Abortion In Uttar Pradesh

Abortion Assessment Project India

State level Dissemination Meeting Uttar Pradesh

September 2, 2004

At I.C.C.M.R.T, Luknow

Organised by Health Watch UP, Bihar C- 1485 Indira Nagar Lucknow. UP 226016 In collaboration with CEHAT Sai Ashray, Aram Society Road Vakola, Santacruz East Mumbai 400055 Healtwatch C/o GIDR Near Goys Char Rasta Gota, Ahmedabad 380060

Abortion In Uttar Pradesh

Published by: Kriti Resource Centre C-1485, Indira Nagar Lucknow, U.P. India Phone 0522-2341319 E-mail : kritirc@sahayogindia.org

Layout: Deepak

Printed by : Creative Printers

Reported by Paramita Guha

Edited by Pinky

Abortion In Uttar Pradesh

PREFACE In October 2000, at the United Nations Millennium Summit, all countries agreed on the global imperative to reduce poverty and inequities. The need to improve maternal health was identified as one of the key Millennium development Goals, with a target of reducing levels of maternal mortality by three-quarters between 1990 and 2015. The causes of maternal deaths are multiple. Abortion is one of the leading causes of maternal deaths all over the world. Over the last decade abortion has indeed become a major global issue in the context of reproductive rights of women. Worldwide of the 210 million pregnancy outcomes each year 46 million or 21.9% are estimated to be induced abortions. These are very large numbers and given the context of wide-ranging restriction on free use of abortions in a number of countries and also an outright ban in many countries, the risks faced by women who are often forced to use unsafe alternatives is tremendous and this is reflected in 13% of maternal mortality worldwide being due to unsafe abortions. Even though abortion is a major health problem of women, the information available on abortion in India is inadequate. A study - Abortion Assessment Project-India aimed at getting a comprehensive picture of the issue. This initiative was co-coordinated by CEHAT and Health Watch Trust. This study included a policy review, and several working papers . A number of in-depth field studies were also undertaken in this project to understand the ground realities. A one-day meeting was organized at ICCMRT, Lucknow on 2nd September 2004 to share the findings of the study with concerned stakeholders in Uttar Pradesh. A large number of participants representing a wide range of stakeholder groups including representatives of Government agencies, International organizations, NGOs, womens groups, researchers as well as the media participated in the meeting. The recommendations, discussions and presentations of this meeting are described in this report.

Abortion In Uttar Pradesh

Recommendations for enhancing safety in abortion and womens access to safe abortion services, Uttar Pradesh
Ensure access to contraceptives v Include single women within the eligibility criteria for contraceptive use. v Awareness building on various methods of family planning including spacing methods. v Promote male participation in contraception v Increase availability of various contraceptives, especially spacing methods Protect womens rights and respect womens choices v Increase awareness among women on abortion as their reproductive right. v Increase awareness among women and the community about negative impacts of son preference and coercive abortion. v Respect womens choices Improve abortion service delivery v Simplify the registration procedures for doctors and clinics that provide abortion services. v Encourage the registration of doctors and clinics under MTP Act. v Ensure availability of at least one lady doctor in each PHC and CHC v Privacy and confidentiality in service delivery v Free distribution of medicines. v Training of providers on the socio-cultural factors around abortion and abortion seeking behaviour v Reporting system of abortion must be made systematic and regularized. v Increase accountability of Govt. hospital to the patients. Comprehensive IEC activities v IEC activities must give information on abortion as legal and sex preselection as illegal. v Promote sex education in school curricula. v Abortion health must be included in IEC activities. v IEC activities should focus on male involvement and participation with respect to abortion. Community based planning and review v Community based review of maternal morbidity and mortality v Community based review of existing practices and needs assessment.

Abortion In Uttar Pradesh

v Involvement of panchayats for awareness building, planning and monitoring on this issue

Abortion In Uttar Pradesh

A brief report of the meeting Context Abortion is one of the leading causes of maternal deaths all over the world. Abortion is also a very contested issue in many places. However India is one country where abortion laws are very l beral and have been in place since i 1970s. Despite this a large proportion of abortions continue to be conducted illegally, using dangerous methods. It contributes a large proportion to the over one hundred thousand maternal deaths that take place in the c ountry every year. Even though abortion is a major health problem of women, the information available on abortion is inadequate. A study called Abortion Assessment Project-India has been recently completed which aimed at getting a comprehensive picture of the issue. This study was conducted across the length and breadth of the country covering 14 states and in collaboration with 21 organizations. This initiative was co-coordinated by CEHAT and Health Watch Trust. This study was started in August 2000, with the preparation of background papers which included a policy review, and several working papers . A number of in-depth field studies were also undertaken in this project to understand the ground realities. Considering the importance of the issue of abortion and the significance of the study, a series of dissemination meetings were organized across different states. The purpose of these meetings was to share the results of the study with concerned stakeholders in the different states. It was also expected that these sharing meetings would come out with recommendations on how to make abortion safer and more easily accessible to the women in the respective States and reduce the mortality and morbidity that is associated with it. Objectives The objectives of the meeting were: To disseminate key findings of the AAP India project. To bring together key stakeholders on a common platform to discuss issues which these findings throw up. To bring to the table issues and concerns on abortion and related reproductive health issues which may be specific to the state /region.

