortions. Of adolescents providers. Chhabra and Nuna (1947) note
who sought abortion in the second trimester that “doctors . . . receive blanket indemnity
almost one in four suffered complications, under the MTP Act – instead of functioning
compared to only one percent of those who as for other surgical procedures and taking
underwent abortion in the first trimester the consequences of any default or neglect”.
(Aras 1987). Jesani and Iyer (1995) state “[C]learly the
MTP Act does NOT encompass a fundamental
III. MEDICAL TERMINATION OF right to induced abortion but is limited to the
PREGNANCY (MTP) IN INDIA liberalisation of the conditions under which
women may have access to abortion services
A. Legal Status of Abortion provided by approved medical practitioners”.
The Medical Termination of Pregnancy The law constrains women’s access to legal
Act, approved in India in 1971 and enacted abortion services by requiring providers
in 1972, permits abortion (or MTP) for a broad receive a level of training that is difficult to
range of social and medical reasons, achieve given the shortage of training
including: to save the life of the woman; to facilities in the country and the absence of
preserve physical health; to preserve mental incentives to receive formal training (Khan
health; to terminate a pregnancy resulting et al. 1999).
from rape or incest and in cases of fetal
Bureaucracy associated with registering
impairment. Contraceptive failure also is
MTP facilities with the government and with
sufficient ground for legal abortion (United
reporting and recording MTP procedures,
Nations 1993).
further contributes to the end result that
Barring medical emergencies, legal many physicians provide abortion illegally
abortions must be performed within the first (Chhabra and Nuna 1994). When a physician
20 weeks of pregnancy and must be performs abortion without registering the
15
procedure, the physician can avoid the provider and the necessary equipment to
extensive paperwork associated with re- provide safe abortion services. Many doctors
porting MTP (Barge et al. 1994; Chhabra and who are authorized to provide MTP feel
Nuna 1994; Kerrigan et al. 1995). inadequately trained to provide the service
safely. In addition, many women do not know
B. Inadequate Legal Abortion Service Pro- MTP is legally available at government
vision facilities. Unfortunately, many government
Despite the broad range of indications for facilities that are supposed to provide MTP
legal abortion, illegal and unsafe abortions services free of charge actually charge
are common in India for many reasons. clients for MTP services, placing another
Women access care from uncertified barrier to women’s access of safe abortion
providers because certified providers are from the formal health care system (Khan et
geographically inconvenient; staff at al. 1999; Khan et al. 1998). Furthermore,
certified facilities tend to not respect evidence suggests that contraceptive
women’s confidentiality; because women are acceptance can be a precondition to the
unaware of certified facilities; because abortion (Ganatra et al., 2000; Lakshmi and
registered facilities often do not have a Pelto, 1999; Gupte et al. 1997, as cited in
trained provider and/or the necessary Ganatra 2001).
equipment to provide safe abortion services; Table 5 shows that on an average, MTP fa-
and many women are unaware that abortion cilities do not perform high numbers of MTPs
is legal and publicly available. Cost, coercion, annually. Still, there is significant variation
moral dilemma, late knowledge of pregnancy among the states in terms of average num-
and unmarried status are addi-tional reasons ber of MTPs performed per MTP facility.
women seek abortion from illegal providers. Assam has the highest number of MTP per-
Some providers do not approve of elective formed per institution, followed by West Ben-
abortion and scold the client as they provide gal, Orissa, Madhya Pradesh, and Haryana.
treatment; the pressure to accept Gujarat and Karnataka have the fewest num-
sterilization or other long-term ber of MTP performed per facility. It is not
contraception after an abortion discourages clear whether states with higher levels of
women from using registered facilities. MTP per facilities better meet women’s needs
When the reason a woman elects to abort a and thus attract more clientele or have in-
pregnancy is not legally sanctioned, for sufficient number of clinics and thus a
example for a sex-selective procedure; or heavier client load. Likewise states with
when the procedure is highly socially stig- fewer MTP per facility may have more ad-
matized, for example to terminate an equate number of facilities or may run in-
extramarital pregnancy, women must access adequate facilities that prevent clients from
the more confidential services of uncertified presenting.
abortion providers (Barge et al. 1997; Barge,
et al. 1994; Chhabra and Nuna 1994; Gupte More telling statistics are the number of
1997; Kerrigan et al. 1995; Khan et al. 1999; MTPs per 1000 people and the number of MTP
Khan et al. 1998; Ravindran and Sen 1994; facilities per population by state in Table 5.
World Bank 1996). Uttar Pradesh and Bihar have the lowest ra-
tios of MTP per 1000 person yet are ranked
Government facilities are acknowledged to have among the highest levels of total
to be inadequate providers of abortion abortion (see Table 1). This combination in-
services. MTP facilities are most often located dicates that more abortions are performed
in urban areas while the vast majority of outside certified facilities in Uttar Pradesh
Indian women live in rural areas. Only about and Bihar than in any other Indian states
ten percent of the clinics that are registered and suggests that the level of unsafe abor-
to provide MTP actually have a trained
16
 Table 5: Ratios of MTPs, Government Approved MTP Facilities and Population by State
State No. of No. of State MTP: MTP: 1000 Population
MTPs Facilities Population Facility Population Facility ratio
(1993-94) (1993-94) (1996) ratio ratio
Andhra Pradesh 13719 373 72,155,000 37 0.19 193,445
Assam 21372 100 24,726,000 214 0.86 247,260
Bihar 11060 209 93,005,000 53 0.12 445,000
Gujarat 10263 700 45,548,000 15 0.23 65,069
Haryana 22438 228 18,553,000 98 1.21 81,373
Karnataka 9077 471 49,344,000 19 0.18 104,764
Kerala 34433 559 30,965,000 62 1.11 55,394
Madhya Pradesh 33086 295 74,185,000 112 0.45 251,475
Maharashtra 97079 1775 86,587,000 55 1.12 48,781
Orissa 19510 169 34,440,000 115 0.57 203,787
Punjab 19436 242 22,367,000 80 0.87 92,426
Rajasthan 29023 316 49,724,000 92 0.58 157,354
Tamil Nadu 42364 623 59,452,000 68 0.71 95,429
Uttar Pradesh 12103 425 156,692,000 29 0.08 368,687
West Bengal 64273 452 74,601,000 142 0.86 165,047

