New evidence from India on ways to improve safe abortion access and knowledge

Friday, May 5, 2017

Sign with information on safe abortion for Indian womenResearchers studied the effectiveness of signs like this one conveying information about safe, legal abortion in India.

Abortion has been legal in India since 1971, yet in this sprawling country of more than one billion people, progressive laws do not guarantee access to safe abortion services. An estimated 50 percent of abortions performed in India are unsafe.

With an eye toward reducing deaths caused by unsafe abortion, two recent studies in India explored ways to improve women’s access to and knowledge of safe, legal services. Both were led by Sushanta K. Banerjee, a senior director at the Ipas Development Foundation (IDF), which works in partnership with Ipas.

One study, published in BMC Health Services Research, focused specifically on poor women’s access to care in Madhya Pradesh state. Unsafe abortion is common in Madhya Pradesh, which has a large rural population. With technical assistance from IDF, the state government began working in 2006 to ensure that all women, whether rich or poor, have access to the comprehensive abortion care provided at public facilities. The initiative included training physicians, orienting nursing staff, providing facilities with essential equipment and drugs, and publicly displaying posters or wall signs on the availability of abortion services at primary health centers. 

“Maternal mortality reflects the greatest health divide between rich and poor women, and this is especially pronounced with respect to access to safe abortion services,” says Banerjee. “Even though abortion services are free at public facilities in India, poor women, out of concern for confidentiality, tend to seek care at private facilities. That care is often expensive and provided by untrained providers, which can lead to serious postabortion complications, or even death.”

The study looked at the socio-economic profile of more than 1,000 women who sought abortion services or treatment for postabortion complications at 19 randomly selected public health facilities in 2014. Most of the women (57 percent) were poor and from rural areas. And while they received abortion care free of charge, they had some out-of-pocket costs for food and transportation. Poor women were also the predominant users of treatment for postabortion complications, suggesting that they had relied on “informal providers” for their initial pregnancy termination.

“Our study is one of the first studies in India in recent years to examine the profile of women seeking abortion services at public sector facilities and assess this access in the context of poverty. And what we found is that improvements made in Madya Pradesh did, indeed, improve poor women’s access to abortion care,” says Banerjee. “Safe, accessible and affordable services should continue to be scaled up and supported in public facilities across India, particularly in poor and rural areas.”  

Such measures would especially benefit poor women. A recent study led by the Guttmacher Institute found that the costs related to receiving abortion care in Madhya Pradesh had “damaged household well-being” for many women. Half of the women interviewed for the study said they had to borrow money to cover the costs of the abortion.

Comparing effectiveness of behavior-change models

The second IDF-led study, published in BMJ Open, compared the effectiveness of two behavior-change models designed to improve women’s knowledge and use of safe abortion services. Both were communications campaigns centered on a fictional young woman named Kalyani, meaning “auspicious.” One was “high intensity” and reached women through group meetings, interactive games, wall signs, street dramas and distribution of low-literacy reference materials. The other, “low-intensity” model relied on community intermediaries (such as auxiliary nurse midwives) and wall signs in populous villages.

Cross-sectional household sample surveys among married women aged 15-49 years were used to assess the efficacy of these interventions. The evaluation found that while both models improved women’s knowledge of abortion, the high-intensity model was more effective in improving comprehensive knowledge about abortion—in particular about the legality of abortion and nearby sources of comprehensive abortion care. The evaluation also found that the more often women were exposed to the messaging and activities associated with the campaigns, the more likely they were to have improved knowledge and awareness.

The study recommends that efforts such as these to increase comprehensive abortion knowledge “should be paired with increased availability of women-centered abortion services at the primary health centre level to ensure that women have access to high-quality services.”

“Many women—especially those who are poor and live in rural areas, such as Madhya Pradesh state—are not aware that abortion is legal or that comprehensive care is available at public facilities,” adds Danish Umair Khan of IDF, one of the co-authors of the study. “Behavior-change strategies such as those used in this study may be part of a sustainable strategy for ensuring that messages about the legality and availability of care reach those women.”