Abortion In Uttar Pradesh

Introductory Session Mr.Utkarsh Sinha, core group member of Health Watch U.P - Bihar, welcomed all participants. He stressed that the discussions on abortion had become important and urgent in the context of son preference, the increasing availability of ultrasonography and the widespread prevalence of sex-preselection. He said that in urban areas abortion rates are higher than that in rural areas and amongst classes and social groups too there was a clear gradient indicating that those better of had much higher rates than those economically and socially disadvantaged. In his background note Dr. Abhijit Das of Health Watch U.P - Bihar, said despite the provision of the legal Act on abortion, illegal abortions continue to pose a huge problem. Every year over 50 lakh-induced abortions take place in the country and abortion related complications were responsible for a large proportion of maternal deaths. However there are very few studies documenting the status of abortion in the country. Access to safe abortion services is lacking in most parts of the rural areas. In U.P there is no abortion facility at PHC and even CHC lack these many a times. In most of the PHCs and CHCs lady doctors are not available thus most of the rural women access informal providers for abortion facilities. Even government paramedics were known to function as informal providers. Some of the new challenges in the context of abortion were the increasing practice of sex-preselection and abortion of the female foetus. It is related to the age-old phenomenon of son preference and is emerging as a major issue of concern. In U.P there were reports that there is something called safai ki batti, which is a kind of stick, which is introduced through the cervix into the uterus for doing abortion. This is quite common in the eastern parts of the State. He also expressed a word of caution on the recently introduced oral abortion drugs, which could be used indiscriminately in private practice. He shared that there was a great potential for risk of heavy bleeding if these drugs were used without proper back up support. He said that the findings of the study would provide useful insights in designing appropriate policies and interventions. Sunita Singh, Research Officer, CEHAT made a brief presentation on the findings of the Abortion Assessment project India. a. Objectives of AAP-India v Review Govt. policy towards abortion care, programme environment in the country. v Map, understand and analyze abortion care provider related issues.

Abortion In Uttar Pradesh

v Study social, economic and cultural factor that influence decision making. v Study, understand and analyze user perspective with special focus on womens perception of quality, availability, accessibility, confidentiality, consent, and attitude of service providers. b. Study Area of AAP-India o Rajasthan, o Haryana, o M.P, o Orissa, o Kerala, o Mizoram. c. Findings v On an average there are 4 formal (medically qualified though not necessarily certified for abortion) abortion facilities per 1,00,000 population in India. v Of all formal abortion providers 55% are gynecologists and 64% of the facilities have at least one female service provider. v Informal abortion providers handle one third of the cases. v Certified and legal abortion facilities are only 24% of all private abortion facilities in the country. v 73% of abortions are conducted for pregnancies with less than 12 weeks gestation. v Dilatation and Curettage (D&C) appeared to be the preferred method for nearly 89% of induced abortions. v Information and counseling are better in public facilities. v Physical access seems to be fairly good, social access remains restricted. v Services are not provided to women if they come alone. v Decision for undergoing an abortion is rarely womens. v 87% of the abortion market is controlled by the private sector. v In urban areas abortion rates were nearly twice than that in rural areas. v Better off women had more abortion than economically and socially disadvantage women. v Poorer sections were much larger users of public facilities. v Unwanted pregnancy was due to non-use of contraception rather than contraception failure. v All respondents reported knowledge of sterilization as a method of limiting family size. v Women were aware that sex selective abortion is illegal. v In order to handle delayed periods and early abortion women largely use informal providers. v These providers use oral methods like herbs, khadas, tablets etc. v Informal providers cater unmarried women. 8

Abortion In Uttar Pradesh

v In many areas informal providers are linked with formal abortion providers and abortion seekers. The studies revealed that when couples have more than two female children, then female selective abortion was approved by the family and condoned by the community. There was an overwhelming perception that private facilities were better and the private doctors have better facilities and equipment. While the services of private facility cost money, govt. hospitals were also not cost free. Women had to pay for medicine. The cost varied according to the type of provider and the gestation period. Discussion Session Chairperson: Dr. Chandrawati, King George Medical University, Lucknow v Dr. Chandrawati shared that In U.P there are large number of gynecologists who are not registered. The procedure of registration takes too much time. This leads to a situation where most of the doctors who practice abortion are not registered. Secondly most of the women seeking abortion prefer a lady doctor. They prefer quack lady to a certified male doctor. She said that the private facilities are much better and take much less time. Private doctors have better facilities and equipments. Moreover they treat women in a much better way and ensure confidentiality. In contrast in the public sector service provider are less, most of ANM and compounder conduct abortion in unscientific ways and women have to make repeated visits thus they do not continue using these. v Speaking about the registration of doctors in U.P. Dr. P.C.Kanojia, Additional Director of Family Welfare Department of U.P. stressed that registration of doctor used to be a complicated process earlier but the process has been streamlined and now it takes only one year. Applications for registration must be filled in the prescribed form and along with the certificates submitted through the CMO at the district. He said that in our society male gynecologist are not accepted and there is a shortage of lady doctors in the interior areas because most of them want to settle in the city. As a consequence most of the PHCs and CHCs do not have lady doctor. v Dr. Manjari Trivedi pointed out a number of shortcomings in dealing with abortion cases in public sector. She said that most of the PHC and CHC do not have a lady doctor. In private sector doctors have better facilities and equipments. Most of the rural women go to quack only because they are easily available and after abortion they are available locally. In most of the cases, doctors do not check the health condition 9