India 609915 9271 934,218,000 63 0.65 100,768

Sources: Number of MTP: Government of India. Ministry of Health and Family Welfare. Family Welfare
Program in India: Year Book (1993-94). Number of MTP Facilities: Nirman Bhavan, New Delhi: Ministry of
Health and Family Welfare, [n.d.]; State Populations: (UNFPA 1997).

tion may be higher in Uttar Pradesh and This further suggests that MTP facilities
Bihar than elsewhere in India. could explore means of improving services
to the population the facilities are meant to
The population per MTP facility ratios in
serve. This would include
Primary exploring means
Table 5 show that Bihar has one MTP center of making MTP † more
Health Centre
accessible to the
„ Community Health
for every 445,000 people. In Uttar Pradesh, 100women meant to be served by the facilities.
Centre
Madhya Pradesh, Assam and Orissa MTP fa-
cilities are more prevalent but still each fa-
90
Figure 1. Percent of PHCs and CHCs
cility serves an average of over 200,000 80 offering MTP services by state
people. The six states that have the highest
number of abortions (Assam, Bihar, Madhya 70
Pradesh, Orissa, Uttar Pradesh and West
Bengal according to results of three indirect 60
estimation techniques presented in Table 1)
50
mirror the states with fewest facilities per
population. This suggests the population 40
most needing access to MTP facilities are
also the population least likely to have ac- 30
cess to MTP facilities.
20
The data presented in Table 5 together
with the incidence data presented in Table Gujarat Maharashtra Tamil Nadu Uttar Pradesh
1 suggest that though MTP facilities are in-
adequate to meet the needs of the popula-
tion, the available facilities are underused.

17
Source: Khan et al. 1999 Methods
In the Seventh Five-Year Plan (1985- Because of the barriers preventing
1990) the Government of India stated the women from accessing MTP, women access
intention to equip all primary health cen- abortion from unregistered, uncertified
tres1 with staff and supplies to conduct abor- providers. Abortion services from
tion services. Khan et al. (1999) relay that unregistered providers range from
“according to the national norm, all commu- completely safe – provided by trained medical
nity health centres2 , postpartum centres, doctors in appropriate facilities – to life-
and similar higher level facilities are ex- threatening – provided by a range of providers
pected to provide abortion services”. Figure in various settings (Mathai 1998; Kerrigan
1 shows this goal remains unrealised. et al. 1995; Johnston et al. 2001). Uncertified
Around one-quarter of primary health cen- abortion providers can include trained
ters in Uttar Pradesh and Maharashtra pro- medical doctors and nurses in hospitals,
vide abortion services. One-third and almost Auxiliary Nurse Midwives (ANM), ayurvedics,
two-thirds provide these services in Gujarat homeopaths, dais or traditional birth
and Tamil Nadu, respectively. Among com- attendants, family health workers, village
munity health centres only 59 percent in health practitioners, pharmacy shop-keepers
Uttar Pradesh and 78 percent in Gujarat pro- and village women (Bandewar n.d.; Mathai
vide abortion services. Eighty-nine percent 1998; Johnston et al. 2001).
of community health centres provide MTP in
Common methods of inducing abortion
Maharashtra. In Tamil Nadu, 95 percent of
include vaginal and oral methods. Dais use
community health centers and sub-district
methods such as inserting sticks, herbs,
hospitals provide MTP. However, in Tamil
roots, and foreign bodies into the uterus to
Nadu abortions are offered primarily on ster-
induce abortion. Other vaginal methods
ilization days and according to several stud-
include pins, laminaria tents, and Fetex
ies abortion providers pressure abortion cli-
Paste 3 . Rural Medical Providers (RMPs or
ents to accept sterilization (Khan et al. 1999).
“quacks”) sell medicines for oral use to
Information presented in this section sug- induce abortion. ANMs (Auxiliary Nurse/
gests that abortion services from PHCs are Midwives) and ISMPs (Indian System of
inadequate, yet underutilised. This corrobo- Medical Practitioners) use intramniotic
rates data from other sources suggesting injections such as intramniotic saline and
that women often turn to certified and intramniotic glycerine with iodine to induce
uncertified providers at private facilities for abortion. Orally ingested abortificants
abortion services. For example, in include indigenous and homeopathic
Maharashtra, over two-thirds of the approved medicines, chloroquine tablets,
MTP centers are in the private sector (Barge prostoglandins, high dose progesterones and
and Rajagopal 1996). estrogens, papaya seeds with high dose
progesterones and estrogens, liquor before
C. Illegal Abortion – Providers and
distillation, seeds of custard apple and
carrots, etc. (Mathai 1998; Johnston et al.

