Ultrasound of a growing foetus in the mother’s womb at 23 weeks of age. Photo: Flickr/hose902, CC BY-NC-ND 2.0
- All available evidence indicates that good post-abortion care services help reduce maternal mortality and morbidity rates and improve health outcomes for women.
- Despite progressive laws and amendments, access to safe and approved abortion facilities still remains a significant challenge for a large number of women in India.
- The rates of both abortion and complications from abortion have reduced marginally between the NFHS-4 and NFHS-5 survey periods (2015-2016 to 2019-2021).
- Private facilities were preferred for performing abortions in both survey periods. A significant number of respondents performed abortions at home as well.
- The Indian government has recognised the need for comprehensive abortion care services and has issued guidelines time and again, but they remain on paper.
The recent history of abortion laws in India takes us back to the British Raj, where colonial laws made abortion a crime that was punishable for both the woman and the abortionist, unless the abortion was performed to save the woman’s life.
After Independence, the Government of India has observed an increase in maternal mortality linked to insanitary abortion practices in the country. It responded by constituting the Shah Committee in 1964 and tasked it with preparing a comprehensive review of the socio-economic, medical and legal aspects of abortion in India.
Acting on the Shah Committee report, the Medical Termination of Pregnancy (MTP) Act was passed by Parliament in 1971, legalising abortion up to a limit of 20 weeks on medical and humanitarian grounds in the country, with the exception of the state of Jammu and Kashmir.
In 2002, the government amended the MTP Act to reduce bureaucracy and administrative delays associated with the setting up of abortion facilites. The amendment also rationalised physical standards for abortions, recognised medical abortions and approved mifepristone for the same.
To improve access and the ambit of reproductive health services to women in India on social, humanitarian and therapeutic grounds, the latest amendment to the MTP was passed in 2021. With key revisions such as a 24-week upper gestation limit, provision of MTP services irrespective of women’s marital status and a confidentiality clause, the amendment is expected to improve maternal mortality and contribute to the UN’s Sustainable Development Goals 3.1, 3.7 and 5.6.
Further, a complete cost-cover for abortion is provided by public national health insurance funds, Ayushman Bharat and Employees’ State Insurance.
Despite progressive abortion laws and amendments, access to safe and approved abortion facilities still remains a significant challenge for a large number of women in India, especially among those at the lower socio-economic levels. The impact of the very recent 2021 MTP Amendment Act on sanitary universal access also remains yet to be seen.
At this juncture, we take a closer look at National Family Health Survey (NFHS) data for post-abortion care – a vital aspect of women’s health with physiological and mental ramifications but which remains largely ignored.
What is post-abortion care?
Post-abortion care can be broadly classified into two categories: curative and preventive. Curative care largely deals with emergency treatment for complications related to spontaneous or induced abortions, and counselling for mental well-being. Preventive care pertains to counselling vis-à-vis family planning, birth control, etc. Here, we focus on the curative aspect of post-abortion care.
A major milestone in this context was the International Conference on Population and Development in 1994. Irrespective of the legality of abortion in their nations, more than 180 parties resolved to the following (paragraph 8.25): “In all cases, women should have access to quality services for management of complications arising from abortion. Post-abortion counselling, education and family planning services should be offered promptly, which will help to avoid repeat abortions.”
Per a 2018 comment in The Lancet, abortion-related complications are an important and preventable cause of maternal mortality, accounting for 8-9% of maternal deaths worldwide, with 42 to 63 women dying out of every 100,000 abortions. The number in South Asia is approximately 5.9% of maternal deaths. Another study estimated in 2018 that at least 9% of the abortion-related hospital admissions have a near-miss event and approximately 1.5% end in a death.
All available evidence points to the fact that good-quality post-abortion care services help reduce maternal mortality and morbidity rates, thus improving health outcomes for women.
We delved into the data from the NFHS-4 (2015-2016) and NFHS-5 (2019-2021).
* Abortion rates have come down marginally between the two survey periods – although the decline isn’t very significant.
* The rate of complications from abortions has decreased marginally between NFHS-4 and NFHS-5. This could be due to better access to the right methods and expertise at the right time for women. Among the women who experienced complications, there was an increased demand for treatment of these complications, which is a positive development.
* Private facilities were preferred for performing abortions in both survey periods. A significant number of respondents performed abortions at home as well. The lack of use of public facilities could very well be due to their ineptness in terms of doctors, nurses and equipment.
* Private facilities continue to attract more women for treatment of complications. This is also corroborated by a survey from Gujarat, which estimated that only 31% of public facilities in the state offered any abortion-related services. Only 14% also had any sort of post-abortion care facilities.
* Notably, public facility use was higher for post-abortion complication treatment than for abortions. Private facility usage is marginally higher for abortions than for post-abortion complication treatment.
The Indian government has recognised the need for comprehensive abortion care services and has issued guidelines time and again – but they remain mostly on paper. The policies under the National Population Policy 2000 and the Reproductive and Child Health-II and the National Health Mission programmes are categorised as follows:
- Integrated strategic approach under the reproductive, maternal, newborn, child and adolescent health
- Establishing comprehensive abortion care service delivery
- Generating awareness
Women in urban as well as rural areas are accessing post-abortion care services in high numbers – but the challenge of universal coverage still remains. One positive step was the Maternity Benefit (Amendment) Act 2017, which offers women six weeks of paid leave after a miscarriage or medical termination of pregnancy. But more needs to be done to save lives.
First, health systems must ensure local delivery of care through primary and community health centres. A study from Gujarat suggested that approximately 90% of primary health centres don’t have a facility for post-abortion care. Per NFHS-5 data, approximately 21% of respondents not seeking treatment said treatment was unaffordable. Equipping local centres will surely improve affordability and access. Second, work should be done to destigmatise seeking care for abortion-related complications, especially for the mental health ramifications.
Fifteen percent of respondents to the NFHS-5 said their husbands didn’t allow them to be treated for the complications. Community health workers can play a pivotal role here in educating both potential mothers as well as family members, especially husbands and fathers, about complications and treatments. There is also a serious lack of mental healthcare professionals, which needs to be addressed at the earliest.
Third, we must ensure that follow-ups take place after the procedure is performed.
These follow-ups should guide the women about potential signs to take care of, and connect them to other reproductive health care services such as screening for sexually transmissible infections and gynaecological cancers, which can save them from serious diseases in future.
Aditya Gulia, Kaivalya Karkare and Pruthvi Shah are alumni of IIM Indore.