Abortion In India: A Literature Review - Guttmacher Institute
December 2014Abortion in India: A Literature ReviewMelissa Stillman, Jennifer J. Frost, Susheela Singh, Ann M. Moore and Shveta KalyanwalaHIGHLIGHTSnnnnnnnThis report reviews and synthesizes the peer-reviewed literature, as well as important greyliterature, published between 2002 and 2014 on abortion in India.Over the past decade, some key policy developments have contributed to improved availability, accessibility and safety of induced abortion services; these include revised regulationsexpanding services to primary health centers, the approval of medical abortion for terminatingearly pregnancies, and the promotion of manual vacuum aspiration as the preferred methodfor early surgical abortion.The impact of these efforts has been dampened by difficulties in implementation. For example, the expansion of abortion services into lower-level facilities has been uneven, leavingmany districts with few public facilities that provide the services. Studies indicate that manyof the largest, least developed states are disproportionately underserved by certified facilities.National- and state-level studies suggest that the majority of women in India who seekabortion services do so to limit family size, space births or protect their health, or because ofpoverty and economic constraints. Only a small proportion of all abortions are likely performedfor sex-selective reasons.The incidence of complications among women having unsafe abortions is poorly documented.Such complications appear to have declined over the past decade, but limited knowledgeand poor access to safe and legal services mean that many women seeking abortion makeat least one unsuccessful attempt before they end their pregnancy. Some of these attemptscarry health consequences for the women.Young and unmarried women are particularly vulnerable to poor sexual and reproductivehealth in general, and they have especially poor access to safe abortion services, which leadsto delays in obtaining services and reliance on unsafe providers.Estimates of abortion in India are based on a variety of indirect methods that likely underestimate its prevalence; improved incidence studies are an important area for future research.
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CONTENTSIntroduction. 4Purpose of the Literature Review.4Background and Context.5Methodology.7December 2014Abortion in India: A Literature ReviewMelissa Stillman, Jennifer J. Frost, Susheela Singh,Ann M. Moore and Shveta KalyanwalaLaws, Policies and Guidelines. 9Medical Termination of Pregnancy Act.9Providers of Legal Abortion Services Under the MTP Act.9Amendments to the MTP Act.9Policies on Provision of Medical Abortion.10Proposed 2014 Amendment to the MTP Act.10Pre-Conception and Pre-Natal Diagnostics Technique Act.10Guidelines for Abortion and Postabortion Care.10Estimates of Abortion Incidence. 12Unsafe Abortion and its Consequences. 14ACKNOWLEDGMENTSThis report was written by Melissa Stillman, Jennifer Frost,Susheela Singh and Ann Moore, all of the Guttmacher Institute,and Shveta Kalyanwala, independent consultant. It was editedby Haley Ball, and Kathleen Randall oversaw production; bothare of the Guttmacher Institute.The authors would like to thank the following individuals fortheir insightful comments on an early draft: Kalpana Apte,Family Planning Association of India; Sushanta Banerjee, IpasDevelopment Foundation; Ravi Duggal, International Budget Partnership, India; Rupsa Mallik, Creating Resources forEmpowerment in Action; T. K. Sundari Ravindran, Sree ChitraTirunal Institute for Medical Sciences and Technology; andLeela Visaria, Gujarat Institute of Development Research. Theauthors are grateful to Rajib Acharya and Shireen Jejeebhoy,of Population Council, New Delhi, and Chander Shekhar, of theInternational Institute for Population Sciences (IIPS), for readingan early draft of this report. They also wish to thank the following Guttmacher Institute colleagues: Akinrinola Bankole, SnehaBarot, Gustavo Suárez and Aparna Sundaram for their reviewand comments, and Alyssa Browne for research assistance.This is the first published report from A National Assessment ofthe Incidence of Unintended Pregnancy and Induced Abortionin India, a study currently being conducted by the GuttmacherInstitute in partnership with IIPS, Mumbai, and the PopulationCouncil, New Delhi. It was made possible by grants from theUK government, the David and Lucile Packard Foundation, theJohn D. and Catherine T. MacArthur Foundation and the FordFoundation. The findings and conclusions contained within arethose of the authors and do not necessarily reflect positionsand policies of the donors.The Guttmacher Institute gratefully acknowledges the generalsupport it receives from individuals and foundations—includingmajor grants from The William and Flora Hewlett Foundationand the David and Lucile Packard Foundation—which undergirds all of the Institute’s work.Women Seeking Abortion: Their Reasons and Characteristics. 