1
Primary health centres (PHCs) cover a population of about 30,000, staffed by a medical officer, associated facility staff and field
supervisors (World Bank 1996)
2
Community health centres (CHCs) serve as “first referral units” and cover a population of approximately 100,000 staffed by
specialists in pediatrics, surgery and obstetrics and gynecology (World Bank 1996).

3
Fetex Paste (brand name) contains benzoin, iodine, thymol, potassium iodide and saponified vegetable oil paste. It is introduced
vaginally as an abortificant (Marathi 1998).

18
2001). Chloroquine is applied contraception is generally high, lack of
intramuscularly as an abortificant. Abdo- availability of spacing methods,
minal massage, witchcraft, dilation and misinformation and apprehension about the
curettage, vacuum aspiration and heat appli- different contraceptive options prevents
cations are also used to induce abortion widespread contraceptive use and abortion
(Indian Council of Medical Research 1989; is used as an alternative to contraception
Kamalajayaram and Parameswari 1988; (Parivar Seva Sanstha 1998).
Maitra 1998; Meenakshi, et al 1995; Rani et
Indian women access abortion through-
al. 1996; Sood 1995, as found in Mathai 1998).
out their reproductive years. A 1990-91 study
D. Characteristics of women who termi- shows that more than 80 percent of women
nate unwanted pregnancies who obtain MTP are in the 20-34 age group
(Chhabra and Nuna 1994). Adolescents, both
The reasons Indian women terminate married and unmarried, also obtain abortion
unwanted pregnancies are many and varied. services in significant numbers. According
Conditions that can lead to a pregnancy to Chhabra, 27 percent of the 2755 abortions
being unwanted include: financial reasons; conducted in a clinic in rural Maharashtra
already having too many children or having in the period 1976-87 were for adolescents
too many female children; becoming (Chhabra 1988) and as many as 30 percent
pregnant after too short a birth interval; of 1684 abortions conducted in an urban
experiencing health problems during hospital setting were for adolescents
pregnancy; becoming pregnant at an older (Solapurkar and Sangam 1985). A substantial
age; becoming pregnant soon after marriage; number of unwanted pregnancies among
suspecting husband’s infidelity; having an adolescents result from forced sexual
extra-marital pregnancy and becoming intercourse. A Bombay study published in
pregnant as a result of rape are all conditions the late 1970s showed that around 20 percent
that can lead to a pregnancy being unwanted of pregnancies of adolescents obtaining
(Barge et al. 1997; Jejeebhoy 1998; Sinha et abortion were reported to have resulted from
al. 1998). rape (Divekar et al. 1979, as cited in
For most of these conditions, a more Jejeebhoy 1996).
proximate determinant of unwanted As adolescents have less access to
pregnancy is lack of access to appropriate reproductive health information and
contraception. For some women, contracep- services compared to older married
tion is not an option because of family counterparts, they are more likely to delay
pressure. Other women can not access a recognising pregnancy, to delay obtaining
contraceptive method appropriate for them. care, and to access care from unsafe
For unmarried adolescents, contraception is providers (Jejeebhoy 1996; Mathai 1998).
generally not available. In such cases, Seventy two percent of the unmarried
abortion may be the predominant means of women who sought abortion at a rural clinical
birth control (Gupte et al. 1997). facility, most of whom were under age 20,
Contraceptive failure and user failure sought MTP in the second trimester
can lead to unwanted pregnancies that can (Chhabra 1988). In a clinic-based study
be aborted legitimately in the Indian medical conducted in the mid 1980s, a majority (59
system. Reasons for contraceptive failure percent) of unmarried adolescents presented
should be explored and addressed and for second trimester abortions, while a
contraceptive options should be made more minority (26 percent) of married adolescents
adequate. Though awareness of came in during their second trimester of

