Unsafe abortion: why restricting abortive drugs only makes a bad situation worseBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3159 (Published 31 May 2013) Cite this as: BMJ 2013;346:f3159
- Meera Kay, freelance journalist, Bangalore
Abortion is legal in India but access to safe abortion facilities remains a distant dream for ordinary Indian women. Instead, women who seek abortion encounter stigma, discrimination, and rejection. The social taboo attached to rape, domestic abuse, and sex outside marriage can result in unwanted pregnancy and leave women in need of a confidential abortion service. In most cases providers are untrained and practise unsafe abortion methods. Many women do not know how to find a safe abortion provider. Poverty and illiteracy also cause women to seek unsafe abortions.
Data from government statistics on family welfare in India record that 620 472 abortions took place in 2010-11 at approved institutions.1 These data report a low incidence of abortion among Indian women. The Consortium on National Consensus for Medical Abortion in India—a national association of gynaecologists, non-governmental organisations, and policy makers—say that these numbers are gross underestimates because hospitals record only legal and reported abortions.2
Accurate data on the number of unsafe abortions conducted in India do not exist because it is done clandestinely by untrained individuals or by the pregnant women themselves.
Only two fifths of abortions in India are considered safe.3 A study on illegal abortion in rural areas, conducted by the Indian Council of Medical Research (ICMR) found that more than twice as many illegal abortions occurred as legal ones (13.5 v 6.1 per 1000 pregnancies).4
Associated maternal mortality
Suchitra Dalvie, gynaecologist and coordinator of Asia Safe Abortion Partnership and CommonHealth, highlights how women’s access to safe abortion is severely restricted in India. “According to the Consortium on National Consensus for Medical Abortion in India, every year about 11 million abortions take place [about 700 000 are reported] and around 20 000 women die due to abortion related complications,” she says.
Unsafe abortion methods range from vaginal abortifacients—such as herbal preparations or misprescribed drugs for medical abortion—to physical curettage. Women might not be well enough informed to judge the relative safety of abortion methods, which can include insertion of an intrauterine foreign body (for example, a stick, root, leaf, or wire), a vaginal abortifacient (for example, herbal preparations or misprescribed drugs for medical abortion), or sharp curettage.5
Each year about 2.3 million women in Asia are admitted to hospital with the complications of unsafe abortion.3 Incomplete abortion, excessive blood loss, and infection are the commonest causes. Less common but serious complications include septic shock, perforation of internal organs, and inflammation of the peritoneum.
Women with untreated complications often experience long term health consequences, such as anaemia, chronic pain, inflammation of the reproductive tract, pelvic inflammatory disease, and infertility.
As India tries to reduce maternal mortality as part of the millennium development goals, fostering women’s access to safe medical abortion is crucial.
Access to medical abortion drugs
Medical abortion drugs mifepristone and misoprostol are available in India. Mifepristone was licensed for use as a prescription only drug in 2002 and misoprostol is available for off-label use as an abortive drug. The drugs can be prescribed by any doctor trained in medical termination of pregnancy at any approved site. However, a survey of 209 chemists, in the states of Bihar and Jharkhand in 2004, showed that many drugs were available over the counter for abortion.6 But despite improving access to medical abortion drugs, the situation changed dramatically in 2011.
“During 2006-2011, the access to medical abortion drugs was improving everywhere in India.” says Sushanta K Banerjee, senior adviser in research and evaluation at International Pregnancy Advisory Services (Ipas) India. “The whole scenario changed immediately after the release of census results in 2012, which pointed out further decline in [the] child sex ratio.” The number of girls per 1000 boys dropped from 927 in 2001 to 914 in 2011 for children aged 0-6 years.7 Most notable was Maharashtra state, which recorded a decline in the sex ratio from 913 in 2001 to 883 in 2011. With a media spotlight on the state, it has set out to “save the girl child” with its Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act. The state seeks to ban the sale of abortion pills or place them on schedule X, which requires rigorous record keeping of customers who purchase the pills with the potential to trace their whereabouts. A clampdown on manufacturers and retailers of abortion pills has led to the withdrawal of these pills from the market and an ensuing shortage.6
Another multi-city study conducted in 2012 across 238 chemist shops in eight cities in Maharashtra found that mifepristone and misoprostol were available in only 10% of the chemist shops.7 Fifty eight per cent of the chemists interviewed reported that they had stopped stocking medical abortion drugs recently. The most prominent reasons given by chemists for not stocking these drugs were the increased burden of documentation for dispensing them (91%), and threats from drug inspectors or other authorities against stocking them (56%).8
“Doctors posted at public sector facilities stopped providing medical abortion, [and] state governments had shown no interest [in] procuring drugs at public sector sites. With frequent media coverage and fear of being penalised by the drug authorities, chemist shops also stopped keeping stock of MA [medical abortion] drugs. Naturally, women in India had limited access to medical abortion,” says Banerjee.
