Despite a liberal law since 1972 and approval of medical abortion since 2003, the provision of legal or formal abortion services at primary care level in rural India continues to be limited. This analysis shows that provision of safe, legal abortion services at rural primary care facilities is feasible and can fulfill the needs of a large proportion of women with unwanted pregnancy. Our data also suggests that rural poor women, opt for safe abortion services as the first choice, if they are accessible, provided in a confidential and sensitive manner, and are affordable.
Our analysis shows that a large majority of women prefer medical over surgical abortion if given a choice, in line with other studies. For example, analysis of factors associated with abortion technique in France showed that given a choice, 84 % women adopted a medical method [14]. In other settings too, when women had information about both methods and were given a choice, they prefer medical abortion [15–17]. In our setting, medical abortion was not available till 2003, and subsequently was only offered to women till 7 weeks gestation, thereby rendering many ineligible. Later when the use of mifepristone-misoprostol was approved up to 9 weeks, and as provider experience grew, a greater proportion of women were considered eligible for medical abortion and were given a choice of methods. We believe that when choice is available, greater proportions of women choose medical abortion in order to avoid surgical intervention - fear of undergoing surgery is an important barrier in low-income countries [18].
Medical abortion provides an advantage when providers visit a facility for a limited number of hours. In our facilities, even if a woman arrived close to end of the working day when the provider was to leave, it was possible to provide medical abortion but not MVA, since the latter requires more preparation time.
The majority of women in our analysis were currently married, which is perhaps related to the low age at marriage in the area and state [9]. More than half the women had three or more children, indicating that abortion seekers are generally married women, who seek abortion to avoid yet another birth. From a community in which the socio-economically underprivileged scheduled caste or tribe groups constitute 47 % of the population, 66 % of women coming to our facilities belonged to this group – this is probably because our clinics provide highly subsidized, non-discriminatory services with differentially lower rates for the tribal community. During the period 2001 to 2015, the two rural blocks in which ARTH provided services did not have any other legal private abortion facility. Each block has one government Community Health Centre and 3–4 Primary Health Centres, which if staffed by a trained abortion provider, could have provided services. A review of annual reports of abortion service provision during two sample periods, 2007–10 (3 years) and during 2014–15 (1 year) revealed that none of these facilities reported performing a single abortion. While it is possible that a few abortions might have been performed without being reported, these were likely to be sporadically accessible in a clandestine manner. Hence, women seeking formal abortion service would either need to go to an urban clinic at one of the district headquarters (30 to 70 km away) or visit an ARTH facility. We therefore feel that women visiting ARTH facilities were representative of those seeking first trimester abortion in a rural community.
A pilot study from same rural area in 1998–99 showed that nearly 76 % of women with unwanted pregnancy who were referred to the city for an abortion, did not go to the city -- the majority continued with the pregnancy [11]. A few other studies from India shed light on profile of abortion seekers, however, all of them are from urban tertiary hospitals [19–21]. These studies too show that majority of the women seeking abortions were married women with one or more children.
Among women with unwanted pregnancy, less than a fourth had ever used a modern contraceptive. This to an extent is not surprising, given that information and utilization of reversible methods of contraceptives is limited in rural areas [9]. Government front-line workers seldom approach unmarried or recently married women regarding contraception, and in the bid to achieve programme objectives, the information they provide to women with two or more children is largely about sterilization. Our experience in the rural community suggests that there is a large pool of women that wishes to avoid sterilization despite not wanting more children, many abortion seekers are drawn from this pool.
After the abortion, 55 % women adopted a contraceptive on the day of abortion itself, or on day of follow-up visit. We provided counseling on all methods of contraception and women did not face any disincentives or pressure for not adopting contraceptives. A recent study from Nepal has shown similar rates of initiation of contraception after medical or surgical abortion [22]. The preference of type of contraceptive changed over the years. Initially, the copper IUD was the most common method, but its use declined over the years. The popularity of DMPA increased over the years, yet the overall initiation of contraception declined over the years. We believe that this was related to increase in the proportion of medical abortion. A study from eastern India has shown that the women who underwent medical abortion were significantly less likely to adopt contraception in the month following abortion compared to those undergoing surgical abortion (58 % vs 86 %), although the difference narrowed by the end of the second month [23]. A study from Australia has also shown that immediate provision of long acting reversible contraceptives (LARC) was more likely after surgical than after medical abortion [24].