Abortion In Uttar Pradesh

of the patient before conducting abortion due to which morbidity rates are much higher after abortion. v Dr.Rina Mukherjee, retired Joint Director of Family Welfare Department, U.P. said that at the village level, there is a need to generate awareness among TBAs(Dai) who generally conduct abortions using traditional methods. She advocated for the inclusion of abortion related information in IEC activities, simplification of the application form for registration of a doctors and making the reporting system of abortion cases systematic and regularized. v Dr. Chandrakala Padia, Director, School of Womens Studies, Benares Hindu University, said that in the family welfare programme there must be a basic course of sex education. She pointed out that there is ignorance regarding sexual health not only in rural women but also among urban women. v Sunita Singh mentioned that abortion rate is not so high among dalit and poor section. It is not only because of money and distance but there is also an ethical factor. The desire to restrict families to two children is far more common in towns rather than in the villages. v Dr. Asha Pandey Executive Secretary UP Voluntary Health Association stressed the need to generate awareness on emergency contraception. Presentation of study on Quality of Care Dr. Seema Parveen of SAHAYOG and Mr Rajdeve Chaturvedi of Gramin Punarnirman Sansthan made a joint presentation on an ongoing study on Womens Perception of Quality in Reproductive Health Services in U.P. She mentioned that this study was also part of a CEHAT Healthwatch collaborative initiative on Quality of Care. Similar studies were being conducted in Jharkhand, Maharastra, and Gujarat. Sahayog conducted this study jointly with a partner NGO i.e. Grameen Purarnirman Sansthan in the district of Azamgarh in Uttar Pradesh. Through this study an attempt was made to understand the nature of services available to women through the public health system and map out the gaps that exists between womens perception and expectation of quality on one hand and the availability of quality reproductive health care services within the public health system on the other. The objectives of the study were v To understand which health care services poor rural women access for select reproductive and child health needs and their reasons for doing so. 10

Abortion In Uttar Pradesh

v To understand womens as well as providers (public, private and informal) perception of quality of services provided. v To understand the capacity of the public health facilities at different levels to meet the select reproductive and child health needs of poor rural women. The study had explored five aspects of reproductive health i.e. normal and complicated delivery, contraception, abortion and RTI. The presentation was limited to the findings that emerged from the section on contraception and abortion. Perceptions of providers as to what women expected in terms of quality of care ANMs Doctors Doctors (Pvt) Informal Providers (Govt)
v Appropriate / proper advice v Female provider v Relief v 24 hours availability v Confidentialit y v Easily Accessible v Cleanness specially toilets v Personal relation v Availability at home v Proper treatment v Availability of all services v Advice/fac ility for unwanted pregnancy v Availability of doctors and other staff v Availability of Free medicine v v v v v v v v v v v v v v v Easy accessibility Privacy Cheap services Clean place Behaviour of Dai & doctors Ask properly Satisfaction Less expenditure Relief from illness Proper treatment Personal behaviour Good services Available in emergencies Should be cured Convince the family to care v Relief v Confidentiality v Easy Accessibility v Good Behaviour v Cheap/ cost effective v Reputation v Reliability v Certainty about the course for relief v Privacy v Experience of provider v Sympathy with poor v Payment in installments v Counseling v Belief/ satisfaction v Best medication v Quick relief v Good treatment Medicine

ANMs

Main constraints and limitations providers had in providing quality services Doctors (Govt) Doctors (Pvt) Informal Providers
v v v v v v v v v v v v The male/ female dynamics Women do not want to see male provider No lady trained colleague Check-up is done by ANM Inadequate examination room and space No back up or lab facility Lack of good medicines Woman can not take decision alone on our advice Understanding level of patients Have to talk in local dialect Interaction has to be with the guardian Women do not take advice seriously they rely on traditional methods v Lack of modern equipments Investigation for diagnosis becomes a barrier v Patient cannot afford medicines and nutrititous diet v Dependent on male members for contraception of T/T, they go where men take them Cost Distance Poverty Awarene ss v No lady Doctor v v v v

v No electricity v Lack of appropriate labour room v No essential equipments v Lack of proper building v No cleanliness v Heavy Workload v Target of sterilization campaign

11

Abortion In Uttar Pradesh

Rajdev Chaturvedi presented the perspective of community women. The study revealed: v Contraceptive awareness among women is high but actual use of contraceptive methods is low. v Misconceptions on contraceptive methods were widespread leading to decreased use even among women who want no more children. v Additional barriers to contraceptive use include the accessibility and lack of autonomy of women of reproductive age in their household. v A preference for sons discouraged contraceptive use. v Women from socio-economically backward were less aware of contraceptive methods and were less able to access contraceptive methods and services. The study revealed that women were aware of the importance of contraception and their opinion reveals: v They want to use contraception but nobody (husband and in-laws) else in the family is helping them or understands them. v Women do not want frequent pregnancies. It is a source of discomfort, and women get weaker day by day v Men are not using any method of contraception v Men think childbirth is womens problem, so they should use contraceptives With regard to abortion the study revealed: v Women seeking abortion first attempt to induce abortion using noninvasive techniques that are accessible at home or in the village. Home remedies include consuming heat-producing solution such as vinegar, sonth (dry ginger powder), and alcohol. When home remedies do not work, they seek inexpensive non-invasive medical method available from village stores or invasive procedures. When village level method do not work or lead to complications, women generally seek care from a provider outside their village. v It is interesting to note that women, especially young women did not think that abortion is a crime. According to them they are under compulsion when they have to do it, because they do not have any alternative to prevent childbirth. But elderly women consider it wrong because they considered it as a creation of god. According to them safai or bachche girwana(abortion) is wrong. v Most of the women revealed that they abort their child during the first trimester (between 2-3 months) through the use of home remedy and local practitioners. But if pregnancy advances more than 5 6 month then they go to private nursing home because they feel it could be risky 12

