Abortion as a Maternal Health Issue

1. Abortion as a Maternal Health Issue

2. Deaths due to unsafe abortions • Between 8 and 18 per cent of all maternal deaths in India are due to unsafe abortions • What are some of the reasons why women go for unsafe abortions?

3. Safe vs Unsafe, Legal vs Illegal Abortions • Induced abortions vs spontaneous • Induced • Medical Termination of Pregnancy Act • Legal vs illegal • Safe vs unsafe • Modern methods • Manual Vacuum Aspiration • Medical Abortion • Abortions very often kept confidential – so complications and death under reported. • Prevention • Provision of safe abortion services • Detection and treatment of complications

4. What are Safe Abortion Services? • Wantedness of pregnancy • According to provisions of MTP Act • Safe abortion services • Manual Vacuum Aspiration • Medical Abortion • Respectful care • Privacy and confidentiality • Post abortion care and contraception

5. Access to safe abortion services Highlights from readings 1-5

6. Need for safe abortion services • Abortion an important need for women: 13% -18% of women had had at least one abortion according to one study covering six Rajasthan districts • Barriers to accessing services exist at many levels, resulting in only a very small proportion (estimates from 10-30%) of women using licensed facilities/providers. Serious risk to health. • Serious morbidity following unsafe abortions including incomplete or failed abortion reported from Jharkhand study; facility studies confirm that when women return with a complications, these are quite serious, requiring several days of hospitalisation.

7. Barriers to seeking safe abortion services • Vast majority of women and men do not know that abortion is legal in India. • Many women (have to) seek services unknown to their husbands who they believe will object to the termination. They therefore seek services closer to home and services that do not involve high costs. • Husbands may choose services and providers who are less expensive. • Tertiary care facilities felt to be women-unfriendly, often the least preferred option for many rural women.

8. Supply-side barriers Legal: • Only a gynaecologist or a physician trained in a government-sanctioned facility can perform MTP • Two such physicians have to concur for abortions after 12 weeks -20 weeks. • Private facilities have to be certified and have a trained physician/gynaecologist • Time and effort needed to procure certification of an abortion facility discourages certification.

9. Supply-side barriers-2 • Grossly inadequate service delivery centres: one estimate of 17,600 couples per abortion centre. Rural areas, less developed states/districts particularly disadvantaged. • Public sector services – usually available only in district hospitals and teaching hospitals. • Cost a major barrier even in public facilities, but especially in certified private facilities. Rate increases with duration of pregnancy

10. Barriers after reaching a service delivery point • Legally, providers have the final say. • Majority of trained providers in public facilities uncomfortable with providing MTP services. Discourage women from having MTP or provide it conditionally, under specific circumstances • Single women, women who come unaccompanied are denied MTP; spousal consent is insisted upon in many places; FP acceptance becomes the condition on which MTP is provided in many public facilities.

11. “Unsafe” abortion even in certified facilities Poor quality of care: • No counseling about the procedure or complications, or post-abortion care • Often no use of pain relief • Various kinds of abuse of the women coming for abortion • Limited adherence to asepsis • use of out-dated methods like D&C • Doctors with inadequate training, not very confident to provide MTP