19
pregnancy (Aras 1987; Jejeebhoy 1996). Data National Family Health Survey (1992-93)
from the 1970s suggest that eighty percent reports the sex ratio at birth to have been
of adolescents receiving abortion sought almost constant at 106.3-106.6 for five-year
abortion in the second trimester (Bhatt 1978; periods since 19724 , offering no support to
Purandare and Krishna 1994). This compares arguments that sex selective abortion is
to 34 percent of older women who sought skewing sex ratios at birth at the national
abortion in their second trimester. level. As a comparison, in China and South
Korea, where sex selective abortion is
India’s second trimester abortion rate is
reportedly common, sex ratios at birth were
thought to be among the highest in the world
119 and 114 respectively in 1992
and increasing (Chhabra and Nuna 1994).
(International Institute for Population
Of women accessing legal abortion services
Sciences 1995).
at specific teaching hospitals in 1981, a
range of between ten and forty percent were While women from all socio-economic
in their second trimester (Indian Council of groups access abortion, there is a class
Medical Research 1981). Second trimester differential in where women from different
abortions increase risks to women in two socio-economic groups obtain abortions.
ways. First, women are more likely to go to Women who obtain abortions at safe facilities
an uncertified provider because the tend to be the women who can afford to pay
procedure is more difficult to obtain legally the transport costs and additional associated
than first trimester abortion (Kerrigan, et al. fees (Barge et al. 1997). Because legal
1995; Ravindran and Sen 1994). Second, in abortion is not an option for most Indian
the second trimester the risk of women from lower socio-economic classes,
complications is higher for physiological these women tend to obtain abortion services
reasons (Jones 1991). from less trained, but more accessible
providers (Jejeebhoy 1998).
Sex selective abortions and delay of
accessing abortion services for an unwanted E. Decision-making issues
pregnancy are the two most common reasons
Making the decision to abort a pregnancy
for second trimester abortions (Mathai 1997).
can be difficult and cause delays in abortion
A strong son preference and the availability
seeking. Factors that cause delays in acces-
of prenatal diagnostic techniques have
sing abortion services include not initially
resulted in an increased use of prenatal sex
recognizing the pregnancy, postponing
tests, even among rural poor. Some private
communicating the news of an unwanted
clinics provide prenatal sex tests and offer
pregnancy to a decision maker, lack of
abortion services (United Nations 1993).
awareness of available abortion services,
While this practice was outlawed in 1994,
lack of resources (financial, transport etc.)
it apparently remains widespread and
to access available services and fear of social
impossible to accurately quantify. In 1989,
stigmatization. For adolescents and
eleven percent of abortions were thought to
unmarried women, the confidentiality of the
be to abort a female fetus (Indian Council
abortion service is particularly crucial and
of Medical Research 1989). Indian non-
delays in accessing abortion are more likely
governmental organizations suggest that
(Ganatra 1997; Indian Council of Medical
over 2 million sex selective abortions are
Research 1989 as found in Mathai 1998).
reported every year, representing only the
tip of the iceberg, according to a recent A woman may make the decision to abort
newspaper article-Reuters 1999. The a pregnancy but often the decision-making

4 The typical sex ratio at birth is 104-107 males to 100 females (Shryock and Siegel 1976)

20
role is taken by husbands, mothers-in-law reportedly do not maintain client confi-
or other household members or community- dentiality; can be expensive5 ; and tend to be
level health care providers. Decision makers far from where women live and thus difficult
may support a woman’s choice, pressure her to access (Barge et al. 1997; Indian Council
into having an abortion or object to her of Medical Research 1989).
having an abortion. Sinha et al. (1998) report
In Uttar Pradesh, a study of women who
women turn to a range of confidants to help
sought abortion from either legal public or
make the abortion decision. In a study of 132
private sector clinics found that the most
women conducted in Uttar Pradesh, the
important priority of women accessing
majority of women (32 out of 49) who wanted
abortion services from private clinics was
to abort their unplanned pregnancy first the clinic’s reputation for providing high
discussed the prospect with their husband. quality care. In contrast, the most important
Many husbands were supportive of the priority for women who sought care from
decision to abort and actually facilitated the public clinics was the convenience of the
abortion process. Mothers-in-law, sisters-in- location of the clinic. Other reasons for
law, health workers, neighbours and other choosing clinics that were much less
relatives were also consulted (Sinha et al. important to the respondents included
1998). On the other hand, fear of disapproval, knowing the doctor, family members’
opposition or violence can result in women suggestions, cooperative behavior of staff and
hiding the abortion from her family (Ganatra doctor and confi-dentiality of services (Barge
2001; Gupte et al. 1996). et al. 1997).
Choosing an abortion provider can be
influenced by multiple factors. Study results IV. POSTABORTION CARE SERVICES
show that people who obtain abortion from
legal and unregistered facilities generally A. Management of Abortion-related
have different characteristics and priorities. Complications
Low-income women and women who live in Issue of comlications related to abortion
rural areas are severely limited in choices will exit while, safe abortion services are
for abortion services, causing such women eccessible to all whomen. Clearly activities
to be more likely to access abortion from should address decreasing unwanted
providers of unsafe abortion. In rural areas, pregnancies and increasing women’s access
uncertified providers thrive because they can to safe abortion services. However, the need
offer abortion services at an affordable price, to address ongoing complications from
and are often located closer to women’s unsafe abortion services cannot be ignored.
residences than legal providers (Parivar Seva
Sanstha 1998). As a result of limited access The majority of morbidity and deaths
to safe providers in rural areas, rates of from unsafe abortion are preventable.
unsafe abortion are thought to be Recognizing abortion complications and
significantly higher in rural than in urban accessing appropriate medical care promptly
areas (Kerrigan et al. 1995). can reduce the risks of chronic morbidity and
mortality from complications of unsafe
Women who have the choice between abortion (Greenslade et al. 1994; Johnson et
public and private providers report feeling al. 1992; Salter et al. 1997; World Health
more satisfied with the services of private
Organization 1994). The successful
providers. Care in government facilities is
treatment of abortion-related complications
reportedly inadequate; such facilities
5 While abortion services are supposed to be free in public sector clinics, clients report having to pay for doctor’s fee, hospital
room fee, medicine, transport and food (Barge et al. 1997).

