Shveta Kalyanwala

Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India.

BACKGROUND Although legal, access to safe abortion remains limited in India. Given positive experiences of task-shifting from other developing countries, there is a need to explore the feasibility of expanding the manual vacuum aspiration (MVA) provider base to include nurses in India. STUDY DESIGN A prospective, two-sided equivalence study was undertaken in five facilities of a non-government organisation in Bihar and Jharkhand to explore whether efficacy and safety rates associated with MVA provided by newly trained nurses were equivalent to those provided by physicians. Eight hundred and ninety-seven consenting women with gestation ages of ≤ 10 weeks were recruited. RESULTS Nurses were as skilled as physicians in assessing gestation age and completed abortion status, performing MVA and obtaining patient compliance. Overall failure and complication rates were low and equivalent between the two provider types, and both provider types were equally acceptable to women who underwent the procedure (98%). CONCLUSION Findings of the study make a compelling case for amending existing laws to expand the MVA provider base in order to increase access to safe abortion in India.

Abortion experiences of unmarried young women in India: evidence from a facility-based study in Bihar and Jharkhand.

CONTEXT Little is known about the experiences of unmarried young women in India who seek to terminate an unintended pregnancy. METHODS A survey was conducted among 549 unmarried women aged 15-24 who had obtained an abortion in 2007-2008 at one of 16 clinics run by the nongovernmental organization Janani in the states of Bihar and Jharkhand. Differences in background characteristics, and in obstacles to obtaining an abortion, between those who had an abortion in the first trimester and those who did so in the second trimester were compared, and logistic regression analysis identified associations between these factors and obtaining a second-trimester abortion. RESULTS Eighty-three percent of women realized they were pregnant within the first two months of their pregnancy, and 91% within the first trimester. Eighty-four percent decided before the end of the first trimester to have an abortion, but only 75% obtained one in this period. One in six participants said that pregnancy had resulted from a nonconsensual sexual encounter, and such reports were more frequent among those who obtained a second-trimester abortion. Women who were older or who had more schooling had a decreased likelihood of having a second-trimester abortion (odds ratios, 0.9 each), whereas those who lived in rural areas, those who did not receive full support from their partners and those who reported a forced encounter had an increased likelihood of having a late abortion (2.3-4.1). CONCLUSIONS Sex education programs that highlight the importance of recognizing a pregnancy early in gestation, and of obtaining an early abortion if a pregnancy is unwanted, are needed for unmarried young women and men.

Adoption and continuation of contraception following medical or surgical abortion in Bihar and Jharkhand, India

This study was carried out to explore whether the rates of postabortion adoption of a contraceptive method, and continuation of contraception over 6 months, differ among women undergoing medical abortion (MA) or surgical abortion by manual vacuum aspiration (MVA).

Knowledge attitudes and practices of certified providers of medical abortion: evidence from Bihar and Maharashtra India.

To explore Indian abortion providers’ knowledge of medical abortion (MA), their personal experiences and practices of providing medical abortion, and their attitudes toward providing MA to eligible women who were poor, uneducated, and/or from rural areas.