Abortion In Uttar Pradesh

for their life. It is interesting to note that regarding abortion women are not worried about distance and money. They travel 30 to 40 km in such cases. v The decision to induce abortion is generally made in consultation with husband and sometimes with her family. In some cases, the woman herself makes the decision. v Factors influencing the decision of where to seek service included- cost, familiarity with and the trust on the provider. Women give more preference to home remedy and local practitioner because home remedies and village level abortion services is relatively inexpensive, and travel costs are negligible. For these reasons, women often turn to home remedies and village level providers even when they know qualified providers in town are safer and more effective. Discussions v Dr. Kanojia said that all these findings are not new. ANM is not a provider. Even if an ANM is doing abortion through the right method, it is illegal. In U.P the rate of contraception use is 38%. Population control is not the sole responsibility of the health department. If all the departments jointly work then population will be checked through systematic and legal method. v Dr. Idris, from KGMU pointed out that there is need for Community Need Assessment. He also pointed out that most women in urban areas use family planning. In rural areas women do not know about the use of spacing methods. Service providers and NGOs have to create awareness on this issue in urban and rural areas. v Dr. Asha Pande of UPVHA said that it is necessary to not only educate women but also educate men on this issue. v Utkarsha Kumar Sinha of Healthwatch UP Bihar said that there is a need to generate mass awareness on male participation. v Satish Kumar Singh from Sahayog said that abortion should be looked at from social point of view. Even the most educated people do not believe in male sterilization. In most of the cases in U.P, when women come to the doctor for abortion, they are forced to sterilize themselves. v J.P.Sharma of UPVHA mentioned that there is a need to involve Panchayati Raj Institutions in this issue. v Dr.Ramakant Rai of Healthwatch UP Bihar pointed out that most of the women believe that their sexual life will be affected if their husband undergoes sterilization. Now the process of male sterilization is very easy. It takes only 5-10 minutes. Education is the only method to generate awareness about abortion, sterilization and the various methods of family planning. 13

Abortion In Uttar Pradesh

Annexure 2
Dr. P.C Kanaujia Additional Director Directorate of Family Welfare Jagat Narayan Road Lucknow 226003

Participants List
Dr. Rina Mukherjee Retired Joint Director Department of Family Welfare Uttar Pradesh Lucknow Dr. Chandrakala Padia Director, School of Womens Studies Benaras Hindu University Varanasi Dr. M.Z Idris Department os SPM King George Medical University Lucknow Anand Pawar Project Incharge Tathapi Trust Pune Alok Singh Khus Banthana Asha Pandey Executive. Secretary UPVHA Lucknow Asha Pandey Executive. Secretary UPVHA Lucknow Chandra Kriti Resource Centre C- 1485, Indira Nagar Lucknow Ganesh Dey Kriti Resource Centre C- 1485, Indira Nagar Lucknow

Dr. Chandrawati Department of Obstetrics and Gynaecology King George Medical University, Lucknow Dr. Manjari Trivedi Department of SPM Benaras Hindu University Varanasi Dr. Abhilasha Srivastava Giri Institute of Development Studies Aliganj, Lucknow. Abhijit Das Health Watch UP Bihar Anju Varma Kriti Resource Centre C- 1485, Indira Nagar Lucknow Anju Varma Kriti Resource Centre C- 1485, Indira Nagar Lucknow Awedesh Kumar Baba Ramakaran Das Gramin Vikas Samiti Gorkhakhpur

Deepak Mishra Kriti Resource Centre C- 1485, Indira Nagar Lucknow

14

Abortion In Uttar Pradesh

Irfan Ahmed Rambar Charitable & Welfare Societies Lucknow K N Maurya Cosar Trust Lucknow Mob.- 9415086603 Pankaj Singh Srijan Bhatia 481/56 Kha Mohan Meakin Road Lucknow Ph. 9415376225 P.V.Singh Action Aid Lucknow Raj Dev Chaturvedi Gramin Punarnirman Sansthan (GPS) Village: Bilari, Dist: Azamgarh Pin: 223223, Rishi Kesh T & K Advertising & Management (Pvt.) LTD L.D.A Colony, Kanpur Road, Lucknow

J P Sharma UPVHA 5/459 Vivek Khand 5 Gomti Nagar, Lucknow Prof. M. Diwan Benaras Hindu Unversity, Varanasi Paramita Guha Centre for Social Justise 112, Ujala Apartment Indira Nagar, Lucknow

Rajeev Srivastava Alambagh Lucknow Ramakant Rai COSAR and Healthwatch UP Bihar A8 Sarvodaya Nagar Lucknow Sandeep Khare Secretary VIGYAN Foundation D- 3191, Indira Nagar Lucknow Savita Mishra Healthwatch UP Bihar 74/93 Kanpur 2362170 Sudha Tiwari F.P.A.I 27 Dr. B.N.Verma Road, Lucknow Sunita Singh Research Officer CEHAT, Mumbai

Satish Kumar Singh MASVAW C- 1485, Indira Nagar Lucknow Seema Parveen Centre for Social Justice 112, Ujala Apartment Indira Nagar, Lucknow Sumanlata Srivastava F.P.A.I 27 Dr. B.N.Verma Road, Lucknow