21
is highly dependent on the availability of are not giving women appropriate care after
some degree of treatment at all levels of the abortions are provided. For example
health care system. The elements of abdominal pain and prolonged bleeding
postabortion care (PAC) services that can be following abortion are often ignored by
integrated into a comprehensive abortion providers after providing abortions (Indian
care program include: emergency treatment Council of Medical Research 1989).
of incomplete abortion and potentially life-
Even when women access facilities that
threatening complications; abortion
have the basic skills and technology to
contraceptive counseling and services and
provide emergency care, women may get
links to other emergency services and
inappropriate care. In Uttar Pradesh Potts et
reproductive health care services
al. (1998) noted a tendency of registered
(Greenslade et al. 1994). The studies and
providers to scold patients when they present
information gathered on abortion in India
with complications of abortion from an unsafe
suggest that both the availability and quality
of such aspects of abortion care are in- provider. Some clinicians feel the scolding
adequate. attitude discourages women from having
repeat unsafe abortions. There are
Emergency treatment of a complication indications that emergency treatment can
is an essential aspect of abortion care. The be painful, even when pain control is applied
first step for a woman seeking care is re- (Potts et al. 1998).
cognising that she needs care. Then
frontline health providers at the community Delays in receiving appropriate
level must be able to recognise what is treatment may occur for a number of
needed and treat or refer the woman. reasons, including: delay in identifying the
symptoms of a com-plication; inability on the
The care a woman receives when a com- part of the community-level health care
plication is first recognised is crucial. provider to diagnose, manage or stabilise
Typically, the woman is first cared for in her patients; lack of awareness or concern of
own home by the female head of household potential compli-cations; lack of awareness
(Potts et al. 1998). Women with complications of an appropriate higher level facility that
tend to play a peripheral role in making the accepts referrals for complications of
decision of whether or not they should obtain abortion; and lack of transport to higher level
care (Ganatra, et al. 1998). If obtaining care facilities and inability to pay for care and
is determined necessary, the woman may associated costs at higher-level facilities
go to a traditional birth attendant, trained (Ganatra, et al. 1998; Maitra 1998; Potts et
midwife, a range of community level al. 1998). Furthermore, women with severe
providers or a qualified allopathic doctor. complications have reportedly been sent away
There is a general lack of information in rural from private clinics because the clinic does
community about the type of treatment and not want the reputation that women die at
the providers accused by women for abortion their clinic (Kerrigan, et al. 1995).
care. If the women who require emergency
care following an abortion complication are Ensuring the appropriate referral of
not obtaining it in the health care system, patients for clinical care is crucial for im-
this serivce-delivery gap needs to be better proving emergency care for complications of
understood and addressed (Potts et al. 1998; abortion. Components of appropriate referral
include: accurate clinical assessment of the
Johnston et al. 2001).
woman; appropriate stabilization; accurate
Accessing appropriate facilities is a com- diagnosis; complete written record of her
plex issue. Research suggests that providers presenting and referral condition; communi-