The incidence of abortion and unintended pregnancy in India, 2015

Summary Background Reliable information on the incidence of induced abortion in India is lacking. Official statistics and national surveys provide incomplete coverage. Since the early 2000s, medication abortion has become increasingly available, improving the way women obtain abortions. The aim of this study was to estimate the national incidence of abortion and unintended pregnancy for 2015. Methods National abortion incidence was estimated through three separate components: abortions (medication and surgical) in facilities (including private sector, public sector, and non-governmental organisations [NGOs]); medication abortions outside facilities; and abortions outside of facilities and with methods other than medication abortion. Facility-based abortions were estimated from the 2015 Health Facilities Survey of 4001 public and private health facilities in six Indian states (Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu, and Uttar Pradesh) and from NGO clinic data. National medication abortion drug sales and distribution data were obtained from IMS Health and six principal NGOs (DKT International, Marie Stopes International, Population Services International, World Health Partners, Parivar Seva Santha, and Janani). We estimated the total number of abortions that are not medication abortions and are not obtained in a health facility setting through an indirect technique based on findings from community-based study findings in two states in 2009, with adjustments to account for the rapid increase in use of medication abortion since 2009. The total number of women of reproductive age and livebirth data were obtained from UN population data, and the proportion of births from unplanned pregnancies and data on contraceptive use and need were obtained from the 2015–16 National Family Health Survey-4. Findings We estimate that 15·6 million abortions (14·1 million–17·3 million) occurred in India in 2015. The abortion rate was 47·0 abortions (42·2–52·1) per 1000 women aged 15–49 years. 3·4 million abortions (22%) were obtained in health facilities, 11·5 million (73%) abortions were medication abortions done outside of health facilities, and 0·8 million (5%) abortions were done outside of health facilities using methods other than medication abortion. Overall, 12·7 million (81%) abortions were medication abortions, 2·2 million (14%) abortions were surgical, and 0·8 million (5%) abortions were done through other methods that were probably unsafe. We estimated 48·1 million pregnancies, a rate of 144·7 pregnancies per 1000 women aged 15–49 years, and a rate of 70·1 unintended pregnancies per 1000 women aged 15–49 years. Abortions accounted for one third of all pregnancies, and nearly half of pregnancies were unintended. Interpretation Health facilities can have a greater role in abortion service provision and provide quality care, including post-abortion contraception. Interventions are needed to expand access to abortion services through better equipping existing facilities, ensuring adequate and continuous supplies of medication abortion drugs, and by increasing the number of trained providers. In view of how many women rely on self-administration of medication abortion drugs, interventions are needed to provide women with accurate information on these drugs and follow-up care when needed. Research is needed to test interventions that improve knowledge and practice in providing medication abortion, and the Indian Government at the national and state level needs to prioritise improving policies and practice to increase access to comprehensive abortion care and quality contraceptive services that prevent unintended pregnancy. Funding Government of UK Department for International Development (until 2015), the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, and the Ford Foundation.

Experiences of unmarried young abortion-seekers in Bihar and Jharkhand, India

While several studies have documented the prevalence of unprotected pre-marital sex among young people in India, little work has explored one of its likely consequences, unintended pregnancy and abortion. This paper examines the experiences of 26 unmarried young abortion-seekers (aged 15–24) interviewed in depth as part of a larger study of unmarried abortion-seekers at clinics run by an NGO in Bihar and Jharkhand. Findings reveal that recognition of the unintended pregnancy was delayed for many and many who suspected so further delayed acknowledging it. Once recognised, most confided in the partner and, for the most part, partners were supportive; a significant minority, including those who had experienced forced sex, did not have partner support and delayed the abortion until the second trimester of pregnancy. Family support was absent in most cases; where provided, it was largely to protect the family reputation. Finally, unsuccessful attempts to terminate the pregnancy were made by several young women, often with the help of partners or family member. Findings call for programmes for young women and men, their potential partners, parents and families and the health system that will collectively enable unmarried young women to obtain safe abortions in a supportive environment.

Physicians’ and non-physicians’ views about provision of medical abortion by nurses and AYUSH physicians in Maharashtra and Bihar, India