16Reasons for Seeking Abortion.16Characteristics of Women Seeking Abortion.19Availability of Abortion Services. 21Supply of and Demand for Abortion Services.21Public-Sector Delivery Points.21Private-Sector Delivery Points.22Availability, Sales and Preferences Related toMedical Abortion.23Barriers to Obtaining Safe Abortion and Postabortion Services. 25Health System Factors.25Providers’ Roles in Offering Abortion Services andInformation.29Providers’ Knowledge and Attitudes.32Women’s Perspectives.34Discussion. 37The Supply of Safe Abortion Services.37The Demand for Safe Abortion Services.38Improving the Quality of Abortion and Postabortion Care.38Improving the Provision of Safe Medical Abortion.39Addressing Vulnerabilities Among Young andUnmarried Women.39Building Capacity.39Policy Considerations.39Further Research.39References. 41Appendix Table A. 47 Guttmacher Institute, 2014Suggested citation: Stillman M et al., Abortion in India:A Literature Review, New York: Guttmacher Institute, 2014.www.guttmacher.orgGuttmacher Institute3
IntroductionPurpose of the Literature ReviewGlobally, induced abortion—safe or unsafe, legal orillegal—is a reproductive health service that is part of thelives of women, couples and communities in both developed and developing countries. When faced with unintended pregnancies, especially in contexts in which womenlack access to effective family planning, induced abortionis an important part of women’s reproductive health care.Ensuring the safety and availability of abortion servicesis critical to women’s health, and creating a supportivelegal environment is one step in that process. In India, thesecond most populous country in the world, abortion hasbeen legal on a broad range of grounds since 1971.1,2 Asubstantial body of research on various aspects of abortionin India, including policies, service provision and women’sperspectives, has been conducted in the past decade.This report provides a synthesis of recent studies relatedto abortion and presents an up-to-date overview of thestatus of induced abortion in India by highlighting what isknown and what knowledge gaps exist. Some of the questions this review will answer are as follows: How have policies and service provision changed overthe past 10 years? What are the main reasons women have an abortion? What are the characteristics of women who are moreor less likely to seek abortion services? With the growing demand for smaller families and therelatively slow increase in contraceptive use, what isthe role of abortion in women’s reproductive strategies? How reliable are existing estimates of abortionincidence? To what extent and through which pathways do women experience unsafe abortion and suffer consequentmorbidity or mortality? What abortion services are available to women, andwhat are the important gaps in or barriers to obtainingsafe and legal abortion services?To our knowledge, the most recent published literaturereview of abortion in India was written by Heidi Johnstonas part of the Abortion Assessment Project–India (AAPI)working papers series in 2002.3 In her review, Johnstonoutlined abortion services in India at the time, estimatesof abortion rates and associated morbidity and mortality,legal and social factors associated with abortion, and thestate and quality of postabortion care services. In addition to Johnston, the India Working Group, consisting ofmembers from Centre for Enquiry into Health and AlliedThemes, Federation of Obstetric and Gynaecological Societies of India, Family Planning Association of India, Ipas,Society of Midwives–India and United Nations PopulationFund, collated existing information to create a situationalanalysis of unwanted pregnancies and abortion in India.4This 2007–2008 analysis was part of a broader multicountry effort by the International Federation of Gynecologyand Obstetrics Working Group for the Prevention ofUnsafe Abortion to gather country-level information topresent at national and regional workshops in order todiscuss and define plans of action to reduce unsafe abortion in various countries. Most recently, in 2014, Population Council India published a literature review, writtenby Mary Philip Sebastian et al., that focused broadly onreproductive health in India, including trends in fertility,contraceptive use and unmet need, quality of and accessto family planning and abortion services, financing and delivery mechanisms, and barriers to services.5 Sebastian’sreview focused exclusively on the states of Bihar, MadhyaPradesh and Odisha, providing a snapshot of the most current research in these states but not of India as a whole.As a result of the introduction of medical abortion*in 2002, and its subsequent widespread availability, theabortion landscape in India has changed substantially. Themain objective of this review is to synthesize the key findings of studies conducted since Johnston’s review, andto describe the current reality of abortion in India to the*A form of induced abortion performed nonsurgically using medications. In this publication, we use the term to refer specificallyto abortions resulting from the use of a combined oral regimen ofmifepristone and misoprostol.4Guttmacher Institute
