Contraception 90 (2014) 42 – 46

Original research article

Medical students' attitudes and perceptions on abortion: a cross-sectional

survey among medical interns in Maharastra, India☆,☆☆
Susanne Sjöström a, b,⁎, Birgitta Essén a , Filip Sydén a ,
Kristina Gemzell-Danielsson b , Marie Klingberg-Allvin a, b, c
a
Department of Women's and Children's Health, IMCH, Uppsala University, SE-751 85 Uppsala, Sweden
b
Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Karolinska University Hospital,
SE-171 76 Stockholm, Sweden
c
School of Health and Social Sciences, Dalarna University, SE-791 88 Falun, Sweden
Received 14 August 2013; revised 24 January 2014; accepted 7 February 2014

Abstract

Introduction: Although abortion care has been an established routine since decades in India, 8% of maternal mortality is attributed to unsafe
abortion. Increased knowledge and improved attitudes among health care providers have a potential to reduce barriers to safe abortion care by
reducing stigma and reluctance to provide abortion. Previous research has shown that medical students' attitudes can predict whether they
will perform abortions. The objective of our study was to explore attitudes toward abortion among medical interns in Maharastra, India.
Study Design: A cross-sectional survey was carried out among 1996 medical interns in Maharastra, India. Descriptive and analytical
statistics were used to interpret the study instrument.
Results: Almost one quarter of the respondents considered abortion to be morally wrong, one fifth did not find abortions for unmarried
women acceptable and one quarter falsely believed that a woman needs her partner or spouse's approval to have an abortion. Most
participants agreed that unsafe abortion is a serious health problem in India. A majority of the respondents rated their knowledge of sexual
and reproductive health as good, but only 13% had any clinical practice in abortion care services.
Conclusion: Disallowing attitudes toward abortion and misconceptions about the legal regulations were common among the surveyed
medical students. Knowledge and attitudes toward abortion among future physicians could be improved by amendments to the medical
education, potentially increasing the number of future providers delivering safe and legal abortion services.
Implication Paragraph: Abortion is legal in India since decades, but maternal mortality due to unsafe abortions remains high. This survey
of attitudes toward abortion among medical interns in Maharastra indicates that disallowing views prevail. Improved knowledge and clinical
training can increase numbers of potential abortion providers, thus limit unsafe abortion.
© 2014 Elsevier Inc. All rights reserved.

Keywords: Medical abortion; Medical interns; Medical education; Knowledge; Legal regulation; Midlevel providers

1. Introduction number of abortions performed outside registered clinics by

unregistered providers is estimated to be high. Medical
Despite the availability of legal abortion services since abortion up to 63 days of gestation using mifepristone and
1971, regulated by the Medical Termination of Pregnancy misoprostol is recognized in the national guidelines, but
Act (MTP) [1], unsafe abortions are estimated to cause 8% of only included up to 49 days in the MTP act [4,5].
maternal deaths in India [2]. Implementation of the method has been slow, and low
Safe abortion care is not readily available to the awareness and provision of medical abortion among
country's vast rural population due to a lack of trained physicians has been observed. Also, the procedure is
physicians and the scarcity of registered facilities [3]. The more commonly available through private physicians and
☆
in the informal sector [6–8]. Women's general awareness of
The Faculty of Medicine, Uppsala University and the Swedish sexual and reproductive health is considered inadequate:
International Development Cooperation Agency funded the study.
☆☆
The authors declare no financial or other conflicts of interest.
husbands and extended family members influence their
⁎ Corresponding author. decision making. Women also tend to value confidentiality
E-mail address: susanne.sjostrom@ki.se (S. Sjöström). and privacy over medical safety [9].
http://dx.doi.org/10.1016/j.contraception.2014.02.005
0010-7824/© 2014 Elsevier Inc. All rights reserved.
 S. Sjöström et al. / Contraception 90 (2014) 42–46 43