The proportion of women who had attempted to ‘bring on their periods’ before coming to the ARTH facility reduced over the years. The reason for this, we believe, is that as information about the availability of our abortion service increased over the years, women started coming directly to our clinics. Secondly, there is a strong preference for avoiding a surgical procedure. In the early years when medical abortion was not available, several women who wanted to avoid surgical evacuation had tried out (mostly ineffective) non-invasive methods such as herbal tablets or decoctions, and came to the clinic after these methods failed. In later years, when availability and information about (mifepristone-misoprostol) medical abortion increased, more women started coming directly to the facility. A study from India has shown that 31 % women had made at least one unsuccessful attempt to terminate the pregnancy [25].
Our results indicate 52 % came for a follow-up visit after abortion, although the proportion increased over the years. Because of the large fraction of women that did not follow up during 2001–2012, it was difficult to accurately report the rates of complications for the entire period. However, we have data available from a research trial nested within these facilities during 2013–14 [12]. In this study, follow-up contact was established with 97.5 % and the rate of complications (defined as hemorrhage requiring blood transfusion or IV fluids, infection requiring IV antibiotics, or hospitalization) was 0.3 %. About 4 % women had incomplete abortion and 1 % had ongoing pregnancies. Given that service protocols did not change for the trial, we feel this result would hold true, for the entire period.
Over the years, the proportion of women who came for repeat abortions increased, however, despite the increase, the majority were first time users. Compared to first time users, repeat users were more likely to have had three or more children, and also having used a contraceptive in the past. Women who had received an abortion service in the past had likely been counseled and provided a contraceptive, while first time users did not have the opportunity, hence repeat users were more likely to have used a contraceptive in the past. In contrast to our findings, data from countries, such as France and Estonia, shows that repeat abortion seekers are more likely to be young women or students living alone [26, 27]. Our results indicate that women who wish to limit their families face difficulties in meeting their contraceptive needs, possibly because of limited access to long-acting reversible contraceptives (LARCs). India’s national programme lays heavy emphasis on female sterilization, which however, often suffers from poor service quality [28]. In order to enable more women to fulfill their reproductive health needs, a greater choice of LARCs needs to be available at affordable cost through public health system. This is also likely to reduce the need for abortion among women who have completed their families.
In our study, among rural women, 37 % had a phone, and only 34 % had a vehicle at home. This finding has two implications – first, providers need to consider that it might not be easy for rural women to easily reach a health facility for want of transport, hence they should try to reduce the unnecessary visits. For example, women should be provided abortion at the first visit, should be given a choice to use misoprostol at home [29] and should be offered alternatives to routine follow-up [12]. Second, although several programmes have started using phones to transmit messages related to the abortion process [30], mobile phones have still not reached the majority of rural women in India. Hence women in low resource settings would need to be given detailed verbal instructions along with context specific written material at the first visit itself. For women owning a phone, reminders or further instructions could be provided on phone.
Our data also showed that most of the time, only the husband was aware that his wife was undergoing an abortion, other persons were aware in less than a third of cases. This further highlights the need for service providers to maintain confidentiality. Further, in case a woman needs support (e.g., visiting a clinic in the event of a side effect or help with housework), they would need to draw on support from husbands.
Data on monthly variations shows that greater number of women coming during months of December-January and in May. Seasonal variations in delivery rates, induced abortion rates and conception rates have been reported earlier in different settings [31, 32]. In United States, for example, higher caseloads for induced abortions were reported from January through April. We have not systematically explored reasons for higher conception rates during the months preceding December – January and May. Relatively lower conception rates around August-September could possibly be linked to the custom of abstinence among tribal persons during one specific month around this time. Service delivery sites in India should be prepared to deal with higher caseloads during certain months.
Strengths and limitations
The strength of this study is that it documents results from a primary care setting in an interior rural area of India, while most of other studies on abortion service provision are from urban areas or from tertiary level facilities. Our area represents underserved areas of the country, where mortality and morbidity related to unsafe abortion is likely to be higher due to restricted access to the service. Further, our study presents data over 14 years, and its results provide information on changing patterns in profile of women, method of abortion provided and chosen, changes in contraception and followup rates. This understanding can be used to inform policy and planning service delivery. The limitation of this analysis is that we do not have complete data for some of the variables for the entire period. This occurred because this was a service intervention that kept evolving with time.
