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November 10, 2005
Indian couple at clinic
Distance, the prohibitive cost of the drugs for the average Indian, low literacy and familiarity with “home remedies” all hinder the expanded use of medication abortion in India.
Photo courtesy of the David and Lucile Packard Foundation.

In India, only physicians certified under the country’s 1972 Medical Termination of Pregnancy Act can perform legal abortions. So in the world’s second most populous nation, doctors serve as gatekeepers, and what they know — or don’t know — can influence individual women’s and communities’ exposure to newer abortion methods and technologies.

A recent Ipas study shows that Indian doctors and the general population need better awareness of mifepristone and misoprostol, a combined drug regimen that’s used for medication abortion. The report, Medical abortion in Bihar and Jharkhand, is a step forward in learning how the drugs are used and understood.

Principal researcher Bela Ganatra said: “Much is known about the medical safety of these drugs. But though medication abortion became available in India in 2002, very little has yet been documented about how they are being used, who is using them, and how women, service providers and other key stakeholders like chemists perceive them.”

From February to December 2004, Ganatra, Vinoj Manning (both of Ipas) and colleague Surajeen Prasad Pallipamalla conducted their study in the Bihar and Jharkhand states in east India. Those two heavily rural states make up about 10 percent of the national population, yet only 1.2 percent of the certified abortion facilities are located within their borders.

To gauge awareness of medication abortion, the team surveyed 221 obstetrician-gynecologists; physicians who hold Bachelor of Medicine or Bachelor of Surgery (MBBS) degrees; and practitioners of indigenous systems of medicine (ISM). They also polled 209 pharmacists and organized focus groups for men and women.

Not surprisingly, 97 percent of the ob-gyns had heard of the drug combination. But knowledge of mifepristone and misoprostol was markedly lower among MBBS physicians, ISM practitioners and pharmacists. The combo was never spontaneously mentioned by any participant in focus groups.

Awareness of medication abortion does not necessarily mean that service providers will offer it. Almost two-thirds of ob-gyns had provided one or both of the drugs, but less than 10 percent of MBBS physicians had.

While the majority of pharmacists registered some knowledge about the drugs, only 51 percent stocked misoprostol and slightly more than a third stocked the more expensive mifepristone. Among those pharmacists who stocked both drugs, there is some indication that they are sold with or without prescriptions.

Additionally, many pharmacists and some physicians varied dosages and were confused about when the drugs should be administered. Though pharmacists are not abortion providers, they may be perceived as a source of medical advice and should have accurate information to help their clients. However, most of those surveyed believed that medication abortion should be employed no later than 45 days after the last menstrual period (LMP); it’s generally deemed acceptable for up to nine weeks.

With certified abortion doctors few and far between, women often resort to other methods of inducing abortion. Pharmacists reported that their customers often saw Ayurvedic treatments and homeopathic medicines as effective ways to end pregnancies.

Distance, the prohibitive cost of the drugs for the average Indian, low literacy and familiarity with “home remedies” all hinder the expanded use of medication abortion in India.

There may be another factor, as well. The study also found that men in the family often make the first visit to the local practitioner or pharmacist to find out how to terminate an unwanted pregnancy. They may also function as gatekeepers who control information about or access to abortion services, so education efforts must reach out to men and women alike.

It will take a concerted effort from providers and the public-health sector to inform women that they have another safe abortion option.

Ganatra said: “Given the vast unmet demand for safe abortions services in Bihar and Jharkhand, it is inevitable that, with time, use of these drugs will increase. But as demand increases within the context of high cost, poor availability of appropriate providers and provider-imposed barriers, the potential for inappropriate use, self-medication and use by informal untrained providers may also increase.

“Now is the time to take action. We need to promote accurate information among both women and men, providers and pharmacists. We must ensure the widespread availability of the drugs through trained, legal providers at the primary care level. This is the surest way to minimize the potential for misuse and ensure that medical abortion is within the reach of the women who need it most.”

For more information, contact:
Kirsten Sherk
Senior Associate, Media Relations
e-mail: sherkk@ipas.org
phone: 919.960.5612
fax: 919.929.0258