Contrary to the assumptions that nearly half the abortions in India were unsafe, the first national study of the incidence of abortion and unintended pregnancy now suggests that only 5% of the abortions are unsafe.
Safety has been enhanced, primarily, due to safe medical and surgical procedures available now. Safety is an issue where there is lack of availability of services or information.
An estimated 15.6 million abortions were performed in India in 2015. The vast majority of abortions (81%) were achieved using medication abortion (which, in India, is commonly referred to as medical methods of abortion, or MMA) that was obtained either from a health facility or another source while 14% were performed surgically in health facilities, and the remaining 5% were performed outside of health facilities using other, typically unsafe, methods, according to the National Estimate of Abortion and Unintended Pregnancies in India.
Almost half of the 48.1 million pregnancies that occur in India each year are unintended. Two-thirds of all unintended pregnancies end in abortion. Close to one in four abortions in India (22%) are provided in health facilities. Almost three in four abortions (73%) are obtained independently through purchasing medical methods of abortion from a chemist or informal vendor. The remaining 5% are obtained using various methods that are often dangerous and account for 0.8 million abortions, the report says.
Medical methods of abortion (MMA)—using a combination of mifepristone and misoprostol—account for four in five abortions in India. Medical methods of abortion are safe and effective when used in accordance with World Health Organization guidelines.
Only 5% of abortions in India occur in public health facilities, which are a key source of health care for poor and rural women. The majority of primary health centers and substantial proportions of community health centers, the most common types of public health facilities in India, do not offer abortion services. The most common reasons reported for not providing abortion services are lack of trained staff and lack of necessary equipment or supplies.
As many as 47 per 1,000 women aged 15-49 got an abortion done in 2015, according to the National Estimate of Abortion and Unintended Pregnancies in India that also said that of the total 48.1 million pregnancies in 2015, about half were unintended—meaning they were wanted later or not at all. The estimated unintended pregnancy rate was 70 per 1,000 women aged 15–49 in 2015, which is similar to the rates in neighbouring Bangladesh (67) and Nepal (68), and much lower than the rate in Pakistan (93).
The study published in The Lancet Global Health—was conducted jointly by researchers at the International Institute for Population Sciences (IIPS), Mumbai; the Population Council, New Delhi; and the New York– based Guttmacher Institute.
“Although abortion has been legal under a broad range of criteria in India since 1971, we have never had a reliable estimate of the number occurring until now,” says Dr. Chander Shekhar, professor in the Department of Fertility Studies at IIPS and co–principal investigator of the study. “This new evidence provides policymakers with information that is essential for designing and implementing effective reproductive health care programs.”
Unlike previous research on this topic, this study is the first specifically designed to measure the national incidence of abortion in India. The researchers used two direct methods for measuring incidence. One was compiling national sales and distribution data on MMA (mifepristone and mifepristone-misoprostol combipacks), which represents the vast majority of all abortions in India. The second was implementing a large-scale survey of public and private health facilities in six states—Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh—where close to half of Indian women of reproductive age live. The number of abortions to women who used traditional methods was calculated using indirect measures.
Currently, slightly fewer than one in four abortions are provided in health facilities. The public sector—which is the main source of health care for rural and poor women—accounts for only one-quarter of facility-based abortion provision, in part because many public facilities do not offer abortion services. Close to three in four abortions are achieved using MMA drugs from chemists and informal vendors, rather than from health facilities. MMA is safe and effective when used in accordance with World Health Organization guidelines. For example, according to clinical studies, an MMA regimen that combines misoprostol and mifepristone is 95–98% effective when used correctly and within a nine-week gestational limit.
“Women in India face considerable challenges trying to obtain abortion care, including the limited availability of abortion services in public health facilities,” says Dr. Susheela Singh, vice president for international research at the Guttmacher Institute and co–principal investigator of the study. “Our findings suggest that a shortage of trained staff and inadequate supplies and equipment are the primary reasons many public facilities don’t provide abortion care.”
The study proposes a number of steps to improve the availability and quality of abortion services in health facilities, including training and certifying more doctors to provide abortion care. The study also recommends permitting nurses, AYUSH doctors (practitioners of indigenous medicine) and auxiliary nurse midwives to provide MMA. This would substantially expand the number of providers—and facilities—qualified to offer safe abortion services. The authors also note the importance of ensuring that public health facilities have the equipment and drug supplies necessary to provide surgical abortion care and MMA.
To address the needs of the millions of women choosing to obtain MMA from sources other than health facilities, the authors urge the implementation of strategies that will provide women with accurate information about how to use the method safely. Finally, the study recommends improving the quality of contraceptive services, including by offering a wide range of contraceptive methods and providing counselling to help individuals prevent the pregnancies they do not want and achieve their reproductive goals.