22
cation between the initiating center and the also noted that women obtaining second
referral center; and assistance with trimester abortion at a rural Maharashtra
transport to the referral center (Potts et al. clinic often would agree initially to accept
1998; Salter et al. 1997). IUD contra-ception, only to refuse the IUD
Women with abortion complications need after the procedure and leave the clinic
care immediately. Too few resources are without any method of contraception. A study
available to women who experience abortion conducted in rural Uttar Pradesh shows that
complications. The missing resources unregistered abortion providers rarely offer
include knowledge, authority, transport, contraceptive services (Johnston et al. 2001).
close appro-priate medical care and others. Where postabortion contraceptive
At the level of District Hospitals and counseling exists, it is reportedly inadequate
Medical College Hospitals, service-delivery and not based on the principle of informed
challenges include improving provider choice. In Uttar Pradesh only one-third of
attitudes toward abortion patients; ensuring acceptors were counseled about how the
that facility-based policies and management method works, the possible side-effects, and
activities support immediate and high- steps to take if side-effects are experienced
quality emergency postabortion care; (Barge et al. 1997). Issues such as increasing
ensuring availability of blood products and contraceptive method mix and maintaining
medicines essential for clinical treatment; a stable supply of contraceptives are
working to minimize problems of diagnosis longstanding in India. Major logistical issues
and referral; improving providers’ attitudes need to be addressed before the
toward women experiencing abortion contraceptive needs of Indian couples will be
complications; main-taining equipment and met.
expertise for suction machines for the Negative attitudes toward MTP clients by
treatment of incomplete abortion; promptly providers and insufficient contraceptive
treating women with complications and knowledge and counseling skills among MTP
ensuring that patients are not lost to follow- providers are thought to be major reasons
up; recognizing and treating women’s postabortion contraception is not widely
reproductive health and other health needs; accepted (Kerrigan et al. 1995). Other issues
and identifying women who have been in that may limit the extent to which contra-
abusive situations and referring these ception is accepted after an abortion include:
women to appropriate resources (Potts et al. fear of contraceptive side-effects; husband
1998). or other family members may be against
B. Contraceptive counseling and contraceptive use; ignorance of the woman
services and the provider of the immediate return to
fertility after an abortion; a lack of knowledge
Another critical element of abortion care about appropriate contraceptive methods to
is contraceptive counseling and services. use; and an inadequate supply of equipment
Several studies report that the majority of and contraceptive commodities. Additio-
abortion clients accept contraception after nally, weak referral networks may limit the
an MTP procedure (Barge et al. 1997; range of contraceptive method available
Chhabra et al. 1988). However, acceptors (Barge et al. 1997; Potts et al. 1998).
report that accepting the method can be a
precondition for getting an MTP (Barge et al. C. Linkages with other reproductive
1997). Chhabra et al. (1988) report that many
women obtaining MTP have to be motivated
to accept contraception by clinic staff. They
23
 health services thorough review of MTP policy and service-
delivery guidelines may be beneficial.
The third critical aspect of abortion care,
linking women to other reproductive health A. Improving knowledge of abortion in-
services suffers from a lack of information cidence
and appropriate facilities in most countries
including India. Several studies conducted There is an identified absence of verifi-
in Uttar Pradesh have documented a lack of able abortion incidence data in India. Sug-
awareness among medical providers of the gested rates of abortion and unsafe abortion
risk of sexually transmitted diseases (STDs) vary widely. Methods of collecting acceptable
or reproductive tract infections (RTIs) contri- abortion incidence data are intensive, use
buting to the spread of HIV or morbidity such multiple methods of data collection and in-
as secondary infertility and thus a lack of struments must be designed based on local
concern for postabortion reproductive health cultural norms (Anderson et al. 1994; Hun-
care such as screening for and treating STDs tington et al. 1996). These fundamental re-
and RTIs (Barge et al. 1997; Potts et al. 1998). quirements necessitate medium-scale stud-
In addition, women who experience repeat ies (several districts or statewide). Intensive
spontaneous abortion deserve appropriate studies of the incidence of abortion and abor-
counseling and the option of fertility tion complications would be informative and
treatment. would yield valuable information particularly
Women who obtain abortions and post- as baseline measures and guides for inter-
abortion care may have experienced rape or vention studies.
domestic violence. Jejeebhoy (1998) reports B. Improving pregnancy termination ser-
that an alarming proportion of adolescent vices
abortion seekers became pregnant as a
Results of the literature reviewed point
result of rape. In a study conducted in rural
to areas that need to be addressed to improve
Maha-rashtra, Ganatra et al. (1988) found
abortion care in India. Operations research
that domestic violence was the second most
could be conducted to test the effectiveness
common cause of deaths during pregnancy,
of innovative interventions. A thorough
representing additional morbidity associated
review of MTP policy and service-delivery
with pregnancy. The concept of identifying
guidelines may be required. In addition a
women with additional reproductive health
review of MTP policy and service-delivery
and other needs and effectively linking with
guidelines could suggest means of increasing
appropriate reproductive health services is
women’s access to safe abortion services.
clearly an area where additional research
and training is necessary. Training: Motivate qualified practitioners
to attend MTP training courses. The pro-
V. RECOMMENDATIONS cedures for training and licensing providers
Results of the research studies reviewed and licensing abortion facilities need to be
in this paper suggest that abortion and adapted to current situations. MTP training
associated morbidity and mortality from should include training in the various forms
unsafe abortion are common and should be of providing MTP (manual vacuum
a top priority safe motherhood issue in India aspiration, electric vacuum aspiration, and
and point to areas that need to be explored to dilation and curettage), emergency
improve abortion care. Operations research postabortion care, postabortion contraceptive
could be conducted to test the effectiveness services and counseling and linking women
of innovative interventions. In addition a to additional reproductive health services

