“Everything turned out well”: Women’s perspectives on medical abortion

1. “Everything turned out well”: Women’s perspectives on medical abortion Dr. Bela Ganatra Sr. Research & Policy Advisor Expanding Access to Medical Abortion: Building on Two Decades of Experience; Lisbon, Portugal; March 2-4, 2010

2. Whose perspectives? Clinical trials –choice; acceptability; satisfaction. Few studies with in-depth interviews

3. Women’s groups • Do not always see it as promoting autonomy or choice • E.g. in India • Concern about promoting lack of responsibility of health systems; women not having access to care for complications; • Concern over bleeding when many women anemic • Concern over tablets being used to promote population control

4. Women’s needs ..context is everything Self medication; Unsafe providers, alternative drugs Costs increase, providers restrict use in low literacy women, women seek care later LOWHIGH Medical safety Confidentiality Effectiveness Cost; Pain control Minimal disruption Information quick outcome LEGAL, SOCIAL & ECONOMIC VULNERABILITY

5. Abortion with ‘medicines’ not new “Relative” cost Perceptions on effectiveness, safety Strong tablets (like anti-cancer like drugs); ‘foreign tablets’; greater fear of incomplete abortion; chewable tablets less effective than those swallowed Expectation that multiple hospital visits should not be required. Ganatra, Manning et al 2005; Ongoing Ipas pilot in Bihar/ Jharkhand ; India

6. Clinic experience: • Data from a qualitative study in two urban Indian clinics • Choice: • Often negative ( avoid pain, avoid surgery; avoid anesthesia); • Sometimes positive (feels natural, allows more privacy, cost) • Provider influence high –expectation that provider makes the choice • Underlying nuances reflect reality of their life and real meaning to ‘choice’ Ipas/ Pop Council study: Ganatra, Kalyanwala et al 2009

7. What determined the MA experience? Ipas/ Pop Council study: Ganatra, Kalyanwala et al 2009

8. Ipas/ Pop Council study: Ganatra, Kalyanwala et al 2009 ‘The doctor called us and gave us care and medicine. We liked this a lot. The doctor asked me whether I had a lot of pain. At any other place maybe you wouldn't get so much care but here the doctor gave really good care’ ‘He supported me. He insisted that I eat on time and suggested that we ask the doctor about weakness and for a prescription for [pain] medication’ ‘He told me to go to my mother’s place for 15 days. He was quite understanding’

9. Outcome • I thought, I hoped I am not in those 10 percent (of failure cases). I was just praying to God all these days that I hope I am in that 90 percent”. • “The toilet is public toilet on the ground floor. Family members are often there. There are no lights in the toilet. I brought a candle when I went to the toilet but checking (the expulsion) is difficult”. Ipas/ Pop Council study: Ganatra, Kalyanwala et al 2009

10. Madam told me to wait until 4:30 pm for my abortion to take place. I didn't have my abortion by 4:30 pm so I went home. The next day I had bleeding and the day after, it came out. I kept it. I kept it in a carry bag. . .on a pad inside the carry bag. It was whitish and pinkish in color. Two days later, I went back to the hospital and showed it. Only then I knew. “I was told something red would come out but only a white knot came out of this size. Did I abort? I don’t know? ”

11. Lessons learned • Balance between too much and too little information; • Decrease anxiety by ensuring that information about normal variations is conveyed and understood • Ensure that information and communications materials allow for individual context • Even in the clinic setting provider control can be reduced • Role of the ‘provider’ or service as “support” is important in overcoming isolation / stigma etc. • More options of methods and of options within the method (routes, home based; follow up options the better) more likely to meet needs

12. “Everything has turned out well. What else matters? I will definitely use this method again”. Power dynamics, gender inequalities, lack of autonomy and choice get mirrored in the way MA is perceived / used as well Technology or pills (even MA!!) are not the magic bullet …it’s the empowerment that is

13. Visit us online atwww.ipas.org/medicalabortionor write tomedicalabortion@ipas.org