15

Abortion In Uttar Pradesh

Suresh Pd Sal Pragato Sansthan C-2/12 Sector K Aliganj, Lucknow Dr. Surya Narayan MAA E 111/955 Sector 1 Aliganj, Lucknow Tausif Alam Khan Director Centre for Research B- 1077, Indira Nagar Lucknow Vibhas Mishra Parivar Seva Sanstha Shivpuri Lucknow Ajay Srivastava Rashtriya Swarup Alambagh Lucknow A.K.Bhatia U.N.I 5, Park Road Lucknow Peeyush Tripathi Jansatta Express 1/5 Vishal Khand Gomti Nagar, Lucknow

Surendra Coordinator Gramya Sansthan V.D.A colony, Chanmari Lalpur II Varanasi Susheela D. Singh Kriti Resource Centre C- 1485, Indira Nagar Lucknow Utkarsh Sinha CCRS 2/204,Vivek Khand Lucknow

Gomti

Nagar

Dr. S. Javed Dainik Jagaran Mirabai Marg Lucknow Amit Yadav Hindustan (Hindi) 25, Ashok Marg Lucknow Dinesh Yadav Sahara Samay Sahara Tower Aligang Lucknow Shailvee Sharde Times of India Rana Pratap Marg Lucknow

16

Abortion In Uttar Pradesh

Annexure 2 Abortion Assessment Project India: Summary and Key Findings For many decades now maternal health has been recognised as a crucial area of concern. In this context, incidence, access, safety, legality, cost, social and cultural dimensions, and womens control over decision and choice and other related issues regarding abortion and abortion services in India have assumed serious concern in the context of womens reproductive health needs. The Abortion Assessment Project-India (AAP-I), an all-India research study that commenced in August 2000, was initiated with the objective of assessing ground realities through rigorous research. The overall objectives of the project were: Review Government policy towards abortion care, and policy/programme environment in the country 1 Assess and analyse abortion services, including organisation, management, facilities, technology, registration, training, certification and utilisation in the public and private sector2. Study user perspective with special focus on womens perceptions of quality, availability, accessibility (including barriers to utilisation of safe abortion facilities), confidentiality, consent, post-abortion contraception and attitude of service providers3. Study social, economic and cultural factors that influence decision-making: impact of changing social values, male responsibility, family dynamics and decision-making 4. Estimate rate of abortion, resultant morbidity and mortality; causes of spontaneous and reasons for induced abortion5. Document cost and finance issues related to the above6. Disseminate information on abortion issues widely and develop an advocacy strategy on issues of concern in the context of reproductive rights of women. To achieve the above objectives a wide range of studies with differing methodologies were undertaken. Given the prevailing situation of abortion
See Siddhivinayak Hirve (2004), Abortion Policy in India Lacunae and Future Challenges, Abortion Assessment Project India, CEHAT and Healthwatch, Mumbai 2 See facility survey reports of 6 states and the national synthesis report under publication, CEHAT and Healthwatch, Mumbai 3 See Qualitative Studies A Report (2004), Healthwatch and CEHAT, Delhi; and Household study reports from Maharashtra and Tamil Nadu - under publication, CEHAT and Healthwatch, Mumbai 4 Ibid 5 See houshold study reports from Maharashtra and Tamil Nadu under publication, CEHAT and Healthwatch, Mumbai 6 Ibid
1

17

Abortion In Uttar Pradesh

services and the changing perception and values of the community, a national assessment study should not only cover a wide geographic area but also try to capture the various dimensions of the problem. There were five dimensions of this study: I. II. III. Overview paper on policy related issues, series of working papers based on existing data / research and workshops to pool existing knowledge and information in order to feed into this project. (Component I); Multicentric facility survey in six States Kerala, Rajasthan, Haryana, Madhya Pradesh, Orissa and Mizoram(Component II) Eight qualitative studies on specific issues to complement the multicentric studies. These have been done by researchers, grassroots groups and medical establishments in six states Tamilnadu, Karnataka, Andhra Pradesh, Maharashtra, Gujarat, and Haryana. Also a multicentric qualitative study of informal providers was undertaken in Rajasthan, Maharashtra, Madhya Pradesh, Karnataka, Uttar Pradesh, Haryana and Delhi (Component III); Community based studies to estimate abortion rate and out-of-pocket expenditures in Maharashtra and Tamil Nadu (Component IV). Dissemination and advocacy programme through workshops, consultations and meetings with various stakeholders and analytic literature/publication dissemination both via academia and NGOs and through popular media (Component V).

IV. V.

Over the last decade abortion has indeed become a major global issue in the context of reproductive rights of women. Worldwide of the 210 million pregnancy outcomes each year 46 million or 21.9% are estimated to be induced abortions. These are very large numbers and given the context of wide-ranging restriction on free use of abortions in a number of countries and also an outright ban in many countries, the risks faced by women who are often forced to use unsafe alternatives is tremendous and this is reflected in 13% of maternal mortality worldwide being due to unsafe abortions 7. Given this scenario the womens movement and health groups have taken up proactively various concerns related to abortion. In the last decade womens health advocates have tried to draw the attention of policy makers and administrators to a range of issues related to abortion in order to improve the availability, safety and use of services, including: Abortion perceived as an extension of the Governments population stabilisation programme; Tendency to use abortion as yet another means of family planning; Growing trend in some parts of the country towards sex selective abortion;
WHO: Safe Abortion Technical and Policy Guidance for Health Systems, World Health Organisation, 2003, Geneva
7

