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Why Are Unsafe Abortions Still So Common In India?

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Unsafe abortions have devastating effects on women’s health. Every year around 42 million women with unintended pregnancies choose abortion. Nearly half of these procedures that about 20 million abortions are unsafe. Around 68,000 women die because of unsafe abortions, making it one of the causes of increasing maternal mortality rate. Of women who survive unsafe abortions, 5 million suffer long-term health complications. Unsafe abortion is thus a pressing issue.

While some abortions are self-induced, most of them are performed by providers lacking required qualifications and skills to perform abortions and hence termed unsafe WHO defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out either by persons lacking skills or in an environment that does not conform to minimal medical standards or both. According to WHO, every 8 minutes, a woman in a developing country dies due to complications arising out of unsafe abortions.

Safe abortion services protect women’s right to health. Article 12 of International Covenant on Economic, Social, and Cultural Rights, 1966 provides for the right to “the highest attainable standard of health”.  The Programme of Action adopted at United Nations International Conference on Population and Development in Cairo in 1994, states that “Government should deal with the health impacts of unsafe abortion as a major public health concern.”

According to WHO, every 8 minutes, a woman in a developing country dies due to complications arising out of unsafe abortions.

Aim & Objective 

This present study was done on cases reported to various hospitals seeking abortion services or for the complications due to unsafe abortions carried out elsewhere.

This study aimed to explore the trend adopted by women when they required abortion services.

Information was collected to explore the data regarding the first contacted person by the women, abortion services, the use of ultrasonography before coming to the hospitals, any history of domestic physical violence culminating into abortion, and whether the women undergoing/undergone abortion wished to keep confidential or disclose to the relatives regarding the abortion from 44% to 48%.

In Western Nations, only 3% abortions are unsafe whereas, when it comes to Eastern Nations, the rate of unsafe abortions is 55% of all that mostly occur in Latin America, Africa, South East Asia etc.

Scope Of The Problem 

Obtaining correct data for the abortions is quite difficult and a challenging task, especially when it comes to unsafe abortions. Two-thirds of the nations do not have the capacity to collect data, and data collected varies from nation to nation, in both quantity as well as quality. Because unsafe abortions are often done secretly by untrained individuals or bye the pregnant women themselves, most of it goes undocumented/ unrecorded.

Data suggests that the overall rate of abortions has reduced, but when it comes to unsafe abortions, it’s rising, especially in developing countries. From 1995 to 2003, the overall number of abortions reduced, but the rate of unsafe abortions was steadily increasing from 44% to 48%. In Western Nations, only 3% abortions are unsafe whereas, when it comes to Eastern Nations, the rate of unsafe abortions is 55% of all that mostly occur in Latin America, Africa, South East Asia etc.

Medical Transmission Of Pregnancy As Per The Bare Act Of 1971 

This act provides for the termination of certain pregnancies by registered medical practitioners and the matters connected therewith or incidental thereto. This extends to all the states of India except to the state of J&K. This Act provides for the termination of certain pregnancies where the length of pregnancies does not exceed 12 weeks or where the length of pregnancy exceeds 12 weeks but doesn’t exceed 20 weeks.

Such termination of pregnancies can be done only on the recommendation of qualified and registered doctors when such pregnancies may be fatal to the baby or the pregnant mother. Certain pregnancies are also terminated when it is held that the baby will be suffering from some non-curing disease or is defected in some incurable way.

MTP is also recommended in case of pregnancies alleged by the pregnant women to have been caused by rape or because of grave injury to physical or mental health where pregnancy is caused as a result of the failure of any contraceptive device used by an individual to limit the number of children.

The anguish caused by such unwanted pregnancy may be presumed to constitute a grave injury to the mental health of pregnant woman, medical termination of pregnancy is thus recommended. MTP’s shall be done in the hospitals established and maintained by the government or at a place being approved for this Act by Government.

