A need for overhaul of policy on contraception and abortion in India
Authors: Kirti Iyengar, Kristina Gemzell Danielsson
Journal: The Lancet Global Health (2017)

In this issue of The Lancet Global Health, Singh and colleagues1Singh S Shekhar C Acharya R et al.The Incidence of abortion and unintended pregnancy in India, 2015.Lancet Glob Health. 2018; 6: e111-e120Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar report findings on the incidence of abortion and unintended pregnancy in India for 2015. Using data from multiple sources including a representative survey of health facilities and national drug sales data, the investigators found that in 2015, half of the 48·1 million pregnancies in India were unintended and that 15·6 million (14·1–17·3 million) pregnancies ended in abortions. More than 75% of abortions were obtained outside of facilities, and most of these abortions were by women obtaining medical abortion drugs from chemists and informal vendors without prescriptions. Because the investigators largely relied on direct measurements instead of indirect estimation techniques, these data add pivotal value to the existing literature on unintended pregnancies and abortion rates.2Sedgh G Singh S Hussain R Intended and unintended pregnancies worldwide in 2012 and recent trends.Stud Fam Plann. 2014; 45: 301-314Crossref PubMed Scopus (587) Google Scholar, 3Sedgh G Bearak J Singh S et al.Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends.Lancet. 2016; 388: 258-267Summary Full Text Full Text PDF PubMed Scopus (381) Google Scholar Most abortions were found to occur outside health facilities using drugs, whereas 64% of all facility-based abortions were surgical. These findings confirm the observation that women are not able to obtain the abortion method of their choice at formal health-care facilities. The barriers that continue to impede women's access to safe abortion services within the formal health-care system include a shortage of number of trained providers, legal impediments, lack of privacy and confidentiality, and insistence on specific contraception as a precondition for providing abortion services.4Stillman M Jenifer J Singh S Moore AM Kalyanwala S Abortion in India: a literature review. Guttmacher Institute, New York2014Google Scholar Even where trained providers exist, most do not give women a choice of options, whereas data from studies have shown that women overwhelmingly prefer medical abortion.5Iyengar K Iyengar SD Improving access to safe abortion in a rural primary care setting in India: experience of a service delivery intervention.Reprod Health. 2016; 13: 54Crossref PubMed Scopus (9) Google Scholar Furthermore, over-medicalised service delivery protocols are in use for medical abortion, which is approved for use only up to 9 gestational weeks in India.6Ministry of Health and Family WelfareHandbook on medical methods of abortion to expand access to new technologies for safe abortion. Government of India, New Delhi2016Google Scholar Although a large proportion of abortions in India are provided outside a legal framework, not all will necessarily have been unsafe. The notion that safe versus unsafe is not equivalent to legal versus illegal was recently addressed by WHO in an attempt to move beyond a binary understanding of abortion safety.7Ganatra B Gerdts C Rossier C et al.Global, regional, and subregional classification of abortions by safety: estimates for 2010–14.Lancet. 2017; (published online Sept 27.)http://dx.doi.org/10.1016/S0140-6736(17)31794-4Summary Full Text Full Text PDF PubMed Scopus (356) Google Scholar Questions that still need to be answered include: who are the women behind these data, and what are their demographics, gestational lengths, and prior exposure to contraception? In view of the large proportion of abortion pills provided by pharmacists, we need to better understand messages given by pharmacists on medical abortion and subsequent contraception. There is a widespread perception that provision of medical abortion by pharmacists begets high rates of incomplete abortions and complications, but no data exist to support this perception. Information is needed on outcomes in women seeking abortions from pharmacists and informal vendors, including rates of failure, incomplete abortion, and serious complications and whether they used any post-abortion contraception. The study findings indicate that new strategies are needed in India to improve access to safe abortion services, especially medical abortion. Although expanding the scope of providers would be one important step, other strategies such as reducing stigma, simplifying training requirements, and delinking training for medical and surgical abortion would also be required.8Iyengar K Iyengar SD Gemzell Danielsson K Can informal abortion provision in India transition to formal and safe services?.Lancet Glob Health. 2016; 4: e357-e358Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar Simplification of service delivery guidelines for medical abortion by including home administration of misoprostol and self-assessment of abortion outcome would also help increase access, even in rural areas.9Iyengar K Paul M Iyengar SD et al.Self-assessment of the outcome of early medical abortion versus clinic follow-up in India: a randomized, controlled, non-inferiority trial.Lancet Glob Health. 2015; 3: e537-e545Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar Health programmes might also test alternative approaches such as telemedicine,10Gomperts R Jelinska K Davies S Gemzell Danielsson K Kleiverda G Using telemedicine for termination of pregnancy with mifepristone and misoprostol in settings where there is no access to safe services.BJOG. 2008; 115: 1171-1178Crossref PubMed Scopus (0) Google Scholar which could turn out to be safer than the service provided by untrained pharmacists who do not have the skills to counsel women or assess their eligibility. The study results point to the huge burden of unintended pregnancy in India. Historically, India's family welfare programme has been sterilisation-focused and is not able to address the contraceptive needs of a large proportion of people. As emphasised by the authors, improved policies to increase access to contraceptive services is an urgent priority in India to help millions of women avoid unintended pregnancies. The findings confirm the need to rethink medical abortion within the context of India's abortion act, from being a facility-based service to outpatient consultation, a service that should not require specific training by non-specialist providers, a service that could feature in pre-service curricula, and one that would avoid the need for multiple visits. We declare no competing interests. The incidence of abortion and unintended pregnancy in India, 2015Health 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. Full-Text PDF Open Access