24
(Khan et al. 1999). women accessing abortion services.
Women report scolding attitudes
Review the MTP Act to determine means among pro-viders when presenting
in which the Act can be revised to better for abortion services. Counseling
improve abortion services for women. Each training for providers is essential in
recom-mendation presented here represents terms of providing high quality care
multiple steps of reviewing and improving in service provision, by interacting
services to better meet the needs of women with women in a positive manner,
and men at the community level. Some providing them with the information
recommendations to improve health care go they need and helping them to make
beyond current MTP Act, indicating that the informed choices (Mathai 1998).
current MTP policy needs to better meet the
z Increasing geographical accessibility
reproductive health needs of women. Experts
of safe abortion services for women
have recommended reviewing the criteria
of reproductive age in general, and
for certifying providers and considering
for adolescents in particular. One key
including additional care of providers for MR
reason women turn to untrained pro-
and MTP service delivery; reviewing provider
viders is that untrained providers are
training required; reviewing procedures for
more accessible at the community
licensing facilities and reconsidering MTP
level compared to trained providers,
rules and regulations in light of medical
which tend to require additional
methods for terminating pregnancies
travel time and associated costs. To
(Chhabra and Nuna 1994; Mathai 1998; Khan
increase accessibility of safe abortion
et al. 1999).
services, additional providers could be
Upgrade facilities that currently offer based in rural areas. Certainly more
abortion services. Monitoring of safe abortion medical providers, particularly
service providers may be necessary to women pro-viders, could be trained in
ensure that providers are at their sites abortion provision to staff rural
during clinic hours, that charges do not clinics. As many medical providers
exceed a set standard, that high quality care are unwilling to be based in rural
is provided from the patient’s entry into the areas, the strategy of training
clinic throughout service provision and Bachelor of Science Nurses, Lady
contra-ceptive counseling. Public and private Health Visitors (LHV) and Auxiliary
medical officers could provide monitoring Nurse Midwives (ANM), to provide
services (Mathai 1998; Khan et al. 1999; safe abortion services with manual
Bandewar 2000). vacuum aspiration equip-ment might
Orient abortion services to meet the be considered (Khan et al. 1999).
needs of women by: z Increasing affordability of safe
z Prioritizing confidentiality of abortion abortion services. Costs associated
services at public facilities. Confiden- with publicly and privately provided
tiality of abortion services is a priority safe abortion services prompt women
for many women obtaining abortion to access abortion services from less
services. When safe services are not expensive and untrained providers.
confidential many women will turn Addi-tionally, costs associated with
to unsafe but more confidential travel and overnight stays prevent
services (Mathai 1998). women from obtaining care from
trained providers who are often
z Providing high quality care for
25
 located at substantial distances from cation. Many women turn to their husbands
women’s residences and increase for decision-making about reproductive
the likelihood women will obtain health issues. In addition to being informed
abortion services from an untrained about the importance of safe abortion
but more accessible local provider services and signs of abortion complications,
(Johnston et al. 2001). men should be addressed in reproductive
health campaigns that promote small
Increase awareness among women and families and educate about temporary or
men of reproductive age of the availability of permanent contraceptive use (Khan et al.
safe abortion services and the dangers of 1999; Mathai 1998; Johnston et al. 2001).
unsafe abortion. Household decision-makers
are often husbands and mothers-in-law as Improve adolescent reproductive health
well as pregnant women. All could be the services in general. Adolescents are particu-
focus of campaigns that educate about the larly at risk of serious morbidity and mortal-
ity from unsafe abortion. Family Life Educa-
availability of safe abortion facilities and
tion programs that target unmarried and
methods and the dangers of unsafe abortion
married male and female adolescents need
services. Safe abortion services need to
to address issues such as preventing un-
become a priority for women accessing
wanted pregnancy and recognising and safely
abortion and those who decide from whom
managing unwanted pregnancy. Statistics
women will access abortion care. The stage showing increasing rates of unwanted preg-
of gestation at which a woman can safely nancies and unsafe abortion among unmar-
abort a fetus is an important component of ried adolescents demonstrate a need for ado-
any campaign to increase awareness (Khan lescents to be included in reproductive health
et al. 1999; Mathai 1998). education and to be able to access reproduc-
Involve communities and providers at all tive health services, including abortion and
levels to improve reproductive health care. contraception, without the consent of a par-
In implementing activities to make health ent or guardian (Jejeebhoy 1998; Mathai
and medical facilities more responsive to the 1998).
populations served, important roles can be C. Improving abortion care
played by community-level women’s, men’s
and adolescents’ organizations. Private, Sparse literature on the care surround-
public and NGO medical providers, including ing abortion service delivery demonstrates
paramedics and unregistered practitioners that this is a target area for additional re-
at the community level, the government from search. From the available evidence, the fol-
the national level to the village level and the lowing recommendations have been made.
press and other media groups can all be Develop demand for quality emergency
included in campaigns to help women access abortion care. Women and key decision-mak-
improved reproductive health services, in- ers need to be advised of the need to access
cluding safe abortion and a wide array of high-quality abortion care services imme-
voluntary contraceptive services (Khan et al. diately if having complications of induced or
1999). This multi-sector involvement is spontaneous abortion. Women and decision-
particularly relevant as states are actively makers should know that care for abortion
decentralizing health systems and local complications includes stabilization and re-
panchayats become increasingly involved in ferral to appropriate service facilities; emer-
health care delivery. gency treatment as necessary; high quality
Involve men in reproductive health edu- care, including contraceptive counseling and
services and referral to other health facili-
26
ties as necessary (Maitra 1998; Johnston et be reliably available at the community level
al. 2001). to ensure easy access (Maitra 1998;
Johnston et al. 2001).
Decentralise abortion care services at
public and private facilities. Emergency care Provide comprehensive abortion care.
capabilities should be expanded to lower lev- Health care providers in general, and par-
els of the formal health care system. Com- ticularly those at the referral level, need to
munity members and providers should be able be aware that the interface between the
to recognize symptoms of emergency com- woman with the complication and the for-
plications that require treatment or referral mal medical system typically represents a
and be able to get women with these compli- rare opportunity to assess other aspects of
cations to appropriate referral facilities. the patient’s reproductive health and provide
Higher level facilities should be prepared to treatment or refer her to appropriate care.
effectively and efficiently manage cases of Providers need to be trained in this largely
emergency complications and provide appro- unrecognized aspect of abortion-related care
priate postabortion contraceptive counseling (Johnston et al. 2001; Potts et al. 1998).
and services (Kerrigan et al. 1995; Maitra
1998). Involve communities and providers at all
levels to improve abortion care. In imple-
The concept of integrating midlevel pro- menting abortion care activities to make
viders into emergency treatment raises health and medical facilities more
some policy questions. To what degree can responsive to the population they serve,
ANMs and other midlevel providers and TBAs
important roles can be played by community
or dais be included in the abortion care sys-
level women’s, men’s and adolescents
tem? Can ANMs receive training to provide
organizations, LHVs and ANMs, and public
elements of abortion care, including diagnos-
and private and NGO medical communities.
ing, stabilizing and referral when necessary,
Community level providers, including ANMs,
aspirating the uterus, providing postabortion
PHC nurses, Anganwadi workers and local
contraceptive counseling and linking women
doctors, need to be included as much as
to other reproductive health services? What
possible in pro-viding a wide array of
incentives can be introduced to encourage
voluntary contra-ceptive services (Johnston
providers to refer patients when appropriate
et al. 2001; Kerrigan et al. 1995).
instead of providing treatment for a profit?
VI. CONCLUSIONS
Offer informed contraceptive choice.
While postabortion contraceptive counseling This review of literature shows that
and services are not being offered at many morbidity and mortality from unsafe abortion
abortion service sites, postabortion contra- remains a serious problem for Indian
women; 30 years after the indications for
ception is sometimes imposed coercively
legal abortion were greatly liberalized in
(Rajagopal et al. 1996). Identifying determi-
India. Research results show that unsafe
nants of voluntary postabortion contraceptive
abortions are common; adolescents and
acceptance will be key to introducing suc- unmarried women are most at risk of
cessful postabortion contraception programs. morbidity and mortality from unsafe abortion.
Postabortion contraceptive counseling Furthermore, studies show that for a number
should include information about the correct of reasons current legal abortion services are
use of the various available methods, poten- not meeting the needs of Indian women,
tial side effects associated with available con- particularly rural women. In four states, a
traceptive methods, and means of maintain- large sample of registered facilities and
ing a steady supply of the selected method. certified providers have been intensively
Post-abortion contraceptive services should studied and from those four state studies,