It is estimated that approximately 90% of all global (internship) participating in a CAC orientation workshop
abortion-related mortality and morbidity could be averted by held by a nongovernment organization within the medical
the use of effective contraception [10]. In India only 56.3% education program, at each of the included colleges [22]. Of
of married women, 15–49 years, used any contraception a total of 43 medical colleges (5195 students) in Maharastra,
[11]. Limited knowledge and poor attitudes about contra- a convenience sample of 27 colleges (8 government and 19
ceptive methods among providers may have an impact on private) were included. A total number of 2006 students were
women's choices of methods and thus on prevention of eligible at the sampled colleges [23]. Information was given
unintended pregnancies [12]. about the study, and participation was voluntary and
Strategies that have shown to increase access to safe anonymous. Permission to conduct the survey in connection
abortion include improving provider training. Such training with the training program was obtained from the principal at
should address the attitudes of health care providers and their each college. By filling in the questionnaire, written consent
beliefs about sexual and reproductive health, including was given. The Ethical Trials Committee in Stockholm,
induced abortion, privacy and confidentiality, treating all Sweden (2013/415-31/4), gave ethical approval.
women with dignity and respect, and attending to those with
special needs such as adolescents, rape victims and women 2.2. Study instrument
vulnerable for health or socioeconomic reasons [13]. These
A structured questionnaire was developed, based on a
strategies have been implemented in India to some extent
previously tested instrument [24], to assess interns' attitudes
with the establishment of comprehensive abortion care
and perceptions about abortion. It consisted of three sections
(CAC) training centers [14] and a pending amendment of the
covering sociodemographic background, the student's
MTP act to expand the base of health care providers
perception of his/her educational program characteristics
authorized to perform abortions by including general nurse
regarding sexual and reproductive health and training, and
midwives (GNMs).
attitude statements on contraception and abortion. Respon-
Basic medical education is regulated by the Medical
dents indicated their attitude on a 5-point Likert scale:
Council of India [15] and consists of 4.5 years mainly
(1) disagree completely, (2) disagree, (3) neither agreed nor
theoretical education, followed by a 1-year practical rotating
disagree, (4) agree, and (5) agree completely. To avoid any
internship including two months of obstetrics and gynecol-
bias produced by response tendency and to enhance internal
ogy, leading to a degree Bachelor of Medicine and Bachelor
validity, both positively and negatively worded items were
of Surgery. Indian medical education has been criticized for
included in the questionnaire.
not including enough clinical training, and the Medical
Council has recently proposed curricular reforms [16,17].
2.3. Data analysis
A review of the literature revealed that provider attitudes
varied depending on nationality, professional background, All questionnaires containing at least one marked answer
experience in abortion care, religious beliefs and the reasons were included in the analysis. Ten questionnaires were blank
given by women when requesting an abortion [18]. A review and therefore excluded. Descriptive statistics were applied to
of surveys, exploring sex differences in the practice of all sections of the questionnaire. The alternatives “agree” and
obstetrician-gynecologists, found that women in general “agree completely” as well as “disagree” and “disagree
have more supportive attitudes toward abortion [19]. Training completely” were aggregated, and frequencies and pro-
in CAC influence attitudes toward abortion and increase the portions were calculated. Analysis of intergroup differences
likelihood that obstetrician-gynecologists' will perform abor- was made for interns of different genders, types of colleges
tions in their future practice [20]. Little research has examined and places of birth, as well as according to their assessment
the attitudes of medical students and interns toward abortion. A of their educational program content of the topic sexual and
recent study from South Africa indicates that years of study, reproductive health and their knowledge thereof. Statistical
religion, relationship status and sexual experience are factors Package for Social Studies (SPSS) 21 software was used.
affecting student's intentions to provide abortion [21].
The aims of this survey were to explore attitudes toward
abortion held by medical interns in the state of Maharastra, 3. Results
India, and also to determine whether those attitudes differed
between groups of interns defined by sociodemographic A total of 1996 medical interns participated in the study,
backgrounds and study program characteristics. for a response rate of 99% (1996/2006). The majority of the
respondents represented a relatively homogenous group:
1886 (94%) were between the ages of 20 and 24 years, and
2. Materials and methods slightly more than half were men (1134; 57%). Most
2.1. Study setting and design participants were born or raised in urban areas (1444;
72%), and the large majority were Hindus (1747; 88%).
A cross-sectional survey was conducted in February 2011 Most were single. Private medical colleges were represented
among 1996 medical students in their fifth year of training by 1423 (71%) of the participating interns (Table 1).
44 S. Sjöström et al. / Contraception 90 (2014) 42–46