extent possible. We focus on key issue areas on whicha sufficient amount of literature exists: abortion laws,policies and guidelines; abortion services, including theavailability and quality of services among different facilityand provider types; task-shifting related to provision ofabortion services; and the availability, effectiveness andsafety of, and women’s preferences for, different abortion procedures (medical versus surgical). We present thecharacteristics of women who are seeking or obtainingabortion services, as well as the most common reasonswomen cite for terminating a pregnancy. We also discussthe wide range of barriers—on the individual, social andsystemic levels—to safe and legal abortion services thatwomen in India face. Finally, we discuss the policy andprogrammatic implications of the findings and makerecommendations for future research.Background and ContextMore than 1.2 billion people live in India, approximately26% (328 million) of whom are women of reproductiveage (15–49).1 According to Sample Registration Systemdata for 2012, women in India have an average of 2.4births in their lifetime.6 This key indicator of reproductivehealth, known as the total fertility rate, has declined from3.6 in 1991. Women living in urban areas have fewer children (1.8) than their rural counterparts (2.6). Reproductiveoutcomes vary widely throughout India, reflecting the social, demographic and economic diversity of its states anddifferential access to health services across the country.For example, among the bigger states, the total fertilityrate varies from 1.7 in Himachal Pradesh, Punjab, TamilNadu and West Bengal to 3.5 in Bihar. Fertility is higherthan the national average among women living in parts ofthe Central region (2.9 and 3.3 in Madhya Pradesh and Uttar Pradesh), Eastern region (2.8 and 3.5 in Jharkhand andBihar)6 and Northeastern region (3.0 to 3.8 in ArunachalPradesh, Nagaland and Meghalaya).*7The most recent data on the contraceptive prevalence rate among married women in India come from the2012–2013 Annual Health Survey, which covers the ninehigh-focus states.†8 While geographically limited, the datashow that contraceptive use varies widely from state to*Sample Registration System reports from 2012 do not providedata for some small states. In these cases, we used data fromthe 2005–2006 National Family Health Survey.†High-focus states are Assam, Bihar, Chhattisgarh, Jharkhand,Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh andUttarakhand. This group was established by the government ofIndia in 2001 to facilitate focused efforts to promote the Child andReproductive Health Programme in the states that had been lagging behind in a number of sociodemographic indices.Guttmacher Institutestate, ranging from 41% in Bihar to 70% in Rajasthan.The contraceptive prevalence rate also varies acrossdistricts within states; for instance, it ranges from 28% to56% in Bihar, 33% to 79% in Odisha and 55% to 90% inRajasthan. Nationally representative data from the 1992National Family Health Survey (NFHS-1) and the 2007–2008 District Level Household and Facility Survey (DLHS3) indicate that contraceptive use among married womenincreased some between 1992 and 2007, from 41% to55%.9,10 Contraceptive use was higher among womenliving in urban areas (61%) than among those in rural areas(50%).10 Only 7% of married women aged 15–19 and 22%of those aged 20–24 were using a modern method. Ofall current users in India, 88% relied on a modern contraceptive method, and the remaining 12% reported usinga traditional method. Spacing methods were much lesscommon than permanent methods, especially amongwomen aged 35 and older: Female sterilization accountedfor two-thirds of total contraceptive use and for 74% ofmodern method use among married women aged 15–49.Among married women with children, the proportion whohad been sterilized increased with their number of sons:Twenty-five percent of women with two daughters and nosons had been sterilized, compared with 47% of womenwith at least one son.In 2007–2008, approximately 21% of married womenhad an unmet need for contraception—that is, they reported wanting to space or limit births but were not usinga contraceptive method.10 Unmet need was higher amongrural, low-income and young women than among others.In the states of Bihar, Jharkhand, Meghalaya and UttarPradesh, contraceptive use was low (22–38%), and levelsof unmet need were highest (32–36%; Figure 1, page6).10 Nationally, according to results from the 2005–2006National Family Health Survey (NFHS-3), 21% of recentbirths were unintended—10% were wanted later and11% were not wanted at all.7 The proportion of unintended (mistimed or unwanted) births was highest amongwomen aged 40–44 (50%) and lowest among womenyounger than 20 (14%). The total wanted fertility ratewas 1.9 children per women, 30% lower than the actualfertility rate of 2.7 children per woman at that time.‡ Thegap between wanted and actual childbearing was largerfor rural women (0.9 children) than for urban women (0.5children). This gap also varied by state, ranging from 0.1children in Kerala to 1.6 in Bihar. The gap was one child or‡To compare the wanted and actual fertility rates, we useddata from the 2005–2006 NFHS-3 because the 2012 SampleRegistration System data reported earlier in this publication do notinclude the wanted fertility rate.5