Methods Of Unsafe Abortions 

Even safe abortions in developing countries carry the risks that depend on the availability of health facilities, the skills of the doctor and gestational age of the fetus. With unsafe abortions, many additional risks arise that increase the mortality rate of women. Methods of unsafe abortions include drinking of toxic fluids such as turpentine, bleach and drinkable concoctions mixed with livestock manure.

The main cause of deaths due to unsafe abortions are haemorrhage, infections, genital trauma etc.

Other methods include inflicting direct injury to the vagina or elsewhere – inserting herbal preparations into vagina or cervix, placing a foreign body such as a twig or a chicken bone into uterus etc.

Unskilled providers also improperly perform dilation and curettage in unhygienic settings, causing uterine perforations and infections. Methods of external injury are also used, such as jumping from the top of the stairs or roof or inflicting blunt trauma to the uterus/abdomen.

Health Consequences

Worldwide, some 5 million women are hospitalized every year for treatment of abortion-related complications such as haemorrhage and sepsis, and abortion-related deaths leave approximately 220,000 children motherless. The main cause of deaths due to unsafe abortions are haemorrhage, infections, genital trauma etc. Other unmeasurable health consequences due to unsafe abortions include loss of productivity and psychological changes.

The burden of abortions lies not only with the woman but also with the family and public health system. Every woman admitted for emergency post-abortion care may require blood products, antibiotics, oxytocins, anaesthesia, operating rooms and surgical specialists. The financial and logistic impact of emergency care can overwhelm a health system and can prevent attention to be administered to patients.

Why Do Quacks Rule?

While 70% of facilities in the public sector in many states offer comprehensive abortion-care services, only 30% of primary health-care centres, which are the first place that village women visit, offer such comprehensive abortion-care services.

In Bihar and Jharkhand, the studies show that almost 20% of the residents know that abortion is legal while in Madhya Pradesh only 12% of the residents are aware of it. Also, a recent study in Madhya Pradesh revealed that a woman has to travel on an average 20km to reach the abortion provider.

Stigma and attitude towards women, especially young, unmarried women, seeking abortion also contribute to unsafe abortions. Such service providers refuse to perform on young women or demand that they bring their parents to the health centre. This automatically forces women to opt for secret and unsafe abortions. While the law requires the consent of only women of she is over 18 years, in many practices, the providers may ask for the consent of the spouse or some other relative too.

Despite the liberal law, the MTP Act, which governs the abortions in India, non-availability of trained service-providers and detailed documentation coupled with poor knowledge about the legality of abortions contribute to many abortion-related deaths.

Estimates indicate that 2% to 4% of all abortions in the country are due to son preference over daughters. In India, 80-90% of reported cases of abortions take place within the first trimester, while the sex-selection is largely an issue in the second trimester.

Poor, young and unmarried women are more likely to delay abortion because of lack of knowledge, and they are often poorly informed on many fronts: they may not understand the signs of pregnancy, possibility or legality of obtaining the abortion and the location of safe service-providers. Due to all these reasons, women seek terminations from backstreet providers.

Restrictive Laws Equal To Higher Proportion Of Unsafe Abortions 

A newly published evidence shows that the countries where the abortion is completely banned are allowed only in cases where certain pregnancies may be harmful to mother, only 1 out of 4 abortions were safe. On the other hand, where abortion is legal on broader grounds, nearly 9 out of 10 abortions were safe.

The majority of safe abortions took place in developed countries like America and Europe, which also have the lowest abortion rates. Most of these countries have more permissible laws on abortion, high contraceptive use, higher economic development, higher levels of gender-equality etc.

Estimates indicate that 2% to 4% of all abortions in the country are due to son preference over daughters.

Amongst developing regions, the proportions of safe abortions were at maximum found in East Asia (including China). In south-central Asia, however, less than 1 in 2 abortions were safe. Of those unsafe abortions, the majority were categorized as “least safe” abortions.

Many health facilities and health workers in the region are also unable to properly and adequately treat the complications that occur from unsafe abortions.