27
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31
 APPENDIX
TECHNIQUES USED TO ESTIMATE ABORTION RATES
PRESENTED IN THIS REVIEW

Chhabra and Nuna revised an estimate proportion of women reporting ill-timed or

from a study conducted in 1966 by the unwanted pregnancy. The method of
Committee to Study the Question of calculating total induced-abortion potential
Legalisation of Abortion or the Shah is similar to the method of calculating Total
Committee. The Shah Committee’s Fertility Rates with age-specific potential
estimates were based on India’s 1966 induced abortion rates used in place of age-
population of 500 million and crude birth rate specific fertility rates. The author
of 39 and the assumption of a constant ratio acknowledges that these rates could easily
of 15 induced abortions per 73 live births. be underestimates as once a child is born, a
The committee derived this ratio from woman is much less likely to think of the
community studies in Tamil Nadu and associated pregnancy as unwanted or ill-timed.
hospital studies in Delhi. Chhabra and
The indirect estimation technique is a
Nuna’s estimates were based on 1991 birth
residual method based on Bongaarts’
rates and population figures, using the same
proximate determinants of fertility model
Shah Committee ratio of abortions to live
(Bongaarts and Potter 1983), using data
births and suggested 6.7 million legal and
available in the NFHS 1992-93. A standard
illegal induced abortions take place annually
maximum potential fertility rate is reduced
in India (Chhabra and Nuna 1994). This is
by delayed marriage, contraceptive use,
the most widely cited estimate of numbers
postpartum infecundability and actual
of induced abortion in India. The estimation
observed fertility. The residual represents
technique is based on the questionable
fertility reduced by the remaining proximate
assumption that 15 abortions occur per 73
determinant of fertility and induced abortion.
live births. By assu-ming a constant ratio of
This residual can be translated into a total
abortions per live births, the variations in
abortion rate, which represents the average
abortion rates by state are masked.
total number of abortions a woman will have
Mishra et al. (1988) developed an throughout her reproductive years. A key
“induced abortion potential” based on questionable assumption behind this tech-
information recorded on ill-timed and nique is that the minor proximate deter-
unwanted pregnan-cies by the National minants, fecundability (frequency of sexual
Family Health Survey 1992-93. Age-specific intercourse), intrauterine mortality and
pregnancy rates (ASPR) are derived from sterility, which are included as constants in
pregnancies resulting in live births by age the proximate determinants of fertility model,
and age specific fertility rates and represent do not have a varying influence on residual
the number of women in 1000 in a given age fertility (Johnston and Hill 1996). The
category who will conceive in a specified average maximum total potential fertility
year. Out of the number of women at risk of rate per woman is thought to be 15.3 births
pregnancy, the number of pregnancies per woman. If Indian women experience
reported as ill-timed or un-wanted are those lower maximum total potential fertility rates,
considered to be potentially aborted. The as has been proposed, the rates presented
number of potential abortions in the given here will reflect overestimates. However, the
age categories is the ASPR multiplied by the relative rate of abortion will still be representative.
32