Abstract There is only limited evidence on whether certified and uncertified health care providers in India support reforming the Medical Termination of Pregnancy (MTP) Act to expand the abortion provider base to allow trained nurses and AYUSH physicians (who are trained in Indian systems of medicine) to provide medical abortion. To explore their views, we conducted a survey of 1,200 physicians and other health care providers in Maharashtra and Bihar states and in-depth interviews with 34 of them who had used medical abortion in their practices. Findings indicate that obstetrician-gynaecologists and other allopathic physicians were less supportive than non-physicians of nurses and AYUSH physicians providing early medical abortion. The physicians did not think that these providers would be able to assess women’s eligibility for medical abortion correctly. In contrast, the majority of non-physicians found task shifting of medical abortion provision to trained nurses and AYUSH physicians acceptable, and they were confident that these providers would be able to provide medical abortion as safely and effectively as trained physicians. Assuming the reforms are passed, efforts will need to be made by government and medical professional bodies to train these new providers to undertake this role, prepare the health infrastructure to include them, and create an environment, including among physicians, that is conducive to enabling non-physicians to provide medical abortion. Résumé Il est difficile de dire si les prestataires de santé agréés ou non en Inde soutiennent la réforme de la loi sur l’interruption médicale de grossesse qui devrait élargir la base des prestataires de services d’avortement pour permettre aux infirmières qualifiées et aux médecins AYUSH (qui sont formés au système indien de médecine) de pratiquer les avortements médicamenteux. Pour étudier leurs idées, nous avons réalisé une enquête auprès de 1200 médecins et autres prestataires de soins de santé dans les États du Maharashtra et Bihar et des entretiens approfondis avec 34 d’entre eux qui avaient eu recours à l’avortement médicamenteux dans leur pratique. Les conclusions indiquent que les gynécologues-obstétriciens et autres médecins allopathiques étaient moins favorables que les non-médecins à la possibilité pour les infirmières et les médecins AYUSH de réaliser des avortements médicamenteux précoces. Les médecins ne pensaient pas que ces personnels pouvaient évaluer correctement les conditions à remplir pour bénéficier d’un avortement médicamenteux. Au contraire, la majorité des non-médecins trouvaient acceptable le transfert de l’avortement médicamenteux aux infirmières qualifiées et aux médecins AYUSH, et ils pensaient que ces prestataires pourraient pratiquer l’avortement médicamenteux aussi sûrement et efficacement que les médecins qualifiés. Si les réformes sont adoptées, les pouvoirs publics devront s’efforcer de former les nouveaux prestataires à ce rôle, préparer l’infrastructure de santé pour les y inclure et créer, notamment parmi les médecins, un environnement qui soit propice à la réalisation d’avortements médicamenteux par des non-médecins. Resumen Existe limitada evidencia en cuanto a si profesionales de la salud certificados y no certificados en India apoyan la reforma de la ley de Interrupción Médica del Embarazo para ampliar la base de prestadores de servicios de aborto con el fin de permitir que enfermeras capacitadas y médicos de AYUSH (capacitados en sistemas indios de medicina) proporcionen servicios de aborto con medicamentos. Para explorar sus puntos de vista, encuestamos a 1200 médicos y otros profesionales de la salud en los estados de Maharashtra y Bihar y realizamos entrevistas a profundidad con 34 de ellos que habían utilizado el método de aborto con medicamentos en sus consultorios. Los hallazgos indican que los gineco-obstetras y otros médicos alópatas se mostraron más renuentes que profesionales no médicos para apoyar la prestación de servicios de aborto con medicamentos en las etapas iniciales del embarazo por parte de enfermeras y médicos de AYUSH. Los médicos no creían que estos profesionales de la salud podrían evaluar correctamente la elegibilidad de las mujeres para tener un aborto con medicamentos. En cambio, la mayoría de los profesionales no médicos consideraron aceptable asignar a enfermeras y médicos de AYUSH capacitados la tarea de proporcionar servicios de aborto con medicamentos, y confiaban en que estos profesionales de la salud podrían proporcionar dichos servicios tan segura y eficazmente como los médicos capacitados. Suponiendo que las reformas sean aprobadas, el gobierno y las asociaciones de profesionales médicos deberán realizar esfuerzos para capacitar a estos nuevos prestadores de servicios para que asuman este rol, preparar la infraestructura de salud para incluirlos y crear un ambiente, incluso entre médicos, que se preste para permitir que profesionales no médicos proporcionen servicios de aborto con medicamentos.

Unsuccessful prior attempts to terminate pregnancy among women seeking first trimester abortion at registered facilities in bihar and jharkhand, india

Many abortion seekers in India attempt to induce abortion on their own, by accessing oral medication/preparations from a chemist without a prescription or from an unauthorized provider, and present at registered facilities if these attempts fail. However, little is known about those whose efforts fail or the ways in which programmes and policies may address the needs of such women. This paper explores the experiences of women whose efforts failed, including their socio-demographic profile, the preparations they used, and the extent to which they experienced serious complications, delayed seeking care from an authorized provider, or delayed abortion until the second trimester of pregnancy. Data come from a larger study assessing the feasibility of the provision of medical abortion by non-physicians; a total of 3394 women who sought medical abortion from selected clinical settings in Bihar and Jharkhand between 2008 and 2010 constitute the sample. Prior to visiting the clinic, nearly a third of these women (31%) had made at least one unsuccessful attempt to terminate the unwanted pregnancy by using a range of oral medications/preparations available over-the-counter in medical shops. Logistic regression analysis suggests that educated women (OR 1.6-1.7), those from urban areas (OR 6.2) and those from Bihar (OR 1.6) were significantly more likely than women with no education, rural women and those from Jharkhand to have used such medication. Also notable is that the average gestational age of women who had made a previous attempt to terminate their pregnancy was almost identical to that of women who had not done so when they presented at the registered facility. These findings may inform policies and programmes that seek to identify and reduce the potential risks associated with unauthorized abortion-seeking practices, and highlight the need to fully inform women, chemists and providers about oral medications, what works and what does not, and how effective medication must be taken.