Table 1 The respondents' attitudes and perceptions toward

Demographic Data of Participating Medical Interns (n=1996) in Maharastra, abortion are described in Table 3. The first six statements
India, 2011
evaluate attitudes about the general situation regarding
Variable n % reproductive health care in India, including three statements
Age (y) focussing on unmarried women. A majority of the re-
20–24 1886 94.4 spondents agreed that “Unsafe abortion is a serious health
25 and above 98 5.0
problem in India.” Most respondents recognized that
Missing data 12 0.6
Sex “Abortions among unmarried women are rising in India,”
Female 860 43.1 but one fifth of the students (397; 20%) disagreed with the
Male 1134 56.8 statement that “Abortion among unmarried women is
Missing data 2 0.1 acceptable in the case of an unplanned pregnancy.” The
Place of upbringing
next two statements explore personal values regarding
Rural 508 25.5
Urban 1444 72.3 abortion. Almost one quarter of the students, 470 (23%),
Missing data 44 2.2 found that “Abortion is morally wrong,” but 1694 (85%)
Religion believed that “A woman should always have the right to have
Hindu 1747 87.5 an abortion in case of an unwanted pregnancy.” Female
Muslim 97 4.9
interns (761; 89%), interns who felt that the topic sexual and
Christian 17 0.9
Other 133 6.6 reproductive health had been adequately covered in their
Missing data 2 0.1 coursework (1276; 88%), and interns who assessed their
Marital status knowledge to be good (1195; 88%) were more likely to agree
Single 1970 98.7 with the last statement (not shown in tabular form). Two
Married 22 1.1
statements explore methodological issues related to abortion.
Missing 4 0.2
Type of college Surgical abortions were considered more harmful by 1141
Private 1423 71.3 (57%) of the respondents, and only a quarter (480; 24%)
Government 573 28.7 believed women prefer this method.
The statement “A woman needs to have her partners or
spouse's approval to have an abortion” probed views on
The topic of reproductive health had been adequately
covered in their study program according to 1475 (74%) of Table 3
the medical interns, and 1382 (69%) considered their Attitudes and perceptions regarding abortions among medical interns
theoretical knowledge of sexual and reproductive health (n= 1996) in Maharastra, India, 2011 a
“good” or “very good.” However, only 268 (13%) had had Statement Disagree Neither Agree
any clinical practice in abortion care services. No significant Unsafe abortion is a serious health n 67 19 1898
differences between respondents attending private or problem in India. % 3 1 95
government colleges were identified at the 5% significance Abortions at unregistered clinics are more n 121 54 1802
harmful than at registered clinics. % 6 3 90
level (p values not shown) (Table 2).
Abortion clients are treated in privacy n 257 301 1406
in India. % 13 15 70
Table 2 Unmarried women prefer to have n 86 106 1716
Self-assessed educational program characteristics by medical interns at abortions outside public health clinics. % 2 5 90
private (n= 1423) and government (n= 573) colleges, Maharastra, India Unmarried women have more n 339 256 1382
2011 a complications from abortions than % 17 13 69
married women.
Variable All, n (%) Private, Government,
Abortions among unmarried women are n 397 183 1388
n (%) n (%)
acceptable in case of unplanned % 20 9 70
Has the topic of reproductive health been included in your course of study? pregnancy.
Not at all 27 (1.4) 17 (1.2) 10 (1.8) Abortion is morally wrong. n 1208 294 470
Somewhat 468 (23.4) 352 (25.0) 116 (20.6) % 61 15 23
Adequately 1475 (73.9) 1039 (73.8) 436 (77.6) A woman should always have the right n 167 109 1694
How do you assess your theoretical knowledge of sexual and reproductive to an abortion in the case of an % 8 5 85
health? unwanted pregnancy.
Poor 30 (1.5) 24 (1.7) 6 (1.1) Women prefer to have surgical rather n 957 527 480
Fair 552 (27.7) 381 (27.0) 171 (30.9) than medical abortions. % 47 26 24
Good 1122 (56.2) 815 (57.8) 307 (55.4) Surgical abortions are more harmful n 437 387 1141
Very good 260 (13.0) 190 (13.5) 70 (12.6) than medical abortion. % 22 19 57
Have you had clinical practice in abortion care services during your course A woman needs to have her partner or n 1301 172 494
of study? spouse's approval to have an abortion. % 65 9 25
Yes 268 (13.4) 196 (14.1) 72 (13.0) Specially trained GNMs have the capacity n 706 232 1027
No 1678 (84.1) 1196 (85.9) 482 (87.0) to provide abortions in India. % 35 12 52
a a
Missing data not shown. Missing data not shown.
 S. Sjöström et al. / Contraception 90 (2014) 42–46 45