Figure 1. Unmetfor contraceptionis highest inisstatesin inthestateseasternandeasternnortheasternregions of India.FIGUREneed1. Unmetneed for contraceptionhighestin theand northeasternregions of India.Jammu & KashmirHimachal PradeshChandigarhPunjabUttarakhandHaryanaArunachal PradeshNew DelhiSikkimAssam NagalandUttar PradeshRajasthanBiharGujaratMadhya PradeshMeghalayaManipurTripura MizoramJharkhandWest BengalChhattisgarhDaman & DiuDadra and Nagar HaveliOdishaMaharashtraTelanganaGoaAndhra PradeshKarnatakaPuducherryKeralaTamil Nadu% of married women aged 15–49with unmet need*Less than 1515–19.920 or higher*Those who want to avoid pregnancy but are not using any method ofcontraception. Note: The Union Territories of Lakshadweep and the Andamanand Nicobar Islands are not shown on this map. Source: reference 10.more in Bihar (1.6), Uttar Pradesh (1.5), Jharkhand (1.2),and Madhya Pradesh, Nagaland and Rajasthan (1.0 each).7Little is known about the degree to which unmarriedadolescents engage in sexual activity; the subject is sensitive in India and reliable data are lacking. Youth in India:Situation and Needs Study, a large-scale survey of youngmen and women aged 15–24 conducted in six states in2006–2007, showed that about 4% of young womenreported (in face-to-face interviews or written surveys)having had sex prior to marriage.11 Although premaritalsex was likely underreported, the proportion ranged from1–2% in Bihar, Maharashtra, Rajasthan and Tamil Nadu,to 6–7% in Andhra Pradesh and Jharkhand. Among thosewho reported sexual activity, 21% reported having hadmore than one concurrent sexual partner, and only 3% reported consistent condom use. Awareness of sexual andreproductive health matters was also inadequate amongadolescents: Fewer than half of young women knew6that they could get pregnant at first sex or had correctknowledge of how to use at least one modern reversiblemethod of contraception, and only six in 10 were awarethat 18 is the minimum legal age of marriage for women.While data on sexually active unmarried women arelimited, what we do know suggests that contraceptiveuse is relatively low among this population (38%).7 Usevaries by age: Only 9–12% of sexually active unmarried15–24-year-olds were using a modern method in 2005–2006, compared with
to abortion and presents an up-to-date overview of the status of induced abortion in India by highlighting what is known and what knowledge gaps exist. Some of the ques-tions this review will answer are as follow
How to talk about abortion: a guide to rights-based messaging 3 Abortion procedures Abortion is the voluntary ending of a pregnancy.1 There are two main methods of safe abortion: medical abortion, where medication is
Aug 06, 2016 · abortion earlier. Nearly 60% of women who experienced a delay in obtaining an abortion cite the time it took to make arrangements and raise money. Teens are more likely than older women to delay having an abortion until after 15 weeks of pregnancy, when the medical risks associated with abortion are significantly higher.
The American Constitution Society for Law and Policy Truth is Truth: U.S. Abortion Law in the Global Context 2 pregnancy.7 And many have enacted and expanded regulations targeting abortion providers and other barriers making abortion increasingly inaccessible.8 The result is a patchwork of access to abortion care across the United States,9 with restrict
Septic abortion is a spontaneous or induced abortion complicated by fever, endometritis, and parametritis leading to generalized infection or sepsis. It is often the result of an unsafe abortion. Distinction between safe and unsafe abortion Safe abortion is a procedure and technique performe
2019 Abortion Statistics Pennsylvania Department of Health 1 2019 ABORTION STATISTICS Executive Summary Pennsylvania has been monitoring and reporting on abortion data since 1975. This report is produced pursuant to Section 3214 of the Abortion Control Act, 18 Pa. C.S. § 3214(e)(1). In 2019
Shostak, A. & McLouth, G. (1984). Men and Abortion: Lessons, Losses, and Love. New York: Praeger. USA 1000 75 Quantitative/ Qualitative 1000 at time of abortion procedure 75 months and often years after abortion 47% of clinic-day and 63% of post-abortion men agreed that men involved
dilated. The possible diagnosis will be:- A. Missed abortion C. Threatened abortion B. Inevitable abortion D. Complete abortion 4. All of the followings are the nursing management of unclassified abortion at H/C except:- A. Put on IV drip in case of severe ble
1.5 Overview of results 9 1.6 Terminology 9 1.6.1 Abortion terminology 9 1.6.2 Terminology related to the psychological effects of abortion 9 1.7 Availability and prevalence of abortion 10 .0 Reviews of the liter