Abortion In India: A Case Study

A pregnant woman, 28 years old, literate but without any formal education, with a history of two previous abortions presented unescorted in our dispensary situated in an urban slum of Chandigarh, North India.

She worked as a housemaid. She reported that she got her pregnancy detected around one week back by herself using the urine pregnancy kit at her home.

She also told that she wanted to get it aborted as she didn’t want the child because her younger son was only a year old. She asked the resident doctor at the dispensary for an oral abortifacient. On examination, she was thin built and undernourished. She weighed only 45 kgs and had a moderate degree of pallor. Her blood pressure was found to be normal.

On abdomen examination, her uterus was not palpable, implying pregnancy of fewer than 12 weeks of gestation. PV examination was not done. She was advised the routine blood, and urine tests during pregnancy and Ultrasonography (USG) for confirmation of pregnancy and period of gestation. She was asked to get these tests done in a nearby sub-district level hospital. She returned after a week with blood tests and urine test done.

Her haemoglobin was 9.1 gm/dl with normal blood sugar levels, and other parameters were also within normal limits. She could not get the USG done from district hospital as she didn’t have any identification proof (ID proof) in her name. According to the government rules, any pregnant women undergoing ultrasonography at any health facility need to have a valid ID card, photocopy of which is deposited along with the requisition form. She told that she requested the doctor to the hospital to prescribe her the abortion-inducing drug. But they refused she didn’t have the USG report.

She was advised by the doctor there to get the USG done from any private diagnostic centre. But she didn’t have the money in the first place. Also, the private diagnostic centre’s too asked for any of her valid ID proof which they didn’t have as they had recently migrated to Chandigarh from another state for job opportunities.

She was finally advised by us to get an affidavit made for her identity and residential status as it could be used ID proof for getting the USG done. Public health nurses of the dispensary also mentioned that her husband is a chronic alcoholic and that they were living in one room rented house in the locality with their three children.

After two weeks, she presented to us at the dispensary with profuse bleeding from her for three days. She said that it started spontaneously with no history of any drug intake or injury. She was also having lower abdominal pain with extreme weakness and lethargy. On examination, she was found to be had tachycardia with severe pallor, and her Blood Pressure was found to be low. She also said that she had gone to the emergency outpatient department of the hospital, a day before, but they refused admission as her husband did not accompany her. An attendant was required to get her admitted there.

They had prescribed her tablet tranexamic acid to stop the bleeding along with iron and folic acid tablets. We suspected induced abortion. On probing and enquiring further, she accepted that she had contacted an unqualified doctor who practised in the locality who prescribed her some tablets to induce abortion. She took these pills. She started to bleed from the next day, which was excessive and continued to date.

In this case, the staff escorted the index case to the higher health facility for the lifesaving treatment. We liaised with the higher health facility effectively in this case to remove some of the procedural hurdles. We also called her husband to our health centre so that emotional support component (to the wife) can be taken care of. She was admitted there for three days.

She finally underwent dilation and curettage (D and C) to remove the product of conception, which was the cause of bleeding in her case. She was also transfused with three-unit of blood during her stay. She was counselled for using Copper-T following the D and C.

What Can Be Done To Avoid Such Unsafe Terminations? 

According to the National Family Health Survey-3 (2005-2006), nearly 21% of pregnancies are either unwanted or mistimed. Unmet need for family planning (FP), which refers to the condition in which there is the desire to avoid or postpone childbearing, without the use of any means of contraception, ultimately leads to unwanted pregnancies. The concept points to the gap between some women’s reproductive intentions and their contraceptive behaviour.

Globally, unmet need for contraception remains a problem. However, in developing countries like India decision to use family planning methods is determined mainly by the husband or the family rather than the women herself due to the low position of women in society. According to the World Health Organization (WHO), unmet need is especially high among groups such as adolescents, migrants, urban slum dwellers, refugees and women in the postpartum period.