18

Abortion In Uttar Pradesh

Inadequate safe abortion facilities within reach of the majority of poor women in rural and urban areas; Dearth of medically approved abortion providers and registered facilities; Inadequacy of post-abortion family planning counselling and services; and Abortion not perceived as a womens health issue among policy makers and service providers;

Government of Indias decision in the post Cairo period (1996) to introduce a more comprehensive Reproductive and Child Health (RCH) program in place of the vertical safe motherhood, child surviv al and family planning programs gave womens health advocates an opportunity to re-establish the importance of a holistic approach. Donors supporting the Governments efforts (UNFPA, WHO, European Community, SIDA, DANIDA and DFID) highlight the importance of looking at abortion-related mortality and morbidity as a part of the RCH package. This has created a favourable climate in the country to examine the issue from different dimensions and work towards making abortion safe. In the last six years donors hav e been working with the Government of India and various State Governments to develop district-specific plans for Reproductive and Child Health Programs. The first phase of the RCH program is now coming to an end and plans for the next phase are being finalized. While the first phase of the RCH program may have limited achievements, greater participation of larger number of stakeholder in its review and the next phase planning shows willingness on the policy front to move ahead. These efforts have been noteworthy and administrators are trying to grapple with hitherto unexplored public policy issues. With regard to abortion, despite the US gagrule, during the first phase of the RCH program some important changes in the MTP Act and Rules related to certification, penal provisions and medical abortion have been made. Also the struggle by activists with regard to sexselective abortions has moved up this issue in the state agenda and implementation within the states of the PNDT has improved substantially. Also the Government of India has recently passed the completely amended PNDT Act, which now also covers pre-conception techniques. While the climate seems to be favourable to initiate debate on safe abortion among key stakeholders, lack of reliable information, wide regional variations, rural-urban differences and a thin research base, make it difficult for policy makers, administrators and womens health advocates to develop strategic interventions. There is little dialogue between different stakeholders and it is not uncommon to see registered service providers, unregistered / untrained practitioners, womens health advocates, population control lobby, public health advocates and others working at cross purposes. While the moderate spectrum in all the above constituencies are open to dialogue and change, it is indeed a big challenge to bring them together in a non-confrontational forum.

19

Abortion In Uttar Pradesh

The policy review, working papers and various studies undertaken in this project highlight the inadequate attention given to abortion within the health and population policy of the country and reiterates the often voiced concern that even the recent Reproductive and Child Health programme, initiated by GOI in 1997, has failed to address issues related to abortion. Key findings 1. The study of 380 abortion facilities across six states (Kerala, Madhya Pradesh, Orissa, Rajasthan, Haryana and Mizoram) tells us that on an average there are 4 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). Of all the formal abortion providers 55% are gynaecologists and 64% of the facilities have at least one female provider. Each of these facilities average 120 abortions per year and this adds up to 4.8 million (one third in public facilities) abortions being handled in formal abortion facilities annually. In addition to this there are more or less similar number of informal (traditional and/or medically non-qualified) abortion providers but they undertake on an average about one-third of the cases handled by formal providers. This gives us an estimate of about 6.4 million abortions annually in India. 2. The Medical Termination of Pregnancy Act (MTP Act), which legalised abortion, has been around for 33 years. Though amended in 2003 to facilitate better implementation the proportion of certified and legal abortion facilities accounts for only 24% of all private abortion facilities in the country. The 380 facilities (285 private) across six states (Kerala, Madhya Pradesh, Orissa, Rajasthan, Haryana and Mizoram) covered in the study provide evidence that those who were certified had obtained certification on an average within a month and of those who were not certified, 68% had never tried to obtain certification. Thus the problem lies largely in the domain of the medical professionals who are not keen to register and become accountable to the authorities. Lack of ethics in medical practice and absence of self-regulation amongst the profession is largely responsible for the present state of affairs. On the positive side it is observed that two-thirds of the providers in the non-certified facilities had the requisite training or qualification as per MTP Act to conduct abortions; thus a majority of uncertified facilities were perhaps providing safe abortions. The latter is confirmed with by the fact that with regard to technical aspects and infrastructure facilities the difference between the certified and non-certified facilities was small.

20

Abortion In Uttar Pradesh

3. On the method of abortion, our research found that 73% of abortions are conducted for pregnancies with less than 12 weeks gestation. However, dilatation and curettage (D&C) seems to be the preferred method for nearly 89% of induced abortions; even amongst those who use vacuum aspiration the practice of check curettage is very common. This obsession with curettage both adds to the cost of the procedure as also contributes substantially to post-abortion complications and infections thus affecting quality of care. Physical infrastructure was overall better in private facilities as also availability of equipment and instruments. But information provision to clients and counselling are better in public facilities. 4. As regards referrals about two-thirds of the facilities said that they referred cases to higher facilities and as many as onefifth were referring more than 50% of the cases. It is interesting to note that 78 percent of the providers have mentioned that it is the second trimester cases that are most commonly referred. Medical risk and incomplete abortion conducted elsewhere constitutes 58 percent and 25 percent respectively of the referrals. The data thus suggests that the providers, especially in the unregistered private facilities, really do not take any chance in handling a case with which they are not comfortable. The place where the referrals are sent are mainly government hospitals which include district hospital (44 percent), medical college (25 percent), post-partum centers (15 percent), sub-district hospital (11 percent) and CHC (7 percent). 5. While physical access seems to be reasonably good, social access remains restricted since providers, especially in formal and certified facilities, do not provide services to women if they come alone and/or if the spouse or some close relative does not give consent. In the household and qualitative studies 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 the womans freedom to access such services and hence to protect her confidentiality and privacy she may often resort to providers who may not be very safe. As regards reasons for seeking induced abortions, only 25% of them fall into what is permitted under the MTP Act (failure of contraceptives, threat to the womans life, biological reasons), the rest were unwanted pregnancy, economic reasons and even unwanted sex of the foetus. The community-based household surveys, qualitative studies and working papers all indicate the prevalence of the practice of sex-determination and female-selective abortions. 6. Public investment in abortion services is grossly inadequate. Only 25% of abortion facilities in the formal sector are public facilities, 87% of the 21