The clampdown has affected poor women seeking abortion in rural and urban settings. “Of course, poor rural women are most affected by lack of access, whether surgical or medical,” says Dalvie.
“If they are refused once, they don’t have any alternative options other than to approach an unskilled provider. On the other hand, rich women can manage to go to a senior gynaecologist who can ensure access to all methods,” says Banerjee.
Access to trained abortion providers and facilities
Inadequate safe abortion facilities within reach of the majority of poor women in rural and urban areas is a considerable barrier in India. “According to the Abortion Assessment Project of India Report, of the total abortion facilities surveyed, the public sector accounts for only one fourth of the facilities,” says Dalvie. Abortion Assessment Project of India studied 380 abortion facilities across six states (Kerala, Madhya Pradesh, Orissa, Rajasthan, Haryana, and Mizoram) and reports that on average there are four formal (medically qualified though not necessarily certified for abortions) abortion facilities per 100 000 population in India. At the country level this adds up to 40 000 facilities or 48 000 providers—each facility averages 1.2 providers.9
Although physical access seems to be reasonably good, social access remains restricted because providers, especially in formal and certified facilities, do not provide services to women if they come alone or if the spouse or a close relative does not give consent. In the household and qualitative studies conducted by the Abortion Assessment Project9 women said that the decision for undergoing an abortion is rarely their own; more often than not their spouse or some relative decides for them. This affects a woman’s freedom to access such services, and so to protect her confidentiality and privacy she may go to providers who are not safe. Only 25% of reasons for seeking induced abortions fall into what is permitted under the Medical Termination of Pregnancy Act—failure of contraceptives, threat to the woman’s life, biological reasons; the rest were unwanted pregnancy, economic reasons, and unwanted sex of the fetus, the Abortion Assessment Project reported.8
One third of abortions in India are performed by untrained, informal providers says the Abortion Assessment Project report. These providers are rural medical practitioners or traditional birth attendants (dais) with no concept of infection prevention, who follow a variety of dangerous practices for abortion. Another 35% of abortions are performed by doctors with a basic medical degree (MBBS) and a postgraduate degree in obstetrics and gynaecology. The final 32% of abortions are performed by trained general practitioners who are medical providers with a basic MBBS degree in medicine. Although these doctors can carry out surgery and deliver babies, they graduate from medical school with only theoretical exposure to abortion procedures summarises the report.
Parity in purchasing power
Women from poorer backgrounds do not go to safe abortion facilities because the services are expensive and the women have to travel long distances to get to them. Abortion Assessment Project India reports that public investment in abortion services is grossly inadequate.8 The report says that only 25% of abortion facilities in the formal sector are public facilities—87% of the abortion market is controlled by the private sector; the average (median) cost of seeking abortion in the private sector in the facilities studied is 1294 rupees (£15; €18; $24), 7.5 times more than the cost in public facilities. This constitutes a major handicap for women who come from poorer classes or other disadvantaged groups such as “dalits” and “adivasis.”
Small steps forward
The government is taking action to tackle the country’s high mortality from unsafe abortions by providing medical termination services at 25 000 primary healthcare centres across the country.
“Improving the retail stock of MA drugs through reduced documentation burden and fear of being hassled by the Drug Control board could also be a step towards better access to safe-abortion,” says Banerjee.
Allowing mid-level health providers, such as allopathic physicians, ayurvedic physicians, and nurses, to perform medical abortions after training might improve women’s access to the procedure. It could help lead to the substantial reduction in unsafe abortion that India needs.
Cite this as: BMJ 2013;346:f3159
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.