The burden of unsafe induced abortion in developing countries like India is too high. According to WHO, every eight minutes, a woman dies due to complications arising from unsafe abortions in developing countries, making it the leading cause of maternal mortality (13%). Because hazardous abortion is often done clandestinely by untrained individuals or by the pregnant women themselves, much of it goes undocumented; figures are therefore estimates.

Poor, young and unmarried women are more likely to delay abortion because of lack of knowledge.

Worldwide, some 5 million women are hospitalized each year for treatment of abortion-related complications such as bleeding and sepsis, and abortion-related deaths leave 220,000 children motherless.

Poor quality of care and procedural barriers at government health facilities, particularly for underprivileged sections of society is a significant problem in India as identified in our case.

The government doctors refused the woman the abortifacient/abortion-inducing drugs because her USG could not be done. Stringent Prenatal Diagnostic Techniques Act amended in the year 2003 and renamed as Pre-Conception. Pre-natal Diagnostic Techniques aims to prevent sex determination of the fetus by providing penal action, including imprisonment for both the service provider and the beneficiary in case of sex determination and sex-selective abortion.

However, the Act is under criticism for issues in documentation and its inflexible nature. It was identified as a significant barrier to access and receive quality care in the current case as it was on this ground that her USG could not be done as documentation requirement of Act necessitates that the pregnant women undergoing USG should have an Identity proof which she didn’t have. Data indicate an association between unsafe abortion and restrictive abortion laws.

Abortion-related deaths are more frequent in countries with more restrictive abortion laws (34 deaths per 100,000 childbirths) than in countries with less stringent laws (1 or fewer per 100,000 childbirths). In India, unsafe, illegal abortions persist despite India’s passage of the Medical Termination of Pregnancy Act in the early 1970s.

The Act was passed to remove legal hindrances to terminating pregnancies in the already underfunded public health care system. However, women still turn to unqualified local providers for abortion, as also evident in this case. The implications of the law never reached the population that require them most, i.e. the underprivileged section of the society.

 What Can We Do?

  • Strengthen Access To Safe Abortion Services In Current Context

Dissemination and implementation of the comprehensive abortion care training and service delivery guidelines are imperative. It must be ensured that providers are trained and equipped, and drugs are available at all levels of facilities.

  • Expand The Base Of Legal Abortion Providers

India basically has a ‘physician only’ abortion law. The number of providers could be significantly increased by amending the law to authorize medical practitioners with a bachelor’s degree in Unani, Ayurveda or homoeopathy to provide abortion care.

  • Increase The Upper Gestational Limit For Abortion

In cases where there is a diagnosis of substantial fetal abnormalities, the MTP Act should be amended to allow for the later terminations, i.e. beyond 20 weeks of gestation.

  • Make Act More Comprehensive And Clear

It needs to be clearly communicated that only the consent of women is required for the medical termination of pregnancy procedure. This would address the common practice providers insisting that a women’s husband also consent to the abortion.

  • Simplify Access To Legal Abortion Services

As per current law, women must obtain the opinion of one doctor for a first-trimester abortion and opinion of two doctors for second-trimester abortion. Amending the MTP Act to simplify and reduce the requirement for a provider’s opinion for both first and second-trimester abortions would greatly increase women’s access.

  • Restrictions On Selling Abortifacients Without Prescription

Medical store persons should not be allowed to dispense the abortifacients without certified medical practitioner’s prescription.

Unsafe abortions can be prevented by ensuring that women and girls can prevent unintended pregnancies, having access to comprehensive sexuality education as well as a choice of effective and affordable modern contraceptive methods, including emergency contraception. Crucially, countries need to ensure that women and girls gave access to safe, legal abortion and post-abortion care.

Provision of safe, legal abortion is essential to fulfilling the global commitment to Sustainable Development Goal of universal access to sexual and reproductive health. World Health Organization (WHO) provides global technical and policy guidance on the use of contraception to prevent unintended pregnancies, safe abortions and treatment of complications from unsafe abortions.

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