Abortion In Uttar Pradesh

abortion market is controlled by the private sector; the average (median) cost of seeking abortion in the private sector in the facilities studied is Rs.1294, 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 like dalits and adivasis. The household studies under this project reveal that women from poorer classes and from dalit and adivasis communities have significantly lower rates of induced abortion because they often do not have the purchasing power to access abortion services from the private sector or travel long distances to access public services. This makes a strong case for both strengthening as well as expanding public abortion facilities across the country. The RCH-2 phase currently under preparation needs to factor this in if reproductive health and healthcare of women have to improve. 7. The incidence of abortion recorded in Maharashtra and Tamil Nadu as per the household studies is higher than hitherto known studies for both states. In Maharashtra induced abortion during the reference period (1996-2000) was 4.54% of pregnancy outcomes in contrast to nearly twice that in Tamil Nadu (7%). The difference of abortion rate across rural and urban areas as well across classes and social groups in both states was significantly different in urban areas abortion rates were nearly twice than that in rural areas (more so in Maharashtra) and amongst classes and social groups too there was a clear gradient indicating that those better off had much higher rates than those economically and socially disadvantaged. Such association clearly indicates that access both physical and financial is a critical factor in determining abortion rates and use of abortion services. 8. As regards utilisation of services the poor access of the public health sector in providing abortion services comes out very sharply with the share of public health facilities being less than one-fifth of the abortions reported in the studies in both states. The access of public services in urban areas was twice better than in rural areas in both states. But with regard to socio-economic class it was clear that the poorer sections were much larger users of public facilities for abortion services wherever they are available. This read along with the pattern of abortion incidence across classes increases the strength of the evidence that physical and financial access is the most crucial determinant in access to abortion care and services and this makes a very strong case for the public sector to strengthen its participation in abortion care. Interestingly the out-ofpocket burden (median of Rs. 1220 in Maharashtra and Rs.950 in Tamil Nadu) for accessing abortion services as revealed in the household studies is very similar to the costs recorded in the facility surveys. Extrapolating this cost per abortion to the total number of estimated abortions of 6.4 million we find that the abortion economy is worth 22

Abortion In Uttar Pradesh

Rs.800 crores. This is a mere 0.64% of the total health sector expenditures out-of-pocket. 9. The eight qualitative studies revealed that the overwhelming reason for seeking abortion among married women was to limit the family size. When women were asked to indicate the situations in which they would seek abortion or had actually sought abortion, the majority of the women in studies conducted in Maharasthra, Gujarat, Andhra Pradesh and Tamil Nadu reported limiting the family size as the main reason for abortion. Equally disturbing was the finding that non-use of contraception rather than contraceptive failure was reported to be the chief reason why the unwanted pregnancy situations described above tended to occur. Actual contraceptive failure was reported in very few cases. Though all respondents across studies reported knowledge of sterilisation as a method of limiting family size and a majority of the women knew about the reversible methods of contraception such as condoms, oral pills and IUD for spacing births yet this knowledge did not translate into practice for a range of reasons fear about its effect on health, pain and discomfort, irregular supply and problems with obtaining permission from husband. Use of condoms for contraception was rare! Paradoxically, there was a perception that abortion was safe and did not have any long-term adverse health consequences. For some respondents it was seen as a safer option than the use of IUDs and other spacing methods! 10. Also, almost all women were aware that sex selective abortion was illegal, and admitted that women approach different facilities for ascertaining the sex of the foetus and for abortion. Awareness of the new PNDT Act was far greater among women and service providers in comparison to the details of the MTP Act. Group discussions invariably turned spirited when sex selection was discussed. While most respondents admitted that sex selective abortion is indeed illegal, they expressed helplessness as their status in the family and sometimes the very survival of their marriage depended on their ability to produce sons. Women openly and without any hesitation talked about it in almost all the areas. The studies also revealed that when couples have more than two female children, then female selective abortion was approved by the family and condoned by the community. There was no social stigma associated with sex selective abortion especially for mothers with many daughters. Women from Gujarat and Haryana also reported that while they were not comfortable with abortion per se, when it was done for the sake of the family, then they accepted it. 11. There was an overwhelming perception that private facilities were better. The reason for preferring private providers was quite wide, 23