legal governing of abortion. One quarter (494; 25%) of the Half of the participating interns in Maharastra were in
interns stated that spousal consent was needed for abortion. favor of GNMs providing abortions in India. This support for
Female respondents, respondents from urban areas and task shifting is relatively higher than what has previously
those attending private colleges were less likely than male been observed among obstetrician-gynecologists in a study
students to hold this misconception (result not shown in from the Indian states of Bihar and Jharkhand [25]. The
table form). About half 1027 (52%) of the respondents finding may demonstrate a growing understanding of the
agreed that GNMs have the capacity to provide abortions in need to increase the number of abortion providers in India and
India; respondents from rural areas were less likely to share knowledge about the recently described feasibility and safety
this belief (Table 3). of allowing midlevel providers to perform abortions [30].
4.1. Methodological considerations
4. Discussion The method of using anonymous questionnaires is
suitable for sensitive topics such as sexual and reproductive
We found that one quarter of the participating medical health. The fact that the questionnaire was distributed before
students considered abortion to be morally wrong, and one a lecture covering the subject under investigation might
fifth did not agree that unmarried women should have the influence the result. However, the student's knowledge,
right to termination in case of an unwanted pregnancy. perceptions and attitudes reflect the content of their basic
Almost one in four respondents falsely believed that a education program. Since the CAC workshop was offered on
woman needs her spouse's consent to have an abortion. a once-yearly basis, pretesting of the instrument was not
Attitudes toward abortion depend on multiple factors, carried out in the population studied in this survey, which
including professional background and religious beliefs. A may influence reliability and validity. Additional questions
previous study from India showed that 20% of general in the study instrument could have further clarified matters
physicians and 30% of obstetrician-gynecologists held less such as the importance of family values, the influence of
permissive attitudes toward abortion [25]. It has been shown relatives on women's and practitioners' decision making,
that premartial sexual relations in India are increasing and and practitioners' perceptions of legislation regulating
that unmarried women are a particularly vulnerable group abortion. Another limitation is that the content of each
when facing unwanted pregnancy [26]. One study from medical intern's individual course of study was not explored.
Vietnam showed that midwifery students held traditional The lack of studies such as ours in other parts of India made
values and were against providing abortions to adolescents, national and international comparisons difficult, and our
although attitudes were more supportive among students with findings may not be generalizable, even to other states of
longer training, which was also true among South African India. Qualitative in-depth interviews with providers and
medical students [27,21]. Previous studies have shown that abortion seekers would give a more complete picture.
clinical training is an important predictor of future abortion
provision influencing providers' views toward abortion and
their understanding of the importance of legal access to safe 5. Conclusion
abortion care [28]. Only 13% of our respondents had
experienced clinical practice in abortion care services; This is, to our knowledge, the first study to assess the
increased practical training during education may reduce attitudes of medical students' in Maharastra toward abortion.
future provider's moral obstacles to abortion care. We found a widespread resistance to women's right to have
Providers in India have been shown to be reluctant to an abortion on demand, and misconceptions about legal
provide services if women seek care alone, or if a spouse did regulations governing abortion were common. Attitudes
not give consent [8]. A convenience interpretation of the MTP toward abortion among future physicians in Maharastra
act is common among physicians wanting to protect could be improved by reformed education and training.
themselves against social and legal repercussions, thus Medical schools in Maharastra have the potential to increase
limiting women's access to safe abortion care [3]. Our finding the numbers of future abortion providers and reduce
that one quarter of the polled medical students expressed maternal ill-health, by expanding their instruction in sexual
the need for spousal consent mirrors these views and stress and reproductive health, and including practical training in
the need for increased education and training including abortion care services.
values clarification in the aspect of abortion provision.
Although medical abortion has been shown to be feasible Acknowledgment
in India implementation of the method has been slow [29].
That slightly more than half of our respondents believe We would like to thank Ipas, India, as part of a partner
surgical abortion to be more harmful than medical abortion, driven cooperation between Uppsala University and Swedish
and only one quarter believe that women prefer surgical International Development Cooperation Agency aiming to
abortion may implicate that views toward medical abortion increase access to CAC in Maharastra and Madhya Pradesh,
are becoming less hesitant. for distributing the questionnaires.
46 S. Sjöström et al. / Contraception 90 (2014) 42–46

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