Abortion In Uttar Pradesh

suggesting that the women and their families do weigh the alternatives before deciding where to go. Reasons cited by women were: a. Abortion in private facility takes much less time everything is done in one visit, meaning that they do not waste time waiting and going thro ugh formalities (as most government hospitals are not client friendly) and that everything could be wrapped up in one visit. b. Private doctors have better facilities and equipment and that they are not in a hurry to discharge women soon after the procedure if they need rest for an hour or so before going home. In public hospitals, on the other hand, given a shortage of beds women are asked to leave as soon as possible. c. Private doctors treat women better and ensure confidentiality. 12. It was accepted that while the services of private providers cost money, visits to the government hospitals were also not cost-free because women had to pay for medicines separately. They were sometimes required to make repeat visits before the abortion was performed. The long waiting period implied that the time of the service seeker and of the accompanying person (generally women do not go alone to impersonal large facilities) was wasted, leading particularly in poor families foregoing wages for that time. The cost varied according to the type of provider and the gestation period. 13. In the multicentric study of informal providers using qualitative methodologies across seven states it came out quite clearly that such providers are largely used by women to handle delayed periods and very early abortion. A majority of informal providers are using oral methods like herbs, kadhas, tablets etc.. However there is considerable variation across states wherein it emerges very clearly that in states like Rajasthan and Uttar Pradesh where access to formal providers is very limited the informal providers continue to use invasive methods in contrast to other states like Maharashtra, Karnataka, Haryana and Delhi where access to formal providers is reasonably good. Findings also reveal that the informal providers cater in a very large way to unmarried women. Also in many areas the informal providers are a link between formal abortion providers and abortion seekers, especially in rural areas. Infact, the latter is viewed as a future trend for the role of informal providers to work in collaboration with formal providers as referral links between communities and abortion services. 14. As part of the AAP India project a policy review was undertaken that focused on the dynamics of the MTP legislation and involved consultation with a wide range of stakeholders to identify lacunae and concerns on abortion policy. The review paper also brings out the future challenges 24

Abortion In Uttar Pradesh

and issues for advocacy on the abortion policy front, which are crucial to take abortion into the rights domain. Apart from the policy review a number of working papers were commissioned which reviewed a wide range of abortion issues and concerns based on existing literature 8. Similarly a special issue of Seminar (Issue No 532, December 2003) was commissioned which published 13 original articles largely based on the various studies under the AAP India project. Emerging Advocacy issues Based on the findings of the study and discussions and consultations with various stakeholders during the various stages of the studies a number of key issues and concerns vis--vis abortion and abortion services have emerged. In a national consultation held in New Delhi in Nov. 2003 all these findings and issues of concern were brought together in the presence of a wide array of stakeholders who are active on the abortion and womens health issues. On the basis of the discussion, debate and suggestions which emerged during this consultation the following advocacy issues were short listed to be taken forward during the dissemination phase of the AAP India project to be advocated with policy makers, medical profession, NGOs, donor community etc. and for future actions beyond the phase of this project. We hope the dissemination meetings in different states will add their experiences and take forward these issues and others, which may emerge in the state level meetings that will take place between July and Sept 2004 bringing to an end this phase of the AAP India project. The following issues do not constitute a complete list but only an indicative list of the major key issues which were identified for future action and advocacy: o Changing mindset of providers through their professional associations to accept certification on a universal basis o Integrating abortion services under Primary Health Centres and Community Health Centres through a strengthened RCH programme which would automatically enhance womens access to abortion care services.

The papers published so far include: Abortion Policy in India lacunae and Future Challenges (Siddhivinayak Hirve), Abortion Practice in India a review of literature (Heidi Johnston), Negative Choice sex determination and sex selective abortion in India (Rupsa Mallik), Abortion Options for Rural Women case studies from the villages of Jharkhand (Lindsay Barnes), Abortion Training a long way to go (Sangeeta Btra and Sunanda Rabindranath), Professional Abortion Seekers the sex workers of Kolkatta (Swati Ghosh), Assessing Potential for Induced Abortion among Indian Women (US Mishra and TR Dilip), Methodological Issues in Abortion Estimation (Shelley Saha), Abortion Costs and Financing a review (Ramamani Sundar), Sexuality Abortion and the Media a review odf adolescent concerns (Anita Anand). These papers are available with cehat@vsnl.com
8

25

Abortion In Uttar Pradesh

o Substantial increase in investments in public facilities to strengthen abortion services o Promoting safer technologies by changing the mindset of providers away from unnecessary use of curettage o Strengthening regulation of abortion facilities to evolve minimum standards for quality care and accreditation o Promoting safe spacing methods of contraception to reduce the need to resort to abortion as a spacing method o Broadening the base of providers by training paramedics for early trimester abortions as is done in many countries like South Africa, Bangladesh etc. o The need to widely display certification status of abortion facilities so that women can recognise a safe abortion facility o The need to educate providers on ethics of sex-determination tests and respecting the provisions of the PNDT Act o The need for medical associations to get active in training abortion providers, especially those in the private sector o Promoting apprenticeship as a method of training o Reskilling of traditional providers to play alternative roles in supporting abortion services The studies referred to above were carried out by various research institutions and individual researchers in the different states and coordinated by Ravi Duggal from CEHAT, Mumbai and Vimala Ramachandran from Healthwatch, Delhi. The AAP-India project was supported by the Ford Foundation, Delhi, MacArthur Foundation, Chicago and Rockefeller Foundation, New York. Copies of papers and reports are available at the addresses below.

The meeting was organized in two sections the first section included Context note by Dr. Abhijit Das, from Healthwatch UP, Bihar Key finding of AAP-India by Sunita Singh, Cehat Discussion session. The post lunch session included Findings of Womens perception of quality health care services presented Dr. Seema Parveen, Sahayog, and Mr. Rajdev Chaturvedi, Grammen Punarnirman Santhan Discussions on key recommendation for the state.

26